*Purpose: Transplant-related Hepatitis E virus (HEV) infection is a rarely recognized entity with significant clinical importance given potential for chronic hepatitis post-transplant. We evaluated HEV diagnosis, treatment, and outcomes after liver, kidney and heart transplant in a single center.

*Methods: We evaluated all patients transplanted at a single center and identified patients diagnosed with HEV by serologic testing. We gathered data on patient outcomes, laboratory evaluation, treatment course, reduction in immunosuppression, and mortality.

*Results: 13 transplant recipients developed HEV infection between 2017-2020. The average age for all patients was 62 years (range 47-74 years) with 46% male. The average time between transplantation and positive HEV IgM antibody testing was 35 months (range 3-240 months). Ten patients received a liver transplant for reasons including Hepatitis C virus, Hepatitis B virus, alcoholic cirrhosis, and Hepatocellular Carcinoma. Two patients received a kidney transplant for SLE and hypertensive nephrosclerosis respectively. One patient had a heart transplant for hypertrophic cardiomyopathy.All 13 patients presented with elevated liver enzymes and were positive for HEV IgM antibody. Nine patients had an undetectable HEV PCR Quantitative. Four patients did not have HEV PCR testing done. Three patients were treated with ribavirin for an average of 84 days (range 56-120 days) with two patients at 800mg per day and one patient at 600 mg per day. One of these patients had a recurrence of HEV but recovered after immunosuppression was reduced. All three patients’ liver enzymes normalized with therapy. Eight patients had their immunosuppression reduced without anti-viral treatment. Seven of these patients’ liver enzymes normalized and they recovered. One of these patients died of acute pancreatitis two months after positive HEV IgM antibody. Two patients had spontaneous reduction of liver enzymes without treatment or change to immunosuppression.

*Conclusions: The gravity of active HEV infections in transplant recipients necessitates prompt diagnosis and treatment. In order to prevent ongoing hepatic inflammation and irreversible damage, HEV PCR should follow a positive HEV IgM antibody test. The PCR confirmation is vital given that HEV IgM antibody testing may have false positivity for active infection. Ribavirin and reducing immunosuppression are effective treatments. Larger multi-center studies are needed to confirm the risks and benefits of adding ribavirin therapy versus simple reduction of immunosuppression as first line therapy of HEV post-transplant.

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