POS-755 POST-TRANSPLANT LYMPHOPROLIFERATIVE DISORDER (PTLD) IN A 26 YEAR OLD FEMALE RENAL RECIPIENT - WHAT YOU CAN LEARN FROM OUR EXPERIENCE

Abstract

PTLD accounts for almost 20% of all cancers occurring in solid organ transplantation. It represents infiltration of B cells driven by EBV/CMV infection in the background of severe immunosuppression and impaired T-cell immune surveillance. Current case presents PTLD 7 months post 2nd renal transplantation and reflects on early detection/prevention and management. Case Presentation A 26-year old female presented with 2/52 fatigue, fever, night sweats and abdominal pain, 7 months post 2nd cadaveric renal transplant EBV/CMV mismatched. Medical history included cyclophosphamide-treated proliferative lupus nephritis, tacrolimus-based immunotherapy and antirejection treatment. On examination, there was tenderness of the right iliac fossa with femoral lymph nodes. Patient had anaemia, leukopenia, deterioration in renal function, elevated LDH, EBV PCR 18,752 copies/mL and CMV PCR 300 copies/ml. CT abdomen showed an 8cm soft tissue mass obstructing the graft. Biopsy confirmed polymorphic PTLD (pictures 1, 2). View Large Image Figure ViewerDownload Hi-res image Download (PPT)View Large Image Figure ViewerDownload Hi-res image Download (PPT) Outcome: The patient was treated with reduction of immunosuppression and withdrawal of both Tacrolimus and Mycophenolate Mofetil. Prednisolone 5 mg daily remained and EBV load monitored weekly. Immunotherapy with CD 20 monoclonal antibody, rituximab, commenced weekly for 4 weeks. Complete remission was achieved in 3 months, Kidney function returned to baseline and 18F Fluorodeoxyglucose PET-CT revealed no sign of lymphoma. Four-year post diagnosis, patient remained disease-free as demonstrated on repeat 18 FDG PET- CT, with stable graft function and negative EBV/CMV viral load. Immunosuppression remained minimal. Seronegative EBV/CMV recipients accepting seropositive grafts have 24 times higher incidence rate of PTLD, likely within the 1st year post transplantation. Significant increase in the viral load can predict/diagnose early PTLD. Lower immunosuppression with reduction/withdrawal of Tacrolimus and rituximab use can be effective for prevention and treatment. Ganciclovir has proved to be of equal value. FDG PET-CT is highly sensitive to detect disease extent and response to treatment.