post transplant lymphoproliferative disorders (ptld)
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Post Transplant Post Transplant Lymphoproliferative Lymphoproliferative DisordersDisorders(PTLD)(PTLD)
PTLDPTLDPTLD is a group of lymphoproliferative disorders that range from hyperplasias to aggressive non-Hodgkin’s lymphoma
PTLD is seen after both solid organ and stem cell transplant
90% of PTLDs are Ebstein-Barr Virus (EBV) positive
IncidenceIncidencePTLD occurs in 1% to 25% of solid organ transplant patients
PTLD occurs in < 2% of stem cell transplant patients
Incidence is 4 times higher in pediatric transplant patients versus adults
Incidence by Type of Incidence by Type of
Organ TransplantedOrgan TransplantedIntestinal transplant 18%Lung 8%Heart 3%Liver 3%Renal <1%
Clinical PresentationClinical PresentationSome patients are asymptomaticOthers may have non specific
symptoms Fever Malaise Weight loss
May resemble infectious mononucleosisEnlarged tonsilsLymphadenopathyIntestinal Perforation
Systems Potentially Systems Potentially Involved in PTLDInvolved in PTLDCentral Nervous SystemBone MarrowKidneysLiverLungsSmall intestinesSpleen
CharacterizationCharacterizationEarly PTLD presents within one year following transplantation ◦60% develop within one year
Late PTLD occurs more than one year post transplant◦30% develop within 1 to 5 years◦10% develop after 5 years
Risk FactorsRisk FactorsEBV seronegative recipientType of Organ transplantedType of immunosuppressionSimultaneous cytomegalovirus disease
Younger AgeMale
Prevention/Prevention/MonitoringMonitoringEBV Surveillance
◦Monitor EBV-DNA load
EBV vaccine◦Not standard treatment
Anti-viral agents◦Questionable value◦Agents used include Acyclovir & Ganciclovir
Treatment of PTLDTreatment of PTLDReduction of Immunosuppression
therapyAnti-viral agents and IVIG are of
limited valueInterferon alphaRituximabCHOP
◦Doxorubicin, Cyclophosphamide, Vincristine and Prednisone
ConclusionConclusionPrognosis is poor5 year survival rates◦25 to 60%
High mortality rateLack of standard treatment
ReferencesReferencesBakker, N.A., van Imhoff, G.W., Verschuuren, E.A.M., & van Son, W.
(2006). Presentation and early detection of post transplant lymphoproliferative disorder after solid organ transplantation.Transplant International, 20, 207-218
Everly, M.J., Bloom, R.D., Tsai, D.E. & Trofe, J. (2007). Posttransplant Lymphoproliferative Disorder. The Annals of Pharmacotherapy, 41, 1850-1858
Faye, A. & Vilmer, E. (2005). Post-Transplant Lymphoproliferative Disorder. Pediatric Drugs, 7, 1, 55-65
Gottschalk, S., Rooney, C.M., & Heslop, H.E. (2005). Post-Transplant Lymphoproliferative Disorders, 56, 29-44
Lee, J.J., Lam, M.S.H., & Rosenberg, A. (2007). Role of Chemotherapy and Rituximab for Treatment of Posttransplant Lymphoproliferative Disorder in Solid Organ Transplantation. The Annals of Pharmacotherapy, 41, 1648-1659
Shroff, R. & Rees, L. (2003). The post-transplant lymphoproliferative disorder – a literature review. Pediatric Nephrology, 19, 369 -377