Page 31 - Heart Transplant Protocol

Heart Function Service: Heart Transplant Protocols

of options in medical management of EBV viremia ranging from diminishment of maintenance
immunosuppression to prophylactic treatment with anti-B cell therapy. However, mixed benefits of each
therapeutic regimen have been shown in various studies leaving providers with an unknown risk-benefit
ratio between prophylactic treatment and risk of elevated rejection, risk of medication toxicity, and risk
of potentially detrimental effects to immune system balance. Once transformation from EBV viremia,
symptomatic or otherwise, to PTLD occurs; treatment regimens become increasingly complex and
multifaceted based upon disease subtype, disease burden, and disease response to early interventions.
Treatment of PTLD therefore requires a multidisciplinary approach involving both the heart transplant
and oncology teams, and this treatment will inevitably be tailored to patient-specific factors.

Definitions
1. Post-transplant patients will be defined as high risk/high alert patients based upon risk
factors for eventual development of PTLD. As defined by previous studies, patients who are
of younger age at the time of transplantation, patients who were EBV naïve at the time of
transplantation, patients who have required high levels of immune suppression, patients
with chronically “high” level of EBV viremia, and patients with a history of PTLD represent a
high risk group for development of PTLD or PTLD recurrence.
2. Post-transplant patients will be defined as low risk if they have positive EBV serology in
absence of passive antibody or a quantitative whole blood EBV PCR <5 log IU/ml with no
attributable symptoms.

Major Risk Factors:

1. Primary infection after transplantation is the most clearly defined risk factor, increasing
incidence of PTLD by 10-76 fold. It usually occurs when an EBV-seronegative recipient (R-)
receives an organ from a seropositive donor (D+), but it can also occur in the setting of D-/R-
2. Young recipient age
3. Net state of immunosuppression
4. CMV disease

EBV PCR:
1. In surveillance studies involving pediatric SOT recipients, high EBV virus loads have been
found to be sensitive but not specific predictors of PTLD development (9). Trends are more
likely to be of value than single measures.
2. EBV PCR may be used for surveillance and as an adjunct to the diagnosis of PTLD.
3. Whole blood quantitative EBV PCR (test used at CMC):
5
a. High risk > log

Pretransplant screening:
A. Serum EBV panel (EBV VCA IgG, EBV VCA IgM, EBNA, and EA) will be obtained and evaluated at
transplant evaluation, and it will be evaluated in the recipient and donor at the time of
transplantation to assess risk.

EBV Viral Load Monitoring and Preemptive Therapy
EBV PCR viral load will be monitored post-transplant at the following times:
1. 2 weeks, 1, 3, 6, 12 months and then annually
2. Additional EBV PCR testing

Updated November 9, 2017 31