POSTTRANSPLANTATION LYMPHOPROLIFERATIVE DISORDER IN THE EPSTEIN-BARR VIRUS-NAIVE LUNG-TRANSPLANT RECIPIENT

Post-transplantation lymphoproliferative disorder (PTLD) is a widely r ecognized and often catastrophic complication of organ transplantation . The incidence of PTLD after lung transplantation ranges from 6.2 to 9.4% and is two-fold higher than that seen after organ transplantation of other organs. Primary Epstein-Barr virus (EBV) infection is a majo r risk factor for PTLD, but the incidence of PTLD in EBV seronegative (EBV-) patients seems to vary with type of organ transplant. The goal of this study was to quantify the risk of PLTD based on pre-lung trans plantation EBV serostatus in lung transplant patients. Pre- and post-l ung transplant serostatus was defined in 80 patients, and our six case s of PTLD occurred in this group. Six of 94 lung transplant patients ( 6.4%) who survived > 1 mo developed PTLD. All cases of PTLD involved t horacic structures at presentation and occurred in the first post-oper ative year. Patients who were EBV- before lung transplant were much mo re likely to develop PTLD than those who were seropositive (EBV+) (fiv e of 15 [33%] versus one of 60 [< 20%], p < 0.001). Consistent with th e prevailing-adult (donor) EBV+ rate (85%), two of our EBV- patients r emained EBV- after lung transplant. Therefore, the tate of PTLD was 42 % in those with primary EBV infection. As compared with EBV- patients that remained tumor-free, those who developed PLTD had similar levels of immunosuppressants and doses of anti-viral therapy. We conclude tha t PLTD occurs predominantly in EBV-naive patients (risk similar to 1/3 ). EBV- patients should be monitored more closely after lung transplan tation and, possibly, managed with lower immunosuppression. Our data a lso suggest that anti-viral therapy alone does not decrease the incide nce of PTLD in high risk patients, PTLD can be successfully treated in most cases, and EBV-naive patients should not be excluded from lung t ransplant because their risk of death from PTLD is < 15%.