Acute liver failure caused by hepatitis E virus genotype 3 and 4: A systematic review and pooled analysis

Recent advances in hepatitis E virus research and the Japanese clinical practice guidelines for hepatitis E virus infection

Acute hepatitis E was considered rare until reports emerged affirming the existence of hepatitis E virus (HEV) genotypes 3 and 4 infections in Japan in the early 2000s. Extensive studies by Japanese researchers have highlighted the pivotal role of pigs and wild animals, such as wild boars and deer, as reservoirs for HEV, linking them to zoonotic infections in Japan. Currently, when hepatitis occurs subsequent to the consumption of undercooked or grilled pork, wild boar meat, or offal (including pig liver and intestines), HEV infection should be considered. Following the approval of anti-HEV immunoglobulin A antibody as a diagnostic tool for hepatitis E by Japan's Health Insurance System in 2011, the annual number of diagnosed cases of HEV infection has surged. Notably, the occurrence of post-transfusion hepatitis E promoted nationwide screening of blood products for HEV using nucleic acid amplification tests since 2020. Furthermore, chronic hepatitis E has been observed in immunosuppressed individuals. Considering the significance of hepatitis E, heightened preventive measures are essential. The Japan Agency for Medical Research and Development Hepatitis A and E viruses (HAV and HEV) Study Group, which includes special virologists and hepatologists, held a virtual meeting on February 17, 2024. Discussions encompassed pathogenesis, transmission routes, diagnosis, complications, severity factors, and ongoing and prospective vaccination or treatments for hepatitis E. Rigorous assessment of referenced studies culminated in the formulation of recommendations, which are detailed within this review. This comprehensive review presents recent advancements in HEV research and Japanese clinical practice guidelines for HEV infection.

Inborn errors of type I interferon immunity in patients with symptomatic acute hepatitis E

BACKGROUND AND AIMS

The clinical spectrum of human infection by HEV ranges from asymptomatic to severe acute hepatitis. Furthermore, HEV can cause diverse neurological manifestations, especially Parsonage-Turner syndrome. Here, we used a large-scale human genomic approach to search for genetic determinants of severe clinical presentations of HEV infection.

APPROACH AND RESULTS

We performed whole genome sequencing in 3 groups of study participants with PCR-proven acute HEV infection: (1) 24 patients with symptomatic acute hepatitis E; (2) 12 patients with HEV-associated Parsonage-Turner syndrome; and (3) 16 asymptomatic blood donors (controls). For variant calling and annotation, we used GATK4 best practices followed by Variant Effect Predictor (VEP) and Annovar. For variant classification, we implemented the American College of Medical Genetics and Genomics/Association for Molecular Pathology Bayesian classification framework in R. Variants with a probability of pathogenicity >0.9 were considered damaging. We used all genes with at least 1 damaging variant as input for pathway enrichment analyses.We observed a significant enrichment of type I interferon response pathways in the symptomatic hepatitis group: 10 out of 24 patients carried a damaging variant in one of 9 genes encoding either intracellular viral sensors ( IFIH1 , DDX58 , TLR3 , POLR3B , POLR3C ) or other molecules involved in type I interferon response [interferon regulatory factor 7 ( IRF7 ), MYD88 , OAS3 , GAPDH ]. We did not find any enriched pathway in the Parsonage-Turner syndrome group or in the controls.

CONCLUSIONS

Our results highlight the essential role of type I interferon in preventing symptomatic acute hepatitis E.

Is dyslipidemia a risk factor for trastuzumab-induced cardiotoxicity in breast cancer patients? A systematic review and meta-analysis

INTRODUCTION

Breast cancer patients undergoing trastuzumab therapy have greater risk of cardiovascular disease. Risk factors for this effect have been proposed. However, the role of dyslipidemia is not completely understood. This systematic review aimed to explore the role of dyslipidemia in trastuzumab-induced cardiotoxicity.

METHODS

The investigators searched MEDLINE, Scopus, and Web of Science up to October 25, 2020. A random-effects model was used to determine pooled estimates of the results. The primary endpoint was trastuzumab-induced cardiotoxicity in patients with and without dyslipidemia.

RESULTS

A total of 39 studies were selected for inclusion in our systematic review assessing 21079 patients. One study demonstrated a statistically significant association between dyslipidemia and cardiotoxicity (OR=2.28, 95% CI 1.22-4.26, p=0.01). In all other studies, no such association was observed. Twenty-one studies including 6135 patients were eligible for meta-analysis. In this meta-analysis of unadjusted data, dyslipidemia was significantly associated with cardiotoxicity (OR=1.25, 95% CI 1.01-1.53, p=0.04, I2=0%), however, a subgroup analysis of studies reporting adjusted measures did not demonstrate a significant association (OR=0.89, 95% CI 0.73-1.10, p=0.28, I2=0%).

CONCLUSION

This systematic review and meta-analysis did not demonstrate a significant association between dyslipidemia alone and the development of cardiotoxicity. In the absence of other relevant cardiovascular risk factors, review of lipid profile may not be obligatory, and management of patients could be performed without referral for cardio-oncology assessment. Further investigation of risk factors for trastuzumab-induced cardiotoxicity is required to confirm these results.

Surgical management of upper limb lipoma arborescens: a systematic review

Background

Lipoma arborescens (LA) is a rare benign synovial tumour characterized by the proliferation of mature adipocytes within the synovial cells. Given its rarity, current evidence is mainly based on case reports and case series, and no guidelines are available. The present study investigated the current surgical management and related outcomes of LA in the upper limb.

Methods

This systematic review was conducted following the PRISMA guidelines. PubMed, Scopus, and Virtual Health Library were accessed in September 2021. Clinical studies evaluating patients with LA undergoing surgical treatment were considered eligible for this systematic review. Only studies which reported data on LA located in the upper limb with histopathological confirmation were considered. Articles that reported data from nonsurgical management were not considered.

Results

A total of 21 studies reporting 22 lesions in 21 patients were assessed. The mean age of the patients was 48.48 years (range 22–77). Most studies evaluated the restoration of range of motion and symptom resolution for the functional outcome assessment. Open or arthroscopic excision and synovectomy were the most common surgical procedures for LA. The concomitant lesions were treated in a single-stage procedure. All patients had satisfactory outcomes after open or arthroscopic excision and synovectomy without recurrence at a mean follow-up of 21.14 months (range 2–60). One patient developed postoperative cellulitis (4.55%).

Conclusion

Open and arthroscopic excision combined with synovectomy should be considered the standard treatment option of upper limb LA. Concomitant pathologies can be addressed in a one-stage procedure. Although LA was recognized as a clinical entity decades ago, there is a lack of evidence based guidelines and long term outcome data are unavailable.

Transfusion-transmitted hepatitis E: What we know so far?

Hepatitis E virus (HEV) is a major cause of viral hepatitis globally. There is growing concern about transfusion-transmitted HEV (TT-HEV) as an emerging global health problem. HEV can potentially result in chronic infection in immunocompromised patients, leading to a higher risk of liver cirrhosis and even death. Between 0.0013% and 0.281% of asymptomatic blood donors around the world have HEV viremia, and 0.27% to 60.5% have anti-HEV immunoglobulin G. HEV is infectious even at very low blood concentrations of the virus. Immunosuppressed patients who develop persistent hepatitis E infection should have their immunosuppressant regimen reduced; ribavirin may be considered as treatment. Pegylated interferon can be considered in those who are refractory or intolerant to ribavirin. Sofosbuvir, a nucleotide analog, showed modest antiviral activity in some clinical studies but sustained viral response was not achieved. Therefore, rescue treatment remains an unmet need. The need for HEV screening of all blood donations remains controversial. Universal screening has been adopted in some countries after consideration of risk and resource availability. Various pathogen reduction methods have also been proposed to reduce the risk of TT-HEV. Future studies are needed to define the incidence of transmission through transfusion, their clinical features, outcomes and prognosis.

Walking Speed and Mortality: An Updated Systematic Review

OBJECTIVE

The aim of our systematic review was to update the current evidence on the association between slow walking speed (WS) and mortality, expanding the current knowledge available in the literature.

METHODS

A systematic review of the published data on the association of WS and mortality was carried out by searching on PubMed and ISI Web of Knowledge databases.

RESULTS

From a title and abstract analysis, 61 articles were included that met the prespecified criteria. After a full-text analysis, 6 articles were excluded and the remaining articles accounted for 120,838 patients and > 25,148 deaths were registered. The duration of follow-ups ranged between 2 and 21 years. In general, studies have shown a consistent association between WS and mortality from all causes.

CONCLUSIONS

WS showed continuous and consistent evidence to be a good predictor of mortality. As such, our study supports the use of this tool in clinical practice as a way to improve health care.

Liver chemistries in glycogenic hepatopathy associated with type 1 diabetes mellitus: A systematic review and pooled analysis

BACKGROUND & AIMS

Glycogenic hepatopathy (GH) in type 1 diabetes-mellitus (T1DM) is characterized by hepatomegaly and perturbations of liver chemistries (LC) that have not been well studied. Furthermore, misdiagnosis with other hepatic complications of T1DM, such as nonalcoholic fatty liver disease, has been described. We perform a systematic review of biopsy-proven GH reports in T1DM patients to identify LC patterns.

METHODS

A systematic review identified reports of biopsy-proven GH in patients with T1DM. We excluded GH with other liver diseases, Mauriac syndrome, or GH without T1DM. Two reviewers screened and extracted studies and assessed their methodological quality. LC elevation magnitude, AST-to-ALT ratio, R-ratio to designate hepatocellular, cholestatic or mixed pattern of hepatic injury, and evolution of transaminases after glycemic control were analyzed.

RESULTS

A total of 192 patients were included, with median age of 20 years, 73% adults, 66% females, median duration of T1DM before diagnosis 10 years, median adult body mass index 21 kg/m² , median HbA1c 12%, at least one episode of diabetic ketoacidosis 70%, and hepatomegaly 92%. ALT and AST showed moderate-to-severe elevation in 78% and 76%, respectively, AST/ALT >1 in 71% and hepatocellular to mixed pattern of hepatic injury in 81%. Transaminase improvement with glycemic control was the rule, regardless of other factors in multilinear regression analysis.

CONCLUSION

GH tends to have AST-predominant elevation with a median of 13 times the upper normal limit and R-ratio >2, which may distinguish it from other etiologies of AST-predominant LC elevation, and in the appropriate clinical context, may obviate invasive tests.

Analyses of Clinical and Biological Data for French and Belgian Immunocompetent Patients Infected With Hepatitis E Virus Genotypes 4 and 3

Hepatitis E virus (HEV) genotypes 3 and 4 are the major causes of acute hepatitis in industrialized countries. Genotype 3 is mainly found in Europe and America, while genotype 4 is predominant in Asia. Several Japanese studies have suggested that genotype 4 is more virulent than genotype 3. We investigated this aspect by analyzing the clinical and biological data for 27 French and Belgian immunocompetent patients infected with HEV genotype 4. Their infections were probably acquired locally, since none of these patients reported traveling outside France or Belgium during the 2–8 weeks before symptoms onset. Each patient was matched for age (±5 years) and gender with two patients infected with HEV genotype 3. Bivariate analysis indicated that the HEV genotype 4-infected patients had significantly higher alanine aminotransferase (ALT) (2067 IU/L) and aspartate aminotransferase (AST) (1581 IU/L) activities and total bilirubin concentrations (92.4 μmol/L) than did those infected with HEV genotype 3 (1566 IU/L, p = 0.016; 657 IU/L, p = 0.003 and 47 μmol/L, p = 0.046) at diagnosis. In contrast, more patients infected with HEV genotype 3 reported dark urine (71% vs. 39%, p = 0.02) and experienced asthenia (89% vs. 58%, p < 0.01) than did those infected with HEV genotype 4. Two HEV genotype 4-infected patients died of multi-organ failure, while none of the genotype 3-infected patients died (p = 0.035). Finally, stepwise regression analysis retained only a greater increase in ALT (odds-ratio: 1.0005, 95% confidence interval: 1.00012–1.00084) and less frequent fever (odds-ratio = 0.1244; 95% confidence interval: 0.01887–0.82020) for patients infected with HEV genotype 4. We conclude that HEV-4 infections are likely to be associated with higher ALT activity than HEV-3 infections. Additional immunological and virological studies are required to confirm these findings and better understand the influence, if any, of genotype on HEV pathophysiology.

ST-segment elevation in patients with COVID-19: a systematic review

Coronavirus disease 2019 (COVID-19) can cause a wide range of cardiovascular diseases, including ST-segment elevation myocardial infarction (STEMI) and STEMI-mimickers (such as myocarditis, Takotsubo cardiomyopathy, among others). We performed a systematic review to summarize the clinical features, management, and outcomes of patients with COVID-19 who had ST-segment elevation. We searched electronic databases from inception to September 30, 2020 for studies that reported clinical data about COVID-19 patients with ST-segment elevation. Differences between patients with and without obstructive coronary artery disease (CAD) on coronary angiography were evaluated. Forty-two studies (35 case reports and seven case series) involving 161 patients were included. The mean age was 62.7 ± 13.6 years and 75% were men. The most frequent symptom was chest pain (78%). Eighty-three percent of patients had obstructive CAD. Patients with non-obstructive CAD had more diffuse ST-segment elevation (13% versus 1%, p = 0.03) and diffuse left ventricular wall-motion abnormality (23% versus 3%, p = 0.02) compared to obstructive CAD. In patients with previous coronary stent (n = 17), the 76% presented with stent thrombosis. In the majority of cases, the main reperfusion strategy was primary percutaneous coronary intervention instead of fibrinolysis. The in-hospital mortality was 30% without difference between patients with (30%) or without (31%) obstructive CAD. Our data suggest that a relatively high proportion of COVID-19 patients with ST-segment elevation had non-obstructive CAD. The prognosis was poor across groups. However, our findings are based on case reports and case series that should be confirmed in future studies.

Efficacy and safety of combined endoscopic cyanoacrylate injection and balloon-occluded retrograde transvenous occlusion (BRTOcc) of gastrorenal shunts in patients with bleeding gastric fundal varices

Background

Endoscopic cyanoacrylate (glue) injection of fundal varices may result in life-threatening embolic adverse events through spontaneous gastrorenal shunts (GRSs). Balloon-occluded retrograde transvenous occlusion (BRTOcc) of GRSs during cyanoacrylate injection may prevent serious systemic glue embolization through the shunt. This study aimed to evaluate the efficacy and safety of a combined endoscopic–interventional radiologic (BRTOcc) approach for the treatment of bleeding fundal varices.

Methods

We retrospectively analysed the data of patients who underwent the combined procedure for acutely bleeding fundal varices between January 2010 and April 2018. Data were extracted for patient demographics, clinical and endoscopic findings, technical details, and adverse events of the endoscopic–BRTOcc approach and patient outcomes.

Results

We identified 30 patients (13 [43.3%] women; median age 58 [range, 25–92] years) with gastroesophageal varices type 2 (53.3%, 16/30) and isolated gastric varices type 1 (46.7%, 14/30) per Sarin classification, and median clinical and endoscopic follow-up of 151 (range, 4–2,513) days and 98 (range, 3–2,373) days, respectively. The median volume of octyl-cyanoacrylate: Lipiodol injected was 7 (range, 4–22) mL. Procedure-related adverse events occurred in three (10.0%) patients, including transient fever, non-life-threatening pulmonary glue embolism, and an injection-site ulcer bleed. Complete gastric variceal obturation was achieved in 18 of 21 patients (85.7%) at endoscopic follow-up. Delayed variceal rebleeding was confirmed in one patient (3.3%) and suspected in two patients (6.7%). Although no procedure-related deaths occurred, the overall mortality rate was 46.7%, primarily from liver-disease progression and co-morbidities.

Conclusion

The combined endoscopic–BRTOcc procedure is a relatively safe and effective technique for bleeding fundal varices, with a high rate of variceal obturation and a low rate of serious adverse events.

Mortality and use of angiotensin-converting enzyme inhibitors in COVID 19 disease: a systematic review

BACKGROUND

Interest exists concerning the use of angiotensin-converting enzyme inhibitors (ACEis) in patients with COVID-19 disease.

OBJECTIVES

The aim of the study was to perform a systematic review on mortality associated to the use of ACEi in patients with COVID-19 disease.

METHODS

Search in Medline (PubMed), in ISI Web of Knowledge and in medRxiv database; use of other sources.

RESULTS

A total of 33 articles were evaluated. Concerning the papers used to produce the meta-analyses, 7 studies were selected, 5 of which were used. These 5 studies involved a total number of 944 patients treated with ACEi and 5173 not treated with ACEi. Increased mortality was seen in association to the use of ACEi in the context of COVID-19 disease (ACEi users vs nonusers; odds ratio, 1.48; 95% confidence interval, 1.02-2.15; P = .04). When compared to mortality in patients treated with angiotensin receptor blockers, mortality of patients treated with ACEi was not significantly different (odds ratio, 0.96; 95% confidence interval, 0.76-1.21; P = .74). Concerning the remaining reports, different types of data adjustments were used by several authors, after which increased mortality was not seen in association to the use of ACEi in this context.

CONCLUSIONS

ACEi use could act as a marker of increased mortality risk in some but not all COVID-19 disease settings. The data now presented do not prove a causal relation but argue in favor of carrying out clinical trials studying ACEi in COVID-19 patients, to establish the safety of ACEi use in this context.

Clinical outcomes of leadless pacemaker: a systematic review

INTRODUCTION

Transvenous pacemakers are associated with a significant amount of complications. Leadless pacemakers (LP) are emerging as an alternative to conventional devices. This article provides a systematic review of patient eligibility, safety and clinical outcomes of the LP devices.

EVIDENCE ACQUISITION

A systematic search for articles describing the use of LP was conducted. Out of two databases, 24 articles were included in the qualitative analysis. These articles comprised a total of 4739 patients, with follow-up times of 1-38 months. Further information was obtained from 10 more studies.

EVIDENCE SYNTHESIS

From a population of 4739 patients included in the qualitative analysis, 4670 LP were implanted with success (98.5%). A total of 248 complications were described (5.23%) during the follow-up. The most common were pacing issues such as elevated thresholds, dislodgements or battery failure (68 patients), events at the femoral access site such as hemorrhage, hematoma or pseudoaneurysms (64 patients) and procedure related cardiac injuries such as cardiac perforation, tamponade or pericardial effusion (47 patients). There were 360 deaths during the follow-up and 11 were described as procedure or device related. Four studies presented the strategy of using a combined approach of atrioventricular node ablation (AVNA) and LP implantation.

CONCLUSIONS

Leadless pacemakers seem to have a relatively low complication rate. These devices may be a good option in patients with an indication for single-chamber pacing, in patients with conditions precluding conventional transvenous pacemaker implantations. Studies directly comparing LP and transvenous pacemakers and data on longer follow-up periods are needed.

Swine hepatitis E virus: Cross-species infection, pork safety and chronic infection

Swine hepatitis E virus (swine HEV) belongs to the species Orthohepevirus A within the genus Orthohepevirus in the family Hepeviridae. Four different genotypes of swine HEV within the species Orthohepevirus A have been identified so far from domesticated and wild swine population: genotypes 3 (HEV-3) and 4 (HEV-4) swine HEVs are zoonotic and infect humans, whereas HEV-5 and HEV-6 are only identified from swine. As a zoonotic agent, swine HEV is an emerging public health concern in many industrialized countries. Pigs are natural reservoir for HEV, consumption of raw or undercooked pork is an important route of foodborne HEV transmission. Occupational risks such as direct contact with infected pigs also increase the risk of HEV transmission in humans. Cross-species infection of HEV-3 and HEV-4 have been documented under experimental and natural conditions. Both swine HEV-3 and swine HEV-4 infect non-human primates, the surrogates of man. Swine HEV, predominantly HEV-3, can establish chronic infection in immunocompromised patients especially in solid organ transplant recipients. The zoonotic HEV-3, and to lesser extent HEV-4, have also been shown to cause neurological diseases and kidney injury. In this review, we focus on the epidemiology of swine HEV, host and viral determinants influencing cross-species HEV infection, zoonotic infection and its associated pork safety concern, as well as swine HEV-associated chronic infection and neurological diseases.

Genetic Variability and Evolution of Hepatitis E Virus

Hepatitis E virus (HEV) is a single-stranded positive-sense RNA virus. HEV can cause both acute and chronic hepatitis, with the latter usually occurring in immunocompromised patients. Modes of transmission range from the classic fecal-oral route or zoonotic route, to relatively recently recognized but increasingly common routes, such as via the transfusion of blood products or organ transplantation. Extrahepatic manifestations, such as neurological, kidney and hematological abnormalities, have been documented in some limited cases, typically in patients with immune suppression. HEV has demonstrated extensive genomic diversity and a variety of HEV strains have been identified worldwide from human populations as well as growing numbers of animal species. The genetic variability and constant evolution of HEV contribute to its physiopathogenesis and adaptation to new hosts. This review describes the recent classification of the Hepeviridae family, global genotype distribution, clinical significance of HEV genotype and genomic variability and evolution of HEV.

Donor-Derived Genotype 4 Hepatitis E Virus Infection, Hong Kong, China, 2018

Hepatitis E virus (HEV) genotype 4 (HEV-4) is an emerging cause of acute hepatitis in China. Less is known about the clinical characteristics and natural history of HEV-4 than HEV genotype 3 infections in immunocompromised patients. We report transmission of HEV-4 from a deceased organ donor to 5 transplant recipients. The donor had been viremic but HEV IgM and IgG seronegative, and liver function test results were within reference ranges. After a mean of 52 days after transplantation, hepatitis developed in all 5 recipients; in the liver graft recipient, disease was severe and with progressive portal hypertension. Despite reduced immunosuppression, all HEV-4 infections progressed to persistent hepatitis. Four patients received ribavirin and showed evidence of response after 2 months. This study highlights the role of organ donation in HEV transmission, provides additional data on the natural history of HEV-4 infection, and points out differences between genotype 3 and 4 infections in immunocompromised patients.

Computed tomography-guided pericardiocentesis: a systematic review concerning contemporary evidence and future perspectives

BACKGROUND

Pericardial effusion (PE) can develop in several pathological scenarios, and is often initially evaluated by means of echocardiography. Computed tomography (CT) has been used as an aid in the management of patients presenting with PE, in selected cases. The role of CT-guided pericardiocentesis in contemporary practice, however, remains not fully ascertained. We aimed at presenting a systematic review concerning the state-of-the-art of this technique.

METHODS

A systematic review of published data on the use of CT for guiding pericardiocentesis was carried out (search performed on PubMed, ISI Web of Knowledge and Scopus databases).

RESULTS

From title and abstract analysis, 14 articles were included that met the prespecified criteria. After full-text analysis, six articles were excluded. The eight articles under analysis included a total of 635 procedures performed in 571 patients. CT guidance was mostly used in a postoperative setting (364 procedures). Most procedures were done mainly for therapeutic purposes (528 procedures). Success rates ranged from 94% to 100%. Complications ranged from 0% to 7.8%.

CONCLUSION

CT-guided pericardiocentesis is a useful technique in the approach to PE, in several clinical scenarios. Its use can be especially relevant in the postoperative period, as well as in individuals with suboptimal image quality (as assessed by echocardiography, for the moment the first choice in the approach to most cases of PE).