post transplant lymphoproliferative disorders (ptld)
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Post Transplant Post Transplant Lymphoproliferative Lymphoproliferative DisordersDisorders(PTLD)(PTLD)
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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
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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
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Incidence by Type of Incidence by Type of
Organ TransplantedOrgan TransplantedIntestinal transplant 18%Lung 8%Heart 3%Liver 3%Renal <1%
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Clinical PresentationClinical PresentationSome patients are asymptomaticOthers may have non specific
symptoms Fever Malaise Weight loss
May resemble infectious mononucleosisEnlarged tonsilsLymphadenopathyIntestinal Perforation
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Systems Potentially Systems Potentially Involved in PTLDInvolved in PTLDCentral Nervous SystemBone MarrowKidneysLiverLungsSmall intestinesSpleen
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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
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Risk FactorsRisk FactorsEBV seronegative recipientType of Organ transplantedType of immunosuppressionSimultaneous cytomegalovirus disease
Younger AgeMale
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Prevention/Prevention/MonitoringMonitoringEBV Surveillance
◦Monitor EBV-DNA load
EBV vaccine◦Not standard treatment
Anti-viral agents◦Questionable value◦Agents used include Acyclovir & Ganciclovir
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Treatment of PTLDTreatment of PTLDReduction of Immunosuppression
therapyAnti-viral agents and IVIG are of
limited valueInterferon alphaRituximabCHOP
◦Doxorubicin, Cyclophosphamide, Vincristine and Prednisone
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ConclusionConclusionPrognosis is poor5 year survival rates◦25 to 60%
High mortality rateLack of standard treatment
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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