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Heldman MR, Edlefsen KL, Pepper G, Kapnadak SG, Rakita RM, Fisher CE, Limaye AP. Combined assessment of Epstein-Barr virus viral capsid antigen and Epstein-Barr virus nuclear antigen-1 serology for post-transplant lymphoproliferative disorder risk stratification in adult solid organ transplant recipients. Transpl Infect Dis 2022; 24:e13933. [PMID: 36000190 PMCID: PMC9780159 DOI: 10.1111/tid.13933] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 07/21/2022] [Accepted: 07/26/2022] [Indexed: 12/25/2022]
Abstract
BACKGROUND Epstein-Barr virus (EBV) seronegative solid organ transplant recipients (SOTRs) are at increased risk for post-transplant lymphoproliferative disorder (PTLD). Assays for EBV serostatus assess antibody to both EBV viral capsid antigen (VCA) and Epstein-Barr nuclear antigen-1 (EBNA-1), but PTLD risk among SOT recipients with discordant VCA and EBNA-1 results is unknown. METHODS We performed a retrospective, single-center cohort study to determine the risk of PTLD among adult (≥ 18 years) SOTRs with discordant pre-transplant VCA and EBNA-1 IgG compared to that of SOTRs with concordantly negative or concordantly positive serology using univariable and multivariable Cox-proportional hazards models. RESULTS Of 4106 SOTRs, the number (%) who were concordantly positive, concordantly negative, and discordant was 3787 (92.2%), 149 (3.6%), and 170 (4.2%), respectively. The adjusted hazard of PTLD was significantly higher among discordant SOTRs compared to concordantly positive SOTRs (aHR 2.6, 95% CI 1.04-6.6, p =.04) and lower compared to concordantly negative SOTRs (aHR 0.27, 95% CI 0.10-0.76, p <.001). The adjusted hazard of EBV+ PTLD among those with discordant serology was also significantly higher compared to the concordantly positive cohort (aHR 3.53, 95% CI 1.04-12.0, p =.04) and significantly lower compared to the concordantly negative cohort (aHR 0.23, 95% CI 0.06-0.82, p =.02). CONCLUSIONS Risk of PTLD among SOTRs with discordant VCA and EBNA-1 may be intermediate between those with concordantly positive and negative serology. If confirmed in future studies, revision of national EBV serology reporting to include both VCA and EBNA results may be needed to optimize PTLD risk stratification.
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Affiliation(s)
- Madeleine R. Heldman
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, WA, USA
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Kerstin L. Edlefsen
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA, USA
| | - Gregory Pepper
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA, USA
| | - Siddhartha G. Kapnadak
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Robert M. Rakita
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Cynthia E. Fisher
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Ajit P. Limaye
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, WA, USA
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA, USA
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Abstract
Benefits of solid organ transplantation in end stage organ diseases are indisputable. Malignancy is a feared complication of solid organ transplantation and is a leading cause of mortality in patients with organ transplantation. Iatrogenic immunosuppression to prevent graft rejection plays a crucial role in the cancer development in solid organ transplant recipients. Chronic exposure to immunosuppression increases the malignancy burden through deregulation of host immune defense mechanisms and unchecked proliferation of oncogenic viruses and malignancies associated with these viruses. Vigorous screening of candidates undergoing transplant evaluation for malignancies, careful assessment of donors, and vigilant monitoring of transplant recipients are necessary to prevent, detect, and manage this life-threatening complication.
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Sprangers B, Riella LV, Dierickx D. Posttransplant Lymphoproliferative Disorder Following Kidney Transplantation: A Review. Am J Kidney Dis 2021; 78:272-281. [PMID: 33774079 DOI: 10.1053/j.ajkd.2021.01.015] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 01/02/2021] [Indexed: 12/13/2022]
Abstract
Posttransplant lymphoproliferative disorder (PTLD) is one of the most feared complications following kidney transplantation. Over a 10-year period, the risk of PTLD in kidney transplant recipients (KTRs) is 12-fold higher than in a matched nontransplanted population. Given the number of kidney transplants performed, KTRs who experience PTLD outnumber other organ transplant recipients who experience PTLD. Epstein-Barr virus infection is one of the most important risk factors for PTLD, even though 40% of PTLD cases in contemporary series are not Epstein-Barr virus-associated. The overall level of immunosuppression seems to be the most important driver of the increased occurrence of PTLD in solid organ transplant recipients. Reduction in immunosuppression is commonly accepted to prevent and treat PTLD. Although the cornerstone of PTLD treatment had been chemotherapy (typically cyclophosphamide-doxorubicin-vincristinr-prednisone), the availability of rituximab has changed the treatment landscape in the past 2 decades. The outcome of PTLD in KTRs has clearly improved as a result of the introduction of more uniform treatment protocols, improved supportive care, and increased awareness and use of positron emission tomography combined with computed tomography in staging and response monitoring. In this review, we will focus on the most recent data on epidemiology, presentation, risk factors, and management of PTLD in KTRs.
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Affiliation(s)
- Ben Sprangers
- Department of Microbiology, Immunology and Transplantation, Laboratory of Molecular Immunology (Rega Institute for Medical Research), KU Leuven; Division of Nephrology, University Hospitals Leuven, Leuven, Belgium
| | - Leonardo V Riella
- Division of Nephrology and Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Daan Dierickx
- Laboratory of Experimental Hematology, Department of Oncology, KU Leuven; Department of Hematology, University Hospitals Leuven, Leuven, Belgium.
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Abstract
OPINION STATEMENT Cellular immunotherapy has been rapidly evolving and increasingly utilized in the management of relapsed and refractory lymphoma. CD19-specific chimeric antigen receptor T cells (CARTs) have achieved impressive results in pivotal clinical trials. Although CART development continues, these products have fundamental limitations that may make them less desirable in particular settings. For example, CARTs can only target cell surface antigens and thus are incapable of targeting intracellular tumor-associated proteins. In contrast to CARTs, conventional T cell receptors (TCR) allow T cells to target any cellular antigen, including intracellular proteins, since they interact with peptides presented by MHC I and II molecules. T cells recognizing EBV antigens through native TCRs have been successfully employed for treatment and prophylaxis of EBV-associated lymphomas, including post-transplant lymphoproliferative disorder. Currently, transgenic TCR-transduced T cells targeting nonviral tumor antigens remain experimental but, if successful, could become an invaluable cellular therapy option. Because the manufacturing process of autologous T cell products, including CARTs and other tumor-specific T cells, takes several weeks, patients often need bridging therapy to maintain disease control, which may be challenging. Novel cellular platforms, such as genetically modified NK and NKT cells, may be amenable to allogeneic use and thus may allow production as a readily available, "off-the-shelf" product. As cellular therapies beyond CART continue to grow, available therapeutic options for relapsed and refractory lymphoma patients are expected to expand further.
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Affiliation(s)
- Mahmoud R Gaballa
- Hematology-Oncology Section, Department of Medicine, Baylor College of Medicine, 6565 Fannin A6-080, Houston, TX, 77019, USA
| | - Carlos A Ramos
- Hematology-Oncology Section, Department of Medicine, Baylor College of Medicine, 6565 Fannin A6-080, Houston, TX, 77019, USA.
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5
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Arslan Davulcu E, Bülbül H, Ulusoy Y, Soyer NA, Demir D, Özsan N, Ak G, Şahin F, Töbü M, Tombuloğlu M, Vural F, Saydam G. Solid Organ Transplantasyonu Sonrası Post-Transplant Lenfoproliferatif Hastalıklar: Tek Merkez Deneyimi. DICLE MEDICAL JOURNAL 2019. [DOI: 10.5798/dicletip.661282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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6
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Fung SKS, Chau KF, Chow KM. Clinical practice guidelines for the provision of renal service in Hong Kong: Potential Kidney Transplant Recipient Wait-listing and Evaluation, Deceased Kidney Donor Evaluation, and Kidney Transplant Postoperative Care. Nephrology (Carlton) 2019; 24 Suppl 1:60-76. [PMID: 30900332 DOI: 10.1111/nep.13502] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
| | - Ka Foon Chau
- Department of Medicine, Queen Elizabeth Hospital, Hong Kong
| | - Kai Ming Chow
- Department of Medicine & Therapeutics, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong
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The Changing Epidemiology of Posttransplant Lymphoproliferative Disorder in Adult Solid Organ Transplant Recipients Over 30 Years. Transplantation 2018; 102:1553-1562. [DOI: 10.1097/tp.0000000000002146] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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8
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Husain S, Gitman MR. And the evidence piles on. Pediatr Transplant 2017; 21. [PMID: 28833881 DOI: 10.1111/petr.13030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/06/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Shahid Husain
- Multi-Organ Transplant Program, Division of Infectious Diseases, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Melissa Randy Gitman
- Multi-Organ Transplant Program, Division of Infectious Diseases, University Health Network, University of Toronto, Toronto, Ontario, Canada
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Association of Baseline Viral Serology and Sirolimus Regimens With Kidney Transplant Outcomes: A 14-Year Registry-Based Cohort Study in the United States. Transplantation 2017; 101:377-386. [PMID: 28121742 DOI: 10.1097/tp.0000000000001520] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The risks for transplant outcomes associated with baseline viral serostatus in kidney transplant recipients (KTR) on sirolimus have not been widely studied. METHODS We performed a cohort-study of 61 590 adult KTR in 2000 to 2013. We used Cox regression models to determine the adjusted hazard ratio (aHR) of patient death, death-censored graft loss and posttransplant malignancy associated with the baseline serostatus (+ or -: hepatitis B core [HBc], hepatitis C virus [HCV], Epstein-Barr virus [EBV], or cytomegalovirus [CMV]) in KTR on sirolimus (SRL) + mycophenolate (MPA) or SRL + tacrolimus (Tac), relative to the control-regimen: Tac + MPA. RESULTS Compared with Tac + MPA, SRL + MPA, and SRL + Tac were associated with higher risks of 5-year mortality (aHR, 1.41; 95% CI, 1.23-1.60 and aHR, 1.59; 95% CI, 1.38-1.83, respectively) and death-censored graft loss (aHR, 1.41; 95% CI, 1.24-1.60 and aHR, 1.38; 95% CI, 1.21-1.57, respectively). In KTR with negative pretransplant EBV, CMV, HBc, or HCV serostatus, SRL + MPA not SRL + Tac was associated with a lower risk of posttransplant malignancy compared with control (aHR, 0.27; 95% CI, 0.10-0.72; aHR, 0.61; 95% CI, 0.43-0.88; aHR, 0.79; 95% CI, 0.64-0.97; and aHR, 0.80; 95% CI, 0.65-0.98, respectively, for SRL + MPA and aHR, 0.98: 95% CI, 0.52-1.80; aHR, 0.69; 95% CI, 0.46-1.06; aHR, 0.83; 95% CI, 0.66-1.06 and aHR, 0.85; 95% CI, 0.67-1.07, respectively, for SRL + Tac). In KTR with positive serostatus to any of the above viruses, SRL + MPA or SRL + Tac was not associated with a different malignancy risk compared with control. CONCLUSIONS Compared with Tac + MPA, SRL regimens were associated with higher risks for patient death and graft loss, although SRL + MPA was associated with a lower risk for posttransplant malignancy in kidney allograft recipients with negative pretransplant HBc, HCV, EBV, or CMV serology.
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Yilmaz M, Sezer TÖ, Günay E, Solak I, Çeltik A, Hoşcoşkun C, Töz H. Efficacy and Safety of ATG-Fresenius as an Induction Agent in Living-Donor Kidney Transplantation. Transplant Proc 2017; 49:481-485. [PMID: 28340817 DOI: 10.1016/j.transproceed.2017.02.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Induction therapy is mostly recommended for deceased-donor transplantation, whereas it has some controversies in live-donor transplantation. In this study, we described the outcomes of live-donor renal transplant recipients who received ATG-Fresenius (ATG-F) induction. METHODS Live-donor transplantations in patients over 18 years old with ATG-F induction between 2009 and 2015 were included. All patients received quadruple immunosuppression, one of which was ATG-F induction. Biopsies after the artery anastomosis (zero hour) and protocol biopsies at the 6th month and at the 1st first year were obtained. Acute graft dysfunction was defined as a 20% to 25% increase in creatinine level from baseline. All acute rejection episodes were biopsy-confirmed. All episodes were initially treated with intravenous methyl prednisolone (MP) or ATG-F if resistant to MP. Four hundred twenty-two patients with live-donor transplantation were evaluated. The mean age was 40 ± 13 (18-73) years. The mean panel-reactive antibody levels were 42% ± 30% and 45% ± 30% for class I and II, respectively. RESULTS The mean mismatch number for living unrelated donors (n = 112) was 4.6 ± 1.0. Acute rejection rate was 29.1% (123 patients) within the first year. The mean cumulative ATG-F doses for per patient and per kilogram were 344 ± 217 mg and 5.1 ± 2.7 mg, respectively. Patient survival rates were 98.3% and 96.7% for 12 months and 60 months, respectively. Death-censored graft survival rates were 97.6% and 92.1% for 12 months and 60 months, respectively. CONCLUSIONS ATG-F induction provided excellent graft and patient survival rates without any significantly increased side effects. Increasing sensitized patient numbers, more unrelated donors, increasing re-transplantation numbers, and more desensitization protocols make ATG-F more favorable in an induction regimen.
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Affiliation(s)
- M Yilmaz
- Ege University, School of Medicine, Department of Nephrology, Izmir, Turkey.
| | - T Ö Sezer
- Ege University, School of Medicine, General Surgery, Izmir, Turkey
| | - E Günay
- Ege University, School of Medicine, Department of Nephrology, Izmir, Turkey
| | - I Solak
- Ege University, School of Medicine, General Surgery, Izmir, Turkey
| | - A Çeltik
- Ege University, School of Medicine, Department of Nephrology, Izmir, Turkey
| | - C Hoşcoşkun
- Ege University, School of Medicine, General Surgery, Izmir, Turkey
| | - H Töz
- Ege University, School of Medicine, Department of Nephrology, Izmir, Turkey
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11
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Le J, Durand CM, Agha I, Brennan DC. Epstein-Barr virus and renal transplantation. Transplant Rev (Orlando) 2016; 31:55-60. [PMID: 28089555 DOI: 10.1016/j.trre.2016.12.001] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Revised: 12/12/2016] [Accepted: 12/25/2016] [Indexed: 01/22/2023]
Abstract
Epstein-Barr virus (EBV) is a gamma herpesvirus associated with diseases ranging from asymptomatic viremia to post-transplant malignancies in kidney transplant recipients. EBV specifically is associated with post-transplantation lymphoproliferative disorder (PTLD), in kidney transplant recipients, with increased risk in EBV seronegative patients with EBV seropositive donors on intensified immunosuppression. The diagnosis of PTLD relies on clinical suspicion plus tissue biopsy with polymerase chain reaction (PCR) testing of blood currently used for risk determination in high-risk recipients. Therapeutic strategies for PTLD include reduction of immunosuppression, chemotherapy and rituximab, and consideration of sirolimus-based immunosuppression. Antivirals such as ganciclovir are used to prevent reactivation of cytomegalovirus and other herpes viruses but are not onco-therapeutic. Radiation therapy or surgery is indicated for bulky, disseminated or recalcitrant disease. Prognosis varies depending on the type of malignancy identified and stage of disease.
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Affiliation(s)
- Jade Le
- University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390, United States
| | - Christine M Durand
- Johns Hopkins Medical Institute, 1830 East Monument Street, Room 450D, Baltimore, MD 21287, United States
| | - Irfan Agha
- Dallas Renal Group, 3571 W. Wheatland Road, Suite 101, Dallas, TX 75237, United States
| | - Daniel C Brennan
- Washington University School of Medicine, 660 S Euclid Ave, St. Louis, MO 63110, United States.
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12
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Lee JJ, Lam MSH, Rosenberg A. Role of Chemotherapy and Rituximab for Treatment of Posttransplant Lymphoproliferative Disorder in Solid Organ Transplantation. Ann Pharmacother 2016; 41:1648-59. [PMID: 17848421 DOI: 10.1345/aph.1k175] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Objective: To evaluate the role of chemotherapy and/or rituximab for treatment of posttransplant lymphoproliferative disorder (PTLD) in solid organ transplantation. Data Sources: A MEDLINE search (1966–May 2007) was conducted using the key words posttransplant lymphoproliferative disorder, solid organ transplantation, chemotherapy, and rituximab. References of relevant articles and abstracts from recent hematology, oncology, and transplantation scientific meetings (2004–May 2007) were also reviewed. Study Selection and Data Extraction: Prospective and retrospective studies identified from the data sources were evaluated, and all information deemed relevant was included for this review. Data Synthesis: Overall response rates ranged from 53% to 68%, 25% to 83%, and 74% to 100% for rituximab monotherapy, chemotherapy, and chemotherapy plus rituximab, respectively. Positive response to treatment was influenced by prognostic factors, including presence of Epstein-Barr virus in tumor cells, normal lactate dehydrogenase levels, good performance status, early disease onset after transplantation, and early disease stages. These factors in study patients likely contribute to the variability in response rates seen between treatment options. Severe adverse effects, ranging from grade 3 neutropenia to infection resulting in death, occurred more frequently in patients receiving chemotherapy than in patients receiving only rituximab. Conclusions: Although reduction in immunosuppressive medications remains the first-line therapy for PTLD treatment, many cases do not respond to this treatment alone, especially monomorphic or more aggressive cases of lymphoma. Therefore, it is reasonable to begin active treatment including rituximab and/or chemotherapy initially, along with reduction in immunosuppression in many cases. Further prospective, comparative studies are urgently needed to confirm the efficacy of these treatment strategies as well as to clarify which subset of patients may benefit most from them.
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Affiliation(s)
- Jin-Joo Lee
- College of Pharmacy, University of Florida, Gainesville, FL, USA
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13
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Hosseini-Moghaddam SM, Alhomayeed B, Soliman N, Weir MA, House AA. Primary Epstein-Barr virus infection, seroconversion, and post-transplant lymphoproliferative disorder in seronegative renal allograft recipients: a prospective cohort study. Transpl Infect Dis 2016; 18:423-30. [PMID: 27016725 DOI: 10.1111/tid.12533] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Revised: 09/29/2015] [Accepted: 01/20/2016] [Indexed: 01/21/2023]
Abstract
BACKGROUND Epstein-Barr virus (EBV)-seronegative renal transplant recipients are at risk of post-transplant lymphoproliferative disorder (PTLD). We compared primary EBV infection, seroconversion, and PTLD in EBV-seronegative patients who received renal allograft from seropositive or seronegative donors (D+/R- and D-/R-, respectively). METHODS We prospectively followed 25 D+/R- and 8 D-/R- recipients. We followed patients from January 1999 to June 2009 with clinical visits, monthly EBV polymerase chain reaction tests, and serologic tests for a period of 1 year after kidney transplantation and on an individual basis thereafter. RESULTS Three patients (9%) developed PTLD including 2 early-onset (<12 months) and 1 late-onset (>12 months) disease. In D+/R- and D-/R- patients, the frequencies of PTLD (8% vs. 12.5%, P = 0.7), EBV seroconversion (64% vs. 50%, P = 0.4), and EBV viremia (40% vs. 25%, P = 0.6) were not significantly different. Clinical, serologic, and virologic surveillance as well as reduction in immunosuppression after evidence of primary EBV infection resulted in a PTLD rate of 9%, despite a seroconversion rate of 60.6%. Rate of graft loss after reduction in immunosuppression was 10% (2 of 20), which was not significantly different from 13 patients without EBV seroconversion (no graft loss, P = 0.5). Rates of viremia, seroconversion, and PTLD in D+/R- and D-/R- patients appear to be similar. CONCLUSIONS The incidence of PTLD in renal transplants ranges from 0.5% to 2.9%. Our data show a significantly higher rate in EBV-seronegative renal allograft recipients, suggesting the need for close surveillance. Our data also suggest that donors for EBV-seronegative recipients may be accepted irrespective of positive or negative serostatus, with ongoing surveillance important in either circumstance.
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Affiliation(s)
- S M Hosseini-Moghaddam
- Multi-organ Transplant Program, University Hospital, London, Ontario, Canada.,Program of Experimental Medicine, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.,Division of Infectious Diseases, Western University, London, Ontario, Canada
| | - B Alhomayeed
- Department of Nephrology, King Fahad Hospital, Medinah Munawrah, Saudi Arabia
| | - N Soliman
- Department of Obstetrics and Gynecology, University of Calgary, Calgary, Alberta, Canada
| | - M A Weir
- Multi-organ Transplant Program, University Hospital, London, Ontario, Canada.,Program of Experimental Medicine, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.,Division of Nephrology, Western University, London, Ontario, Canada.,Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - A A House
- Multi-organ Transplant Program, University Hospital, London, Ontario, Canada.,Program of Experimental Medicine, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.,Division of Nephrology, Western University, London, Ontario, Canada
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14
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Lam GY, Halloran BP, Peters AC, Fedorak RN. Lymphoproliferative disorders in inflammatory bowel disease patients on immunosuppression: Lessons from other inflammatory disorders. World J Gastrointest Pathophysiol 2015; 6:181-192. [PMID: 26600976 PMCID: PMC4644882 DOI: 10.4291/wjgp.v6.i4.181] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Accepted: 09/28/2015] [Indexed: 02/06/2023] Open
Abstract
Immunosuppressive agents, such as thiopurines, methotrexate, and biologics, have revolutionized the treatment of inflammatory bowel disease (IBD). However, a number of case reports, case control studies and retrospective studies over the last decade have identified a concerning link between immunosuppression and lymphoproliferative disorders (LPDs), the oncological phenomenon whereby lymphocytes divide uncontrollably. These LPDs have been associated with Epstein-Barr virus (EBV) infection in which the virus provides the impetus for malignant transformation while immunosuppression hampers the immune system’s ability to detect and clear these malignant cells. As such, the use of immunosuppressive agents may come at the cost of increased risk of developing LPD. While little is known about the LPD risk in IBD, more is known about immunosuppression in the post-transplantation setting and the development of EBV associated post-transplantation lymphoproliferative disorders (PTLD). In review of the PTLD literature, evidence is available to demonstrate that certain immune suppressants such as cyclosporine and T-lymphocyte modulators in particular are associated with an increased risk of PTLD development. As well, high doses of immunosuppressive agents and multiple immunosuppressive agent use are also linked to increased PTLD development. Here, we discuss these findings in context of IBD and what future studies can be taken to understand and reduce the risk of EBV-associated LPD development from immunosuppression use in IBD.
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15
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Biller P, Michaux L, Pauw LD, Camboni A, Mourad M, Kanaan N. Post-transplant lymphoproliferative disorder after kidney transplantation: time to adopt monitoring of Epstein-Barr virus? Acta Clin Belg 2015; 70:218-22. [PMID: 25541210 DOI: 10.1179/2295333714y.0000000112] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Although post-transplant lymphoproliferative disorder is a classical complication encountered after kidney transplantation, its diagnosis can still be challenging and its outcome life-threatening. Most cases are related to Epstein-Barr virus (EBV) infection and occur mainly in the first year post-transplant, favoured by the seronegative EBV status of the recipient transplanted with a kidney from a seropositive donor, and strong immunosuppression. We report the case of a young kidney-pancreas transplant recipient who developed post-transplant lymphoproliferative disorder (PTLD) early after transplantation, with a rapid fatal issue. We review the pathogenesis, clinical presentation, and management of PTLD with a focus on prevention.
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16
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Cathro HP, Bullock GC, Bonatti H, Meriden Z, Cook S, Aguilera N. Post-transplant lymphoproliferative disorders are not associated with IgG4 sclerosing disease. Transpl Infect Dis 2014; 16:897-903. [PMID: 25298125 DOI: 10.1111/tid.12300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2013] [Revised: 07/07/2014] [Accepted: 07/29/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND Although the majority of post-transplant lymphoproliferative disorder (PTLD) cases are associated with Epstein-Barr virus (EBV), 20-42% of cases are EBV negative (EBV-N). The antigenic stimulus that drives EBV-N PTLD is unknown, but is likely heterogeneous. A common feature of PTLD, regardless of EBV status, is an abnormal polytypic lymphoplasmacytic infiltrate. Immunglobulin-G4 (IgG4) syndrome is also characterized by a polytypic lymphoplasmacytic infiltrate with a predominance of IgG4-positive (IgG4-P) plasma cells. METHODS We investigated the possibility of an association between EBV-N PTLD and IgG4 syndrome. Of 33 evaluated PTLD cases, 9 (27%) were EBV-N. EBV-N PTLD cases showed longer transplantation-to-diagnosis times than EBV-positive cases. RESULTS A single patient had a preceding benign duodenal biopsy with focally prominent IgG4-P plasma cells; however, no clinical data supported IgG4 syndrome, precluding an association between IgG4 syndrome and subsequent EBV-N PTLD in this patient. CONCLUSION As none of 29 evaluable cases of PTLD (including all 9 EBV-N cases) were associated with an increase in IgG4-P plasma cells, IgG4 syndrome does not appear to play a role in the etiology of EBV-N PTLD. The significance of these findings and the current understanding of the etiology of EBV-N PTLD are discussed.
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Affiliation(s)
- H P Cathro
- Department of Pathology, University of Virginia, Charlottesville, Virginia, USA
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17
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Zimmermann H, Trappe RU. Therapeutic options in post-transplant lymphoproliferative disorders. Ther Adv Hematol 2013; 2:393-407. [PMID: 23556105 DOI: 10.1177/2040620711412417] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Post-transplantation lymphoproliferative disorders (PTLD) are the second most frequent malignancies after solid organ transplantation and cover a wide spectrum ranging from polyclonal early lesions to monomorphic lymphoma. Available treatment modalities include immunosuppression reduction, immunotherapy with anti-B-cell monoclonal antibodies, chemotherapy, antiviral therapy, cytotoxic T-cell therapy as well as surgery and irradiation. Owing to the small number of cases and the heterogeneity of PTLD, current treatment strategies are mostly based on case reports and small, often retrospective studies. Moreover, many studies on the treatment of PTLD have involved a combination of different treatment options, complicating the evaluation of individual treatment components. However, there has been significant progress over the last few years. Three prospective phase II trials on the efficacy of rituximab monotherapy have shown significant complete remission rates without any relevant toxicity. A prospective, multicenter, international phase II trial evaluating sequential treatment with rituximab and CHOP-based chemotherapy (cyclophosphamide, doxorubicin, vincristine, prednisone) is ongoing and preliminary results have been promising. Cytotoxic T-cell therapy targeting Epstein-Barr virus (EBV)-infected B cells has shown low toxicity and high efficacy in a phase II trial and will be a future therapeutic option at specialized centers. Here, we review the currently available data on the different treatment modalities with a focus on PTLD following solid organ transplantation in adult patients.
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The Seville expert workshop for progress in posttransplant lymphoproliferative disorders. Transplantation 2012; 94:784-93. [PMID: 22992767 DOI: 10.1097/tp.0b013e318269e64f] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
: Posttransplant lymphoproliferative disorders (PTLDs) are associated with significant morbidity and mortality among solid-organ transplant patients, but approaches to diagnosis and management vary considerably. An international multidisciplinary panel evaluated current understanding of risk factors and classification systems and developed recommendations to aid in PTLD prevention. We considered evidence on PTLD risk factors including Epstein-Barr virus serostatus and immunosuppression and identified knowledge gaps for future research. Recommendations address prophylactic and preemptive strategies to minimize PTLD development, including modulation of immunosuppression and antiviral drug regimens. Finally, new classification criteria were outlined that may help facilitate standardized reporting and improve our understanding of PTLD.
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19
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Post-transplantation lymphoproliferative disorder in living-donor liver transplantation: a single-center experience. Surg Today 2012; 42:741-51. [DOI: 10.1007/s00595-012-0127-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2011] [Accepted: 06/27/2011] [Indexed: 12/18/2022]
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Moir JAG, Simms RJ, Wood KM, Talbot D, Kanagasundaram NS. Posttransplant lymphoproliferative disorder presenting as multiple cystic lesions in a renal transplant recipient. Am J Transplant 2012; 12:245-9. [PMID: 22244123 DOI: 10.1111/j.1600-6143.2011.03761.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
We report a case of a 67-year-old man who experienced allograft dysfunction following a renal transplantation from a donation after cardiac death. The postoperative course was initially complicated by episodes of E. coli urinary sepsis causing pyrexia and a raised creatinine level. Ultrasound scanning 5 weeks posttransplant revealed mild hydronephrosis with several parenchymal cystic areas measuring up to 2 cm with appearances suggestive of fungal balls. Aspirated fluid again grew Escherichia coli, and this was treated with the appropriate antimicrobial therapy. The patient continued to have episodes of culture-negative sepsis; therefore, a computed tomography scan was performed 6 months posttransplant, which revealed multiple lesions in the renal cortex as well as liver and spleen. Subsequent biopsy revealed an Epstein-Barr virus-driven lymphoproliferation consistent with a polymorphic posttransplantation lymphoproliferative disorder (PTLD). This rare case of PTLD presenting as multiple renal, hepatic and splenic lesions emphasizes the need for a high index of clinical suspicion for this condition. Abnormal para-renal allograft masses should be biopsied to allow swift and effective management of a disease that can disseminate and become significantly more challenging to manage.
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Affiliation(s)
- J A G Moir
- Renal Transplant Unit, Newcastle Upon Tyne Hospitals NHS Foundation Trust, UK.
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Nee R, Hurst FP, Dharnidharka VR, Jindal RM, Agodoa LY, Abbott KC. Racial variation in the development of posttransplant lymphoproliferative disorders after renal transplantation. Transplantation 2011; 92:190-5. [PMID: 21577180 DOI: 10.1097/tp.0b013e3182200e8a] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND We previously reported that posttransplant lymphoproliferative disorders (PTLD) occurred more frequently in non-African American (AF) kidney transplant recipients. An in-depth analysis of racial differences in the development of PTLD has not been reported. METHODS We assessed Medicare claims for PTLD in a retrospective cohort of 53,719 patients who underwent transplantation from January 2000 to September 2006 and followed up through December 2007. RESULTS There were 719 (1.3%) patients with claims for PTLD. Non-AF recipient race (including all races analyzed separately, adjusted hazard ratio [AHR] 1.38, 95% confidence interval [CI] 1.13-1.68), recipient Epstein-Barr virus (EBV) immunoglobulin G (IgG) seronegative status (AHR 1.88, 95% CI 1.53-2.34), and de novo sirolimus (AHR 1.22, 95% CI 1.03-1.45) were associated with an increased risk of PTLD. Furthermore, de novo sirolimus showed a significant interaction with EBV IgG; among EBV IgG-negative recipients, sirolimus use was significant (P = 0.003), but among EBV IgG-positive recipients, it was not significant (P = 0.18). EBV IgG-seronegative status was significant in all races except for AFs, and racial differences were a significant effect modifier for EBV IgG status and risk of PTLD. Mortality subsequent to PTLD did not differ by race. CONCLUSIONS.: AF kidney transplant recipients were at lower risk for PTLD, irrespective of the recipient EBV IgG serostatus. On the contrary, recipient EBV IgG-seronegative status was associated with a higher risk of PTLD in the non-AF population. De novo sirolimus therapy was associated with increased risk of PTLD in EBV IgG-negative recipients, regardless of race.
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Affiliation(s)
- Robert Nee
- Nephrology Service, Walter Reed Army Medical Center, Washington, DC 20307, USA.
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Heemann U, Abramowicz D, Spasovski G, Vanholder R. Endorsement of the Kidney Disease Improving Global Outcomes (KDIGO) guidelines on kidney transplantation: a European Renal Best Practice (ERBP) position statement. Nephrol Dial Transplant 2011; 26:2099-106. [PMID: 21555392 DOI: 10.1093/ndt/gfr169] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
KDIGO (Kidney Disease: Improving Global Outcomes) is an international independent body aiming to 'improve the care and outcomes of kidney disease patients worldwide, through the development and implementation of clinical practice guidelines'. Recently, the KDIGO work group has produced comprehensive clinical practice guidelines for the care of kidney transplant recipients (KTRs). The guideline makes recommendations for immunosuppression, graft monitoring, as well as prevention and treatment of infection, cardiovascular disease, malignancy and other complications that are common in KTRs, including haematological and bone disorders. Because most guidelines were 'soft' rather than 'strong', and because global guidelines need to be adapted and implemented into the regional context where they are used, the European Renal Best Practice (ERBP) Advisory Board appointed a work group of transplant nephrologists and surgeons to review the newest KDIGO guideline and comment on its relevance and applicability for European KTRs. In this article, we concentrate only on those guidelines which we considered worth amending or adapting. All guidelines not mentioned are fully endorsed.
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Reshef R, Vardhanabhuti S, Luskin MR, Heitjan DF, Hadjiliadis D, Goral S, Krok KL, Goldberg LR, Porter DL, Stadtmauer EA, Tsai DE. Reduction of immunosuppression as initial therapy for posttransplantation lymphoproliferative disorder(★). Am J Transplant 2011; 11:336-47. [PMID: 21219573 PMCID: PMC3079420 DOI: 10.1111/j.1600-6143.2010.03387.x] [Citation(s) in RCA: 154] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Reduction of immunosuppression (RI) is commonly used to treat posttransplant lymphoproliferative disorder (PTLD) in solid organ transplant recipients. We investigated the efficacy, safety and predictors of response to RI in adult patients with PTLD. Sixty-seven patients were managed with RI alone and 30 patients were treated with surgical excision followed by adjuvant RI. The response rate to RI alone was 45% (complete response-37%, partial response-8%). The relapse rate in complete responders was 17%. Adjuvant RI resulted in a 27% relapse rate. The acute rejection rate following RI-containing strategies was 32% and a second transplant was feasible without relapse of PTLD. The median survival was 44 months in patients treated with RI alone and 9.5 months in patients who remained on full immunosuppression (p = 0.07). Bulky disease, advanced stage and older age predicted lack of response to RI. Survival analysis demonstrated predictors of poor outcome-age, dyspnea, B symptoms, LDH level, hepatitis C, bone marrow and liver involvement. Patients with none or one of these factors had a 3-year overall survival of 100% and 79%, respectively. These findings support the use of RI alone in low-risk PTLD and suggest factors that predict response and survival.
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Affiliation(s)
- R Reshef
- Abramson Cancer Center Department of Biostatistics & Epidemiology Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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Quinlan SC, Pfeiffer RM, Morton LM, Engels EA. Risk factors for early-onset and late-onset post-transplant lymphoproliferative disorder in kidney recipients in the United States. Am J Hematol 2011; 86:206-9. [PMID: 21264909 DOI: 10.1002/ajh.21911] [Citation(s) in RCA: 139] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Solid-organ transplant recipients have an elevated risk for some malignancies because of the requirement for immunosuppression [1]. In particular, non-Hodgkin's lymphoma (NHL) is common and comprises one end of a spectrum of post-transplant lymphoproliferative disorder (PTLD) ranging from benign hyperplasia to lymphoid malignancy [2]. PTLD risk is influenced by the type of organ transplanted, the age and Epstein-Barr virus (EBV) serostatus of the transplant recipient, and the intensity of immunosuppression [3-9]. PTLD incidence is high immediately after transplantation, decreases subsequently, and then rises again 4-5 years from transplantation [10,11]. This incidence pattern suggests the presence of separate early-onset and late-onset PTLD subtypes. Early-onset PTLDs tend to be EBV-positive and, when extranodal, are more likely than late-onset PTLDs to be localized to the transplanted organ [12,13]. Late-onset PTLD is less likely to be associated with EBV and, overall, is more likely than early-onset PTLD to be extranodal [13,14]. The Scientific Registry of Transplant Recipients (SRTR) includes data on a large number of solid-organ transplant recipients in the United States and information on malignancies diagnosed post-transplantation. We used these data to conduct a retrospective cohort study among kidney transplant recipients to examine differences in risk factors between early-onset PTLD and late-onset PTLD.
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Affiliation(s)
- Scott C. Quinlan
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland
| | - Ruth M. Pfeiffer
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland
| | - Lindsay M. Morton
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland
| | - Eric A. Engels
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland
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Belatacept-based regimens versus a cyclosporine A-based regimen in kidney transplant recipients: 2-year results from the BENEFIT and BENEFIT-EXT studies. Transplantation 2011; 90:1528-35. [PMID: 21076381 DOI: 10.1097/tp.0b013e3181ff87cd] [Citation(s) in RCA: 138] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND At 1 year, belatacept was associated with similar patient/graft survival, better renal function, and an improved cardiovascular/metabolic risk profile versus cyclosporine A (CsA) in the Belatacept Evaluation of Nephroprotection and Efficacy as Firstline Immunosuppression Trial (BENEFIT) and Belatacept Evaluation of Nephroprotection and Efficacy as Firstline Immunosuppression Trial-EXTended criteria donors (BENEFIT-EXT) studies. Acute rejection was more frequent with belatacept in BENEFIT. Posttransplant lymphoproliferative disorder (PTLD)--specifically central nervous system PTLD--was observed more frequently in belatacept-treated patients. This analysis assesses outcomes from BENEFIT and BENEFIT-EXT after 2 years of treatment. METHODS Patients received a more intensive (MI) or a less intensive (LI) regimen of belatacept or a CsA-based regimen. RESULTS Four hundred ninety-three of 666 patients (74%) in BENEFIT and 347 of 543 (64%) in BENEFIT-EXT completed 2 years of treatment. The proportion of patients who survived with a functioning graft was similar across groups (BENEFIT: 94% MI, 95% LI, and 91% CsA; BENEFIT-EXT: 83% MI, 84% LI, and 83% CsA). Belatacept's renal benefits were sustained, as evidenced by a 16 to 17 mL/min (BENEFIT) and an 8 to 10 mL/min (BENEFIT-EXT) higher calculated glomerular filtration rate in the belatacept groups versus CsA. There were few new acute rejection episodes in either study between years 1 and 2. Because PTLD risk was highest in Epstein-Barr virus (EBV) (-) patients, an efficacy analysis of EBV (+) patients was performed and was consistent with the overall population results. There were two previously reported cases of PTLD in each study between years 1 and 2 in the belatacept groups. The overall balance of safety and efficacy favored the LI over the MI regimen. CONCLUSIONS At 2 years, belatacept-based regimens sustained better renal function, similar patient/graft survival, and an improved cardiovascular/metabolic risk profile versus CsA; outcomes that were maintained in EBV (+) patients. No new safety signals emerged.
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Khedmat H, Taheri S. Early versus late outset of lymphoproliferative disorders post-heart and lung transplantation: The PTLD.Int Survey. Hematol Oncol Stem Cell Ther 2011; 4:10-6. [DOI: 10.5144/1658-3876.2011.10] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
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Dudley C, Harden P. Renal Association Clinical Practice Guideline on the Assessment of the Potential Kidney Transplant Recipient. ACTA ACUST UNITED AC 2011; 118 Suppl 1:c209-24. [DOI: 10.1159/000328070] [Citation(s) in RCA: 85] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2010] [Accepted: 01/12/2011] [Indexed: 01/08/2023]
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Végso G, Hajdu M, Sebestyén A. Lymphoproliferative disorders after solid organ transplantation-classification, incidence, risk factors, early detection and treatment options. Pathol Oncol Res 2010; 17:443-54. [PMID: 21193979 DOI: 10.1007/s12253-010-9329-8] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2010] [Accepted: 10/26/2010] [Indexed: 12/12/2022]
Abstract
Posttransplant lymphoproliferative disorder (PTLD) is a heterogeneous disease group of benign and malignant entities. The new World Health Organisation classification introduced in 2008 distinguishes early lesions, polymorphic, monomorphic and classical Hodgkin lymphoma-type PTLD. Based on the time of appearance, early and late forms can be identified.PTLDs are the second most frequent posttransplantation tumors in adulthood, and the most frequent ones in childhood. The incidence varies with the transplanted organ-from 1%-2% following kidney transplantation to as high as 10% following thoracic organ transplantation-due to different intensities in immunosuppression. Immunocompromised state and Epstein-Barr virus (EBV) infection are the two major risk factors.In Europe and the US approximately 85% of PTLDs are of B-cell origin, and the majority are EBV-associated. Symptoms are often unspecific; extranodal, organ manifestations and central nervous system involvement is common. Early lesions respond well to a decrease in immunosuppression. Malignant entities are treated with rituximab, chemotherapy, radiotherapy and surgical therapy. Adoptive T-cell transfer represents a promising therapeutic approach. The prognosis is favorable in early PTLD, and poor in late PTLD. Five-year survival is 30% for high-grade lymphomas. The prognosis of EBV-negative lymphomas is worse.Lowering the risk of PTLD may be achieved by low dose maintenance immunosuppression, immunosuppressive drugs inhibiting cell proliferation, and special immunotherapy (e.g. interleukin-2 inhibitors). Early detection is especially important for high risk-e.g. EBV-negative-patients, where the appearance of EBV-DNA and the increase in its titer may help.
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Affiliation(s)
- Gyula Végso
- Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary.
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29
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An Integrated Safety Profile Analysis of Belatacept in Kidney Transplant Recipients. Transplantation 2010; 90:1521-7. [DOI: 10.1097/tp.0b013e3182007b95] [Citation(s) in RCA: 99] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Inoue T, Satoh S, Saito M, Horikawa Y, Tsuchiya N, Habuchi T. Post-transplant lymphoproliferative disorder involving the ovary as an initial manifestation: a case report. J Med Case Rep 2010; 4:184. [PMID: 20565880 PMCID: PMC2896377 DOI: 10.1186/1752-1947-4-184] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2008] [Accepted: 06/18/2010] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Because the normal ovary is assumed to be devoid of lymphoid tissue, it is unusual for it to be an initial manifestation of malignant lymphoma. This case is the first report, to our knowledge, of post-transplant lymphoproliferative disorder involving the ovary as an initial manifestation. CASE PRESENTATION Twenty-nine weeks after a living renal transplantation, a 38-year-old Japanese female, whose ethnic origin was Asian, presented with abdominal pain and a chronic high fever. Computed tomography revealed a right ovarian tumor and liver metastases. The patient underwent oophrectomy based on the clinical diagnosis of liver metastasis from the primary ovarian tumor. The pathological diagnosis was Epstein-Barr Virus-associated post-transplant lymphoproliferative disorder. While ovarian malignant lymphoma has a poor prognosis, complete remission of liver involvement in this case was achieved only with a reduction of immunosuppressants. CONCLUSION Clinicians should remember that malignant lymphoma could initially involve the ovary, especially if the patient is immunosuppressed after transplantation therapy.
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Affiliation(s)
- Takamitsu Inoue
- Department of Urology, Akita University School of Medicine, Akita 010-8543, Japan.
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31
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Morgans AK, Reshef R, Tsai DE. Posttransplant Lymphoproliferative Disorder Following Kidney Transplant. Am J Kidney Dis 2010; 55:168-80. [DOI: 10.1053/j.ajkd.2009.09.026] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2009] [Accepted: 09/30/2009] [Indexed: 01/20/2023]
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Issa N, Amer H, Dean PG, Kremers WK, Kudva YC, Rostambeigi N, Cosio FG, Larson TS, Habermann TM, Stegall MD, Griffin MD. Posttransplant lymphoproliferative disorder following pancreas transplantation. Am J Transplant 2009; 9:1894-902. [PMID: 19519812 DOI: 10.1111/j.1600-6143.2009.02691.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The incidence, risk factors and impact on patient and graft survival were evaluated for posttransplant lymphoproliferative disorder (PTLD) among 212 pancreas transplant recipients. Thirteen (6.1%) developed PTLD during 71 +/- 27 months follow-up. Cumulative incidences of PTLD at 1, 3, 5 and 10 years posttransplant were 4.2%, 5.3%, 6.0% and 7.0%, respectively. Incidence of PTLD was lower for recipients of simultaneous pancreas kidney compared to pancreas after kidney transplant or pancreas transplant alone, though not significantly so. Recipient Epstein-Barr virus (EBV) seronegativity and number of doses of depleting antibody therapy administered at transplant were associated with increased risk of PTLD, while recipient age, gender, transplant type, cytomegalovirus mismatch maintenance immunosuppression type and treated acute rejection were not. All 13 cases underwent immunosuppression reduction, and 10 received anti-CD20 monoclonal antibody. During follow-up, 10/13 (77%) responded to treatment with complete remission, while 3 (23%) died as a result of PTLD. Patient and graft survivals did not differ for recipients with and without PTLD. The strong association of PTLD with EBV-seronegativity requires considering this risk factor when evaluating and monitoring pancreas transplant recipients. With reduction of immunosuppression and anti-CD20 therapy, survival for pancreas transplant recipients with PTLD was substantially better than previously reported.
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Affiliation(s)
- N Issa
- Department of Medicine, Division of Nephrology and Hypertension, Mayo Clinic College of Medicine, Rochester, MN, USA
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Avoiding pitfalls: what an endoscopist should know in liver transplantation--part II. Dig Dis Sci 2009; 54:1386-402. [PMID: 19085103 DOI: 10.1007/s10620-008-0520-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2007] [Accepted: 08/27/2008] [Indexed: 02/07/2023]
Abstract
Over the last decade the number of patients undergoing transplantation has increased. At the same time, effective peri- and postoperative care and better surgical techniques have resulted in greater numbers of recipients achieving long-term survival. Identification and effective management in the form of adequate treatment is essential, since any delay in diagnosis or treatment may result in graft loss or serious threat to patient's life. Various aspects of endoscopic findings that can be commonly encountered among liver transplant recipients are discussed herein. Topics include: persistent and/or recurrent esophageal varices, reflux, Candida or cytomegalovirus (CMV) esophagitis, esophageal neoplasms, posttransplant peptic ulcer, biliary complications, posttransplant lymphoproliferative disorder (PTLD), Kaposi's sarcoma, CMV colitis and inflammatory bowel disease, colonic neoplasms, Clostridium difficile infection, and graft versus host disease (GVHD).
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Selvarajah V, Lake K, Robertson S, Carman W, Isles C. Post-transplant lymphoproliferative disorder: case report and review of susceptibility to EBV in the Scottish adult renal transplant pool. Clin Kidney J 2009; 2:52-4. [PMID: 25949287 PMCID: PMC4421486 DOI: 10.1093/ndtplus/sfn180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2008] [Accepted: 10/27/2008] [Indexed: 12/03/2022] Open
Abstract
We report a case of high-grade non-Hodgkin's lymphoma following Epstein-Barr virus (EBV) infection in a 38-year-old renal transplant recipient who was successfully treated with rituximab and remains alive 6 years later with reasonable graft function. We subsequently undertook a survey showing that 1.8% of the Scottish adult transplant pool are susceptible to EBV infection. Though a vaccine for EBV is currently not yet available, routine screening of potential renal transplant recipients for EBV should help identify those at increased risk of post-transplant lymhoproliferative disorder (PTLD), while tailoring of immunosuppression and antiviral prophylaxis with Ganciclovir may help reduce the emergence of this potentially life-threatening disease.
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Affiliation(s)
- Viknesh Selvarajah
- Department of Renal Medicine, Dumfries and Galloway Royal Infirmary, Dumfries DG1 4AP
| | - Katie Lake
- Department of Renal Medicine, Dumfries and Galloway Royal Infirmary, Dumfries DG1 4AP
| | - Sue Robertson
- Department of Renal Medicine, Dumfries and Galloway Royal Infirmary, Dumfries DG1 4AP
| | - William Carman
- West of Scotland Specialist Virology Laboratory , Gartnavel General Hospital , Glasgow G12 0ZA , UK
| | - Chris Isles
- Department of Renal Medicine, Dumfries and Galloway Royal Infirmary, Dumfries DG1 4AP
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Pietersma F, Piriou E, van Baarle D. Immune surveillance of EBV-infected B cells and the development of non-Hodgkin lymphomas in immunocompromised patients. Leuk Lymphoma 2008; 49:1028-41. [PMID: 18452077 DOI: 10.1080/10428190801911662] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
After infection with the Epstein - Barr virus, a common gammaherpes virus which infects and persists in the B cells, an equilibrium is established in which newly infected and differentiating B cells are controlled by cytotoxic T cell (CTL) responses. Disturbance of this equilibrium, which can occur in immunocompromised situations, can lead to uncontrolled lymphoproliferation and subsequent development of non-Hodgkin Lymphomas (NHL). Here, we review the role of immunesurveillance of EBV-infected B cells and two situations where immunesurveillance is altered because of immunodeficiencies, transplantation recipients and HIV infection, which can lead to EBV-mediated NHL. In transplant recipients, immunosuppression prior and during transplantation can lead to lack of immunesurveillance and results in proliferation of infected B cells, which would normally be controlled by CTL responses. Interestingly, in HIV infection both deregulation of the normal B cell biology and a reduction in immunity play a role in developing NHL. Therefore, the nature of EBV infection in HIV-positive subjects is very different from that in transplanted individuals, in whom (re-)appearance of EBV-specific CD8(+) T cells - either by a decrease in immune suppression or infusion of donor lymphocytes - immediately leads to a decrease in EBV load.
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Affiliation(s)
- Floor Pietersma
- Department of Immunology, University Medical Center Utrecht, Utrecht, the Netherlands
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37
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Aita K, Noguchi M, Nagata M. An autopsy case of late-onset Epstein-Barr virus associated post-transplant lymphoproliferative disorders 11 yr after kidney transplantation. Clin Transplant 2008. [DOI: 10.1111/j.1399-0012.2008.00858.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Pourfarziani V, Taheri S, Lessan-Pezeshki M, Nourbala MH, Simforoosh N, Nemati E, Makhdoomi K, Ghafari A, Ahmadpour P, Nafar M, Einollahi B. Lymphoma after living donor kidney transplantation: an Iranian multicenter experience. Int Urol Nephrol 2008; 40:1089-94. [PMID: 18592392 DOI: 10.1007/s11255-008-9377-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2007] [Accepted: 03/24/2008] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Post-transplant lymphoproliferative disorders (PTLD) are well-recognized complications in solid organ recipients. Limited data exist about the development of PTLDs in living kidney recipients. This study deals with a multicenter nationwide experience with kidney recipients from living donors. METHODS We reviewed data of PTLD patients from a total population of 6,500 patients transplanted at three different transplant centers in Iran from 1984 to 2006. We also compared their data with 2,250 normal kidney recipients of Baqiyatallah Transplant Center. Data were analyzed to determine potential correlates with the occurrence of PTLD and patient outcome. RESULTS Overall, 31 patients were diagnosed as having post-transplant lymphomas. The incidence of PTLD in our kidney transplant population comprised 0.47%. Sixteen (53%) PTLD patients were females, whereas 15 (47%) were males. The mean ages at transplantation and diagnosis were 37.1 and 41.9, respectively. Twelve (63%) patients died, and seven are alive. All deaths occurred within the 1st year after PTLD diagnosis. The mean time period from transplantation to diagnosis of PTLD was 64 (0.7-173) months. Localization of PTLD in the brain associated the worst outcome. Compared to non-PTLD patients, PTLD patients were significantly female predominated (51.6% vs. 32.2%; P = 0.03) and had lower age at transplantation (36.9 years vs. 42.9 years, respectively; P = 0.01). Patients under immunosuppressive regimens containing azathioprine were at higher risk for acquiring PTLDs compared to those with a MMF-containing regimen. CONCLUSION PTLD is a major threat to kidney transplant recipients. Immunosuppressive agents have a significant role in developing the disease. Early detection of the disease and using more safe immunosuppresants may have beneficial effects on patient outcomes and incidence of the disease.
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Affiliation(s)
- Vahid Pourfarziani
- Nephrology and Urology Research Center, Baqiyatallah Hospital, Mullasadra St., 14155-6437, 1435915371, Tehran, Iran.
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Castón JJ, Cisneros JM, Torre-Cisneros J. [Effects of viral infection on transplant recipients]. Enferm Infecc Microbiol Clin 2008; 25:535-48. [PMID: 17915112 PMCID: PMC7130329 DOI: 10.1157/13109990] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Viral infection remains an important cause of morbidity and mortality in transplant recipients. The risk of viral infection in these patients depends on several factors, such as the type of organ transplanted, the intensity of immunosuppression, and the recipient's susceptibility. In additional to direct effects, viral infection cause indirect effects, including greater risk of replication of other viruses, graft rejection, opportunistic infections and other specific entities for each type of transplant. These indirect effects result from the immunomodulatory activity of some viruses, such as cytomegalovirus and human herpes virus-6. For the most part, quantitative molecular tests have replaced serologic testing and in vitro culture for diagnosing infection. This approach is particularly prominent for cytomegalovirus, Epstein-Barr virus, hepatitis B virus, and hepatitis C virus. Despite these diagnostic advances, the development of specific antiviral agents and effective antiviral vaccines is limited. Thus, prophylactic strategies are still essential in transplant recipients.
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Affiliation(s)
- Juan José Castón
- Unidad Clínica de Enfermedades Infecciosas. Hospital Universitario Reina Sofía. Córdoba. España
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Babel N, Vergopoulos A, Trappe RU, Oertel S, Hammer MH, Karaivanov S, Schneider N, Riess H, Papp-Vary M, Neuhaus R, Gondek LP, Volk HD, Reinke P. Evidence for genetic susceptibility towards development of posttransplant lymphoproliferative disorder in solid organ recipients. Transplantation 2007; 84:387-91. [PMID: 17700165 DOI: 10.1097/01.tp.0000269617.60751.c4] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Posttransplant lymphoproliferative disorder (PTLD) is a life-threatening complication after organ transplantation. The identification of risk factors for PTLD development is important for disease management. It has been shown that cytokine gene polymorphisms are associated with lymphoma and Epstein-Barr virus (EBV)-associated diseases in nonimmunosuppressed patients. In the present case-control study, we analyzed the impact of -1082 interleukin (IL)-10, -308 tumor necrosis factor (TNF)-alpha, transforming growth factor (TGF)-beta1 (codon 10, 25), and +874 interferon (IFN)-gamma gene single-nucleotide polymorphisms on the late onset EBV-associated PTLD. METHODS Out of 1,765 solid organ recipients, 38 patients with late-onset EBV-associated PTLD and 408 matched solid organ recipients were selected and enrolled in the study. Single nucleotide polymorphisms (SNPs) for -1082IL-10, -308TNF-alpha, TGF-beta1 (codon 10, 25), and +874IFN-gamma genes were analyzed by a sequence specific primer polymerase chain reaction and were related to the PTLD development, and the disease course and outcome. RESULTS The TGF-beta1 (codon 25) GG genotype was detected more frequently in controls than in PTLD patients (odds ratio=0.34, 95% confidence interval: 0.17-0.69, P=0.0022). The frequency of -1082 IL-10 GG genotype was also significantly higher in controls than in PTLD patients (odds ratio=0.5, 95% confidence interval: 0.25-1.0, P=0.044). There were no associations between -308TNF-alpha, TGF-beta1 codon 10, and +874IFN-gamma SNPs and PTLD. Disease course and outcome were not associated with any cytokine SNPs. CONCLUSIONS Polymorphisms in two key anti-inflammatory cytokines, IL-10 and TGF-beta, are associated with susceptibility to EBV-associated PTLD, suggesting that a shift in pro-/anti-inflammatory response is involved in the pathogenesis of PTLD.
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Affiliation(s)
- Nina Babel
- Department of Nephrology, Charité University Medicine Berlin, Campus Virchow Clinic, Berlin, Germany.
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Bakker NA, van Imhoff GW, Verschuuren EAM, van Son WJ. Presentation and early detection of post-transplant lymphoproliferative disorder after solid organ transplantation. Transpl Int 2007; 20:207-18. [PMID: 17291214 DOI: 10.1111/j.1432-2277.2006.00416.x] [Citation(s) in RCA: 119] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Post-transplant lymphoproliferative disorder (PTLD) is a serious and still frequently observed complication of solid organ transplantation. Despite the recent introduction of anti B-cell monoclonal antibody therapy (rituximab) for treatment of PTLD, mortality rates remain high. Because PTLD often presents in a nonspecific way in clinically unsuspected patients, it is a major challenge to diagnose PTLD at an early stage. Epstein-Barr virus (EBV)-DNA load monitoring is a promising tool for the identification of patients at risk for PTLD development. However, there are some limitations of this method, and not all patients at risk for PTLD can be identified by EBV-DNA measurements alone. Therefore, it is of major importance to recognize early clinical signs and symptoms of PTLD. In this review, risk factors for PTLD development, disease presentation, and methods for early detection will be discussed. Special attention is given to allograft and digestive tract localization and the relation with time of onset of PTLD. The value and pitfalls of EBV-DNA load monitoring are discussed. In addition, because fluorodeoxyglucose (FDG)-positron emission tomography (PET) has shown to be a powerful tool for staging and response evaluation of malignant lymphoma, the role of FDG-PET for early diagnosis and staging of PTLD is addressed.
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Affiliation(s)
- Nicolaas A Bakker
- Department of Haematology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands.
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Ramadan KMA, Bowers M, El-Agnaf MR, Kettle P. Late-onset post-transplant lymphoproliferative disease: a report of four patients in one center. Leuk Lymphoma 2006; 47:1191-3. [PMID: 16840223 DOI: 10.1080/10428190500473295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Hill CE, Harris SB, Culler EE, Zimring JC, Nolte FS, Caliendo AM. Performance Characteristics of Two Real-Time PCR Assays for the Quantification of Epstein-Barr Virus DNA. Am J Clin Pathol 2006. [DOI: 10.1309/abeyv2vke6dhxaaa] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Humar A, Hébert D, Davies HD, Humar A, Stephens D, O'Doherty B, Allen U. A randomized trial of ganciclovir versus ganciclovir plus immune globulin for prophylaxis against Epstein-Barr virus related posttransplant lymphoproliferative disorder. Transplantation 2006; 81:856-61. [PMID: 16570008 DOI: 10.1097/01.tp.0000202724.07714.a2] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Transplant recipients who are Epstein-Barr virus (EBV)-seronegative and receive organs from seropositive donors (EBV D+/R-) are at increased risk for posttransplant lymphoproliferative disorder (PTLD) and may benefit from antiviral prophylaxis. We performed a multi-center trial assessing two different antiviral regimens and their effect on EBV replication. METHODS EBV D+/R- solid organ transplant recipients were randomized to receive either ganciclovir and placebo or ganciclovir and immunoglobulin (IG) for 3 months. Following this, patients were unblinded and IG patients received additional IG therapy until 6 months. EBV viral loads were done at least monthly. RESULTS.: Thirty-four patients (25 pediatric, 9 adult) completed the protocol (16 placebo; 18 IG). The incidence of a detectable viral load within the first year posttransplant was 13/16 (81.3%) in the ganciclovir arm vs. 13/18 (72.2%) in the ganciclovir and IG arm (P=0.8). Time to first detectable viral load, and time to high-level viral load were not significantly different. By repeated measures ANOVA analysis, and by estimation of viral load AUC, no significant effect of randomization group was observed on EBV viral loads. PTLD developed in 3 (8.8%) patients (all in IG arm; P=0.23). CONCLUSIONS No significant difference in EBV viral load suppression was observed when ganciclovir was compared with ganciclovir and IG in high-risk EBV D+/R- patients.
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Affiliation(s)
- Atul Humar
- Transplant Infectious Diseases, University of Toronto, and University Health Network, Toronto General Hospital, 585 University Avenue, Toronto, Ontario, Canada M5G 2N2.
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Momose A, Mizuno H, Kajihara S, Saitoh H, Mikuni T, Katsunori N, Funyu T. EBV-associated nasal-type NK/T-cell lymphoma of the nasal cavity/paranasal sinus in a renal allograft recipient. Nephrol Dial Transplant 2005; 21:1413-6. [PMID: 16364984 DOI: 10.1093/ndt/gfk020] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
MESH Headings
- Adult
- Biopsy, Needle
- Epstein-Barr Virus Infections/diagnosis
- Epstein-Barr Virus Infections/immunology
- Follow-Up Studies
- Graft Survival
- Herpesvirus 4, Human/immunology
- Herpesvirus 4, Human/pathogenicity
- Humans
- Immunohistochemistry
- Immunosuppressive Agents/adverse effects
- Immunosuppressive Agents/therapeutic use
- Kidney Failure, Chronic/diagnosis
- Kidney Failure, Chronic/surgery
- Kidney Transplantation/adverse effects
- Kidney Transplantation/methods
- Killer Cells, Natural/immunology
- Living Donors
- Lymphoma, T-Cell/diagnosis
- Lymphoma, T-Cell/etiology
- Lymphoma, T-Cell/immunology
- Magnetic Resonance Imaging
- Male
- Paranasal Sinus Neoplasms/etiology
- Paranasal Sinus Neoplasms/pathology
- Paranasal Sinus Neoplasms/virology
- Risk Assessment
- Severity of Illness Index
- Transplantation Immunology/physiology
- Transplantation, Homologous
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Affiliation(s)
- Akishi Momose
- Department of Urology, Oyokyo Kidney Research Institute, Hirosaki Hospital, 90 Kozawa Yamazaki, Hirosaki, 036-8243 Japan.
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Funch DP, Walker AM, Schneider G, Ziyadeh NJ, Pescovitz MD. Ganciclovir and acyclovir reduce the risk of post-transplant lymphoproliferative disorder in renal transplant recipients. Am J Transplant 2005; 5:2894-900. [PMID: 16303002 DOI: 10.1111/j.1600-6143.2005.01115.x] [Citation(s) in RCA: 166] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Given its association with Epstein-Barr virus (EBV), there is considerable interest in assessing the impact of prophylactic anti-viral therapy on post-transplant lymphoproliferative disorder (PTLD). A recently completed multi center case-control study assessed the impact of immunosuppressive therapy on PTLD risk among renal transplant patients and collected information on the use of anti-viral therapy. Biopsy-confirmed PTLD cases (n = 100) were matched to 375 controls by center, date of transplant, and age. Data were collected on immunosuppression and rejection therapies, demographics, pre-transplant viral status, number of rejections, and anti-viral use. With adjustment for known risk factors, prophylactic anti-viral use was associated with up to 83% reduction in the risk of PTLD, depending on the anti-viral agent. These results were stronger for the first year post-transplant. For every 30 days of ganciclovir treatment, risk of PTLD during the first year was lower by 38% (Odds Ratio [OR]= 0.62; 95% confidence interval [CI]= 0.38-1.0); acyclovir effects were less striking (OR = 0.83; 95% CI = 0.59-1.16). Anti-viral therapy appears to play a role in reducing the risk of PTLD in renal transplant patients. Ganciclovir may be more potent than acyclovir.
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Affiliation(s)
- D P Funch
- Ingenix Epidemiology, Auburndale, Massachusetts, USA.
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Babel N, Gabdrakhmanova L, Hammer M, Rosenberger C, Oppert M, Volk HD, Reinke P. Induction of pre-transplant Epstein-Barr virus (EBV) infection by donor blood transfusion in EBV-seronegative recipients may reduce risk of post-transplant lymphoproliferative disease in adolescent renal transplant patients: report of two cases. Transpl Infect Dis 2005; 7:133-6. [PMID: 16390402 DOI: 10.1111/j.1399-3062.2005.00110.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Post-transplant lymphoproliferative disease (PTLD) is a life-threatening complication following organ transplantation. The greatest risk is seen in Epstein-Barr virus (EBV)-seronegative patients receiving allografts from EBV-seropositive donors. We demonstrate a new approach of pre-transplant prophylaxis of EBV-related PTLD, suggesting that, prior to living-related renal transplantation, blood transfusion from an EBV-seropositive donor to an EBV-seronegative recipient could induce primary EBV infection in the recipient, developing EBV immunity and decreasing risk of PTLD. METHODS Recipients underwent weekly donor-specific blood transfusion (3 x 100 mL) before transplantation. EBV-mRNA expression, viral load, serological tests, and clinical signs of EBV infection were assessed following blood transfusion. RESULTS We explored a new approach in 2 young EBV-seronegative renal allograft recipients. Both patients developed primary EBV infection following blood transfusion before transplantation and showed symptom-free seroconversion post-transplantation without persistent EBV activation. There were no signs of PTLD during 5-year follow-up. CONCLUSIONS A new effective and inexpensive approach is suggested for development of EBV immunity and probably for prophylaxis of EBV-associated PTLD.
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Affiliation(s)
- N Babel
- Interdisciplinary Transplant Research Laboratory, Charité University Medicine, Berlin, Germany.
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Sagedal S, Hartmann A, Rollag H. The impact of early cytomegalovirus infection and disease in renal transplant recipients. Clin Microbiol Infect 2005; 11:518-30. [PMID: 15966969 DOI: 10.1111/j.1469-0691.2005.01190.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Human cytomegalovirus (HCMV) infection is the single most frequent infectious complication in the early period after kidney transplantation. The HCMV load in blood, measured by HCMV PCR or the HCMV pp65 antigen test, is a predictor of HCMV disease in seropositive recipients. However, plasma virus load measurements are of only modest value in predicting the risk of HCMV disease in seronegative recipients of kidneys from seropositive donors. HCMV infection is an independent risk-factor for acute kidney graft rejection. There is also evidence that HCMV is associated with an increased long-term mortality and post-transplant diabetes mellitus. Whether pre-emptive or prophylactic therapy should be the preferred strategy is not yet decided. Some studies indicate that HCMV prophylaxis may reduce the risk of acute rejection, and thereby increase long-term graft survival in seronegative recipients of kidneys from seropositive donors.
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Affiliation(s)
- S Sagedal
- Department of Internal Medicine, Rikshospitalet University Hospital, Oslo, Norway.
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Agraharkar ML, Cinclair RD, Kuo YF, Daller JA, Shahinian VB. Risk of malignancy with long-term immunosuppression in renal transplant recipients. Kidney Int 2005; 66:383-9. [PMID: 15200447 DOI: 10.1111/j.1523-1755.2004.00741.x] [Citation(s) in RCA: 96] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Improvements in immunosuppressive regimens have significantly enhanced patient and graft survival in renal transplant recipients. However, susceptibility to neoplastic disorders is increased as a consequence of prolonged immunosuppression. Available data pertaining to cancer risks in renal transplant recipients have been inconsistent, and much of it is derived from international studies, which may not be truly representative of the United States population. METHODS We studied a total of 1979 transplants performed in 1739 patients from a single center in the United States with a mean follow-up of 6.1 years, and a total of 9852 person-years' follow-up. RESULTS The mean age at the time of diagnosis of cancer was 50 years, and the mean interval between transplant and diagnosis of cancer was 95 months. Older patients receiving a transplant had a significantly higher risk for developing cancer as opposed to younger patients (RR 6.2 for >60 years compared with <40 years). When compared with the general population using data from the Surveillance, Epidemiology and End Results (SEER) registry, the overall risk for nonskin malignancies was modestly increased in our transplant recipients, with a standardized incidence ratio (SIR) of 1.4 (P= 0.01). When stratified by age groups, younger age at transplant (<40 years) had the highest SIR, at 2.3 (P < 0.001). Similarly, duration post-transplant >10 years had an SIR of 2.4 (P < 0.001). CONCLUSION We believe that this study is representative of the United States' renal transplant population, and highlights the need for reduced immunosuppression in the long-term and increased vigilance for cancers in younger patients receiving renal transplantation.
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Affiliation(s)
- Mahendra L Agraharkar
- Division of Nephrology, Department of Internal Medicine, University of Texas Medical Branch, Galveston, Texas, USA.
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Weinberger B, Plentz A, Weinberger KM, Hahn J, Holler E, Jilg W. Quantitation of Epstein-Barr virus mRNA using reverse transcription and real-time PCR. J Med Virol 2004; 74:612-8. [PMID: 15484273 DOI: 10.1002/jmv.20220] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Monitoring of Epstein-Barr virus (EBV) infection and reactivation in immunocompromized patients (e.g., after organ or bone-marrow transplantation) is based mainly on serological assays and detection of viral DNA. For further characterization of virus reactivation and monitoring of viral transcription we established real-time RT-PCR assays using TaqMan technology to sensitively quantify viral transcripts expressed at different times of the lytic cycle: for BZLF1, an immediate early transactivator initiating the transition from latency to lytic replication, for the DNA-polymerase BALF5 and for the major viral glycoprotein gp350/220 (BLLF1). RNA-isolation was optimized to eliminate contaminating DNA. Preparations were shown to be virtually DNA-free for up to 10(6) copies of RNA. With our PCR systems, it is possible to detect 10 copies of DNA or 100 copies of RNA per reaction as shown with serial dilutions of DNA-plasmids or in vitro transcribed RNA, respectively. This corresponds to a detection limit of 8 x 10(2) copies/10(6) peripheral blood mononuclear cells (PBMCs). Evaluation of this system showed that even in healthy carriers borderline levels of BLLF1 mRNA were sometimes detectable. In patients with acute infectious mononucleosis (IM) viral transcripts were regularly found in varying concentrations. Extremely high levels of all three mRNA species could be seen in a patient after bone-marrow transplantation monitored during an episode of lymphoproliferation which regressed during treatment with acyclovir and transfusion of donor T-cells. This sensitive and reproducible method to detect and quantify different transcripts of EBV can be used to closely monitor reactivation of EBV, e.g., in immunocompromized patients.
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Affiliation(s)
- Birgit Weinberger
- Institute for Medical Microbiology and Hygiene, University of Regensburg, Regensburg, Germany.
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