Purpose: More than 90% of pediatric PTLD after solid organ transplantation is associated with EBV infection. Reduction in immunosuppression is the first step to prevent PTLD after EBV infection, but EBV infection often persists and progresses despite immunosuppression reduction. Following stem cell transplantation, depletion of the EBV reservoir B cells using RTX is used as preemptive treatment strategy for PTLD in some centers. The aim of study is to assess the efficacy and safety of RTX in prevention of PTLD in pediatric patients with SOT.

Methods: From September 2013 to July 2014, pediatric recipients of SOT in Seoul National University Children's Hospital were studied. We evaluated EBV DNA load using quantitative PCR assay and if the EBV load were greater than 10⁵ copies/mL or over 10⁴ copies/mL for consecutive 2 weeks, a single dose of RTX (375mg/m²) was administered.

Results: Ten patients with SOT, 3 kidney-, 6 liver-, and one kidney-liver recipients, received preemptive RTX therapy for uncontrolled EBV infection. Median age at TPL was 1.6 years (0.3-7.0 years) and median age at RTX treatment was 4.0 years (0.7-11.7 years). Before SOT, 7 patients were EBV seronegative and 3 patients were EBV seropositive. Median EBV viral loads before and after administration of RTX were 56214 copies/mL (19101-275349 copies/mL) and 0 copies/mL (0-215685 copies/mL), respectively. In seven patients, EBV viral load was undetectable after RTX. After RTX therapy, five patients experienced neutropenia and 6 patients were admitted for viral or bacterial infection. During follow-up, rebound of EBV load along with recovery of B cells was observed in 5 patients.

Conclusions: Preemptive RTX was effective for reducing EBV viral load in pediatric recipients of SOT. However, reduction of EBV viral load was not persistent and side effect of RTX, infection and neutropenia, was clinically significant.

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