Acute hepatitis E virus infection in patients with acute liver failure in China: Not quite an uncommon cause

This is the authors' abstract. We don't add key points for this paper.

Potential conflict of interest: Nothing to report. Author names in bold designate shared co‐first authorship. TO THE EDITOR: We read with interest the article by Fontana and colleagues published in Hepatology.1 The study tested anti‐hepatitis E virus (HEV) antibodies in samples from 681 American adults with acute liver failure (ALF). Anti‐HEV immunoglobulin M (IgM) was detected in only 3 (0.4%) patients and HEV RNA was not detected in any of them. The study concluded that HEV infection is a rare cause of ALF in the United States. The United States is a country with low endemicity of HEV and is dominated by genotype 3 HEV (HEV‐3).2 However, in China, HEV is hyperendemic and the dominant HEV subtype is HEV‐4.3 We have investigated the role of HEV infection in patients with ALF consecutively admitted to the People's Liberation Army (PLA) Liver Disease Center, Bayi Hospital, which is a tertiary hospital specialized in hepatology in Nanjing, Jiangsu (a province in eastern China with approximately 80 million people). The number of daily outpatient visits and monthly treated inpatients with relevant liver diseases to the PLA Liver Disease Center is nearly 250 and 300, respectively. In the period between January 2014 and August 2016, 291 patients with ALF were admitted and constitute the basis of this report (Fig. 1). Among these patients, anti‐HEV IgM (Wantai, Beijing, China) was positive in 19 male patients (19 of 291; 6.5%), in 10 (52.6%) of whom there was evidence of underlying chronic liver disease (CLD). HEV RNA was detected in the serum samples of 10 (10 of 19; 52.6%) patients, 4 (40%) of them in the 10 patients with underlying CLD. In all patients with positive HEV‐RNA, there were no other causes that would explain ALF. All isolates belonged to HEV‐4 genotype.Figure 1: Overview of the recruited patients. Among the 291 patients, 19 were positive for anti‐HEV IgM. Anti‐HEV IgG was found positive in 18 of them. Ten patients have positive HEV RNA results. Abbreviations: HB, hepatitis B; DILI, drug‐induced liver injury; AH, alcoholic hepatitis; AIH, autoimmune hepatitis; HA, hepatitis A.Mortality rate was higher in hepatitis E patients with underlying CLD (5 of 10; 50%) than in those who were solely infected with HEV (3 of 9; 33.3%). Although the difference was not significant statistically (Fisher's exact test, P = 0.6499). In general, our data suggest that acute HEV infection is not an uncommon cause of ALF in a highly endemic region, and, not unexpectedly, patients with underlying CLD who develop an acute‐on‐chronic infection with HEV have a higher mortality rate. In the future, larger, prospective, multicenter cohort study is required in order to further confirm these findings.