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Kanji A, Ahmad R, Bala L, Mallon E. Cutaneous Post-transplant Lymphoproliferative Disorder. Cureus 2024; 16:e63951. [PMID: 39104985 PMCID: PMC11299132 DOI: 10.7759/cureus.63951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2024] [Indexed: 08/07/2024] Open
Abstract
Post-transplant lymphoproliferative disorders (PTLD) involve T- or B-cell proliferation in an immunosuppressed transplant recipient. It usually presents at extra-nodal sites and can affect several organs. Cutaneous manifestations of PTLD are relatively rare and can be very heterogeneous. We report a case of a 36-year-old male cardiac transplant recipient on long-term immunosuppression (ciclosporin, azathioprine, and prednisolone) who presented with a three-month history of a painless ulcer on the right lower leg. A skin biopsy showed a dermal atypical lymphoid infiltrate positive for PAX5, CD20 and MUM1 on immunohistochemistry and EBV with in-situ hybridisation and a 70% Ki-67 cell proliferation index. A whole body fluorodeoxyglucose (FDG) positron emission tomography (PET) scan showed increased tracer uptake corresponding to the site of the cutaneous ulcer, the anterior cortex of the right lower tibia, an area adjacent to the right superficial femoral artery and the right inguinal node. These findings were in keeping with monomorphic B-cell post-transplant lymphoproliferative disorder (PTLD) consistent with diffuse large B-cell lymphoma, non-germinal centre subtype. Cessation of azathioprine and treatment with an anti-CD20 antibody, rituximab, led to clinical resolution of the ulcer and a negative FDG-PET scan, with no disease recurrence to date. We present a rare case of monomorphic PTLD with cutaneous involvement, presenting with a solitary, painless ulcer, which was successfully treated with a reduction in immunosuppression and additional rituximab monotherapy, given the aggressive subtype. PTLD can arise many years post-transplant and is a serious, potentially life-threatening complication. Therefore, early recognition and prompt treatment are of paramount importance.
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Affiliation(s)
- Alpa Kanji
- Dermatology, Imperial College Healthcare NHS Trust, London, GBR
| | - Raida Ahmad
- Pathology, Imperial College Healthcare NHS Trust, London, GBR
| | - Laksha Bala
- Dermatology, Imperial College Healthcare NHS Trust, London, GBR
| | - Eleanor Mallon
- Dermatology, Imperial College Healthcare NHS Trust, London, GBR
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2
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Order KE, Rodig NM. Pediatric Kidney Transplantation: Cancer and Cancer Risk. Semin Nephrol 2024; 44:151501. [PMID: 38580568 PMCID: PMC11734768 DOI: 10.1016/j.semnephrol.2024.151501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2024]
Abstract
Children with end-stage kidney disease (ESKD) face a lifetime of complex medical care, alternating between maintenance chronic dialysis and kidney transplantation. Kidney transplantation has emerged as the optimal treatment of ESKD for children and provides important quality of life and survival advantages. Although transplantation is the preferred therapy, lifetime exposure to immunosuppression among children with ESKD is associated with increased morbidity, including an increased risk of cancer. Following pediatric kidney transplantation, cancer events occurring during childhood or young adulthood can be divided into two broad categories: post-transplant lymphoproliferative disorders and non-lymphoproliferative solid tumors. This review provides an overview of cancer incidence, types, outcomes, and preventive strategies in this population.
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Affiliation(s)
- Kaitlyn E Order
- Division of Nephrology, Department of Pediatrics, Boston Children's Hospital, Boston, MA
| | - Nancy M Rodig
- Division of Nephrology, Department of Pediatrics, Boston Children's Hospital, Boston, MA.
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3
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Velagala VR, Velagala NR, Singh A, Kumar T, Thakre S, Lamture Y. Immunological Nuances and Complications of Pediatric Organ Transplant: A Narrative Review. Cureus 2023; 15:e46309. [PMID: 37916238 PMCID: PMC10616683 DOI: 10.7759/cureus.46309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 10/01/2023] [Indexed: 11/03/2023] Open
Abstract
Organ transplantation is considered an exaggerated immune state in which the body reacts in an elaborate cascade of reactions against the lifesaving graft transplanted. Unrepairable organ damage is the main indication for a pediatric patient to undergo a transplant. The host and the donor must fulfill the criteria for a successful transplant to have as few side effects as possible. There has been much-needed research in the domain of surgery of organ transplantation, thereby extending into the pediatric age group. This article elaborates on the post-transplant management, the immuno-biochemistry aspect, and its post-surgery treatment. The post-surgery period requires great emphasis as morbidity and mortality are highest. There is much to understand about managing transplant patients to avoid complications such as infections, hypertension, or side effects of immunosuppressive drugs. The treating clinician faces the challenges of managing the dose and frequency of immuno-suppressive medicines to prevent complications in the patients. If the dose is inadequate, there are chances of graft rejection. If the immuno-suppression is prolonged, there may be chances of infections in the patient. This article aims to summarize the mechanism of graft rejection and put forth the need for further research about creating a universal protocol for managing a patient's immune system post-transplant. The authors hope this protocol will help the clinician better understand the patient's current state and help in appropriately using immuno-suppressive drugs. It calls upon the need for a reliable and easily repeatable battery of investigations that will help solve this dilemma.
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Affiliation(s)
- Vivek R Velagala
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Namrata R Velagala
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Arihant Singh
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Tanishq Kumar
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Swedaj Thakre
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Yashwant Lamture
- Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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4
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Afify Z, Orjuela-G rimm M, Smith CM, Dalal M, Ford JB, Pillai P, Robles JM, Reddy S, McCormack S, Ehrhardt MJ, Ureda T, Alperstein W, Edington H, Miller TP, Rubinstein JD, Kavanaugh M, Bukowinski AJ, Friehling E, Rivers JM, Chisholm KM, Marks LJ, Mason CC. Burkitt lymphoma after solid-organ transplant: Treatment and outcomes in the paediatric PTLD collaborative. Br J Haematol 2023; 200:297-305. [PMID: 36454546 PMCID: PMC11195532 DOI: 10.1111/bjh.18498] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 09/08/2022] [Accepted: 09/21/2022] [Indexed: 12/05/2022]
Abstract
Burkitt lymphoma arising in paediatric post-solid-organ transplantation-Burkitt lymphoma (PSOT-BL) is a clinically aggressive malignancy and a rare form of post-transplant lymphoproliferative disorder (PTLD). We evaluated 35 patients diagnosed with PSOT-BL at 14 paediatric medical centres in the United States. Median age at organ transplantation was 2.0 years (range: 0.1-14) and age at PSOT-BL diagnosis was 8.0 years (range: 1-17). All but one patient had late onset of PSOT-BL (≥2 years post-transplant), with a median interval from transplant to PSOT-BL diagnosis of 4.0 years (range: 0.4-12). Heart (n = 18 [51.4%]) and liver (n = 13 [37.1%]) were the most frequently transplanted organs. No patients had loss of graft or treatment-related mortality. A variety of treatment regimens were used, led by intensive Burkitt lymphoma-specific French-American-British/Lymphomes Malins B (FAB/LMB), n = 13 (37.1%), and a low-intensity regimen consisting of cyclophosphamide, prednisone and rituximab (CPR) n = 12 (34.3%). Median follow-up was 6.7 years (range: 0.5-17). Three-year event-free and overall survival were 66.2% and 88.0%, respectively. Outcomes of PSOT-BL patients receiving BL-specific intensive regimens are comparable to reported BL outcomes in immunocompetent children. Multi-institutional collaboration is feasible and provides the basis of prospective data collection to determine the optimal treatment regimen for PSOT-BL.
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Affiliation(s)
- Zeinab Afify
- Pediatric Hematology Oncology, Primary Children’s Med. Ctr, Salt Lake City, Utah, USA
| | - Manuela Orjuela-G rimm
- Division of Pediatric Hematology Oncology and Stem Cell Transplantation, and Department of Epidemiology, Columbia University Medical Center, New York, New York City, USA
| | | | - Mansi Dalal
- University of Florida, Gainesville, Florida, USA
| | - James B. Ford
- University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Pallavi Pillai
- Mount Sinai Kravis Children’s Hospital, New York, New York City, USA
| | - Joanna M. Robles
- Department of Pediatrics, Division of Hematology/Oncology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Sonika Reddy
- Division of Pediatric Hematology Oncology and Stem Cell Transplantation, and Department of Epidemiology, Columbia University Medical Center, New York, New York City, USA
| | - Sarah McCormack
- Cancer and Blood Diseases Institute, Cincinnati Children’s Hospital Medical center, Cincinnati, Ohio, USA
- Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | | | - Tonya Ureda
- Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Warren Alperstein
- Sylvester Comprehensive Cancer Center, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Holly Edington
- Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Tamara P. Miller
- Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Jeremy D. Rubinstein
- Cancer and Blood Diseases Institute, Cincinnati Children’s Hospital Medical center, Cincinnati, Ohio, USA
- Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Madison Kavanaugh
- UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Andrew J. Bukowinski
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Erika Friehling
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Julie M. Rivers
- Department of Pediatrics, Seattle Children’s Hospital, Seattle, Washington, USA
| | - Karen M. Chisholm
- Department of Laboratories, Seattle Children’s Hospital, Seattle, Washington, USA
| | - Lianna J. Marks
- Department of Pediatrics, Division of Pediatric Hematology and Oncology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Clinton C. Mason
- Department of Pediatrics, Division of Pediatric Hematology and Oncology, University of Utah, Salt Lake City, Utah, USA
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5
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Grenda R. Non-Hodgkin lymphoma after pediatric kidney transplantation. Pediatr Nephrol 2022; 37:1759-1773. [PMID: 34633534 PMCID: PMC9239945 DOI: 10.1007/s00467-021-05205-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 05/27/2021] [Accepted: 06/24/2021] [Indexed: 11/18/2022]
Abstract
Non-Hodgkin lymphoma (NHL) that develops after kidney transplantation belongs to post-transplant lymphoproliferative disorders (PTLD) occurring with an incidence of 2-3%. Most pediatric cases are related to primary infection with Epstein-Barr virus (EBV), able to transform and immortalize B cells and widely proliferate due to the lack of relevant control of cytotoxic T cells in patients receiving post-transplant immunosuppression. NHL may develop as a systemic disease or as a localized lesion. The clinical pattern is variable, from non-symptomatic to fulminating disease. Young age of transplant recipient, seronegative EBV status at transplantation, and EBV mismatch between donor and recipient (D+/R-) are regarded as risk factors. Immunosuppression impacts the development of both early and late NHLs. Specific surveillance protocols, including monitoring of EBV viral load, are used in patients at risk; however, detailed histopathology diagnosis and evaluation of malignancy staging is crucial for therapeutic decisions. Minimizing of immunosuppression is a primary management, followed by the use of rituximab in B-cell NHLs. Specific chemotherapeutic protocols, adjusted to lymphoma classification and staging, are used in advanced NHLs. Radiotherapy and/or surgical removal of malignant lesions is limited to the most severe cases. Outcome is variable, depending on risk factors and timing of diagnosis, however is positive in pediatric patients in terms of graft function and patient survival. Kidney re-transplantation is possible in survivors who lost the primary graft due to chronic rejection, however may be performed after at least 2-3 years of waiting time, careful verification of malignancy-free status, and gaining immunity against EBV.
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Affiliation(s)
- Ryszard Grenda
- Department of Nephrology, Kidney Transplantation & Hypertension, Children's Memorial Health Institute, Warsaw, Poland.
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6
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Sinha R, Agrawal N, Xue Y, Chanchlani R, Pradhan S, Raina R, Marks SD. Use of rituximab in paediatric nephrology. Arch Dis Child 2021; 106:1058-1065. [PMID: 34112638 PMCID: PMC8543203 DOI: 10.1136/archdischild-2020-321211] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 02/27/2021] [Accepted: 03/10/2021] [Indexed: 11/03/2022]
Abstract
Rituximab is a chimeric monoclonal antibody capable of depleting B cell populations by targeting the CD20 antigen expressed on the cell surface. Its use in oncology, initially in B cell lymphoma and post-transplant lymphoproliferative disorders, predates its current utility in various fields of medicine wherein it has become one of the safest and most effective antibody-based therapies. It was subsequently found to be effective for rheumatological conditions such as rheumatoid arthritis and antineutrophil cytoplasmic antibody-associated vasculitis. Over the past decade, rituximab has generated a lot of interest in nephrology and has become an emerging or accepted therapy for multiple renal conditions, including systemic lupus erythematosus, lupus nephritis, vasculitis, nephrotic syndrome and in different scenarios before and after kidney transplantation. This review outlines its current use in paediatric nephrology practice, focusing on the knowledge required for general paediatricians who may be caring for children prescribed this medication and reviewing them on a shared care basis.
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Affiliation(s)
- Rajiv Sinha
- ICH, Institute of Child Health, Kolkata, India
| | - Nirav Agrawal
- Department of Nephrology, Akron Children's Hospital, Akron, Ohio, USA
| | - Yuanxin Xue
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Rahul Chanchlani
- Division of Pediatric Nephrology, Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Subal Pradhan
- Department of Pediatrics, Sardar Vallabhbhai Patel Post Graduate Institute of Paediatrics(SVPPGIP), Cuttack, Odisha, India
| | - Rupesh Raina
- Department of Nephrology, Akron Children's Hospital, Akron, Ohio, USA
| | - Stephen D Marks
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- NIHR Great Ormond Street Hospital Biomedical Research Centre, University College London Great Ormond Street Institute of Child Health, London, UK
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7
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Zierhut H, Kanzelmeyer N, Buescher A, Höcker B, Mauz-Körholz C, Tönshoff B, Metzler M, Pohl M, Pape L, Maecker-Kolhoff B. Course of renal allograft function after diagnosis and treatment of post-transplant lymphoproliferative disorders in pediatric kidney transplant recipients. Pediatr Transplant 2021; 25:e14042. [PMID: 34021949 DOI: 10.1111/petr.14042] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 03/23/2021] [Accepted: 04/23/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Post-transplant lymphoproliferative disease (PTLD) is a life-threatening complication in renal transplant recipients. Immunomodulatory and chemotherapeutic treatment potentially affect allograft function. The aim of this study was to evaluate graft function of pediatric kidney transplant recipients following diagnosis and standardized treatment of PTLD. METHODS Patients were identified from the German Ped-PTLD registry, and data on renal function were retrospectively retrieved from patient charts. For PTLD treatment, immunosuppressive therapy was reduced and all children received rituximab (375 mg/m2 ) for up to six doses. Two patients required additional low-dose chemotherapy. Renal allograft function was monitored by consecutive measurements of estimated glomerular filtration rate (eGFR) at defined time points. Follow-up was up to 60 months after PTLD. RESULTS Twenty patients were included in this cohort analysis. Median time from transplantation to PTLD was 2.4 years. Histopathology showed monomorphic lesions in 16 and polymorphic in 4 patients. Two patients experienced PTLD relapse after 2 and 14 months. Range-based analysis of variance showed stable allograft function in 17 of 20 patients (85%). Mean eGFR increased during early treatment phase. One patient experienced graft rejection 5.3 years after diagnosis of PTLD. Another patient developed recurrence of primary renal disease (focal-segmental glomerulosclerosis) and lost his renal allograft 3.8 years post-transplant (2.0 years after PTLD diagnosis). CONCLUSION Treatment of PTLD with rituximab with or without low-dose chemotherapy in combination with reduced immunosuppression, mostly comprising of an mTOR inhibitor-based, calcineurin inhibitor-free regimen, is associated with stable graft function and favorable graft survival in pediatric renal transplant patients.
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Affiliation(s)
- Henriette Zierhut
- Department of Pediatric Hematology and Oncology, Hannover Medical School, Hannover, Germany
| | - Nele Kanzelmeyer
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Anja Buescher
- Department of Pediatric Nephrology, University Hospital of Essen, Essen, Germany
| | - Britta Höcker
- Department of Pediatrics I, University Children's Hospital, Heidelberg, Germany
| | - Christine Mauz-Körholz
- Pediatric Hematology and Oncology, Gießen and Medical Faculty of the Martin-Luther University of Halle, Justus-Liebig-University, Giessen, Germany
| | - Burkhard Tönshoff
- Department of Pediatrics I, University Children's Hospital, Heidelberg, Germany
| | - Markus Metzler
- Department of Pediatrics, University Hospital Erlangen, Erlangen, Germany
| | - Martin Pohl
- Department of General Pediatrics, Adolescent Medicine and Neonatology, Faculty of Medicine, Medical Center - University of Freiburg, University of Freiburg, Freiburg, Germany
| | - Lars Pape
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Britta Maecker-Kolhoff
- Department of Pediatric Hematology and Oncology, Hannover Medical School, Hannover, Germany
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8
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Ahlenstiel-Grunow T, Pape L. Novel ways to monitor immunosuppression in pediatric kidney transplant recipients-underlying concepts and emerging data. Mol Cell Pediatr 2021; 8:8. [PMID: 34309698 PMCID: PMC8313639 DOI: 10.1186/s40348-021-00118-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 07/07/2021] [Indexed: 12/11/2022] Open
Abstract
After pediatric kidney transplantation, immunosuppressive therapy is given to avoid acute and chronic rejections. However, the immunosuppression causes an increased risk of severe viral complications and bacterial infections and is associated with serious side effects. It is therefore crucial to achieve the optimal individual balance between over- and under-immunosuppression and thereby avoid unnecessary exposure to immunosuppressive drugs. In routine use, steering of immunosuppressants is performed primarily by monitoring of trough levels that mirror pharmacokinetics (although not, however, pharmacodynamics). Other diagnostic and prognostic markers to assess the individual intensity of immunosuppression are missing. Potential methods to determine immune function and grade of immunosuppression, such as analysis of the torque teno virus (TTV) load, QuantiFERON Monitor®, and ImmuKnow® as well as virus-specific T cells (Tvis), are currently being evaluated. In some studies TTV load, QuantiFERON Monitor® and ImmuKnow® were associated with the risk for post-transplant rejections and infections, but randomized controlled trials after pediatric kidney transplantation are not available. Post-transplant monitoring of Tvis levels seem to be promising because Tvis control virus replication and have been shown to correlate with virus-specific as well as general cellular immune defense, which represents the individual’s susceptibility to infections. Additional Tvis-monitoring provides an innovative opportunity to personalize the antiviral management and the dosing of the immunosuppressive therapy after pediatric kidney transplantation to avoid unnecessary therapeutic interventions and identify over-immunosuppression.
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Affiliation(s)
- Thurid Ahlenstiel-Grunow
- Department of Pediatrics II, University Hospital of Essen, University of Essen-Duisburg, Hufelandstraße 55, 45147, Essen, Germany
| | - Lars Pape
- Department of Pediatrics II, University Hospital of Essen, University of Essen-Duisburg, Hufelandstraße 55, 45147, Essen, Germany.
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9
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Montanari F, Orjuela-Grimm M. Joining Efforts for PTLD: Lessons Learned from Comparing the Approach and Treatment Strategies Across the Pediatric and Adult Age Spectra. Curr Hematol Malig Rep 2021; 16:52-60. [PMID: 33544319 DOI: 10.1007/s11899-021-00606-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2021] [Indexed: 12/28/2022]
Abstract
PURPOSE OF REVIEW Post-transplant lymphoproliferative disorders are a rare and heterogeneous group of diseases, where large prospective studies have been difficult to perform and treatment paradigms are often based on retrospective studies. Here, we critically analyze and present the clinical algorithms commonly used for this disease, with a special focus on the challenges and differences of the approaches in the adult and pediatric populations. RECENT FINDINGS Clinical trials exploring combinations of immunochemotherapies with a sequential and risk-stratified strategy have demonstrated exciting results, but are hampered from specialty and age-determined silos. Approaches introducing novel-targeted therapies and cellular therapies are currently being explored with a goal of joining efforts across the pediatric and adult age spectra. We propose that future therapeutic approaches would benefit from combining pediatric and adult PTLD efforts, gaining from the experience garnered from the age- and subtype-specific tailored strategies, with the aim of limiting treatment-related toxicities while maximizing the efficacy. Joining of efforts holds enormous potential for accelerating access to novel therapeutic strategies for PTLD in the near future.
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Affiliation(s)
- Francesca Montanari
- Department of Hematology, Yale Cancer Center, Smilow Cancer Hospital, New Haven, USA
| | - Manuela Orjuela-Grimm
- Division of Pediatric Hematology, Oncology, and Stem Cell Transplant, Departments of Pediatrics and Epidemiology, Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, Mailman School of Public Health, 722 West 168th street, Room 730, New York, NY, 10032, USA.
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10
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Wang Z, Xu Y, Zhao J, Fu YX. Epstein-Barr virus-associated monomorphic post-transplant lymphoproliferative disorder after pediatric kidney transplantation: A case report. World J Clin Cases 2021; 9:469-475. [PMID: 33521117 PMCID: PMC7812878 DOI: 10.12998/wjcc.v9.i2.469] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 11/18/2020] [Accepted: 11/29/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Post-transplant lymphoproliferative disease (PTLD) is the most common malignant tumor that occurs after kidney transplantation in children, and is associated with Epstein-Barr virus (EBV).
CASE SUMMARY We report a case of PTLD that occurred in a 17-year-old female patient at 5 mo post-transplant. The first symptom was abdominal pain accompanied by fever, nausea, and vomiting. EBV-associated monomorphic PTLD with multiple abdominal nodules was diagnosed by pathology, clinical manifestations, imaging results, and the presence of EB-DNA. After successful treatment with rituximab, the abdominal nodules in the spleen and liver disappeared.
CONCLUSION Early pathological biopsy to confirm the diagnosis is critical to treatment and prognosis. Reducing immunosuppression and rituximab therapy are effective methods for treating PTLD, but need to be initiated as early as possible.
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Affiliation(s)
- Zhen Wang
- Department of Kidney Transplantation, Tianjin First Central Hospital, Tianjin 300192, China
| | - Yang Xu
- Department of Kidney Transplantation, Tianjin First Central Hospital, Tianjin 300192, China
| | - Jie Zhao
- Department of Kidney Transplantation, Tianjin First Central Hospital, Tianjin 300192, China
| | - Ying-Xin Fu
- Department of Kidney Transplantation, Tianjin First Central Hospital, Tianjin 300192, China
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11
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Virus-specific T cells in pediatric renal transplantation. Pediatr Nephrol 2021; 36:789-796. [PMID: 32221706 PMCID: PMC7910244 DOI: 10.1007/s00467-020-04522-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 02/25/2020] [Accepted: 02/25/2020] [Indexed: 12/15/2022]
Abstract
After pediatric kidney transplantation, immunosuppressive therapy causes an increased risk of severe viral complications, especially from cytomegalovirus (CMV), BK polyomavirus (BKPyV) or Epstein-Barr virus (EBV), and less frequent from adenovirus (ADV). However, suitable predictive markers for the individual outcome of viral infections are missing and the therapeutic management remains a challenge to the success of pediatric kidney transplantation. Virus-specific T cells are known for controlling viral replication and there is growing evidence that virus-specific T cells may serve as a prognostic marker to identify patients at risk for viral complications. This review provides an overview of the usability of virus-specific T cells for improving diagnostic and therapeutic management of viral infections with reference to the necessity of antiviral prophylaxis, timing of pre-emptive therapy, and dosing of immunosuppressive medication after pediatric kidney transplantation. Several studies demonstrated that high levels of virus-specific T cells are associated with decrease of virus load and favorable outcome, whereas lack of virus-specific T cells coincided with virus-induced complications. Accordingly, the additional monitoring of virus-specific T cells aims to personalize the management of antiviral therapy, identify overimmunosuppression, and avoid unnecessary therapeutic interventions. Prospective randomized trials in pediatric kidney recipients comparing standard antiviral and immunosuppressive regimens with T cell-guided therapeutic interventions are needed, before monitoring of virus-specific T cells is implemented in the routine care of pediatric kidney graft recipients.
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12
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Ashoor IF, Dharnidharka VR. Non-immunologic allograft loss in pediatric kidney transplant recipients. Pediatr Nephrol 2019; 34:211-222. [PMID: 29480356 DOI: 10.1007/s00467-018-3908-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Revised: 01/26/2018] [Accepted: 01/26/2018] [Indexed: 01/13/2023]
Abstract
Non-immunologic risk factors are a major obstacle to realizing long-term improvements in kidney allograft survival. A standardized approach to assess donor quality has recently been introduced with the new kidney allocation system in the USA. Delayed graft function and surgical complications are important risk factors for both short- and long-term graft loss. Disease recurrence in the allograft remains a major cause of graft loss in those who fail to respond to therapy. Complications of over immunosuppression including opportunistic infections and malignancy continue to limit graft survival. Alternative immunosuppression strategies are under investigation to limit calcineurin inhibitor toxicity. Finally, recent studies have confirmed long-standing observations of the significant negative impact of a high-risk age window in late adolescence and young adulthood on long-term allograft survival.
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Affiliation(s)
- Isa F Ashoor
- Division of Nephrology, LSU Health New Orleans and Children's Hospital, 200 Henry Clay Avenue, New Orleans, LA, 70130, USA.
| | - Vikas R Dharnidharka
- Washington University and St. Louis Children's Hospital, 600 South Euclid Ave, St. Louis, MO, 63110, USA
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13
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Cleper R. Post-transplantation lymphoproliferative disease in pediatric kidney transplant recipients-early success does not mean the battle is over! Transpl Int 2018; 31:361-363. [DOI: 10.1111/tri.13087] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Accepted: 10/16/2017] [Indexed: 11/26/2022]
Affiliation(s)
- Roxana Cleper
- Pediatric Nephrology Unit; Dana-Dwek Children's Hospital; Tel Aviv Israel
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