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Chronic HEV in Transplant — SCE Infectious Diseases MCQ

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ModerateHepatitisChronic HEV in TransplantSCE Infectious Diseases

A 45-year-old man develops acute hepatitis E. He is on Tacrolimus and Mycophenolate for a liver transplant. HEV RNA is detected in serum and stool. After 3 months, HEV RNA remains positive. What is the recommended first step to prevent chronic HEV?

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Correct answer: B — Reduce immunosuppression (particularly Tacrolimus dose reduction by ~50%) — this allows immune clearance of HEV in approximately 30% of transplant recipients

In solid organ transplant recipients, HEV genotype 3 (the genotype endemic in Europe) can become chronic (defined as HEV RNA persistence >3 months). The first management step is reduction of immunosuppression — particularly Tacrolimus dose reduction by approximately 50%. This allows approximately 30% of patients to clear HEV spontaneously through restored immune function. If HEV persists after immunosuppression reduction (waiting 3 months), Ribavirin (600–800 mg daily for 3–6 months) is the second-line treatment with ~80% SVR. Pegylated Interferon is contraindicated in organ transplant recipients.

Reference: EASL 2024 – HEV guidelines; NICE 2024 – HEV in transplant