The role of quantitative Epstein-Barr virus polymerase chain reaction and preemptive immunosuppression reduction in pediatric liver transplantation: A preliminary experience

Background: Risk factors for the development of posttransplant lymphoprolif erative disease (PTLD), a major cause of morbidity and mortality after pedi atric liver transplantation, are primary Epstein-Barr virus (EBV) infection and intensity of immunosuppression. The authors assessed monitoring of EBV replication and preemptive immunosuppression reduction in pediatric liver transplant recipients. Methods: The authors prospectively followed monthly EBV-quantitative compet itive polymerase chain reaction to measure EBV replication in 23 patients w ho underwent liver transplant between July 1997 and November 1998. Preempti ve immunosuppression reduction was instituted for significant EBV replicati on. Patients were followed up for at least 1 year and divided in two groups for analysis (group 1, pretransplant seronegative for EBV [13 patients]; g roup 2, seropositive for EBV [10 patients]). Results: In group 1, 9 of 13 patients had positive polymerase chain reactio n results at a mean time of 22.4 weeks after transplantation. All but one o f these patients were asymptomatic. In seven of nine patients, preemptive i mmunosuppression reduction was undertaken without development of PTLD or re jection. In two of nine patients, immunosuppression could not be continuous ly reduced, and both patients experienced low-grade and medically responsiv e PTLD. In no patient in group 2 did an EBV-positive viral load or PTLD dev elop. Conclusions: Prospective longitudinal measurement of EBV by quantitat ive competitive polymerase chain reaction permits early detection of asympt omatic viral replication. Subsequent preemptive reduction of immunosuppress ion may prevent the progression to PTLD.