Hepatitis E Virus (HEV) - heart recipient

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Record number: 
Adverse Occurrence type: 
MPHO Type: 
Estimated frequency: 
Anecdotally reported in the literature
Time to detection: 
Around one to two months
Alerting signals, symptoms, evidence of occurrence: 
The suspicion was based on an elevation of hepatic transaminases in the index case (a liver transplant recipient). The other four recipients (two kidneys, heart and lung) were completely asymptomatic although all of them developed low-grade hepatitis. Once the first patient was diagnosed the transmission of the hepatitis E virus was quickly suspected and diagnosed on the other recipients.
Demonstration of imputability or root cause: 
Demonstration of imputability was demonstrated by performing phylogenetic analyses of the partial RNA-dependent RNA polymerase region of HEV strains as blood samples were collected and stored for both donor and recipients
Imputability grade: 
3 Definite/Certain/Proven
Reference attachment: 
Suggest references: 
Sridhar S, et al. Donor-Derived Genotype 4 Hepatitis E Virus Infection, Hong Kong, China, 2018. EID Vol. 25, No. 3, March 2019
The record will be cloned for the following MPHO: kidney, lung, heart (EP)
Expert comments for publication: 
Organs can be accepted regardless of the anti-HEV-IgG status of the donor, except in cases of acute HEV infection in the donor with known viraemia, where consultation of a transplant infectious disease expert is recommended. In HEV-endemic countries, retrospective screening of donors by HEV-NAT should be considered. In cases of HEV-viraemic donors, the treatment option with ribavirin is the choice of treatment. Recipient monitoring of HEV RNA is recommended Regarding the transmission of the hepatitis E virus itself, acute HEV infection in the donor with known viremia may be considered a contraindication if recipients do not have antibodies against HEV that confer protection. The risk of Hepatitis E Virus (HEV) transmission during transplantation has been previously acknowledged in both the United Kingdom and Spain. The prevalence of hepatitis E infection in these countries stands at approximately 1%. The UK's national organ procurement organization has instituted a policy of universal HEV screening for deceased organ donors. A recently published study conducted by Ines Ushiro-Lumb et al. has revealed an incidence of nearly 1 per 1000 donors tested for HEV ribonucleic acid (RNA). The preferred screening method is nucleic acid amplification testing, which offers heightened sensitivity compared to serologic testing. This approach is crucial as organ donation procedures can occur during the window period of hepatitis E infection. Furthermore, the possibility of subclinical, long-term HEV carriage without seroconversion cannot be ruled out. The serologic status of the recipient does not appear to significantly influence the protection against infection from an infected donor. The detection of HEV RNA in the donor's plasma does not imply a contraindication for organ donation. Consequently, screening for HEV infection in donors is done post-transplantation. In the event of detecting donor HEV viremia, it is imperative to promptly notify transplant centers due to the highly efficient transmission of the virus through solid organs, especially liver grafts, even at low viral load levels. It is recommended to closely monitor recipients for HEV infection by continually detecting HEV RNA. This monitoring should persist for a minimum of three months, particularly in grafts other than the liver, where transmission can be detected within days following the procedure. Spontaneous clearance of the virus is uncommon, and liver function tests typically remain within the normal range. Ribavirin is the choice of treatment for HEV-infected recipients along with careful adjustment of immunosuppressive therapy.