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.  

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.