BACKGROUND: Prior studies indicate that 1% to 4% of Epstein-Barr virus (EBV)-seronegative recipients of EBV-seropositive donor (EBV D+/R-) kidneys develop posttransplant lymphoproliferative disorder (PTLD). However, these estimates are based on limited data that lack granularity. OBJECTIVE: To determine the associations between pretransplant EBV D+/R- and recipient EBV-seropositive status (R+) and the outcomes of PTLD and graft and patient survival among adult kidney transplant recipients. DESIGN: Retrospective cohort study. SETTING: Two large U.S. transplant centers. PARTICIPANTS: Epstein-Barr virus D+/R- and EBV R+ recipients matched 1:3 on donor, recipient, and transplant characteristics between 1 January 2010 and 30 June 2022. MEASUREMENTS: Exposure was pretransplant donor and recipient EBV serostatus. The primary outcome was biopsy-proven PTLD. Secondary outcomes were all-cause graft loss (death, retransplant, or graft failure) and death. Follow-up was truncated to 3 years after transplant. RESULTS: The final cohort comprised 104 EBV D+/R- recipients matched to 312 EBV R+ recipients. The mean age was 42 years (SD, 17.1), 59% were living donor transplants, and 95% received thymoglobulin induction. Among EBV D+/R- recipients, 50 (48.1%) developed EBV DNAemia, with a median time of 198 days (IQR, 110 to 282 days) after transplantation. Posttransplant lymphoproliferative disorder occurred in 23 (22.1%) EBV D+/R- recipients at a median of 202 days (IQR, 118 to 317 days) after transplantation. Epstein-Barr virus D+/R- recipients had higher all-cause graft failure (hazard ratio, 2.21 [95% CI, 1.06 to 4.63])
mortality was higher but not statistically significant (hazard ratio, 2.19 [CI, 0.94 to 5.13]). LIMITATION: Two-center study. CONCLUSION: Compared with previous studies, this study showed that EBV D+/R- kidney recipients face a 5- to 10-fold higher cumulative incidence of PTLD. Strategies to mitigate the PTLD risk are urgently needed. PRIMARY FUNDING SOURCE: National Institutes of Health.