Status:
Ready to upload
Record number:
2009
Adverse Occurrence type:
MPHO Type:
Estimated frequency:
Mallet (2016, 2018) and Riveiro-Barciela report cases of Hepatitis E virus (HEV) transmission through plasma transfusions during intensive plasma exchange in immunosuppressed transplant recipients and via cryosupernatant plasma in thrombotic thrombocytopenic purpura (TTP) patients. Pathogen-reduced plasma-borne transmission of HEV was demonstrated. Previously, in the Notify library, there were recorded cases in transplant recipients' records (No: 1059, 1425); TTP patients (1419); and in open heart surgery (1661).
HEV is a globally prevalent pathogen distinguished by a single serotype encompassing four genotypes in humans. Genotypes 1 and 2 are in endemic regions primarily responsible for waterborne epidemics. Conversely, genotypes 3 and 4 are linked to zoonotic HEV infections, which are transmitted to humans via the ingestion of raw or undercooked pork and game products, and infrequently, shellfish, or through contact with infected animals. Transmission of genotypes 3 and 4 can also occur via transfusion and transplantation from an infected donor. HEV is transmissible through all forms of blood components, with infectivity depending on the viral load and plasma content within these components. In plasma components, the viral load is expected to be higher than in red blood cells and platelets. However, the risk of getting HEV through plasma transfusion likely differs globally because the prevalence of HEV RNA varies among the general population and blood donors both between and within countries worldwide. The prevalence of HEV among blood donors differs widely by region, from very low to high. Some studies report seroprevalence rates as low as 2% and as high as 49%. Endemic areas generally experience higher rates, whereas developed countries tend to have lower but still detectable rates.
Time to detection:
In these cases, the period from the kidney transplantation to the appearance of signs of infection was over one year and occurred two months after TTP relapse. The interval from transfusing HEV-positive plasma during plasma exchange to the onset of signs is not specified in the articles. Overall, 24 out of 263 (9.1%) patients had acquired HEV serological markers at the average of 9.5 months post-transplantation sample, including two patients with detectable HEV RNA, and 7 (2.3%) patients had long-term persistent HEV markers at the average of 18.2 months post-transplantation sample, including three patients with detectable HEV RNA but without detectable anti-HEV antibodies.
Alerting signals, symptoms, evidence of occurrence:
In the case reports, the patients were asymptomatic but showed elevated aminotransferases and tested positive for HEV serological markers and HEV RNA. In the retrospective cohort study, only the presence of HEV markers and HEV RNA in archived samples without symptoms was noted. The evidence of occurrence included the detection of both HEV RNA and IgG/IgM anti-HEV antibodies in the patient and the donor, as well as a negative result for HEV markers and HEV RNA before plasma exchange treatment, and the exclusion of other routes of exposure in the patient.
Demonstration of imputability or root cause:
Detected HEV serological markers and HEV RNA in the patient and the donor providing the involved plasma, with no alimentary exposure in the patient and HEV negativity in patients before transfusion.
Imputability grade:
3 Definite/Certain/Proven
Groups audience:
Keywords:
References:
Suggest new keywords:
HEV, immunocompromised patients
Reference attachment:
Suggest references:
1) Mallet V, et al. Transmission of Hepatitis E Virus With Plasma Exchange in Kidney Transplant Recipients: A Retrospective Cohort Study. Transplantation. 2018 Aug;102(8):1351-1357
2) Mallet V, et al. Transmission of Hepatitis E Virus by Plasma Exchange: A Case Report. Ann Intern Med. 2016 Jun 21;164(12):851-2
3) Wedemeyer H. E-xchange: Hepatitis E and the Risk of Plasma Products for Organ Transplant Recipients. Transplantation. 2018 Aug;102(8):1209-1210
4) Mar Riveiro-Barciela et al. Thrombotic thrombocytopenic purpura relapse induced by acute hepatitis E transmitted by cryosupernatant plasma and successfully controlled with ribavirin. TRANSFUSION 2018;00;1–5
Note:
MG: Could we please merge Record 1059 https://www.notifylibrary.org/reference/4371 reference into this record? 1059 is no longer needed, this is a complete review, but would be good to include the reference in this new record and remove the old one (1059). 1419 has a "possible" imputability grade, this reference could be added to this new record, and then remove 1419 also from the library (done EP)
Expert comments for publication:
Immunocompromised individuals, such as organ transplant recipients and patients with haematological malignancies, are at increased risk of developing chronic HEV infection and severe liver complications. Plasma exchange that involves a high amount of plasma units transfused is used to treat such patients, exposing them to a higher risk of HEV infection. There is no reliable pathogen reduction method for blood components to prevent HEV transmission. The primary strategy for preventing transfusion-transmitted HEV is to screen blood donations for HEV RNA using nucleic acid testing, either selectively or universally. Furthermore, such patients should be tested for HEV and follow dietary measures to prevent HEV infection.