Reduction of Immunosuppression Based on Whole Blood EBV-Viral Loads in Lung Transplant Recipients

Abstract

<h3>Purpose</h3> Post-transplant lymphoproliferative disorder (PTLD) is a rare but serious complication of transplantation affecting 10% of lung transplant recipients with an overall survival of 39%. Reduction of immunosuppression (RIS) for clinically suspected PTLD is included in guidelines for the treatment of PTLD. Pre-emptive RIS based on EBV DNA load is controversial with small scale studies with anecdotal evidence guiding clinical practice. We evaluated our policy of pre-emptive RIS for PTLD incidence, acute rejection, survival and CLAD in a patient control study. <h3>Methods</h3> 26 patients underwent RIS, eight of these patients received prophylactic rituximab. 52 patients were matched for age, date of transplantation, gender, and cystic fibrosis. 26 of these patients were additionally chosen for high EBV-DNA load. Risk of PTLD, acute rejection, overall survival and CLAD was analysed using Kaplan-Meier survival analysis. <h3>Results</h3> EBV DNA loads were different between the groups (p<0.001) with the RIS group having the highest level and more primary EBV infections (table 1). Acute rejection was seen 7.3 years after RIS and 11.7 and 12.3 in the matched groups (p=0,1). Overall CLAD developed earlier in the RIS group but only years after RIS (table 1). Survival and development of PTLD were not different between the groups. Time to PTLD from RIS was also not different (p=0.5, log-rank test). <h3>Conclusion</h3> Pre-emptive RIS based on EBV DNA load did not lead to a concomitant increase in acute rejection episodes, a change in overall survival or a short term increase in chronic lung allograft rejection (CLAD) diagnosis. We conclude that RIS was safe although this analysis cannot prove a reduction in the incidence of PTLD in this high risk PTLD group. A prospective randomized study for EBV DNA guided RIS possibly with pre-emptive rituximab is needed.