Zusammenfassung
Beim Immunkompetenten verursacht das Epstein-Barr-Virus (EBV) aufgrund seiner geringen zytopathischen Eigenschaften nur selten eine gravierende klinische Symptomatik. Während die Infektion bei Säuglingen und Kleinkindern meist asymptomatisch verläuft, entwickeln immunkompetente Jugendliche und junge Erwachsene typischerweise das Bild einer infektiösen Mononukleose. Auch die akute EBV-assoziierte klinische Symptomatik bei pädiatrischen Nierentransplantatempfängern verläuft mehrheitlich mild. Allerdings kann sich EBV unter medikamentöser Immunsuppression der T-Zell-spezifischen Regulation entziehen mit der Gefahr einer EBV-assoziierten posttransplantations-lymphoproliferativen Erkrankung (PTLD). Pädiatrische Patienten tragen ein erhöhtes PTLD-Risiko, da sie bei Transplantation häufig noch EBV-seronegativ sind und sich durch ein EBV-positives Spenderorgan infizieren. Geeignete diagnostische Surrogatmarker für das Risiko einer PTLD stehen derzeit noch nicht zur Verfügung, da die EBV-spezifische Serologie und die EBV-Viruslast im Blut nur eine geringe prognostische Aussagekraft besitzen. Eine unkritische Reduktion der medikamentösen Immunsuppression und damit Gefährdung des Transplantats, einzig auf einer hohen, persistierenden Viruslast basierend, sollte daher vermieden werden. Die Therapie der PTLD besteht in einer Kombination aus Reduktion der medikamentösen Immunsuppression, Rituximabgabe bei CD20-Antigen-Expression und ggf. Chemotherapie. Die Fünfjahresüberlebensrate nach PTLD beträgt etwa 61–87%, wobei ein Befall des Knochenmarks und/oder des zentralen Nervensystems eine ungünstige Prognose bedeutet. Eine wirksame EBV-Vakzine ist noch nicht vorhanden. Allerdings senkt die antivirale Chemoprophylaxe mit (Val-)Ganciclovir die Inzidenz der EBV-Primärinfektion bei Hochrisikopatienten (Spender EBV-positiv, Empfänger EBV-negativ) und folglich möglicherweise im Langzeitverlauf auch die PTLD-Rate.
Abstract
Due to its mild cytopathic effects, Epstein-Barr virus (EBV) rarely causes severe clinical symptoms in immunocompetent hosts. While infants often remain asymptomatic during EBV infections, young immunocompetent adolescents and adults typically develop signs of infectious mononucleosis. Also, immunocompromised pediatric renal transplant recipients exhibit mostly mild acute EBV-related clinical symptoms. However, immunosuppressive therapy after pediatric renal transplantation may lead to an uncontrolled malignant proliferation of EBV infected B cells, due to the lack of T cell-specific regulation, and thus to post-transplant lymphoproliferative disease (PTLD). Pediatric patients bear an increased risk of PTLD, as they are often EBV seronegative at the time of transplantation and develop EBV primary infection after receiving an EBV positive kidney. The EBV-specific serology and EBV viral load constitute insufficient surrogate markers for the risk assessment of PTLD. An uncritical reduction of immunosuppressive therapy, based solely on the presence of a high, persistent EBV load, may put patients at risk of transplant rejection and subsequent graft failure and should therefore be avoided. Treatment of PTLD comprises reduction of immunosuppression, administration of rituximab in cases of CD20 antigen expression and possibly chemotherapy. The 5-year survival rate after PTLD amounts to approximately 61–87%, with involvement of the bone marrow and/or central nervous system being a risk factor for poor survival. An EBV vaccine is currently not available. An antiviral chemoprophylaxis with (val-)ganciclovir, however, reduces the incidence of EBV primary infection in patients with a high-risk seroconstellation (donor EBV positive, recipient EBV negative) and, hence, potentially the rate of PTLD.
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Höcker, B., Tönshoff, B. Epstein-Barr-Virus-Infektion nach pädiatrischer Nierentransplantation. Nephrologe 8, 71–76 (2013). https://doi.org/10.1007/s11560-012-0684-1
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DOI: https://doi.org/10.1007/s11560-012-0684-1
Schlüsselwörter
- Epstein-Barr-Virus (EBV)
- Posttransplantations-lymphoproliferative Erkrankung (PTLD)
- Pädiatrische Nierentransplantatempfänger
- Morbidität
- Antivirale Prophylaxe