Prevention of Post Transplantation Lymphoproliferative Disorders by Adapted Management of EBV Reactivations. A Monocentric Prospective Study on 101 Patients.

Background:

Post-transplantation lymphoproliferative diseases (PTLD) represent a rare but aggressive graft complication. Patients who have received a solid organ transplantation have a 20 to 120 fold higher incidence of non-Hodgkin’s lymphoma. EBV reactivation represents a major predictive factor for PTLD, especially during the first year after transplantation, but there is no consensual attitude in this situation

Aim:

We conducted a monocentric prospective study in the Hospital of Pitie Salpêtriere, Paris, France, on all new heart or lung-heart transplanted patients. EBV viral load was systematically followed and confirmed reactivations were treated or surveyed, depending on viral load.

Methods:

101 patients were included between January 2004 and December 2006. Twelve to 15 blood samples per year were analysed. If the viral load was more than 50N, patients were treated by diminution of the immunosupression and one injection of rituximab (375 mg/m²), between 10N and 50N, only the immunosupression was modified, and rituximab was used in case of failure, and below 10N, a simple survey was decided. Correlation with CMV reactivation has been analysed.

Results:

45 (44%) patients presented an EBV reactivation. A simple survey has been sufficient in 29 cases, immunosupression decrease was the only treatment in 8 cases, 2 patients had to be treated in a second step by rituximab, because of stability or increase of the viral load beside the immnosupression modification, and 6 patients have been treated by rituximab as first treatment. All EBV reactivations have been controlled by this attitude, no PTLD has been diagnosed during this period and graft rejection rate did not change. From 1987 to December 2003, 24 PTLD have been treated in the same unit (18 EBV positive, 1 unknown), of which 13 were early PTLD (all EBV positive) with a diagnosis of less than one year after transplantation. We did not find any correlation between EBV and CMV reactivations.

Conclusion:

EBV reactivation after organ transplantation can be managed by diminution of immunosupression and/or rituximab, depending on viral load, without serious complication. A prolongation of this study and a longer follow-up are necessary to know if this attitude decreases the incidence of early EBV positive PTLD.