Guideline sources The following summarized guidelines for the evaluation and management of hepatitis E are prepared by our editorial team based on guidelines from the European Association for the Study of the Liver (EASL 2018). 1 Guidelines 1. Screening and diagnosis Indications for testing: test for HEV infection in all patients with symptoms consistent with acute hepatitis. A 2. Diagnostic investigations Laboratory testing: use a combination of serology and NAT testing to diagnose HEV infection. A 3. Diagnostic procedures https://web.pathway.md/diseases/rec7KptJdWUxYyGmX 1/3 6/24/23, 12:41 PM Hepatitis E virus infection Pathway Kidney biopsy: consider renal biopsy for patients with acute or chronic HEV infection who develop new onset proteinuria. C 4. Medical management Indications for treatment: Consider ribavirin treatment in patients with severe acute hepatitis E or acute-on-chronic liver failure. C Consider antiviral treatment for patients with chronic hepatitis E infection infection and associated glomerular disease. C Duration of treatment: complete 12 weeks of ribavirin monotherapy in patients with persisting HEV replication three months after detection of HEV RNA. B Show 3 more Management of non-response to treatment: consider administering PEGylated interferon-alpha for the treatment of hepatitis E infection in liver transplant recipients who show no response to ribavirin. C 5. Nonpharmacologic interventions Dietary modifications: Advise immunocompromised patients, as well as those with chronic liver diseases, to avoid consumption of undercooked meat (pork, wild boar and venison) and shellfish. B Consider advising that immunocompromised patients consume meat only if it has been thoroughly cooked to temperatures of at least 70 degree C. C 6. Specific circumstances Pregnant patients: admit pregnant women with HEV genotype 1 or 2 infection to a high- dependency unit, and transfer to a liver transplant unit if liver failure occurs. A Immunosuppressed patients: decrease immunosuppression at diagnosis of chronic HEV infection in solid organ transplant recipients, if possible. B References 1. European Association for the Study of the Liver. EASL Clinical Practice Guidelines on hepatitis E virus infection. J Hepatol. 2018 Jun;68 6 1256 1271. Open 2. Kamar N, Bendall R, Legrand-Abravanel F et al. Hepatitis E. Lancet. 2012 Jun 30;379 9835 2477 2488. Open https://web.pathway.md/diseases/rec7KptJdWUxYyGmX 2/3 6/24/23, 12:41 PM Hepatitis E virus infection Pathway 3. Ivo Ditah, Fausta Ditah, Pardha Devaki et al. Current epidemiology of hepatitis E virus infection in the United States: low seroprevalence in the National Health and Nutrition Evaluation Survey. Hepatology. 2014 Sep;60 3 815 22. Open 4. Liza Bronner Murrison, Kenneth E Sherman. The Enigma of Hepatitis E Virus. Gastroenterol Hepatol N Y . 2017 Aug;13 8 484 491. Open 5. Glynn W Webb, Harry R Dalton. Hepatitis E an underestimated emerging threat. Ther Adv Infect Dis. 2019 Apr 3;6 2049936119837162. Open 6. Tram T Tran, Joseph Ahn, Nancy S Reau. ACG Clinical Guideline: Liver Disease and Pregnancy. Am J Gastroenterol. 2016 Feb;111 2 176 94; quiz 196. Open 7. Italian Association for the Study of the Liver AISF , Italian Association for the Study of the Liver AISF. AISF position paper on liver disease and pregnancy. Dig Liver Dis. 2016 Feb;48 2 120 37. Open https://web.pathway.md/diseases/rec7KptJdWUxYyGmX 3/3