DDSEP® 8 Quick Quiz

DDSEP® 8 Quick quiz - August 2017 Question 1

Publish date: August 1, 2017

A 64-year-old man arrives at the transplant clinic for his annual posttransplant assessment. He received a deceased-donor liver transplant 4 years ago for nonalcoholic steatohepatitis (NASH)–related cirrhosis. His immediate postoperative course was unremarkable, but he does have posttransplant hypertension, diabetes mellitus (diet controlled), and obesity. His alanine aminotransferase and aspartate aminotransferase levels have been modestly elevated at 1-3 times the upper limit of normal for 2.5 years.

Multiple liver biopsies have shown only nonspecific inflammation, with no features of cellular- or antibody-mediated rejection, or recurrent NASH. Medications include tacrolimus, mycophenolate mofetil, amlodipine, and low-dose aspirin. Tacrolimus trough levels have ranged from 8 to 10 ng/mL intentionally as it was thought that the liver test abnormalities may be an immunologically driven phenomenon despite the lack of objective liver biopsy–based evidence. As a new provider for this patient, you decide to recheck several laboratory values to rule out alternative reasons for the elevated aminotransferases. The lab results are as follows: hepatitis B DNA negative, hepatitis C RNA negative, smooth muscle antibody negative, anti-nuclear antibody negative, pANCA negative, hepatitis E IgG positive.

What is the best treatment for this patient?

Observation

Ribavirin

Sofosbuvir

Pegylated interferon

Q2: Answer: B

This patient has chronic hepatitis E infection, as demonstrated by the positive hepatitis IgG antibody. It is recommended that HEV RNA be identified in serum or stool for diagnosis of hepatitis E. However, HEV RNA PCR is not readily available outside of research settings and therefore the Centers for Disease Control and Prevention states that the diagnosis can be confirmed only by testing for the presence of antibody against HEV or HEV RNA. Providers must be aware of the possibility of false positives and negatives for HEV serologies.

In immunocompetent individuals, hepatitis E is generally a self-limited condition, but in solid-organ transplant recipients, chronic infection can ensue. Hepatitis E infection in solid-organ transplant recipients has been linked to consumption of game meat, pork, and mussels. The infection is largely asymptomatic, but occasionally presents with jaundice. The liver test elevations are mild, with ALT levels up to 300 U/L. Approximately 60% of transplant recipients who are infected with hepatitis E develop chronic infections.

The best treatment for chronic hepatitis E in solid-organ transplant recipients is ribavirin. In one study, the sustained virologic response rate was 78% after a course of approximately 3 months of ribavirin. Pegylated interferon has been used for treatment of hepatitis E, but has less evidence to support its use and has a less favorable side effect profile. Sofosbuvir is a treatment for hepatitis C and therefore is not correct, though there are recent data suggesting that sofosbuvir inhibits hepatitis E virus replication in vitro and results in an additive effect when combined with ribavirin.

Observation is not a correct answer, as about 10% of patients with chronic hepatitis E may develop cirrhosis. Although not one of the provided answers, lowering the overall immunosuppression would be part of the treatment approach in a solid-organ transplant recipient with chronic hepatitis E.

Reference

1. Kamar N., Izopet J., Tripon S., et al. Ribavirin for chronic hepatitis E virus infection in transplant recipients. N Engl J Med. 2014 Mar 20;370(12):1111-20.

2. Dao Thi V.L., Debing Y., Wu X. Sofosbuvir inhibits hepatitis E virus replication in vitro and results in an additive effect when combined with ribavirin. Gastroenterology. 2016 Jan;150(1):82-5.

ginews@gastro.org

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