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Asleh R, Alnsasra H, Habermann TM, Briasoulis A, Kushwaha SS. Post-transplant Lymphoproliferative Disorder Following Cardiac Transplantation. Front Cardiovasc Med 2022; 9:787975. [PMID: 35282339 PMCID: PMC8904724 DOI: 10.3389/fcvm.2022.787975] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 02/01/2022] [Indexed: 11/24/2022] Open
Abstract
Post-transplant lymphoproliferative disorder (PTLD) is a spectrum of lymphoid conditions frequently associated with the Epstein Barr Virus (EBV) and the use of potent immunosuppressive drugs after solid organ transplantation. PTLD remains a major cause of long-term morbidity and mortality following heart transplantation (HT). Epstein-Barr virus (EBV) is a key pathogenic driver in many PTLD cases. In the majority of PTLD cases, the proliferating immune cell is the B-cell, and the impaired T-cell immune surveillance against infected B cells in immunosuppressed transplant patients plays a key role in the pathogenesis of EBV-positive PTLD. Preventive screening strategies have been attempted for PTLD including limiting patient exposure to aggressive immunosuppressive regimens by tailoring or minimizing immunosuppression while preserving graft function, anti-viral prophylaxis, routine EBV monitoring, and avoidance of EBV seromismatch. Our group has also demonstrated that conversion from calcineurin inhibitor to the mammalian target of rapamycin (mTOR) inhibitor, sirolimus, as a primary immunosuppression was associated with a decreased risk of PTLD following HT. The main therapeutic measures consist of immunosuppression reduction, treatment with rituximab and use of immunochemotherapy regimens. The purpose of this article is to review the potential mechanisms underlying PTLD pathogenesis, discuss recent advances, and review potential therapeutic targets to decrease the burden of PTLD after HT.
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Affiliation(s)
- Rabea Asleh
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, United States
- Heart Institute, Hadassah University Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Hilmi Alnsasra
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, United States
- Soroka University Medical Center, Ben Gurion University of the Negev, Beer Sheva, Israel
| | - Thomas M. Habermann
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, United States
| | - Alexandros Briasoulis
- Division of Cardiovascular Disease, University of Iowa Hospitals and Clinics, Iowa City, IA, United States
| | - Sudhir S. Kushwaha
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, United States
- *Correspondence: Sudhir S. Kushwaha
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Fulchiero R, Amaral S. Post-transplant lymphoproliferative disease after pediatric kidney transplant. Front Pediatr 2022; 10:1087864. [PMID: 36568415 PMCID: PMC9768432 DOI: 10.3389/fped.2022.1087864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 11/22/2022] [Indexed: 12/12/2022] Open
Abstract
Post-transplant lymphoproliferative disease (PTLD) is the most common malignancy complicating solid organ transplantation (SOT) in adults and children. PTLD encompasses a spectrum of histopathologic features and organ involvement, ranging from benign lymphoproliferation and infectious-mononucleosis like presentation to invasive neoplastic processes such as classical Hodgkin lymphoma. The predominant risk factors for PTLD are Epstein-Barr virus (EBV) serostatus at the time of transplant and the intensity of immunosuppression following transplantation; with EBV-negative recipients of EBV-positive donor organs at the highest risk. In children, PTLD commonly presents in the first two years after transplant, with 80% of cases in the first year, and over 90% of cases associated with EBV-positive B-cell proliferation. Though pediatric kidney transplant recipients are at lower risk (1-3%) for PTLD compared to their other SOT counterparts, there is still a significant risk of morbidity, allograft failure, and an estimated 5-year mortality rate of up to 50%. In spite of this, there is no consensus for monitoring of at-risk patients or optimal management strategies for pediatric patients with PTLD. Here we review pathogenesis and risk factors for the development of PTLD, with current practices for prevention, diagnosis, and management of PTLD in pediatric kidney transplant recipients. We also highlight emerging concepts, current research gaps and potential future developments to improve clinical outcomes and longevity in these patients.
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Affiliation(s)
- Rosanna Fulchiero
- Department of Nephrology, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Sandra Amaral
- Department of Nephrology, Children's Hospital of Philadelphia, Philadelphia, PA, United States.,Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA, United States
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Baker A, Frauca Remacha E, Torres Canizales J, Bravo-Gallego LY, Fitzpatrick E, Alonso Melgar A, Muñoz Bartolo G, Garcia Guereta L, Ramos Boluda E, Mozo Y, Broniszczak D, Jarmużek W, Kalicinski P, Maecker-Kolhoff B, Carlens J, Baumann U, Roy C, Chardot C, Benetti E, Cananzi M, Calore E, Dello Strologo L, Candusso M, Lopes MF, Brito MJ, Gonçalves C, Do Carmo C, Stephenne X, Wennberg L, Stone R, Rascon J, Lindemans C, Turkiewicz D, Giraldi E, Nicastro E, D’Antiga L, Ackermann O, Jara Vega P. Current Practices on Diagnosis, Prevention and Treatment of Post-Transplant Lymphoproliferative Disorder in Pediatric Patients after Solid Organ Transplantation: Results of ERN TransplantChild Healthcare Working Group Survey. CHILDREN (BASEL, SWITZERLAND) 2021; 8:children8080661. [PMID: 34438552 PMCID: PMC8394841 DOI: 10.3390/children8080661] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 07/19/2021] [Accepted: 07/20/2021] [Indexed: 12/25/2022]
Abstract
(1) Background: Post-transplant lymphoproliferative disease (PTLD) is a significant complication of solid organ transplantation (SOT). However, there is lack of consensus in PTLD management. Our aim was to establish a present benchmark for comparison between international centers and between various organ transplant systems and modalities; (2) Methods: A cross-sectional questionnaire of relevant PTLD practices in pediatric transplantation was sent to multidisciplinary teams from 17 European center members of ERN TransplantChild to evaluate the centers’ approach strategies for diagnosis and treatment and how current practices impact a cross-sectional series of PTLD cases; (3) Results: A total of 34 SOT programs from 13 European centers participated. The decision to start preemptive treatment and its guidance was based on both EBV viremia monitoring plus additional laboratory methods and clinical assessment (61%). Among treatment modalities the most common initial practice at diagnosis was to reduce the immunosuppression (61%). A total of 126 PTLD cases were reported during the period 2012–2016. According to their histopathological classification, monomorphic lesions were the most frequent (46%). Graft rejection after PTLD remission was 33%. Of the total cases diagnosed with PTLD, 88% survived; (4) Conclusions: There is still no consensus on prevention and treatment of PTLD, which implies the need to generate evidence. This might successively allow the development of clinical guidelines.
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Affiliation(s)
- Alastair Baker
- Paediatric Liver, Gastrointestinal and Nutrition Centre, School of Medicine, King’s College Hospital, King’s College London, Denmark Hill, London SE5 9RS, UK; (A.B.); (E.F.)
| | - Esteban Frauca Remacha
- Servicio de Hepatología Pediátrica, Hospital Universitario La Paz, 28046 Madrid, Spain; (E.F.R.); (G.M.B.); (P.J.V.)
| | - Juan Torres Canizales
- Lymphocyte Pathophysiology in Immunodeficiencies Group, La Paz Institute of Biomedical Research (IdiPAZ), Hospital Universitario La Paz and Center for Biomedical Network Research on Rare Diseases (CIBERER U767), 28046 Madrid, Spain;
| | - Luz Yadira Bravo-Gallego
- Lymphocyte Pathophysiology in Immunodeficiencies Group, La Paz Institute of Biomedical Research (IdiPAZ), Hospital Universitario La Paz and Center for Biomedical Network Research on Rare Diseases (CIBERER U767), 28046 Madrid, Spain;
- Correspondence: ; Tel.: +34-917277576
| | - Emer Fitzpatrick
- Paediatric Liver, Gastrointestinal and Nutrition Centre, School of Medicine, King’s College Hospital, King’s College London, Denmark Hill, London SE5 9RS, UK; (A.B.); (E.F.)
| | - Angel Alonso Melgar
- Servicio de Nefrología Pediátrica, Hospital Universitario La Paz, 28046 Madrid, Spain;
| | - Gema Muñoz Bartolo
- Servicio de Hepatología Pediátrica, Hospital Universitario La Paz, 28046 Madrid, Spain; (E.F.R.); (G.M.B.); (P.J.V.)
| | - Luis Garcia Guereta
- Servicio de Cardiología Pediátrica, Hospital Universitario La Paz, 28046 Madrid, Spain;
| | - Esther Ramos Boluda
- Pediatric Gastroenterology Intestinal Rehabilitation Unit, University Hospital La Paz, 28046 Madrid, Spain;
| | - Yasmina Mozo
- Pediatric Hemato-Oncology Department, Hospital Universitario La Paz, 28046 Madrid, Spain;
| | - Dorota Broniszczak
- Department of Pediatric Surgery and Organ Transplantation, Children’s Memorial Health Institute, 04-730 Warsaw, Poland; (D.B.); (P.K.)
| | - Wioletta Jarmużek
- Department of Nephrology and Kidney Transplantation, Children’s Memorial Health Institute, 04-730 Warsaw, Poland;
| | - Piotr Kalicinski
- Department of Pediatric Surgery and Organ Transplantation, Children’s Memorial Health Institute, 04-730 Warsaw, Poland; (D.B.); (P.K.)
| | - Britta Maecker-Kolhoff
- Department of Pediatric Hematology and Oncology, Hannover Medical School, 30625 Hannover, Germany;
| | - Julia Carlens
- Clinic for Paediatric Pneumology, Allergology, and Neonatology, Hannover Medical School, 30625 Hannover, Germany;
| | - Ulrich Baumann
- Division of Paediatric Gastroenterology and Hepatology, Children’s Hospital, Hannover Medical School, 30625 Hannover, Germany;
| | - Charlotte Roy
- Service de Pneumologie Pédiatrique, Hôpital Necker-Enfants Malades, AP-HP, Université Paris, 75015 Paris, France;
| | - Christophe Chardot
- Service de Chirurgie Pédiatrique, Hôpital Necker-Enfants Malades, AP-HP, Université Paris Descartes, 75015 Paris, France;
| | - Elisa Benetti
- Pediatric Nephrology, Dialysis and Transplant Unit, Department of Women’s and Children’s Health, Azienda Ospedaliera di Padova, 35128 Padova, Italy;
| | - Mara Cananzi
- Unit of Paediatric Gastroenterology, Digestive Endoscopy, Hepatology and Care of the Child with Liver Transplantation, Department of Women’s and Children’s Health, Azienda Ospedaliera di Padova, 35128 Padova, Italy;
| | - Elisabetta Calore
- Unit of Paediatric Onco-Haematology, Department of Women’s and Children’s Health, Azienda Ospedaliera di Padova, 35128 Padova, Italy;
| | - Luca Dello Strologo
- Nephrology Unit, Bambino Gesù Children’s Research Hospital, IRCCS, 00165 Rome, Italy;
| | - Manila Candusso
- Department of Hepatology and Gastroenterology, Bambino Gesù Children Hospital, 00165 Rome, Italy;
| | - Maria Francelina Lopes
- Department of Paediatric Surgery, Centro Hospitalar e Universitário de Coimbra, and Faculty of Medicine, University of Coimbra, 3000-075 Coimbra, Portugal;
| | - Manuel João Brito
- Department of Paediatric Oncology and Centro de Investigação e Formação Clínica, Hospital Pediátrico, Centro Hospitalar e Universitário de Coimbra, 3000-075 Coimbra, Portugal;
| | - Cristina Gonçalves
- Paediatric Liver Transplant Unit, Centro Hospitalar e Universitário de Coimbra, 3000-075 Coimbra, Portugal;
| | - Carmen Do Carmo
- Paediatric Nephrology Unit, Hospital Pediátrico, Centro Hospitalar e Universitário de Coimbra, 3000-075 Coimbra, Portugal;
| | - Xavier Stephenne
- Laboratoire d’Hépatologie Pédiatrique et Thérapie Cellulaire, Unité PEDI, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain (UCLouvain), 1200 Brussels, Belgium;
| | - Lars Wennberg
- Department of Transplantation Surgery, Karolinska University Hospital, 171 76 Stockholm, Sweden;
| | - Rosário Stone
- Unidade de Nefrologia e Transplantação Renal, Serviço de Pediatria Médica, Departamento de Pediatria, Hospital de Santa Maria, Centro Académico de Medicina, Universidade de Lisboa, 1649-028 Lisboa, Portugal;
| | - Jelena Rascon
- Centre for Paediatric Oncology and Haematology, Vilnius University Hospital Santaros Klinikos, 08406 Vilnius, Lithuania;
| | - Caroline Lindemans
- Princess Maxima Center for Pediatric Oncology, Pediatric Blood and Marrow Transplantation Program, University Medical Center Utrecht, Utrecht University, 3584 CS Utrecht, The Netherlands;
| | - Dominik Turkiewicz
- Department of Pediatrics, Skåne University Hospital, 222 42 Lund, Sweden;
| | - Eugenia Giraldi
- Pediatric Oncology, Hospital Papa Giovanni XXIII, 24127 Bergamo, Italy;
| | - Emanuele Nicastro
- Pediatric Hepatology, Gastroenterology and Transplantation, Hospital Papa Giovanni XXIII, 24127 Bergamo, Italy; (E.N.); (L.D.)
| | - Lorenzo D’Antiga
- Pediatric Hepatology, Gastroenterology and Transplantation, Hospital Papa Giovanni XXIII, 24127 Bergamo, Italy; (E.N.); (L.D.)
| | - Oanez Ackermann
- Pediatric Hepatology, National Centre for Biliary Atresia, Université París-Saclay, APHP, Hôpital Bicêtre, 94270 Le Kremlin-Bicêtre, France;
| | - Paloma Jara Vega
- Servicio de Hepatología Pediátrica, Hospital Universitario La Paz, 28046 Madrid, Spain; (E.F.R.); (G.M.B.); (P.J.V.)
- La Paz Institute of Biomedical Research, IdiPAZ, Hospital Universitario La Paz, 28046 Madrid, Spain
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