*Purpose: EBV viremia is associated with potentially life-threatening post-transplant lymphoproliferative disorders (PTLD) after solid organ transplantation. The utility of rituximab for treating EBV viremia in the absence of PTLD is well-established in hematopoietic stem cell transplantation due to its ability to deplete B lymphocytes leading to a reduction in EBV-infected cells and viral load. However, its efficacy and safety in organ transplant recipients is less established. Our objective was to assess the efficacy and safety of pre-emptive rituximab in heart and lung transplant recipients.

*Methods: This retrospective review included adult heart or lung transplant recipients who received a transplant and rituximab at our center. Patients who received rituximab for an indication other than treatment of EBV viremia were excluded.

*Results: 58 patients received rituximab but only 10 patients received it for EBV viremia. Patients were primarily male (70%), 58 ± 14 years old at time of transplant and weighed 76 ± 20 kg upon starting rituximab. Five (50%) received a lung transplant, 5 (50%) received a heart transplant, 9 (90%) received basiliximab and 1 (10%) received ATG for induction. One (10%) was EBV IgG D+/R-, 8 (80%) were EBV IgG R+, and one had an unknown status. Nine (90%) had a reduction in immunosuppression and one did not due to history of rejection. A median (range) EBV PCR of 37,996 UI/mL (6,346-551,098 UI/mL) triggered rituximab treatment at 6.3 ± 5.9 years post-transplant. All lung transplant recipients received 375 mg/m² every 2 weeks until EBV PCR was clinically insignificant (<1000 IU/mL). A median of 3 (1-12) doses were given. Two lung recipients continue with treatment, two had complete resolution of EBV viremia, and one died due to BOS while viremic. All heart transplant recipients received one 1,000 mg dose. Three patients experienced relapse; however, none received a subsequent dose. Median time to either a clinically insignificant (<1,000 IU/mL) or a negative EBV PCR from first rituximab dose was 32 (8-246) days. No patients developed PTLD. Infections occurred in six patients, including influenza, shingles, rhinovirus, urinary tract infection, and bacterial vaginosis.

*Conclusions: Rituximab may be an effective option for pre-emptive treatment of EBV viremia in heart or lung transplant recipients where immunosuppression is already maximally reduced. Higher doses may decrease incidence of relapse but increase risk of infection. More studies are needed to determine appropriate dosing and duration of therapy in solid organ transplant recipients.

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