Two decades of hepatitis E in solid organ transplantation: A retrospective monocentric analysis

Nassim Kamar; Florence Abravanel; Olivier Marion; Chloé Couat; Laure Esposito; Anne Laure Hebral; Laurence Lavayssière; David Ribes; Pierre Guy; Sébastien Lhomme; Olivier Cointault; Stanislas Faguer; Julie Bellière; Amandine Darres; Joelle Guitard; Chloé Médrano; Arnaud Del Bello; Jacques Izopet

doi:10.1097/HEP.0000000000001762

Two decades of hepatitis E in solid organ transplantation: A retrospective monocentric analysis

Hepatology. 2026 Apr 3. doi: 10.1097/HEP.0000000000001762. Online ahead of print.

Authors

Nassim Kamar^{1

2

3}, Florence Abravanel^{2

3

4}, Olivier Marion^{1

2}, Chloé Couat¹, Laure Esposito¹, Anne Laure Hebral¹, Laurence Lavayssière¹, David Ribes¹, Pierre Guy¹, Sébastien Lhomme^{2

3

4}, Olivier Cointault¹, Stanislas Faguer^{1

3

5}, Julie Bellière^{1

3

5}, Amandine Darres¹, Joelle Guitard¹, Chloé Médrano¹, Arnaud Del Bello^{1

3

5}, Jacques Izopet^{2

3

4}

Affiliations

¹ Department of Nephrology and Organ Transplantation, Toulouse University Hospital, Toulouse, France.
² INSERM UMR, Toulouse Institute for Infectious and Inflammatory Diseases (Infinity), Toulouse, France.
³ Université de Toulouse, Toulouse, France.
⁴ Department of Virology, Toulouse University Hospital, Toulouse, France.
⁵ Institute of Metabolic and Cardiovascular Diseases (I2MC), Institut National de la Santé et de la Recherche Médicale (INSERM), Toulouse, France.

PMID: 41931106
DOI: 10.1097/HEP.0000000000001762

Abstract

Background and aims: The awareness regarding HEV infection in solid organ transplant (SOT) has increased over the last few decades after the reports of chronicity and associated complications. The aim of this study was to describe HEV outcome over a long period in a large cohort of patients undergoing SOT.

Approach and results: This retrospective, single-center study analyzed 6452 patients undergoing SOT followed between 2001 and 2024 and systematically screened for HEV in cases of elevated liver enzymes. Since 2016, patients undergoing SOT have also been screened for HEV at 3 and 12 months after transplantation. We assessed the incidence, natural history, treatment, and extrahepatic manifestations. HEV infection was diagnosed in 228 patients (3.53%). The incidence was significantly higher in patients undergoing liver transplant compared to others. At 3 months after HEV documentation, 65.1% developed chronic hepatitis, while 34.9% achieved spontaneous viral clearance. Tacrolimus use was independently associated with chronicity, while mycophenolic acid use was protective. Ribavirin was the main antiviral therapy, achieving a 91.5% sustained virological response rate when treatment was extended until complete serum and stool HEV RNA clearance. A minority of patients required multiple treatment courses or failed therapy, with some developing cirrhosis or dying viremic. Three patients died from decompensated HEV-related cirrhosis. HEV-associated neurological manifestations (2.2%) and glomerular diseases (3.9%) were observed, often resolving with viral clearance.

Conclusions: HEV infection is frequent in SOT recipients, with significant risks of chronicity and extrahepatic complications. Ribavirin remains the cornerstone of treatment, and individualized duration improves outcomes. Screening for HEV is mandatory in patients undergoing SOT with elevated liver enzymes.

Keywords: chronic infection; extrahepatic manifestations; hepatitis E; incidence; ribavirin.