HEV has recently been recognized as a potential cause of persistent hepatitis in solid organ transplant recipients. It may cause chronic liver disease if not diagnosed and managed. Transmission is faeco-oral, frequently from undercooked meat products. Infection may not necessarily cause abnormal LFTs, or may be only associated with a mild or transient derangement.
- We check HEV PCR on all renal transplant recipients at 3 months post transplant (as part of Virology at 3 Months Post SOT order set) to check for transmission via the transplant. This may become unnecessary once screening of all UK donors for HEV is introduced.
- All living donors are checked for HEV PCR prior to donation.
- Transient abnormal LFTs are common early post transplant. Unexplained abnormal LFTs or persistently abnormal LFTs should be investigated including HEV PCR testing.
- A positive result should be discussed with the Hepatology team.
A recent BTS guideline document has more detailed information and can be found at https://bts.org.uk/wp-content/uploads/2017/05/BTS-HEV-Guideline-CONSULTATION_DRAFT.pdf. The following is modified from that document:
Newly diagnosed or acute HEV infection
We suggest that:
- The initial management of newly diagnosed or acute HEV infection in solid organ transplant recipients includes observation and monitoring of HEV RNA levels and liver enzymes as >30% will spontaneously clear the infection within three months.
- A strategic reduction in immunosuppression is considered in patients with acute or persistent HEV as this may facilitate viral clearance, but the risk of rejection should be carefully assessed.
- Early treatment with ribavirin may be considered in specific cases of acute hepatitis E, such as patients who develop severe liver dysfunction (jaundice and coagulopathy) or extrahepatic manifestations, although evidence for this recommendation is currently limited.
Persistent HEV infection
This refers to detectable HEV in blood or stool for >3 months and warrants treatment with ribavirin for at least 3 months and monitoring of HEV and LFTs. Guidance from the hepatology team should be sought for specific treatment in individual cases.