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Yamada M, Fukuda A, Ogura M, Shimizu S, Uchida H, Yanagi Y, Ishikawa Y, Sakamoto S, Kasahara M, Imadome KI. Early Detection of Epstein-Barr Virus as a Risk Factor for Chronic High Epstein-Barr Viral Load Carriage at a Living-donor-dominant Pediatric Liver Transplantation Center. Transplantation 2023; 107:1322-1329. [PMID: 36476718 DOI: 10.1097/tp.0000000000004429] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Epstein-Barr virus (EBV) infection and posttransplant lymphoproliferative disorders (PTLDs) after pediatric liver transplantation (LT) account for significant morbidity and mortality. Knowledge of EBV kinetics, epidemiology, and outcomes among pediatric living-donor LT cases is largely lacking. This study aims to provide clinical information related to EBV infection, chronic high EBV load (CHL) carriage, and PTLD at a living-donor-dominant pediatric LT center. METHODS A total of 5827 EBV load measurements from 394 LT recipients fulfilling inclusion criteria and their clinical data were analyzed. EBV loads >1000 copies/μg DNA (742 IU/μg DNA) were considered "high," and CHL was defined by persistence >6 mo. RESULTS The highlighted results were as follows: (1) 94% of recipients underwent living-donor LT; (2) 80% of EBV seronegative recipients developed first EBV infection <2 y post-LT, and their EBV loads were consistently higher than those of seropositive recipients within <3 y post-LT but did not differ thereafter; (3) 61 (15%) recipients met CHL criteria, but none developed PTLD; (4) age <5 y, cytomegalovirus seronegative donors, and early development of EBV DNAemia <6 mo post-LT were independent risk factors for CHL; (5) the incidence of rejections after 1-y post-LT was comparably low among CHL carriers whose immunosuppression was minimized. CONCLUSIONS Early detection of EBV following LT and CMV seronegative donors would facilitate risk stratification to prevent PTLD while titrating immunosuppression among pediatric LT recipients.
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Affiliation(s)
- Masaki Yamada
- Department of Advanced Medicine for Viral Infections, National Center for Child Health and Development, Tokyo, Japan
- Department of Medical Subspecialties, Division of Infectious Diseases, National Center for Child Health and Development, Tokyo, Japan
- Department of Pediatrics, University of Pittsburgh, School of Medicine and UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Akinari Fukuda
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Miyuki Ogura
- Department of Advanced Medicine for Viral Infections, National Center for Child Health and Development, Tokyo, Japan
| | - Seiichi Shimizu
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Hajime Uchida
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Yusuke Yanagi
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Yuriko Ishikawa
- Department of Advanced Medicine for Viral Infections, National Center for Child Health and Development, Tokyo, Japan
| | - Seisuke Sakamoto
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Mureo Kasahara
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Ken-Ichi Imadome
- Department of Advanced Medicine for Viral Infections, National Center for Child Health and Development, Tokyo, Japan
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2
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Ruijter BN, Wolterbeek R, Hew M, van Reeven M, van der Helm D, Dubbeld J, Tushuizen ME, Metselaar H, Vossen ACTM, van Hoek B. Epstein-Barr Viral Load Monitoring Strategy and the Risk for Posttransplant Lymphoproliferative Disease in Adult Liver Transplantation : A Cohort Study. Ann Intern Med 2023; 176:174-181. [PMID: 36645888 DOI: 10.7326/m22-0364] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Primary infection with or reactivation of Epstein-Barr virus (EBV) can occur after liver transplant (LT) and can lead to posttransplant lymphoproliferative disease (PTLD). In pediatric LT, an EBV-DNA viral load (EBV VL) monitoring strategy, including the reduction of immunosuppression, has led to a lower incidence of PTLD. For adult LT recipients with less primary infection and more EBV reactivation, it is unknown whether this strategy is effective. OBJECTIVE To examine the effect of an EBV VL monitoring strategy on the incidence of PTLD after LT in adults. DESIGN Cohort study. SETTING Two university medical centers in the Netherlands. PATIENTS Adult recipients of first LT in Leiden between September 2003 and January 2017 with an EBV VL monitoring strategy formed the monitoring group (M1), recipients of first LT in Rotterdam between January 2003 and January 2017 without such a strategy formed the contemporary control group (C1), and those who had transplants in Leiden between September 1992 and September 2003 or Rotterdam between 1986 and January 2003 formed the historical control groups (M0 and C0, respectively). MEASUREMENTS Influence of EBV VL monitoring on incidence of PTLD. RESULTS After inverse probability of treatment weighting of the 4 groups to achieve a balance among the groups for important patient characteristics, differences within hospitals between the historical and recent era in cumulative incidences-expressed as the number of events per 1000 patients measured at 5-, 10-, and 15-year follow-up-showed fewer events in the contemporary era in both centers. This difference was considerably larger in the monitoring center, whereas the 95% CI included the null value of 0 for point estimates. LIMITATION Retrospective, low statistical power, and incompletely balanced groups, and non-EBV PTLD cannot be prevented. CONCLUSION Monitoring EBV VL may reduce PTLD incidence after LT in adults; larger studies are warranted. PRIMARY FUNDING SOURCE None.
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Affiliation(s)
- Bastian N Ruijter
- Department of Gastroenterology and Hepatology, LUMC Transplant Center, Leiden University Medical Center, Leiden, the Netherlands (B.N.R., M.H., M.E.T., B.v.H.)
| | - Ron Wolterbeek
- Department of Biomedical Data Sciences, Medical Statistics, Leiden University Medical Center, Leiden, the Netherlands (R.W.)
| | - Mitchell Hew
- Department of Gastroenterology and Hepatology, LUMC Transplant Center, Leiden University Medical Center, Leiden, the Netherlands (B.N.R., M.H., M.E.T., B.v.H.)
| | - Marjolein van Reeven
- Department of Surgery, Erasmus MC Transplant Institute, Erasmus Medical Center, Rotterdam, the Netherlands (M.v.R.)
| | - Danny van der Helm
- Department of Gastroenterology and Hepatology and Department of Surgery, LUMC Transplant Center, Leiden University Medical Center, Leiden, the Netherlands (D.v.d.H.)
| | - Jeroen Dubbeld
- Department of Surgery, LUMC Transplant Center, Leiden University Medical Center, Leiden, the Netherlands (J.D.)
| | - Maarten E Tushuizen
- Department of Gastroenterology and Hepatology, LUMC Transplant Center, Leiden University Medical Center, Leiden, the Netherlands (B.N.R., M.H., M.E.T., B.v.H.)
| | - Herold Metselaar
- Department of Gastroenterology and Hepatology, Erasmus MC Transplant Institute, Erasmus Medical Center, Rotterdam, the Netherlands (H.M.)
| | - Ann C T M Vossen
- Department of Medical Microbiology, Leiden University Medical Center, Leiden, the Netherlands (A.C.T.M.V.)
| | - Bart van Hoek
- Department of Gastroenterology and Hepatology, LUMC Transplant Center, Leiden University Medical Center, Leiden, the Netherlands (B.N.R., M.H., M.E.T., B.v.H.)
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3
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Pediatric Infectious Diseases Related to Transplantation: Insights From Japan. Pediatr Infect Dis J 2023; 42:e18-e25. [PMID: 36476531 DOI: 10.1097/inf.0000000000003731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Infectious diseases after transplantation account for significant morbidity and mortality in children undergoing transplantation; the importance of pediatric transplant infectious disease (TID) specialists has therefore been recognized. Although tremendous advancement continues in transplantation medicine, pediatric-specific data and evidence are limited. In Japan, the majority of TIDs had not been managed by infectious disease specialists because pediatric infectious diseases have not been recognized as a solo subspecialty until recently in Japan. However, in the last decade, there was a new movement for pediatric TID in Japan; some pediatric infectious disease specialists trained outside Japan have been playing an important role in managing pediatric TID in a few academic and pediatric institutions. In this review article, we introduce the current status of infectious complications related to pediatric hematopoietic cell and solid organ transplantation, highlighting currently available local evidence, common practice and issues in the field of pediatric TID in Japan.
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4
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Yamada M, Sakamoto S, Sakamoto K, Uchida H, Shimizu S, Osumi T, Kato M, Shoji K, Arai K, Miyazaki O, Nakano N, Yoshioka T, Fukuda A, Kasahara M, Imadome KI. Fatal Epstein-Barr virus-associated hemophagocytic lymphohistiocytosis with virus-infected T cells after pediatric multivisceral transplantation: A proof-of-concept case report. Pediatr Transplant 2021; 25:e13961. [PMID: 33368911 DOI: 10.1111/petr.13961] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 11/28/2020] [Accepted: 12/07/2020] [Indexed: 01/17/2023]
Abstract
BACKGROUND EBV-associated HLH driven by EBV-infected CD8+ T cells is a rare complication after pediatric solid organ transplantation. The etiology and disease spectrum of post-transplant EBV-HLH are poorly understood, and making a precise diagnosis and providing optimal treatment remain a challenge. METHODS/CASE DESCRIPTION/RESULTS We report a 2-year-old multivisceral transplant recipient who developed fever and cytopenia with a persistent high EBV-load state. Repeated tissue examinations and CT scans could not identify a localized mass, which is the key to the diagnosis of PTLD as per the WHO classification. Hence, EBV-HLH was diagnosed by clinical manifestations as well as characterization of EBV-infected cells, pathological examination on cell block of pleural effusion and clonality analysis. This EBV-HLH did not respond to intensive chemotherapy, resulted in the recipient's death, acting similarly to hematological malignancy. CONCLUSIONS Characterization of EBV-infected cells in peripheral blood should be considered when persistent high EBV loads develop with symptoms consistent with PTLD, but no evidence of localized mass, and the tissue diagnosis is unavailable after pediatric solid organ transplantation.
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Affiliation(s)
- Masaki Yamada
- Department of Advanced Medicine for Viral Infections, National Center for Child Health and Development (NCCHD), Tokyo, Japan
| | | | | | | | | | - Tomoo Osumi
- Children's Cancer Center, NCCHD, Tokyo, Japan
| | | | - Kensuke Shoji
- Division of Infectious Diseases, NCCHD, Tokyo, Japan
| | | | | | | | | | | | | | - Ken-Ichi Imadome
- Department of Advanced Medicine for Viral Infections, National Center for Child Health and Development (NCCHD), Tokyo, Japan
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5
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Uchida H, Sakamoto S, Shimizu S, Takeda M, Yanagi Y, Fukuda A, Uchiyama T, Irie R, Kasahara M. Efficacy of Antithymocyte Globulin Treatment for Severe Centrilobular Injury Following Pediatric Liver Transplant: Clinical Significance of Monitoring Lymphocyte Subset. EXP CLIN TRANSPLANT 2020; 18:325-333. [PMID: 32281527 DOI: 10.6002/ect.2019.0387] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Central perivenulitis can occur in association with T-cell-mediated rejection and can sometimes require strong immunosuppressant therapy as refractory rejection. Furthermore, patients with central perivenulitis are more likely to have subsequent episodes of T-cell-mediated rejection and develop chronic rejection than those without central perivenulitis. We retrospectively analyzed clinical data of pediatric patients with episodes of T-cell-mediated rejection according to severity of central perivenulitis and monitored HLA-DR-positive CD8-positive T cells and recent thymic emigrants during treatment for T-cell-mediated rejection. MATERIALS AND METHODS We identified biopsy-proven T-cell-mediated rejection in 50 liver transplant recipients (45 with living-related donors, 5 with deceased donors) between September 2014 and August 2018. Lymphocyte subsets in peripheral blood samples were analyzed. RESULTS Of 50 pediatric patients, 30 were boys and 20 were girls (median age at transplant of 1.1 y; interquartile range, 0.6-6.2 y). Central perivenulitis was found in 46 patients (92%), which was mild in 13, moderate in 16, and severe in 17. Antithymocyte globulin was more frequently administered to patients with severe central perivenulitis than others (P < .05). Patients with antithymocyte globulin treatment were less likely to have subsequent episodes of T-cell-mediated rejection than those without this treatment (P < .05). The absolute number of CD8-positive HLA-DR-positive T cells in patients during treatment was significantly higher than in control patients (P < .05). The absolute number of recent thymic emigrants in patients with active infection was significantly lower than in patients without infection (P < .05). CONCLUSIONS Our results suggest the efficacy and safety of antithymocyte globulin for treating T-cell-mediated rejection with severe central perivenulitis in pediatric liver transplant recipients and suggest that antithymocyte globulin can prevent subsequent episodes of T-cell-mediated rejection. Analyzing lymphocyte subsets during treatment for rejection may help highlight viable therapeutic strategies for achieving a good outcome.
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Affiliation(s)
- Hajime Uchida
- From the Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
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6
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Althubaiti S, Ali S, Renzi S, Krueger J, Chiang KY, Schechter T, Punnett A, Ali M. Lymphocyte subset at time of Epstein-Barr viremia post-allogeneic hematopoietic stem cell transplantation in children may predict development of post-transplant lymphoproliferative disease: CD8:CD20 ratio as a sensitive predictor. Pediatr Transplant 2019; 23:e13574. [PMID: 31496046 DOI: 10.1111/petr.13574] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Revised: 07/31/2019] [Accepted: 08/05/2019] [Indexed: 11/27/2022]
Abstract
EBV-associated PTLD following allogeneic HSCT is a serious complication associated with significant mortality. In this retrospective study, we evaluated whether lymphocyte subset numbers and CD8:CD20 ratio at time of EBV viremia in children undergoing allogeneic HSCT could predict development of PTLD. Absolute lymphocyte count, lymphocyte subsets, and CD8:CD20 ratio at the time of EBV viremia were analyzed. Patients who were treated preemptively with rituximab for high blood EBV viral load were excluded. Out of 266 patients transplanted during the study period, 26 patients were included in the analysis. Patients were divided into two cohorts; cohort 1 included patients with EBV-associated PTLD (n = 5; four with proven, one with probable PTLD). Cohort 2 included patients with EBV viremia without PTLD (n = 21). Lymphocyte recovery was slower in the PTLD group. CD8:CD20 ratio was significantly lower in the PTLD group (median 0.15) compared to the non-PTLD group (median 2.4, P = .012). Using the ROC curve and 1 as the cutoff value, CD8:CD20 ratios were analyzed. In the PTLD group, 4/5 patients (80%) had a ratio <1 whereas in the non-PTLD group, all 21 patients had a ratio >1. Sensitivity and specificity were 80% and 100%, respectively. Negative and PPVs were 95% and 100%, respectively. Profoundly low T-cell count and CD8:CD20 ratio may be used to predict development of PTLD in the context of EBV viremia in children post-allogeneic HSCT. Further studies are needed to validate this finding.
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Affiliation(s)
- Sami Althubaiti
- Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada.,King Abdulaziz Medical City, Ministry of National Guard, Jeddah, Saudi Arabia
| | - Salah Ali
- Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Samuele Renzi
- Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Joerg Krueger
- Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada.,University of Toronto, Toronto, ON, Canada
| | - Kuang-Yueh Chiang
- Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada.,University of Toronto, Toronto, ON, Canada
| | - Tal Schechter
- Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada.,University of Toronto, Toronto, ON, Canada
| | - Angela Punnett
- Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada.,University of Toronto, Toronto, ON, Canada
| | - Muhammad Ali
- Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada.,University of Toronto, Toronto, ON, Canada
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7
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Nakanishi K, Kaito H, Ogi M, Takai D, Fujimura J, Horinouchi T, Yamamura T, Minamikawa S, Ninchoji T, Nozu K, Imadome KI, Iijima K. Three Severe Cases of Viral Infections with Post-Kidney Transplantation Successfully Confirmed by Polymerase Chain Reaction and Flow Cytometry. Case Rep Nephrol Dial 2018; 8:198-206. [PMID: 30397600 PMCID: PMC6206958 DOI: 10.1159/000493092] [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: 05/25/2018] [Accepted: 08/20/2018] [Indexed: 11/19/2022] Open
Abstract
Viral infections in patients with post-kidney transplantation are often difficult to diagnose as well as treat. We herein report three cases with severe viral infections after kidney transplantation. All their causative pathogens could be detected promptly by polymerase chain reaction and flow cytometry during the early stages of infection. These examinations would also be of great use to monitor therapeutic responses and disease activity. It is indeed true that no specific treatment is available for most of the viral infections, but we should be aware that some infections, such as Epstein-Barr virus infection, can be treatable with prompt and specific treatment, such as rituximab.
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Affiliation(s)
- Keita Nakanishi
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hiroshi Kaito
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Miki Ogi
- Hyogo Prefectural Institute of Public Health and Consumer Sciences Public Health Science Research Center, Kobe, Japan
| | - Denshi Takai
- Hyogo Prefectural Institute of Public Health and Consumer Sciences Public Health Science Research Center, Kobe, Japan
| | - Junya Fujimura
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Tomoko Horinouchi
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Tomohiko Yamamura
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Shogo Minamikawa
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Takeshi Ninchoji
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Kandai Nozu
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Ken-Ichi Imadome
- Division of Advanced Medicine for Virus Infections, National Center for Child Health and Development, Tokyo, Japan
| | - Kazumoto Iijima
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
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8
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Characteristics and Risk Factors of Late-onset Bloodstream Infection Beyond 6 Months After Liver Transplantation in Children. Pediatr Infect Dis J 2018; 37:263-268. [PMID: 28859015 DOI: 10.1097/inf.0000000000001754] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Bloodstream infection (BSI) is a major cause of morbidity and mortality after pediatric liver transplantation (LT). However, most studies have focused on BSI occurring within a few months after LT. In this study, we evaluated the characteristics of BSI occurring beyond 6 months after pediatric LT. METHODS We conducted a retrospective cohort study at a pediatric LT center in Japan from November 2005 to March 2016. We evaluated the causative organisms and site of late-onset BSI in children ≤ 18 years of age. The risk factors for developing late-onset BSI and the associations of late-onset BSI with long-term outcomes were also evaluated. RESULTS Three hundred forty cases of LT were evaluated. Thirty-eight BSI developed in 29 (9%) LT recipients. There were 42 organisms (nine Gram-positive cocci, 33 Gram-negative rods) isolated from the blood cultures of recipients with late-onset BSI. The most frequent sites of late-onset BSI was intraabdominal infection (18/38; 47%). There were also 14 (39%) episodes with no apparent focus. In multivariate analysis, a prolonged operative time > 12 hours (odds ratio [OR] = 3.55; P = 0.04) and biliary stenosis (OR = 4.60; P = 0.006) were independent risk factors for developing late-onset BSI. Late-onset BSI was associated with increased retransplantation rate (P = 0.04) and mortality (P < 0.001). CONCLUSION Late-onset BSI developed in 9% of recipients after pediatric LT. Gram-negative rods accounted for the majority of late-onset BSI as a consequence of abdominal infection, but the focus was often unclear. Prolonged operative time at LT and biliary stenosis were independent risk factors for developing late-onset BSI.
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9
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Kullberg-Lindh C, Saalman R, Olausson M, Herlenius G, Lindh M. Epstein-Barr virus DNA monitoring in serum and whole blood in pediatric liver transplant recipients who do or do not discontinue immunosuppressive therapy. Pediatr Transplant 2017; 21. [PMID: 28039929 DOI: 10.1111/petr.12875] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/23/2016] [Indexed: 12/17/2022]
Abstract
The rate of PTLD can be reduced by weaned IS guided by monitoring of EBV DNA. In this single-center retrospective case series study, we analyzed how reduction in IS influenced EBV DNA levels in whole blood and serum in 30 children during the first year after liver transplantation, and how these levels were related to symptoms putatively due to EBV. Primary and reactivated EBV infection was seen in 18 (60%) and eight patients (27%), respectively. Thirteen patients (42%) developed chronic high load the first year post-transplant. IS was successfully discontinued in six patients the first year post-transplant and in another two patients within 3 years. EBV DNA levels were reduced, but persisted long term in all the eight patients who had IS completely withdrawn. There was no case of PTLD. In summary, EBV DNAemia and chronic high load were very common after pediatric liver transplantation. Liver graft tolerance facilitates radical reduction in IS treatment, which may prevent PTLD, but EBV DNAemia may persist long term after discontinued IS.
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Affiliation(s)
- C Kullberg-Lindh
- Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - R Saalman
- Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - M Olausson
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - G Herlenius
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - M Lindh
- Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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10
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Kasahara M, Sakamoto S, Sasaki K, Uchida H, Kitajima T, Shigeta T, Narumoto S, Hirata Y, Fukuda A. Living donor liver transplantation during the first 3 months of life. Liver Transpl 2017; 23:1051-1057. [PMID: 28220684 DOI: 10.1002/lt.24743] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Revised: 01/08/2017] [Accepted: 01/27/2017] [Indexed: 12/28/2022]
Abstract
Living donor liver transplantation (LDLT) is now an established technique for treating children with end-stage liver disease. Few data exist about liver transplantation (LT) for exclusively young infants, especially infants of <3 months of age. We report our single-center experience with 12 patients in which LDLT was performed during the first 3 months of life and compare the results with those of older infants who underwent LT. All of the patients were treated at the National Center of Child Health and Development, Tokyo, Japan. Between November 2005 to November 2016, 436 children underwent LT. Twelve of these patients underwent LT in the first 3 months of life (median age, 41 days; median weight, 4.0 kg). The indications for transplantation were fulminant hepatic failure (n = 11) and metabolic liver disease (n = 1). All the patients received the left lateral segment (LLS) in situ to mitigate the problem of graft-to-recipient size discrepancy. A reduced LLS graft was used in 11 patients and a segment 2 monosegment graft was used in 1 patient. We compared the results with those of infants who were 4-6 months of age (n = 67) and 7-12 months of age (n = 110) who were treated in the same study period. There were significant differences in the Pediatric End-Stage Liver Disease score and the conversion rate of tacrolimus to cyclosporine in younger infants. Furthermore, the incidence of biliary complications, bloodstream infection, and cytomegalovirus infection tended to be higher, whereas the incidence of acute cellular rejection tended to be lower in younger infants. The overall cumulative 10-year patient and graft survival rates in recipients of <3 months of age were both 90.9%. LDLT during the first 3 months of life appears to be a feasible option with excellent patient and graft survival. Liver Transplantation 23 1051-1057 2017 AASLD.
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Affiliation(s)
- Mureo Kasahara
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Seisuke Sakamoto
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Kengo Sasaki
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Hajime Uchida
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Toshihiro Kitajima
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Takanobu Shigeta
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Soichi Narumoto
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Yoshihiro Hirata
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Akinari Fukuda
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
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11
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Dharnidharka VR. Peripheral Blood Epstein-Barr Viral Nucleic Acid Surveillance as a Marker for Posttransplant Cancer Risk. Am J Transplant 2017; 17:611-616. [PMID: 27458691 DOI: 10.1111/ajt.13982] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 07/17/2016] [Accepted: 07/18/2016] [Indexed: 01/25/2023]
Abstract
Several viruses, such as Epstein-Barr virus, are now known to be associated with several human cancers, but not all patients with these viral infections develop cancer. In transplantation, such viruses often have a prolonged time gap from infection to cancer development, and many are preceded by a period of circulating and detectable nucleic acids in the peripheral blood compartment. The interpretation of a viral load as a measure of posttransplant risk of developing cancer depends on the virus, the cancer and associated pathogenic factors. This review describes the current state of knowledge regarding the utility and limitations of peripheral blood nucleic acid testing for Epstein-Barr virus in surveillance and risk prediction for posttransplant lymphoproliferative disorders.
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Affiliation(s)
- V R Dharnidharka
- Division of Pediatric Nephrology, Washington University School of Medicine and St. Louis Children's Hospital, St. Louis, MO
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12
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Matsuda G, Imadome KI, Kawano F, Mochizuki M, Ochiai N, Morio T, Shimizu N, Fujiwara S. Cellular immunotherapy with ex vivo expanded cord blood T cells in a humanized mouse model of EBV-associated lymphoproliferative disease. Immunotherapy 2016; 7:335-41. [PMID: 25917625 DOI: 10.2217/imt.15.2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Donor lymphocyte infusion is not feasible in recipients of cord blood transplantation. AIM We investigated whether infusion of T cells expanded from cord blood is effective in the treatment of model mice of Epstein-Barr virus (EBV)-associated lymphoproliferative disease (LPD). MATERIALS & METHODS Humanized mice with reconstituted human immune system were prepared and LPD was induced by inoculating EBV intravenously. T cells were expanded from the same sample of cord blood as used for generation of humanized mice and infused to EBV-infected humanized mice. RESULTS Mice treated with expanded cord blood T cells lived significantly longer than control mice (p = 0.036). CONCLUSION Infusion of T cells expanded from cord blood was effective in the treatment of model mice for EBV-associated LPD.
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Affiliation(s)
- Go Matsuda
- Department of Infectious Diseases, National Research Institute for Child Health & Development, 2-10-1 Okura, Setagaya-ku, Tokyo 157-8535, Japan
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13
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Nakazawa A, Nakano N, Fukuda A, Sakamoto S, Imadome KI, Kudo T, Matsuoka K, Kasahara M. Use of serial assessment of disease severity and liver biopsy for indication for liver transplantation in pediatric Epstein-Barr virus-induced fulminant hepatic failure. Liver Transpl 2015; 21:362-8. [PMID: 25452116 DOI: 10.1002/lt.24052] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Accepted: 11/14/2014] [Indexed: 02/07/2023]
Abstract
The decision to perform liver transplantation (LT) in patients with Epstein-Barr virus (EBV)-induced fulminant hepatic failure (FHF) relies on a precise assessment of laboratory and pathological findings. In this study, we analyzed clinical and laboratory data as well as the pathological features of the liver in order to evaluate the pathogenesis and the need for LT in 5 patients with EBV-induced FHF. According to the King's College criteria, the Acute Liver Failure Early Dynamic (ALFED) model, and the Japanese criteria (from the Acute Liver Failure Study Group of Japan), only 1 patient was considered to be a candidate for LT. However, explanted liver tissues in 3 cases exhibited massive hepatocellular necrosis together with diffuse CD8-positive T cell infiltration in both the portal area and the sinusoid. EBV was detected in the liver, plasma, and peripheral blood mononuclear cells (PBMNCs). In 2 cases indicated to be at moderate risk by the ALFED model, liver biopsy showed CD8-positive and EBV-encoded RNA signal-positive lymphocytic infiltration predominantly in the portal area, but massive hepatocellular necrosis was not observed. These patients were treated with immunosuppressants and etoposide under the diagnosis of EBV-induced hemophagocytic lymphohistiocytosis or systemic EBV-positive T cell lymphoproliferative disease of childhood. EBV DNA was detected at a high level in PBMNCs, although it was negative in plasma. On the basis of the pathological analysis of the explanted liver tissues, LT was proposed for the restoration of liver function and the removal of the EBV-infected lymphocytes concentrated in the liver. Detecting EBV DNA by a quantitative polymerase chain reaction in plasma and PBMNCs was informative. An accurate evaluation of the underlying pathogenesis is essential for developing a treatment strategy in patients with EBV-induced FHF.
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Affiliation(s)
- Atsuko Nakazawa
- Departments of Pathology, National Research Institute for Child Health and Development, Tokyo, Japan
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14
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Fukuda A, Imadome KI, Sakamoto S, Shigeta T, Uchida H, Matsunami M, Sasaki K, Kanazawa H, Kawano F, Nakazawa A, Fujiwara S, Kasahara M. Evaluation of the immune function assay in pediatric living donor liver transplantation. Pediatr Transplant 2015; 19:144-52. [PMID: 25418834 DOI: 10.1111/petr.12402] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/29/2014] [Indexed: 12/22/2022]
Abstract
The immune function (ImmuKnow) assay is a measure of cell-mediated immunity based on the peripheral CD4+ T cell ATP activity. The efficacy of ImmuKnow in pediatric LDLT is not well documented. The aim of this study was to assess the correlations between the ImmuKnow and the clinical status in pediatric LDLT recipients. A total of 716 blood samples were obtained from 60 pediatric LDLT recipients (one month to 16 yr of age). The recipient's status was classified as follows: stable, infection, or rejection. The ImmuKnow values in the pediatric LDLT recipients with a clinically stable status had a lower immune response (IQR 85-297 ATP ng/mL) than that previously reported in adults. Meanwhile, the ImmuKnow values of the stable patients were not correlated with age. Furthermore, a significant difference was found in the ImmuKnow values between the bacterial or fungal infection and stable groups, but not between the CMV or EBV infection and stable groups. The ImmuKnow levels in the pediatric LDLT were lower than those observed in the adult LDLT. The proposed reference value is between 85 and 297 ATP ng/mL in pediatric LDLT recipients. We conclude that the ImmuKnow assay could be helpful for monitoring pediatric LDLT recipients with bacterial or fungal infections.
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Affiliation(s)
- Akinari Fukuda
- Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
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15
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Hosoi H, Sonoki T, Murata S, Mushino T, Kuriyama K, Nishikawa A, Hanaoka N, Ohshima K, Imadome KI, Nakakuma H. Successful Immunosuppressive Therapy for Severe Infectious Mononucleosis in a Patient with Clonal Proliferation of EBV-infected CD8-positive Cells. Intern Med 2015; 54:1537-41. [PMID: 26073246 DOI: 10.2169/internalmedicine.54.3201] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 30-year-old woman was diagnosed with severe infectious mononucleosis (IM). The Epstein-Barr virus (EBV) had infected both CD19- and CD8-positive cells, and clonal proliferation of EBV-infected cells and T-cells was detected. Although we suspected malignant lymphoma, her condition improved following immunosuppressive therapy. A similar case was recently reported; therefore, this case is the second case of IM with EBV-infected CD8-positive cells and clonal proliferation of EBV-infected cells. Our results demonstrate that the clonal proliferation of EBV-infected cells is not always an indication for chemotherapy in the primary infection phase and that monitoring the EBV viral load is useful for therapeutic decision-making.
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Affiliation(s)
- Hiroki Hosoi
- Hematology/Oncology, Wakayama Medical University, Japan
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16
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Shigeta T, Sakamoto S, Uchida H, Sasaki K, Hamano I, Kanazawa H, Fukuda A, Kawai T, Onodera M, Nakazawa A, Kasahara M. Basiliximab treatment for steroid-resistant rejection in pediatric patients following liver transplantation for acute liver failure. Pediatr Transplant 2014; 18:860-7. [PMID: 25311536 DOI: 10.1111/petr.12373] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/05/2014] [Indexed: 01/08/2023]
Abstract
An IL-2 receptor antagonist, basiliximab, decreases the frequency of ACR in liver transplant (LT) recipients as induction therapy. The aim of this study was to evaluate the effectiveness of basiliximab against SRR as rescue therapy in pediatric LT patients with ALF. Forty pediatric ALF patients underwent LT between November 2005 and July 2013. Among them, seven patients suffering from SRR were enrolled in this study. The median age at LT was 10 months (6-12 months). SRR was defined as the occurrence of refractory rejection after more than two courses of steroid pulse therapy. Basiliximab was administered to all patients. The withdrawal of steroids without deterioration of the liver function was achieved in six patients treated with basiliximab therapy without patient mortality, although one patient developed graft loss and required retransplantation for veno-occlusive disease. The pathological examinations of liver biopsies in the patients suffering from SRR revealed severe centrilobular injuries, particularly fibrosis within one month after LT. We demonstrated the effectiveness and safety of rescue therapy consisting of basiliximab for SRR in pediatric LT recipients with ALF.
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Affiliation(s)
- Takanobu Shigeta
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
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17
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Lauro A, Arpinati M, Pinna AD. Managing the challenge of PTLD in liver and bowel transplant recipients. Br J Haematol 2014; 169:157-72. [DOI: 10.1111/bjh.13213] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Accepted: 10/01/2014] [Indexed: 12/22/2022]
Affiliation(s)
- Augusto Lauro
- General Surgery and Transplant Unit; Department of Hematology & Oncological Sciences ‘Seragnoli’; Sant'Orsola-Malpighi University Hospital; Bologna Italy
| | - Mario Arpinati
- General Surgery and Transplant Unit; Department of Hematology & Oncological Sciences ‘Seragnoli’; Sant'Orsola-Malpighi University Hospital; Bologna Italy
| | - Antonio D. Pinna
- General Surgery and Transplant Unit; Department of Hematology & Oncological Sciences ‘Seragnoli’; Sant'Orsola-Malpighi University Hospital; Bologna Italy
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18
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Marques HHDS, Shikanai-Yasuda MA, Azevedo LSFD, Caiaffa-Filho HH, Pierrotti LC, Aquino MZD, Lopes MH, Maluf NZ, Campos SV, Costa SF. Management of post-transplant Epstein-Barr virus-related lymphoproliferative disease in solid organ and hematopoietic stem cell recipients. Rev Soc Bras Med Trop 2014; 47:543-6. [DOI: 10.1590/0037-8682-0036-2014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Accepted: 07/30/2014] [Indexed: 12/18/2022] Open
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Maguire O, Tario JD, Shanahan TC, Wallace PK, Minderman H. Flow cytometry and solid organ transplantation: a perfect match. Immunol Invest 2014; 43:756-74. [PMID: 25296232 PMCID: PMC4357273 DOI: 10.3109/08820139.2014.910022] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
In the field of transplantation, flow cytometry serves a well-established role in pre-transplant crossmatching and monitoring immune reconstitution following hematopoietic stem cell transplantation. The capabilities of flow cytometers have continuously expanded and this combined with more detailed knowledge of the constituents of the immune system, their function and interaction and newly developed reagents to study these parameters have led to additional utility of flow cytometry-based analyses, particularly in the post-transplant setting. This review discusses the impact of flow cytometry on managing alloantigen reactions, monitoring opportunistic infections and graft rejection and gauging immunosuppression in the context of solid organ transplantation.
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Affiliation(s)
- Orla Maguire
- Laboratory of Flow and Image Cytometry, Department of Pathology and Laboratory Medicine, Roswell Park Cancer Institute, Buffalo, New York, USA
| | - Joseph D. Tario
- Laboratory of Flow and Image Cytometry, Department of Pathology and Laboratory Medicine, Roswell Park Cancer Institute, Buffalo, New York, USA
| | - Thomas C. Shanahan
- Department of Microbiology and Immunology, State University of New York at Buffalo, Buffalo, New York, USA
| | - Paul K. Wallace
- Laboratory of Flow and Image Cytometry, Department of Pathology and Laboratory Medicine, Roswell Park Cancer Institute, Buffalo, New York, USA
| | - Hans Minderman
- Laboratory of Flow and Image Cytometry, Department of Pathology and Laboratory Medicine, Roswell Park Cancer Institute, Buffalo, New York, USA
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21
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Hussein K, Tiede C, Maecker-Kolhoff B, Kreipe H. Posttransplant lymphoproliferative disorder in pediatric patients. Pathobiology 2013; 80:289-96. [PMID: 24013821 DOI: 10.1159/000350331] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Transplantation of solid organs and hematopoietic stem cells is accompanied by profound disturbance of immune function mediated by immunosuppressive drugs or delayed immune reconstitution. Disturbed T cell control of Epstein-Barr virus (EBV)-infected B cells leads to posttransplant lymphoproliferative disorder (PTLD) in up to 10% of patients. Children are at a higher risk because they are more often EBV-naïve before transplantation. Patients with PTLD often present with unspecific symptoms (pain and organ/graft dysfunction). Depending on the onset of PTLD, manifestations vary between mainly nodal (late PTLD) and extranodal sites (early PTLD). Histology, immunohistology, EBER in situ hybridization and molecular pathology are required for diagnosis and subclassification of PTLD. The three major types are early lesions (resembling reactive proliferations in immunocompetent patients), polymorphic PTLD (proliferation of B and T cells with effacement of histoarchitecture) and monomorphic PTLD (presenting as malignant lymphomas, mainly high-grade B cell lymphomas). In a subfraction of cases, including monomorphic PTLD, reduction of immunosuppressive medication alone is sufficient to induce remission. Surgical debulking of tumor mass and anti-CD20-antibody treatment with or without chemotherapy (usually at lower dosages than in immunocompetent patients) constitute the basis of additional therapy.
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Affiliation(s)
- Kais Hussein
- Institute of Pathology, Hannover Medical School, Hannover, Germany
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