Monitoring Infection with Epstein–Barr Virus among Seromismatch Adult Renal Transplant Recipients

Abstract

Patients who undergo Epstein-Barr virus (EBV) seromismatch (D+/R−) transplants have a higher risk for the development of post-transplant lymphoproliferative disorder (PTLD). Adult renal transplant recipients at a single institution were prospectively monitored for EBV during the first year post-transplant. Over a 2-year period, 34 patients (7.78%) were identified as being EBV D+/R− recipients. Patients who developed symptoms or had persistent viremia were pre-emptively administered rituximab. Six recipients were discharged without monitoring on the protocol. Of those six, three (50%) developed PTLD and all three lost their grafts. Twenty (60.6%) of the 34 recipients developed viremia during the first year post-transplant. Of the recipients who became viremic, six (30%) received rituximab. None of the six who received rituximab-developed PTLD. We found that recipients who were not monitored on the protocol were more likely to have PTLD and graft loss compared to those who were (p = 0.008). Post-transplant monitoring of adults who undergo EBV D+/R− kidney transplants for viremia and symptoms associated with EBV infection may prompt intervention which reduces the incidence of PTLD within the first year. Use of rituximab in preventing PTLD among patients with primary EBV infection requires further prospective study to determine its overall safety and efficacy.

Epstein–Barr Virus Infection in Adult Renal Transplant Recipients

“…Preemptive strategies to reduce PTLD incidence include reduction of immunosuppression, and more recently, the use of rituximab in transplant patients with persistent high-level DNAemia. Reduction in incidence of PTLD is reported in liver transplant and pediatric populations with such strategies (5)(6)(7)(37)(38)(39)(40)(41)(42). We calculated an increased risk of PTLD during follow-up for those with DNAemia at recruitment compared to those without detectable DNAemia.…”

“…In these patients, preemptive reduction of immunosuppression and treatments such as rituximab may reduce the incidence of early EBV-related disease and posttransplant lymphoproliferative disease (PTLD) (5)(6)(7). In adult kidney transplant recipients, PTLD is a late event, with median time to presentation in our population of 74 months (8,9).…”

Viral surveillance and subclinical viral infection in pediatric kidney transplantation

“…The utility of antiviral therapy to prevent PTLD is controversial with little evidence to support the role of acyclovir or ganciclovir in response to an elevated or rising EBV viral load without a concomitant reduction of immunosuppression. Preemptive use of rituximab in response to subclinical EBV infection began in the hematopoietic stem cell population and has recently been reported in the adult kidney transplant population [41, 42]. …”

Primary Epstein–Barr virus infection, seroconversion, and post‐transplant lymphoproliferative disorder in seronegative renal allograft recipients: a prospective cohort study

“…In the only published randomized control trial, antiviral prophylaxis was not associated with a significant reduction in the risk of PTLD . Interestingly, Martin et al recently showed that treatment of primary EBV viremia with rituximab provided considerable benefit in terms of PTLD prevention. To our knowledge and based on available data, it seems that the approach of clinical, serology/quantitative EBV PCR monitoring, and subsequently preemptive reduction or cessation of immune suppression, in case of primary EBV infection, is the best method of EBV‐related PTLD prevention in EBV‐seronegative recipients.…”