*Purpose: The use of lymphocyte depleting agents (LDA) for induction immunosuppression among renal transplant (tx) recipients raises concern for the increased susceptibility to viral infections, especially in the seronegative [sero(-)] pediatric patients (ped pts). Here, we examine the rates of Epstein-Barr virus (EBV) viremia among ped pts receiving induction immunosuppression with LDA and non-LDA (NLDA) and assess their ability to mount EBV-specific cytotoxic T-cell (EBV-Tc) response.

*Methods: Twenty-four ped tx pts who received induction with either LDA (anti-thymocyte globulin or alemtuzumab) or NLDA (anti-IL-2R), maintained on mycophenolate mofetil (MMF), tacrolimus, with or without steroids, and had EBV-Tc testing by intracellular IFNγ flow cytometry were included. EBV-PCR monitoring was performed monthly for the first 12M for EBV high risk group (D+/R-), and every 3M for all other groups. EBV-PCR cut off for positivity was >5 copies/PCR. All patients with EBV viremia underwent reduction of MMF by 30% and received a dose of IVIG 1g/kg or rituximab 375 mg/m2 if persistently >100 copies/PCR.

*Results: Of 24 pts, 11 (9 LDA & 2 NLDA) and 13 (9 LDA & 4 NLDA) were EBV sero(-) and seropositive [sero(+)], respectively, at the time of tx. Eight of the 11 sero(-) pts (72.7%) developed subclinical EBV viremia (median 58.5 copies/PCR; range 8.8-718), while 5 of the 13 (38.5%) sero(+) pts did so (p=0.12). Among the sero(-) pts, 6 of 9 LDA (67%) developed viremia, compared to viremia in both of NLDA (100%, p>0.99). Median time to develop viremia was 3M (range 0.3-60.7) in the LDA group and 37.8M (range 1.6-75.7) in the NLDA group (p=0.11). Median time between viremia and EBV-Tc testing was 23.8M (range 0.5-135.3). Eight of the 9 [88.9%, 6 sero(-), 2 sero(+)] LDA with viremia developed EBV-Tc while all four of the NLDA [2 sero(-), 2 sero(+)] with viremia developed EBV-Tc (p>0.99). No pts developed EBV disease.

*Conclusions: There was no increased risk for developing EBV viremia among sero(-) ped renal tx pts who receive LDA induction compared to those who receive NLDA. The majority of pts developed EBV-Tc with some as early as 0.5M post-viremia. Development of EBV-Tc may prevent development of EBV disease and EBV recurrence in this pt cohort. Monitoring EBV-Tc might help for better management of EBV infection in this pt population. Larger studies are needed to validate the role of EBV-Tc in preventing EBV disease.

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