Treatment for Epstein-Barr virus-associated PTLD

The association between Epstein-Barr virus (EBV) and post-transplant lymphoproliferative disease (PTLD) has been recognized since the early days of transplantation. The major pathogenetic defect is the insufficient EBV-specific cytotoxic T-cell control of EBV-driven B-cell proliferations. Despite this understanding, PTLD remains a significant cause of morbidity and mortality for transplant recipients. Determining the right therapy or therapies for any given patient with PTLD remains a major clinical problem. Productive areas of investigation include: identifying who will benefit from reduction of immunosuppression only; improving methods to predict those at highest risk of PTLD; developing safe and effective pre-emptive therapies; identifying who will benefit from rituximab; and developing more effective, less toxic therapies for resistant or aggressive disease. Obstacles that exist are heterogeneity of disease and patient populations, and divergent approaches to immunosuppression and therapeutic interventions. Greater collaboration is needed between infectious disease specialists, pathologists, transplant physicians and oncologists to overcome problems and develop agreed disease definitions and interventions that can be tested in large, prospective multicentre trials.