Identifying predictive factors for posttransplant lymphoproliferative disease in pediatric solid organ transplant recipients with Epstein-Barr virus viremia.

Epstein-Barr virus (EBV) viremia (EV) in pediatric solid organ transplant (SOT) recipients is a significant risk factor for posttransplant lymphoproliferative disease (PTLD) but not all patients with EV develop PTLD. We identify predictive factors for PTLD in patients with EV. We conducted a retrospective chart review of all pediatric SOT recipients (0 to 21 y) at a single institution between 2001 and 2009. A total of 350 pediatric patients received a SOT and 90 (25.7%) developed EV. Of EV patients, 28 (31%) developed PTLD. The median age at transplant was 11.5 months in the PTLD group and 21.5 months in the EV-only group (P=0.003). Twenty-three (37%) EV-only patients had immunosuppression increased before EV, compared with 28 (100%) of PTLD patients (P<0.001). The median peak EBV level was 3212 EBV copies/10 lymphocytes for EV-only and 8392.5 EBV copies/10 lymphocytes for PTLD (P=0.005). All patients who developed PTLD had ≥1 clinical symptoms. Younger age at transplant, increased immunosuppression before EV, higher peak EBV level, and presence of clinical symptoms have predictive value in the development of PTLD in SOT patients with EV.

Graft rejection in pediatric liver transplant patients with Epstein-Barr viremia and post-transplant lymphoproliferative disease.

Treatment of primary EV and PTLD in pediatric LT recipients (pLT) involves IS reduction/cessation. Retrospective review of pLT at our institution from 2001-2009 was conducted to characterize risk factors for GR after EV/ PTLD. Of 184 pLT, EV occurred in 61 (33%) at mean 16.5 m (0-82) and PTLD in 18 (9.8%) at mean 17.7 m (3-78) post-LT. Median age at pLT was 11 m (1-245 m) and follow-up six yr. For EV, 86% underwent IS reduction and 51% received antivirals. GR occurred in 12 (27.9%) with EV and 15 (83.3%) after PTLD diagnosis (relative risk of GR for PTLD 2.98). GR treated with methylprednisolone bolus in half and/or oral IS in half. Following GR therapy, four had PTLD relapses, no graft loss and one EV patient required re-transplantation. GR history before EV was a risk factor for GR after EV (p = 0.024). GR at any point after pLT was a risk factor for PTLD (p = 0.001). Children with EV and GR prior to EV should be monitored closely for GR after IS reduction and GR is a significant risk factor for PTLD. Most children with PTLD eventually developed GR.

Impact of point-of-care B-type natriuretic peptide (BNP) measurement on medical decision-making for older emergency department patients with dyspnea.

Measurement of B-type natriuretic peptide (BNP) has been shown to aid in the Emergency Department (ED) diagnosis of heart failure. We sought to determine how point-of-care BNP measurement influences real-world medical decision-making. Using a commercially available, point-of-care assay, BNP levels were measured in a convenience sample of ED patients over the age of 55 years who complained of dyspnea. Blinded to BNP results, emergency physicians were asked to formulate a differential diagnosis and management plan for each patient. Immediately thereafter, BNP results were disclosed and the physicians were asked what (if any) decisions they would change. With physicians blinded to BNP results, 24 of 88 patients (27%) were given a primary diagnosis of heart failure, and 18 patients (20%) were given a secondary or alternative diagnosis of heart failure. For the former group, disclosure of BNP results resulted in no changes in diagnosis or management. For the latter group, disclosure of BNP results caused heart failure to become the primary diagnosis in 4 patients (22%), and led to five changes in medical management. For the 46 patients initially given neither a primary nor secondary diagnosis of heart failure, disclosure of BNP results caused heart failure to become the primary diagnosis in one patient (2%) and a secondary diagnosis in 4 patients (9%), and led to five changes in medical management. Thus, for ED patients with a primary clinical diagnosis of heart failure, BNP testing had no impact on medical decision-making. However, for other patients with dyspnea, elevated BNP levels did influence medical decision-making, particularly when heart failure was in the differential diagnosis.