Background:

EBV D+/R- organ transplant recipients are a high risk group for developing PTLD. This subgroup of patients has been primarily evaluated in pediatric populations with substantially less data available about the clinical and virologic outcomes in EBV D+/R- adult transplant recipients.

Methods:

Adult EBV D+/R- patients transplanted from Jan 2002-Dec 2013 were identified via a retrospective cohort study. Demographics, transplant type, immunosuppression (IS), antiviral prophylaxis, monitoring strategies, and viral load (VL) data were collected. Clinical and virologic outcomes were evaluated including development of PTLD and rates of EBV viremia. In a subset of patients who received a specific therapeutic intervention for high VL (antivirals or a reduction in IS), detailed viral kinetics were analyzed.

Results:

We identified 127 adult D+/R- patients. Mean age was 42.5±14.0 yrs. Transplant types were kidney(n=37), liver(n=21), lung(n=48), heart(n=6), and combined (n=15). Of these, 84.7% patients received antiviral prophylaxis with valganciclovir for a median of 5 months (range 1-22 months) and 55.1% underwent VL monitoring in the first post-transplant year (defined as at least 6 VLs in the 1st year post-tx). EBV viremia developed in 56/70 (80%) monitored patients. IS was reduced in 23/56 (41.1%) in response to viremia and 23/56 (41.1%) received therapeutic dose (val)ganciclovir. In patients with EBV viremia who received (val)ganciclovir and/or had a reduction in IS and had sufficient viral load time points (n=24), 20 (83%) had a significant decline in viral load at day 14 (median log decline 0.47 (0.06-1.44), p<0.001) and at day 30 (0.90 (0.34-2.8), p<0.001). However, rebound viremia occurred in 15/20 (75%). PTLD developed in 19 (15%) patients (biopsy proven=16, possible=3) at median 0.65 (range 0.2-8.7) years post-transplant with the majority (84.2%) within the first year. Factors associated with PTLD were receipt of lung transplant (p=0.002) and use of azathiaprine (p=0.02) . MMF use was associated with a significantly lower risk of PTLD (p<0.001). EBV VLs were associated with PTLD (median peak VL in PTLD vs. no PTLD was 138025 vs. 13899, p=0.004). Monitoring or use of antiviral prophylaxis was not associated with a lower rate of PTLD.

Conclusion:

This study provides important data on the epidemiology of PTLD in adult EBV D+/R- patients. Antiviral prophylaxis and a VL monitoring strategy were not associated with a lower risk of PTLD. Viral load kinetic analysis revealed only a transient response to therapeutic interventions.

« Back to 2015 American Transplant Congress