Juan Francisco Guerra^1,2, Jason Hawksworth¹, Lee Cummings¹, Raffaele Girlanda¹, Eddie Island¹, Stuart Kaufman¹, Cheryl Little¹, Cal Matsumoto¹, Thomas Fishbein¹

¹Transplant Institute, Georgetown University Hospital, Washington, DC, United States; ²Departamento Cirugia Digestiva, Pontificia Universidad Catolica, Santiago, Chile

Introduction: Posttransplant lymphoproliferative disorder (PTLD) remains a serious complication after intestinal transplantation (ITX). We evaluated risk factors for PTLD development and outcomes.

Methods: We analyzed the clinical features and outcomes of 117 consecutive patients who underwent an ITX with unitivariate analysis. Standard immunosuppression (IS) consisted of basiliximab induction with maintenance consisting of tacrolimus, sirolimus and prednisone. Sensitized patients received anti-thymocyte globulin followed by standard IS. Endoscopic surveillance for PTLD and quantitative EBV monitoring was performed on protocol. All PTLD cases were biopsy proven. Demographics, type of transplant, induction and maintenance IS, rejection rate and its treatment, graft and patient survival were evaluated.

Results: The mean age of the entire cohort was 22.4 years old. The median follow-up was 39 months. The incidence of PTLD was 6.8% (8/117). Six PTLD cases were pediatric recipients, 4 of them were EBV negative and 3 received an EBV positive graft. Both adults were EBV positive before the transplant. In 2 cases PTLD was diagnosed by surveillance endoscopies, 2 cases after lymph node biopsies, 3 after elevated EBV titers and 1 case after graft loss and explant. Three cases died as a consequence of PTLD. 7 patients had monomorphic disease, 2 cases had bone marrow compromise and only 1 patient had CNS involvement. The diagnosis of PTLD in 7/8 cases occurred before 1 year after the transplant. All patients had reduction/withdrawal of IS as initial therapy, followed by rituximab. 4 cases also received concomitant chemotherapy. 1 year graft survival was significantly lower in the PTLD group (p= 0.04). The use of anti-thymocyte globulin as induction IS was the only significant risk factor for the development of PTLD (p= 0.01).

Conclusion: In our experience, the incidence of PTLD after ITX is low. This might be explained by a nondepleting immusuppressive strategy during the induction phase, and by close graft and patient EBV monitoring. The only factor associated with a higher risk of PTLD was the use of anti-thymocyte globulin.