Outcome of PTLD in renal and liver allograft recipients

No Increased Risk of Posttransplant Lymphoproliferative Disorder Following Alemtuzumab Induction in Kidney Transplant

OBJECTIVES

Posttransplant lymphoproliferative disorder is a known complication of solid-organ transplant. The use of depleting induction agents has demonstrated varying associations with incidence of posttransplant lymphoproliferative disorder. Alemtuzumab, a depleting induction agent for kidney transplant patients, has shown promising results in reducing the risk of acute rejection and graft loss in the first year. Its unique mechanism of depleting both T-cell and B-cell populations may be beneficial in preventing the occurrence of posttransplant lymphoproliferative disorder.

MATERIALS AND METHODS

We examined the known risk factors for posttransplant lymphoproliferative disorder in the setting of alemtuzumab induction to determine whether incidence increases with this induction agent. We reviewed medical records of all alemtuzumab-induced kidney transplants from March 2006 to November 2015.

RESULTS

Of the 675 transplant patients who received alemtuzumab induction, 10 developed posttransplant lymphoproliferative disorder, with a cumulative incidence rate of 1.5%. All diagnosed patients had several known risk factors associated with posttransplant lymphoproliferative disorder: 7 with advanced age over 60 years, 5 being cytomegalovirus-negative recipients, and all 10 donor kidneys being male patients and Epstein-Barr virus positive before transplant.

CONCLUSIONS

The incidence rate seen in our patient population was within the range of the average in the United States but far lower than the incidence rates associated with other induction agents. Alemtuzumab is associated with a lower cumulative incidence rate of posttransplant lymphoproliferative disorder compared with published reports of other induction treatments.

An approach to finding indications and contraindications for nephrectomy in post-transplant renal graft lymphomas: PTLD.Int survey

BACKGROUND AND OBJECTIVES

Allograft involvement can occur in some renal transplant recipients who develop post-transplant lymphoproliferative disorders (PTLD). We aimed to find indications and/or contraindications for nephrectomy in renal allograft PTLD based on an outcome analysis of previous reports.

DESIGN AND SETTING

A comprehensive search of Pubmed and Google scholar was performed to find reports of different treatment strategies addressing PTLD occurring within the allograft after renal transplantation.

PATIENTS AND METHODS

Patients who underwent nephrectomy due to kidney allograft localization by PTLD were categorized as the case group, and renal recipients with kidney PTLD for whom nonsurgical treatment modalities were used served as controls.

RESULTS

Survival analysis demonstrated that patients with renal allograft involvement who underwent allograft nephrectomy had a significantly better outcome compared to patients for whom a non-surgical approach was used (P=.03). In patients with disseminated PTLD, nephrectomy was not useful (P>.1). Patients with simultaneous kidney and lung complications by PTLD benefitted from nephrectomy.

CONCLUSIONS

We found that patients with renal graft complication with disseminated PTLD do not benefit from nephrectomy, which can be considered the only contraindication. However, some particular PTLD co-localizations were not as likely to adversely affect the benefit of nephrectomy in these patients, and these can be considered indications for the procedure. Future multicenter studies are needed to confirm our results.

Posttransplantation lymphoproliferative disorders in renal transplant recipients: report of over 20 years of experience

INTRODUCTION

Despite the benefits of immunosuppressive medications to improve graft function, they have several adverse effects, such as development of neoplasms in renal transplant recipients. Posttransplantation lymphoproliferative disorders (PTLDs) are not uncommon complications, so we conducted a study to evaluate the characteristics of affected patients.

METHODS

We enrolled 2117 kidney recipients from June 1984 to March 2004 in order to find pathological and clinical evidence of neoplasms. We collected and analyzed all data on PTLD patients.

RESULTS

Overall there were 46 recipients with different types of neoplasms, among which the most common types were diseases of the skin (24 cases, 52.2%), Kaposi's sarcoma (15 cases, 32.6%), and PTLD (14 cases, 30.4%). The mean (+/- SD) age of PTLD patients at the time of transplantation was 37.86 +/- 9.67 years and 42.8% were women. Median and mean (+/- SD) time interval to PTLD diagnosis were 38.5 and 50.35 +/- 41.7 months, respectively (range 1 to 146 months). Types of PTLD in these patients were kidney lymphoma (14.3%); gastrointestinal (14.3%); brain lymphoma; tonsils; palatine; Hodgkin's lymphoma, large cell lymphoma, and acute lymphoblastic lymphoma (each 7.1%), with 28.6% unspecified types. The 1-, 5-, and 10-year patient survival rates after transplantation were 71.4%, 51.4%, and 44.3%, respectively. Despite discontinuing immunosuppressive therapy in PTLD patients, five of six surviving had graft function up to a mean time of 105.4 +/- 57.6 months after transplantation.

CONCLUSION

Our findings showed that the prevalence of PTLD was 0.66%, which was less than reports from Western countries. The fact that there were surviving grafts for a considerable time despite discontinuing immunosuppressive therapy is of great importance.

Low-Dose Chemotherapy for Epstein-Barr Virus–Positive Post-Transplantation Lymphoproliferative Disease in Children After Solid Organ Transplantation

Purpose

To evaluate the efficacy of a low-dose chemotherapy regimen in children with Epstein-Barr virus (EBV) –positive, post-transplantation lymphoproliferative disease (PTLD) after organ transplantation who have experienced failure with front-line therapy for PTLD.

Patients and Methods

Eligible patients received cyclophosphamide (600 mg/m2 intravenous for 1 day) and prednisone (2 mg/kg orally for 5 days) every 3 weeks for six cycles.

Results

Thirty-six patients treated on study were assessable for analyses. Front-line therapies for PTLD before study entry included immune suppression reduction or withdrawal (n = 36), antiviral therapy (n = 33), surgical resection (n = 8), rituximab (n = 2), and interferon alfa (n = 1). Reasons for failure of front-line therapy included progressive disease (PD; n = 33) and persistent disease with concurrent allograft rejection (n = 3). Thirty patients (83%) had stage III to IV disease, 92% had extranodal disease, and 75% had ≥ three sites of disease. The overall response rate was 83% (75% complete response + 8% partial response). The relapse rate was 19%, with only one of five relapsed patients alive and disease-free. Four patients presented with fulminant, disseminated PTLD; only one of these four patients achieved a response, and all four died of PD. Two patients died of treatment-related toxicity. Three patients (8%) experienced allograft loss, but two of the three patients are alive and disease-free after a second transplantation. The 2-year overall, relapse-free, and failure-free (without PTLD and with functioning original allograft) survival rates were 73%, 69%, and 67%, respectively.

Conclusion

This low-dose chemotherapy regimen is effective for children with EBV-positive, nonfulminant PTLD who have experienced treatment failure with front-line therapy, and this study represents the largest series of PTLD patients treated prospectively with a uniform chemotherapy regimen.

Abdominal-pelvic lymphoproliferative disease after lung transplantation: presentation and outcome

BACKGROUND

Lymphoproliferative disease (LPD) is a well-recognized complication after lung transplantation. However, its presentation in the abdomen and pelvis has not been previously detailed.

METHODS

We retrospectively identified cases of abdominal-pelvic LPD in lung transplant recipients. The cases were characterized clinically, and the outcomes were analyzed.

RESULTS

Abdominal-pelvic LPD was identified in 19 of 603 adult patients who underwent lung or heart-lung transplantation at Barnes-Jewish Hospital between July 1, 1988 and December 31, 2001. The median time from transplantation to the onset of LPD was 5.8 years. Three cases presented early after transplantation (median, 175 days), and 16 cases presented late (median, 2,255 days). The time to diagnosis of LPD was significantly shorter for Epstein-Barr virus (EBV)-seronegative than for EBV-seropositive recipients (median, 175 vs. 2255 days; log-rank, P<0.001). Seventeen cases were non-Hodgkin's lymphomas, one was a Burkitt's lymphoma, and one was an atypical lymphoid proliferation. Among the 19 cases, 12 involved the gastrointestinal tract and 7 occurred in other sites. Immunosuppressive therapy was decreased in all patients. Eleven underwent surgical resection, and nine received chemotherapy. Sixteen patients have died, and 14 deaths were attributable to LPD. The median time from the diagnosis of LPD to death was 68 days.

CONCLUSIONS

Abdominal-pelvic LPD is typically a late complication after lung transplantation; however, when it occurs early, it may be related to a primary EBV infection. This form of LPD is most frequently a non-Hodgkin's lymphoma, and despite aggressive therapy, the prognosis is poor.

Transmission of a pancreatic adenocarcinoma to a renal transplant recipient

Transmission of donor tumours in solid organ transplant recipients is rare, but has been reported with fatal outcome in some cases depending on the original tumour type and location. We report a case of a pancreatic adenocarcinoma of donor origin presented as lymphangitis carcinomatosa of the lung in a renal transplant recipient 9 months after transplantation, which is likely to have contributed to the death of the patient 15 months after transplantation. The donor tumour was originally diagnosed on adrenal tissue removed from the donor kidney during bench preparation. At the time of the diagnosis this kidney and the liver of the multi-organ donor had been transplanted. The liver patient was urgently retransplanted within 24 h. The renal recipient opted not to have a transplant nephrectomy having been made aware of the risk of tumour transmission. The contralateral kidney was discarded. Management of recipients with potential transmission of initially undiagnosed donor malignancy is difficult. Early transplant nephrectomy may be the safest option.

Xenotransplantation: public health risks--patient vs. society in an emerging field

Xenotransplantation is a public health concern because it has the potential to infect human recipients with zoonotic and other infectious agents that are not endemic in human populations, thereby potentially introducing new infections to the human community. From this perspective, xenotransplantation clinical trials combine a potential benefit for individual recipients with a potential risk to the human community. However, the potential for benefit also extends beyond the individual recipient to society as a whole, a fact infrequently recognized in discussions of this topic. Further, diseases neither endemic in human communities nor recognized as classic zoonoses are introduced into humans periodically through routine interactions between human and nonhuman animals. Thus, xenotransplantation is one of multiple potential routes by which infectious agents of nonhuman origin may enter human ecosystems. The intentional and controlled nature of xenotransplantation exposures enables implementation of measures to minimize associated biohazards. Development of guidelines and implementation of regulatory oversight of xenotransplantation clinical trials in most nations where such research occurs has promoted a standard level of practice in the field and markedly reduced the risk of xenotransplant-introduced infection compared to the situation in 1995.