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Ribavirin for Chronic HEV Infection in Solid-Organ Transplant Recipients

Summary and Comment |
March 19, 2014

Ribavirin for Chronic HEV Infection in Solid-Organ Transplant Recipients

  1. Rajesh T. Gandhi, MD

After receiving ribavirin monotherapy, most patients achieved a sustained virologic response.

  1. Rajesh T. Gandhi, MD

Hepatitis E virus (HEV) can cause chronic hepatitis and cirrhosis in immunosuppressed patients, including solid-organ transplant recipients. There are no randomized studies to define optimal therapy. Now, in a retrospective, multicenter case series, investigators in France have analyzed the effect of ribavirin (RBV) monotherapy on chronic HEV infection in solid-organ transplant recipients.

Of the 59 patients evaluated, 37 were kidney-transplant recipients, 10 were liver-transplant recipients, and the remainder had received various other organs. Most were receiving immunosuppressive therapy (e.g., calcineurin inhibitors in 80% and glucocorticoids in 75%). The interval between transplantation and RBV initiation varied from <1 to >20 years. The initial median RBV dose ranged from 29 to 1200 mg per day (median, 600 mg), in part because of dose reduction in patients with renal insufficiency. The duration of RBV therapy was 1 to 18 months (median, 3 months).

At the time of RBV initiation, all patients had detectable serum HEV RNA. At 3 months and at the end of therapy, 95% had no detectable virus. Of the 59 patients, 46 (78%) achieved a sustained virologic response (SVR) after receiving one course of therapy. In addition, four of six patients who were retreated because of recurrent viremia achieved SVR. Transaminase levels normalized in all but two patients. The major adverse event was anemia: 54% of patients received erythropoietin, and 12% required a blood transfusion.

Comment

This retrospective study revealed that most solid-organ transplant recipients with chronic hepatitis E clear the virus after receiving ribavirin monotherapy. Although the authors noted that 3 months of therapy may be appropriate for most patients, determining an optimal treatment course from these data is difficult because patients received a wide range of ribavirin doses for varying amounts of time. As an editorialist points out, this study makes a compelling case for ribavirin therapy in patients with chronic hepatitis E, but additional efforts are needed to define when therapy should be initiated, the preferred dose and duration, and the role of reducing immunosuppression.

  • Disclosures for Rajesh T. Gandhi, MD at time of publication Grant / research support Gilead; Tibotec Leadership positions in professional societies Infectious Diseases Society of America (Education Committee)

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