Volume 206 - Issue 7
Australian transplant recipients are at risk of chronic hepatitis E
Authors: James P Newcombe, Stella McGinn, Bruce Wong, Archie Darbar and George Kotsiou
Med J Aust 2017; 206 (7): 325. || doi: 10.5694/mja16.01204
Published online: 17 April 2017
Published online: 17 April 2017
To the Editor:
Hepatitis E virus (HEV) genotype 3, the most common genotype in high income countries, is transmitted by ingestion of high risk food — including pork, deer and shellfish — and by blood transfusion. Rural residence, travel to hyperendemic areas (eg, southern Europe) and animal exposure are other risk factors.1
Both de novo and reactivated HEV infection can lead to chronic infection in up to 60% of immunocompromised patients, particularly in solid organ transplant (SOT) recipients.1,2 Moreover, 10% of patients who are chronically infected develop cirrhosis.1 In a 2013 study, the seroprevalence of HEV in Australian blood donors was 5.99%.3 Autochthonous transmission in Australia, including one patient who was a liver transplant recipient, is well documented.4,5 However, the seroprevalence and rate of chronic HEV infection in SOT recipients in Australia are unknown.
We carried out a study to investigate this in an Australian tertiary hospital. In phase 1 of our study, we recruited renal transplant recipients attending routine outpatient follow-up in 2014–15; phase 2 was limited to seropositive participants from phase 1. The study was approved by the Northern Sydney Local Health District Human Research Ethics Committee (LNR/14/HAWKE/300).
Seventy-four patients consented to participate in phase 1, and post-transplant stored serum was tested for HEV IgG. Six participants were HEV IgG positive.
One seropositive participant died of invasive fungal infection before phase 2. The remaining five participants who were seropositive consented to phase 2, of whom one was HEV IgM positive. We tested plasma for HEV RNA and no phase 2 participants had evidence of ongoing chronic infection.
While our study had limitations and we did not identify any participant with chronic infection, it is important to note that Australian SOT recipients are exposed to HEV and are at risk of chronic infection. Effective therapy for chronic HEV is available; therefore, we recommend that SOT recipients who have abnormal liver function tests should be tested for HEV RNA in blood to maximise early diagnosis.
In addition, with respect to risk mitigation, previous Australian research supports a link between local pork consumption and HEV infection,4 and French guidelines suggest that SOT recipients should avoid consuming food containing pork liver.6 We believe that similar advice should be given to SOT recipients in Australia. Moreover, consideration should be given to screening donated blood in Australia for HEV RNA, as done in France and the United Kingdom, with experts calling for such screening across the European Union.7,8 The Australian Red Cross Blood Service has undertaken a large scale screening study of donated plasma for HEV RNA to estimate the local risk of HEV transmission by blood transfusion, with results currently pending.9
Competing interests
No relevant disclosures.
Acknowledgements
We thank Paul Collett and David Waugh, renal physicians from the Royal North Shore Hospital, for their assistance with patient recruitment.
References
- Kamar N, Bendall R, Legrand-Abravanel F, et al. Hepatitis E. Lancet 2012; 379: 2477-2488.
- Pas SD, de Man RA, Mulders C, et al. Hepatitis E virus infection among solid organ transplant recipients, the Netherlands. Emerg Infect Dis 2012; 18: 869-872.
- Shrestha AC, Seed CR, Flower RL, et al. Hepatitis E virus and implications for blood supply safety, Australia. Emerg Infect Dis 2014; 20: 1940-1942.
- Yapa CM, Furlong C, Rosewell A, et al. First reported outbreak of locally acquired hepatitis E virus infection in Australia. Med J Aust 2016; 204: 274.
- Speers DJ, Ma MX, Faddy HM, et al. Domestically acquired hepatitis E successfully treated with ribavirin in an Australian liver transplant recipient. Med J Aust 2015; 202: 209-211.
- Moal V, Legris T, Motte A, et al. Systematic serological testing for hepatitis E virus in kidney transplant recipients. J Clin Microbiol 2015; 53: 1523-1530.
- Pawlotsky JM. Hepatitis E screening for blood donations: an urgent need? Lancet 2014; 384: 1729-1730.
- NHS Blood and Transplant. Change to NHSBT pricing of products in 2017/18 and introduction of universal screening for hepatitis E [website]. Watford: NHS; 2016. http://www.nhsbt.nhs.uk/news-and-media/news-articles/news_2016_12_21.asp (accessed Jan 2017).
- Australian Red Cross Blood Service. Hepatitis E study kicks off [website]. Alexandria: ARCBS; 2016. http://www.transfusion.com.au/BSIB_July2016_8 (accessed Jan 2017).