Published online Dec 21, 2016. doi: 10.3748/wjg.v22.i47.10388
Peer-review started: September 21, 2016
First decision: October 20, 2016
Revised: November 1, 2016
Accepted: November 16, 2016
Article in press: November 16, 2016
Published online: December 21, 2016
To examine the clinical features and risk factors for adverse outcomes in chronic hepatitis B (CHB) superimposed with hepatitis E virus (HEV).
This retrospective cohort study included 228 patients with acute HEV infection (showing clinical acute hepatitis symptomology and positivity for anti-HEV immunoglobulin M) with underlying CHB (confirmed by positivity for hepatitis B surface antigen and/or hepatitis B virus (HBV) DNA over 6 mo) who had been admitted to the Shanghai Public Health Clinical Center, which represents the regional tertiary hospital for infectious diseases in Shanghai city, China. Data for adverse outcomes were collected, and included severe liver diseases (defined as liver failure and/or acute liver decompensation) and liver-related mortality. Logistic regression modeling was performed to determine the risk factors for adverse outcomes.
The symptoms caused by superimposed acute hepatitis E (AHE) were much more severe in cirrhotic patients (n = 94) than in non-cirrhotic patients (n = 134), as evidenced by significantly higher liver complications (77.7% vs 28.4%, P < 0.001) and mortality rate (21.3% vs 7.5%, P = 0.002). Most of the cirrhotic patients (n = 85, 90.4%) had no prior decompensation. Among the non-cirrhotic patients, superimposed AHE caused progressively more severe diseases that corresponded with the CHB disease stages, from immune tolerant to immune reactivation phases. Few risk factors were identified in the cirrhotic patients, but risk factors for non-cirrhotic patients were found to be intermediate HBV DNA levels (OR: 5.1, P = 0.012), alcohol consumption (OR: 6.4, P = 0.020), and underlying diabetes (OR: 7.5, P = 0.003) and kidney diseases (OR: 12.7, P = 0.005). Only 28.7% of the cirrhotic patients and 9.0% of the non-cirrhotic patients had received anti-HBV therapy previously and, in all cases, the efficacy had been suboptimal.
CHB-related cirrhosis and intermediate HBV DNA level were associated with severe disease in superinfected patients, and successful antiviral treatment might counter this outcome.
Core tip: To determine whether status of chronic hepatitis B (CHB) affects clinical outcomes of hepatitis E virus (HEV) super-infections, we investigated immunological phases, hepatitis B virus (HBV) serum markers, HBV viral load and anti-viral treatments among 228 patients with HBV-HEV co-infection. Well-compensated patients were majorly affected by HEV super-infections, and hepatitis B e antigen-negative CHB patients had the worst clinical outcomes among non-cirrhotics. Lack of proper anti-HBV treatment may contribute to the worse outcomes. These data may help to facilitate development of vaccination programs that precisely target populations at risk of poor outcome from HBV-HEV co-infections.