Hepatitis E Virus Infection Among Chronic Hemodialysis

Dear Editor,

Recently, we read with great interest the article by Beladi Mousavi et al. (1) entitled “epidemiology of hepatitis E virus infection in patients on chronic hemodialysis" you published in your most valuable journal. The author evaluated the prevalence of anti-HEV IgG antibody among chronic hemodialysis (HD) patients in Imam Khomeini hospital, Ahvaz city, in southwest Iran. The results of this study showed that the prevalence of anti-HEV IgG antibody among these patients is 10.63% without any significant difference due to HEV, age, gender and duration of HD or HCV antibody titer (1). The results of the study are interesting. According to the article, HEV infection is endemic in Khuzestan province, Iran (1). We think that the results of the study are limited by the small number of patients (47 HD patients) enrolled in the study. A multicenter evaluation with a large number of patients is needed for a better estimation of the prevalence of HEV infection among dialysis patients. End stage renal disease (ESRD) is a life-threatening disease with significant complications found in people around the world. In contrast to hepatitis B and C, which are associated with significant mortality among these patients, hepatitis E had been believed to be a self-limited acute infection with spontaneous recovery in almost all cases and without any association with chronic hepatitis (2-7). However, some recent studies have reported several cases of persistent HEV-related chronic hepatitis and its relatively rapid evolution to HEV-related cirrhosis, especially among immunosuppressive patients, including organ transplant recipients (8, 9). For example, Kamar et al. (10) evaluated 241 renal allograft recipients and demonstrated that HEV infection could develop into a chronic active hepatitis in nearly 60% of renal transplant patients who had HEV infection. In addition, although transmission of HEV primarily occurs by the fecal-oral route, some studies have indicated that other modes of transmission such as mother-to-child, parenteral routes, transfusion and HD could potentially play a role in the transmission of HEV. It has also been suggested that the fecal-oral route may also be a pathway for HEV transmission in HD centers (8-10). Due to the to the possibility of HEV transmission in HD centers and the possibility of persistent HEV-related chronic hepatitis and HEV-related cirrhosis, we agree with Beladi Mousavi et al. on the periodic monitoring of HD patients. In this case, careful observation is needed for the diagnosis of HEV infection, especially among ESRD patients who are candidates for kidney transplantation.