Page 32 - Heart Transplant Protocol

Heart Function Service: Heart Transplant Protocols

a. New onset EBV positive PCR
 If recipient was seronegative at time of transplant, recheck in 2 weeks,
monthly x 2 months, then every 3 months
 If recipient was seropositive at time of transplant, recheck with next labs

b. EBV PCR increases from low risk (<5 log IU/ml)to high risk (>5 log IU/ml) recheck
with next labs
c. Before and after treatment for acute rejection
d. During CMV disease

Evaluation and management of patients with an elevated EBV PCR will proceed as follows:
3. EBV PCR <5 log IU/ml
a. No treatment; follow-up per above monitoring protocol
4. EBV PCR >5 log IU/ml
a. Reduce immunosuppression in discussion with Transplant Attending:
 Will not make changes to current calcineurin inhibitor therapy
a. Studies showed that changes in calcineurin inhibitor levels did not
affect viral load3.
 Discontinue Azathioprine or Cellcept and consider starting Rapamycin
a. Studies have shown that there are higher EBV loads in patients on
Azathioprine vs Rapamycin/Everolimus3.
b. Repeat EBV PCR with next labs (consider 3 determinations or until trend is
established)
c. Obtain CMV PCR

Treatment of EBV Disease / PTLD

It is recommended that EBV disease and/or PTLD be considered and EBV PCR testing obtained with
presentation of any of the following symptoms:
1. Protracted fever
2. GI disturbances – diarrhea, abdominal pain, GI bleeding, vomiting, protein losing
enteropathy, weight loss, bowel obstruction/perforation
3. Unexplained elevated liver enzymes
4. Lymphadenopathy
5. Tonsillar hypertrophy
6. Infectious mononucleosis syndrome-sore throat, fatigue, anorexia
7. Hepatic or splenic enlargement
8. Cutaneous nodules
9. Unexplained anemia, pancytopenia, atypical lymphocytosis, thrombocytopenia, or
eosinophilia
10. Headache or focal neurologic symptoms
11. Allograft dysfunction

A. Evaluation and management of patients with an elevated EBV PCR and concern for PTLD will
include:
1. Thorough history and physical examination for symptoms and signs of EBV disease / PTLD
2. Consider contrast enhanced CT scan of neck, chest, abdomen, and pelvis (CT or MRI of brain
if suspicion of CNS disease).
3. Consider endoscopy in the setting of GI symptoms or hypoalbuminemia.

Updated November 9, 2017 32