2011 - ISBTS 2011 Symposium


Oral Communications 10: Immune & Infectious Monitoring

11.218 - The necessity of EBV and CMV PCR screening post paediatric small bowel transplantation

Presenter: Lauren, Johansen, Lichfield, United Kingdom
Authors: Lauren Johansen1, Girish Gupte1, Khalid Sharif1, Darius Mirza1, Deirdre Kelly1, Patrick McKiernan1, Indra van Mourik1, Sue Beath1, Carla Lloyd1, Mitul Patel2, Jane Hartley1


218
The necessity of EBV and CMV PCR screening post paediatric small bowel transplantation

Lauren Johansen1, Girish Gupte1, Khalid Sharif1, Darius Mirza1, Deirdre Kelly1, Patrick McKiernan1, Indra van Mourik1, Sue Beath1, Carla Lloyd1, Mitul Patel2, Jane Hartley1

1Liver Unit, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, West Midlands, United Kingdom; 2Microbiology Department, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, West Midlands, United Kingdom

Background: Cytomegalovirus (CMV) enteritis and Epstein-Barr virus (EBV) related Post-Transplant Lymphoproliferative Disease (PTLD) can cause graft loss and mortality following paediatric intestinal transplantation (ITx). Currently there are no guidelines for viral-PCR monitoring post ITx. 

Aim: To determine the role of monitoring for CMV and EBV viraemia post ITx. 

Method: Retrospective case based analysis of all children undergoing ITx at a tertiary paediatric liver-unit. Children were defined as having viraemia if more than 500 viral copies were detected by PCR.  

Results: 72 children had a primary ITx.  

  Number of Children

Viral Donor-Recipient-Mismatch  (D+R-)

Median Time from Transplant in Days (Range) Detected Through Screening Median Tacrolimus Level in the Month Prior To Detection
Table1: Detection of viraemia, PTLD and CMV enteritis
EBV Viraemia 45(63%) 7(16%) 93(0-2144) 34(76%) 13.8
PTLD 17(24%) 4(24%) 270(75-1310) 2(12%) 11.5
CMV Viraemia 16(22%) 9(56%) 83(7-1508) 7(44%) 13.4
CMV Enteritis 5(7%) 3(60%) 235(28-1508) 3(60%) 10.3

16 children developed EBV related PTLD. 1 child had EBV negative PTLD. 4 children died secondary to PTLD.

Following initial EBV detection 17 had a 10-fold increase in EBV-PCR levels; of these 10(59%) developed PTLD. Median time to 10-fold rise was 158 days.

12(75%) children who developed CMV viraemia had been treated for rejection. Median time from rejection to CMV viraemia was 29 days. 

Summary:

  • EBV viraemia is most frequently detected by screening and can occur at any time post ITx, with approximately 1 in 3 children developing PTLD
  • Children whose EBV PCR levels increase by 10-fold are at increased risk of PTLD
  • Majority of CMV viraemia episodes are associated with rejection.. 

Conclusion: CMV and EBV viraemia have non-specific symptoms therefore regular PCR screening ensures that viraemia is detected promptly, enabling optimal management.

Increased immunosuppression at the time of rejection increases the risk of viraemia. Anti-CMV viral prophylaxis should be optimised during rejection episodes.  


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