Clinical and virologic outcomes in high-risk adult Epstein-Barr virus mismatched organ transplant recipients

Epstein-Barr virus (EBV) D+/R- organ transplant recipients are a high-risk group for developing post-transplant lymphoproliferative disease (PTLD). Little data are available for prevention in the adult EBV mismatched population. We conducted a retrospective study of EBV D+/R- organ transplants performed during 2002-2014. Of the 153 patients identified, 82.4% patients received antiviral prophylaxis with valganciclovir for a median of 4.5 months (range: 0.8-22 months) and 36.6% underwent viral load monitoring in the first post-transplant year. EBV viremia developed in 67.2% monitored patients. In viremic patients, immunosuppression was reduced in 20/37(54.1%) in response to viremia and 17/37 (45.9%) received therapeutic dose valganciclovir. In patients with EBV viremia who received valganciclovir and/or had a reduction in immunosuppression and had sufficient viral load time points (n= 31), 28 (90.3%) had a significant decline in viral load at day 14 (median log decline 0.49 (0.24-0.64), P<. 001) and at day 30 (0.87 (0.52-1.21), P<. 001). PTLD developed in 27 (15%) patients (biopsy proven= 25, possible= 2) at median 8 months (range: 2.4-130) post-transplant with the majority (81.5%) within the first year. In multivariate analysis, viral load monitoring and use of mycophenolate were associated with a lower incidence of PTLD. Antiviral prophylaxis was not associated with a lower risk of PTLD, but viral load monitoring and use of mycophenolate mofetil were protective.