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Matar AJ, Finger EB, Maakaron J, Minja E, Ramanathan K, Humphreville V, Rao JS, Fisher J, Sutherland DER, Matas AJ, Kandaswamy R. Posttransplant Lymphoproliferative Disease Following Pancreas Transplantation: A 40 Year Single-Center Experience. Clin Transplant 2024; 38:e15386. [PMID: 39087488 DOI: 10.1111/ctr.15386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Revised: 05/21/2024] [Accepted: 06/07/2024] [Indexed: 08/02/2024]
Abstract
BACKGROUND Chronic immunosuppression following pancreas transplantation carries significant risk, including posttransplant lymphoproliferative disease (PTLD). We sought to define the incidence, risk factors, and long-term outcomes of PTLD following pancreas transplantation at a single center. METHODS All adult pancreas transplants between February 1, 1983 and December 31, 2023 at the University of Minnesota were reviewed, including pancreas transplant alone (PTA), simultaneous pancreas-kidney transplants (SPK), and pancreas after kidney transplants (PAK). RESULTS Among 2353 transplants, 110 cases of PTLD were identified, with an overall incidence of 4.8%. 17.3% were diagnosed within 1 year of transplant, 32.7% were diagnosed within 5 years, and 74 (67.3%) were diagnosed after 5 years. The overall 30-year incidence of PTLD did not differ by transplant type-7.4% for PTA, 14.2% for SPK, and 19.4% for PAK (p = 0.3). In multivariable analyses, older age and Epstein-Barr virus seronegativity were risk factors for PTLD, and PTLD was a risk factor for patient death. PTLD-specific mortality was 32.7%, although recipients with PTLD had similar median posttransplant survival compared to those without PTLD (14.9 year vs. 15.6 year, p = 0.9). CONCLUSIONS PTLD following pancreas transplantation is associated with significant mortality. Although the incidence of PTLD has decreased over time, a high index of suspicion for PTLD following PTx should remain in EBV-negative recipients.
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Affiliation(s)
- Abraham J Matar
- Department of Surgery, Division of Transplantation, University of Minnesota, Minneapolis, Minnesota, USA
| | - Erik B Finger
- Department of Surgery, Division of Transplantation, University of Minnesota, Minneapolis, Minnesota, USA
| | - Joseph Maakaron
- Department of Medicine, Division of Hematology, Oncology, and Transplantation, University of Minnesota, Minneapolis, Minnesota, USA
| | - Emmanuel Minja
- Department of Surgery, Division of Transplantation, University of Minnesota, Minneapolis, Minnesota, USA
| | - Karthik Ramanathan
- Department of Surgery, Division of Transplantation, University of Minnesota, Minneapolis, Minnesota, USA
| | - Vanessa Humphreville
- Department of Surgery, Division of Transplantation, University of Minnesota, Minneapolis, Minnesota, USA
| | - Joseph S Rao
- Department of Surgery, Division of Transplantation, University of Minnesota, Minneapolis, Minnesota, USA
| | - Jessica Fisher
- Department of Surgery, Division of Transplantation, University of Minnesota, Minneapolis, Minnesota, USA
| | - David E R Sutherland
- Department of Surgery, Division of Transplantation, University of Minnesota, Minneapolis, Minnesota, USA
| | - Arthur J Matas
- Department of Surgery, Division of Transplantation, University of Minnesota, Minneapolis, Minnesota, USA
| | - Raja Kandaswamy
- Department of Surgery, Division of Transplantation, University of Minnesota, Minneapolis, Minnesota, USA
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Preiksaitis J, Allen U, Bollard CM, Dharnidharka VR, Dulek DE, Green M, Martinez OM, Metes DM, Michaels MG, Smets F, Chinnock RE, Comoli P, Danziger-Isakov L, Dipchand AI, Esquivel CO, Ferry JA, Gross TG, Hayashi RJ, Höcker B, L'Huillier AG, Marks SD, Mazariegos GV, Squires J, Swerdlow SH, Trappe RU, Visner G, Webber SA, Wilkinson JD, Maecker-Kolhoff B. The IPTA Nashville Consensus Conference on Post-Transplant lymphoproliferative disorders after solid organ transplantation in children: III - Consensus guidelines for Epstein-Barr virus load and other biomarker monitoring. Pediatr Transplant 2024; 28:e14471. [PMID: 37294621 DOI: 10.1111/petr.14471] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 12/10/2022] [Accepted: 01/02/2023] [Indexed: 06/11/2023]
Abstract
The International Pediatric Transplant Association convened an expert consensus conference to assess current evidence and develop recommendations for various aspects of care relating to post-transplant lymphoproliferative disorders after solid organ transplantation in children. In this report from the Viral Load and Biomarker Monitoring Working Group, we reviewed the existing literature regarding the role of Epstein-Barr viral load and other biomarkers in peripheral blood for predicting the development of PTLD, for PTLD diagnosis, and for monitoring of response to treatment. Key recommendations from the group highlighted the strong recommendation for use of the term EBV DNAemia instead of "viremia" to describe EBV DNA levels in peripheral blood as well as concerns with comparison of EBV DNAemia measurement results performed at different institutions even when tests are calibrated using the WHO international standard. The working group concluded that either whole blood or plasma could be used as matrices for EBV DNA measurement; optimal specimen type may be clinical context dependent. Whole blood testing has some advantages for surveillance to inform pre-emptive interventions while plasma testing may be preferred in the setting of clinical symptoms and treatment monitoring. However, EBV DNAemia testing alone was not recommended for PTLD diagnosis. Quantitative EBV DNAemia surveillance to identify patients at risk for PTLD and to inform pre-emptive interventions in patients who are EBV seronegative pre-transplant was recommended. In contrast, with the exception of intestinal transplant recipients or those with recent primary EBV infection prior to SOT, surveillance was not recommended in pediatric SOT recipients EBV seropositive pre-transplant. Implications of viral load kinetic parameters including peak load and viral set point on pre-emptive PTLD prevention monitoring algorithms were discussed. Use of additional markers, including measurements of EBV specific cell mediated immunity was discussed but not recommended though the importance of obtaining additional data from prospective multicenter studies was highlighted as a key research priority.
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Affiliation(s)
- Jutta Preiksaitis
- Division of Infectious Diseases, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Upton Allen
- Division of Infectious Diseases and the Transplant and Regenerative Medicine Center, Department of Paediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Catherine M Bollard
- Center for Cancer and Immunology Research, Children's National Hospital, The George Washington University, Washington, District of Columbia, USA
| | - Vikas R Dharnidharka
- Department of Pediatrics, Division of Pediatric Nephrology, Hypertension & Pheresis, Washington University School of Medicine & St. Louis Children's Hospital, St. Louis, Missouri, USA
| | - Daniel E Dulek
- Division of Pediatric Infectious Diseases, Monroe Carell Jr. Children's Hospital at Vanderbilt and Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Michael Green
- Division of Pediatric Infectious Diseases, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Olivia M Martinez
- Department of Surgery and Program in Immunology, Stanford University School of Medicine, Stanford, California, USA
| | - Diana M Metes
- Departments of Surgery and Immunology, Thomas E. Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Marian G Michaels
- Division of Pediatric Infectious Diseases, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Françoise Smets
- Pediatric Gastroenterology and Hepatology, Cliniques Universitaires Saint-Luc, UCLouvain, Brussels, Belgium
| | | | - Patrizia Comoli
- Cell Factory & Pediatric Hematology/Oncology, Fondazione IRCCS Policlinico, Pavia, Italy
| | - Lara Danziger-Isakov
- Division of Infectious Disease, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
| | - Anne I Dipchand
- Labatt Family Heart Centre, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | | | - Judith A Ferry
- Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Thomas G Gross
- Center for Cancer and Blood Diseases, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Robert J Hayashi
- Division of Pediatric Hematology/Oncology, St. Louis Children's Hospital, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Britta Höcker
- University Children's Hospital, Pediatrics I, Heidelberg, Germany
| | - Arnaud G L'Huillier
- Faculty of Medicine, Pediatric Infectious Diseases Unit and Laboratory of Virology, Geneva University Hospitals, Geneva, Switzerland
| | - Stephen D Marks
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- NIHR Great Ormond Street Hospital Biomedical Research Centre, University College London, Great Ormond Street Institute of Child Health, London, UK
| | - George Vincent Mazariegos
- Department of Surgery, Hillman Center for Pediatric Transplantation, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - James Squires
- Division of Gastroenterology, Hepatology and Nutrition, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Steven H Swerdlow
- Division of Hematopathology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Ralf U Trappe
- Department of Hematology and Oncology, DIAKO Ev. Diakonie-Krankenhaus Bremen, Bremen, Germany
- Department of Internal Medicine II: Hematology and Oncology, University Medical Centre Schleswig-Holstein, Kiel, Germany
| | - Gary Visner
- Division of Pulmonary Medicine, Boston Children's Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Steven A Webber
- Department of Pediatrics, Vanderbilt School of Medicine, Nashville, Tennessee, USA
| | - James D Wilkinson
- Department of Pediatrics, Vanderbilt School of Medicine, Nashville, Tennessee, USA
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Montanari F, Orjuela-Grimm M. Joining Efforts for PTLD: Lessons Learned from Comparing the Approach and Treatment Strategies Across the Pediatric and Adult Age Spectra. Curr Hematol Malig Rep 2021; 16:52-60. [PMID: 33544319 DOI: 10.1007/s11899-021-00606-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2021] [Indexed: 12/28/2022]
Abstract
PURPOSE OF REVIEW Post-transplant lymphoproliferative disorders are a rare and heterogeneous group of diseases, where large prospective studies have been difficult to perform and treatment paradigms are often based on retrospective studies. Here, we critically analyze and present the clinical algorithms commonly used for this disease, with a special focus on the challenges and differences of the approaches in the adult and pediatric populations. RECENT FINDINGS Clinical trials exploring combinations of immunochemotherapies with a sequential and risk-stratified strategy have demonstrated exciting results, but are hampered from specialty and age-determined silos. Approaches introducing novel-targeted therapies and cellular therapies are currently being explored with a goal of joining efforts across the pediatric and adult age spectra. We propose that future therapeutic approaches would benefit from combining pediatric and adult PTLD efforts, gaining from the experience garnered from the age- and subtype-specific tailored strategies, with the aim of limiting treatment-related toxicities while maximizing the efficacy. Joining of efforts holds enormous potential for accelerating access to novel therapeutic strategies for PTLD in the near future.
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Affiliation(s)
- Francesca Montanari
- Department of Hematology, Yale Cancer Center, Smilow Cancer Hospital, New Haven, USA
| | - Manuela Orjuela-Grimm
- Division of Pediatric Hematology, Oncology, and Stem Cell Transplant, Departments of Pediatrics and Epidemiology, Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, Mailman School of Public Health, 722 West 168th street, Room 730, New York, NY, 10032, USA.
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Di Napoli ML, Rohan V, Nadig SN, Lin A. Small Bowel Perforation as the Initial Manifestation of Post-Transplant Lymphoproliferative Disorder in a Kidney and Pancreas Transplant Recipient: A Case Report. Transplant Proc 2020; 52:2827-2830. [PMID: 32900475 DOI: 10.1016/j.transproceed.2020.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 08/02/2020] [Indexed: 11/16/2022]
Abstract
Post-transplant lymphoproliferative disorder (PTLD) comprises a broad spectrum of diseases and is a rare but serious complication of solid organ transplantation. We report the case of a 45-year-old simultaneous pancreas and kidney (SPK) transplant recipient with diffuse, early-onset PTLD, manifesting as jejunal perforation at 6 months after transplantation. The patient underwent urgent small bowel resection of the affected portion of jejunum. The surgical pathology report was significant for diffuse large B-cell lymphoma. Subsequently, the patient underwent a full workup, including upper and lower endoscopy and whole-body positron emission tomography that revealed involvement of the axial skeleton and multiple abdominal organs with sparing of the grafts. He was treated with rituximab and intrathecal methotrexate for central nervous system prophylaxis. The patient experienced complete resolution of disease by positron emission tomography 8 months after initial presentation. We found no previous report in the literature of intestinal perforation as the initial presentation of PTLD in SPK transplant recipients.
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Affiliation(s)
- Marissa L Di Napoli
- Division of Transplant Surgery, Medical University of South Carolina, Charleston, SC, United States
| | - Vinayak Rohan
- Division of Transplant Surgery, Medical University of South Carolina, Charleston, SC, United States
| | - Satish N Nadig
- Division of Transplant Surgery, Medical University of South Carolina, Charleston, SC, United States
| | - Angello Lin
- Division of Transplant Surgery, Medical University of South Carolina, Charleston, SC, United States.
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