Case Control Study
Copyright ©The Author(s) 2015. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Mar 21, 2015; 21(11): 3266-3273
Published online Mar 21, 2015. doi: 10.3748/wjg.v21.i11.3266
Hepatitis E in hemodialysis and kidney transplant patients in south-east Italy
Gaetano Scotto, Filippo Aucella, Giuseppe Grandaliano, Domenico Martinelli, Mario Querques, Antonio Gesuete, Barbara Infante, Paolo Delli Carri, Salvatore Massa, Giovanna Salatino, Fabio Bulla, Vincenzina Fazio
Gaetano Scotto, Microbiology and Clinical Microbiology, Master’s Degree in Dentistry, University of Foggia, 71100 Foggia, Italy
Filippo Aucella, Antonio Gesuete, Nephrology and Dialysis Unit IRCCS “Casa Sollievo della Sofferenza” San Giovanni Rotondo (FG), 71013 San Giovanni Rotondo, Italy
Giuseppe Grandaliano, Barbara Infante, Nephrology and Dialysis Unit, University of Foggia, 71100 Foggia, Italy
Domenico Martinelli, Institute of Hygiene, University of Foggia, 71100 Foggia, Italy
Mario Querques, Paolo Delli Carri, Giovanna Salatino, Division of Nephrology, Hospital of Foggia, 71100 Foggia, Italy
Fabio Bulla, Clinic of Infectious Diseases, University of Foggia, 71100 Foggia, Italy
Salvatore Massa, Department of Agricultural, Food and Environmental Sciences, University of Foggia, 71100 Foggia, Italy
Vincenzina Fazio, Clinical Chemistry Laboratory, Unit of Virology, Hospital of Foggia, 71100 Foggia, Italy
Author contributions: All authors contributed equally to this work.
Ethics approval: The study was reviewed and approved by the Institutional Review Board of the University Hospital OORR, Foggia, Italy.
Informed consent: All study participants, or their legal guardian, provided informed written consent prior to study enrollment.
Conflict-of-interest: There is no conflict of interest with any financial, commercial, personal, political, intellectual, or religious organization regarding the material discussed in the manuscript.
Data sharing: Technical appendix, statistical code, and dataset available from the corresponding author at Participants gave informed consent for data sharing.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Correspondence to: Gaetano Scotto, MD, Adjunct Professor, Chair of Microbiology and Clinical Microbiology, Master’s Degree in Dentistry, University of Foggia, viale L. Pinto 1, 71100 Foggia, Italy.
Telephone: +39-33-37453981 Fax: +39-8-81732208
Received: October 3, 2014
Peer-review started: October 3, 2014
First decision: October 20, 2014
Revised: November 4, 2014
Accepted: January 8, 2015
Article in press: January 8, 2015
Published online: March 21, 2015

AIM: To investigate the serovirological prevalence and clinical features of hepatitis E virus (HEV) infection in end-stage renal failure patients and in the healthy population.

METHODS: HEV infection is a viral disease that can cause sporadic and epidemic hepatitis. Previous studies unexpectedly showed a high prevalence of HEV antibodies in immunosuppressed subjects, including hemodialysis (HD) patients and patients who had undergone kidney transplant. A cohort/case-control study was carried out from January 2012 to August 2013 in two hospitals in southern Italy (Foggia and S. Giovanni Rotondo, Apulia). The seroprevalence of HEV was determined in 801 subjects; 231 HD patients, 120 renal transplant recipients, and 450 health individuals. All HD patients and the recipients of renal transplants were attending the Departments of Nephrology and Dialysis at two hospitals located in Southern Italy, and were included progressively in this study. Serum samples were tested for HEV antibodies (IgG/IgM); in the case of positivity they were confirmed by a Western blot assay and were also tested for HEV-RNA, and the HEV genotypes were determined.

RESULTS: A total of 30/801 (3.7%) patients were positive for anti-HEV Ig (IgG and/or IgM) and by Western blot. The healthy population presented with a prevalence of 2.7%, HD patients had a prevalence of 6.0%, and transplant recipients had a prevalence of 3.3%. The overall combined HEV-positive prevalence in the two groups with chronic renal failure was 5.1%. The rates of exposure to HEV (positivity of HEV-IgG/M in the early samples) were lower in the healthy controls, but the difference among the three groups was not statistically significant (P > 0.05). Positivity for anti-HEV/IgM was detected in 4/30 (13.33%) anti-HEV Ig positive individuals, in 2/14 HD patients, in 1/4 transplant individuals, and in 1/12 of the healthy population. The relative risk of being HEV-IgM-positive was significantly higher among transplant recipients compared to the other two groups (OR = 65.4, 95%CI: 7.2-592.7, P < 0.001), but the subjects with HEV-IgM positivity were numerically too few to calculate a significant difference. No patient presented with chronic hepatitis from HEV infection alone.

CONCLUSION: This study indicated a higher, but not significant, circulation of HEV in hemodialysis patients vs the healthy population. Chronic hepatitis due to the HEV virus was not observed.

Keywords: Hepatitis E virus infection, Prevalence, Immunosuppressed subjects, Hemodialysis patients, Transplant recipients

Core tip: Hepatitis E, a single-stranded RNA virus, is the main aetiological agent of enteric non-A hepatitis. Previous seroprevalence surveys in developed countries showed variable rates of anti-hepatitis E virus (HEV) positivity in healthy populations, and several studies reported an unexpectedly high prevalence of antibodies against HEV in hemodialysis patients. The purpose of this survey was: (1) to compare the rate of HEV infection in renal transplant recipients and patients undergoing chronic hemodialysis to a control population; (2) to determine if these patients have an increased risk for HEV exposure; and (3) to evaluate the stage of liver disease.