Managing the challenge of PTLD in liver and bowel transplant recipients

Post-transplant lymphoproliferative disorder (PTLD) remains a common complication of liver and bowel transplantion. The ubiquity of Epstein-Barr virus (EBV) combined with engraftment of organs rich with lymphatic tissue and the requirement of highly immunosuppressive regimens are factors that account for the high frequency and poor prognosis of PTLD in this population. Early detection of the virus followed by pre-emptive reduction of immunosuppression are essential components in the management of PTLD, but can increase the risk of graft loss. More recently, the anti-CD20 monoclonal antibody (rituximab) has been shown to improve survival in various transplant populations with PTLD, while other therapeutic options, such as chemotherapy, surgery or radiotherapy, have minimal clinical impact. EBV-directed cytotoxic T cells have shown promise in the management of PTLD but clinical use is currently limited by lack of technical facilities worldwide.