Hepatitis E Guidelines

Updated: Mar 13, 2019
  • Author: Prospere Remy, MD; Chief Editor: BS Anand, MD  more...
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Guidelines Summary

European Association for the Study of the Liver

The European Association for the Study of the Liver (EASL) suggests testing for hepatitis E in patients with unexplained flares of chronic liver disease.

EASL recommends hepatitis E virus (HEV) testing in all immunosuppressed patients with unexplained abnormal liver function tests (LFTs).

Travelers with hepatitis returning from areas endemic for HEV genotype (gt) 1 or 2 should be tested for HEV.

Pregnant women with HEV gt 1 or 2 should be cared for in a high-dependency setting and transferred to a liver transplant unit if liver failure occurs.

EASL recommends HEV testing, irrespective of LFT results, in patients presenting with neuralgic amyotrophy (NA) and GBS (Guillain-Barré syndrome) and suggests HEV testing for patients with encephalitis/myelitis.

EASL suggests testing patients with HEV infection for proteinuria.

Patients with acute or chronic HEV infection who develop new-onset proteinuria may be considered for a renal biopsy.

EASL suggests antiviral treatment for patients with chronic HEV infection and associated glomerular disease.

EASL recommends using a combination of serology and nucleic acid amplification technique (NAT) testing to diagnose HEV infection.

EASL recommends NAT testing to diagnose chronic HEV infection.

All patients with hepatitis should be tested for HEV, as part of the first-line virological investigation, irrespective of travel history.

Patients presenting with suspected drug-induced liver injury (DILI) should be tested for HEV.

Patients with abnormal LFTs after receiving blood products should be tested for HEV.

EASL recommends that blood donor services screen blood donors for HEV by NAT, informed by local risk-assessment and cost-effectiveness studies, both of which may vary considerably by geographic location.

Ribavirin treatment may be considered in cases of severe acute hepatitis E or acute-on-chronic liver failure.

EASL recommends decreasing immunosuppression at diagnosis of chronic HEV infection in solid organ transplant recipients, if possible.

In patients with persisting HEV replication 3 months after detection of HEV RNA, EASL recommends ribavirin monotherapy for a duration of 12 weeks.

At the end of the scheduled period of therapy, HEV RNA should be assessed in the serum and in the stool. If HEV RNA is undetectable in both, EASL suggests stopping ribavirin.

In patients in whom HEV RNA is still detectable in the serum and/or in the stool after 12 weeks, ribavirin monotherapy may be continued for an additional 3 months (6 months therapy overall).

Liver transplant recipients who show no response to ribavirin can be considered for treatment with PEGylated-interferon-α.

Immunocompromised individuals and those with chronic liver diseases should avoid consumption of undercooked meat (pork, wild boar, and venison) and shellfish.

EASL suggests that immunocompromised patients consume meat only if it has been thoroughly cooked to temperatures of at least 70 °C.


EASL clinical practice guidelines on hepatitis E virus infection. European Association for the Study of the Liver. J Hepatol. 2018 Jun;68(6):1256-71. https://www.journal-of-hepatology.eu/article/S0168-8278(18)30155-7/fulltext