Search tips
Search criteria 


Logo of nihpaAbout Author manuscriptsSubmit a manuscriptHHS Public Access; Author Manuscript; Accepted for publication in peer reviewed journal;
Am J Hematol. Author manuscript; available in PMC 2012 March 23.
Published in final edited form as:
Am J Hematol. 2011 February; 86(2): 206–209.
doi:  10.1002/ajh.21911
PMCID: PMC3311225

Risk Factors for Early-onset and Late-onset Post-transplant Lymphoproliferative Disorder in U.S. Kidney Recipients


Incidence of post-transplant lymphoproliferative disorder (PTLD) is bimodal, suggesting distinct early-onset and late-onset subtypes. We evaluated differences in risk factors for early-onset and late-onset PTLD in a retrospective cohort study of U.S. kidney transplant recipients using data from the Scientific Registry of Transplant Recipients (N=156,740, 1999–2007). Multivariate hazard ratios (HRs) for risk factors were estimated using proportional hazards models. For early-onset PTLD, significantly increased risk was associated with young age at transplantation (HR 3.97 for <20 vs. 20–50 years), non-Hispanic white race/ethnicity (HR 1.82), and seronegativity for Epstein Barr virus (EBV) and cytomegalovirus at transplantation (HRs 3.13 and 1.49, respectively). By comparison, younger and older age (HRs 2.68 and 1.28 for <20 and >50, respectively, vs. 20–50 years) and non-Hispanic white race/ethnicity (HR 1.77) increased late-onset PTLD risk. The association with young age was weaker for late-onset than early-onset PTLD (p=0.06), and EBV and cytomegalovirus serostatus were not associated with late-onset PTLD risk. These results support somewhat different etiologies for early-onset and late-onset PTLD. For early-onset PTLD, associations with young age and EBV seronegativity highlight the etiologic role of primary EBV infection. For late-onset PTLD, higher risk with older age is consistent with lymphoma patterns in the general population.

Keywords: kidney transplant, United States, Epstein-Barr Virus, post-transplant lymphoproliferative disorder

Solid organ transplant recipients have an elevated risk for some malignancies, due to the requirement for immunosuppression (1). In particular, non-Hodgkin lymphoma (NHL) is common and comprises one end of a spectrum of post-transplant lymphoproliferative disorder (PTLD) ranging from benign hyperplasia to lymphoid malignancy (2). PTLD risk is influenced by the type of organ transplanted, the age and Epstein Barr virus (EBV) serostatus of the transplant recipient, and the intensity of immunosuppression (39). PTLD incidence is high immediately after transplantation, decreases subsequently, then rises again 4–5 years from transplantation (10;11). This incidence pattern suggests the presence of separate early-onset and late-onset PTLD subtypes. Early-onset PTLDs tend to be EBV-positive and, when extranodal, are more likely than late-onset PTLDs to be localized to the transplanted organ (12;13). Late-onset PTLD is less likely to be associated with EBV, and overall is more likely than early-onset PTLD to be extranodal (13;14). The Scientific Registry of Transplant Recipients (SRTR) includes data on a large number of U.S. solid organ transplant recipients and information on malignancies diagnosed post-transplant. We used these data to conduct a retrospective cohort study among kidney transplant recipients to examine differences in risk factors between early-onset PTLD and late-onset PTLD.

The study included 156,740 kidney transplant recipients (Table 1). During follow-up, 762 cases of PTLD were diagnosed. Cumulative incidence of PTLD at 5 and 10 years after transplantation was 0.7% and 1.4%, respectively. As shown in Figure 1, a “U-shaped” pattern of incidence with time since transplantation was observed, with high PTLD incidence shortly after transplantation, decreasing until approximately 4 years from transplantation, and rising thereafter. Early-onset PTLD (i.e., within the first two years after transplant, N=361) was more likely to be monomorphic than polymorphic (48.2% vs. 41.6%, with 10.2% of unknown pathology), and late-onset PTLD (more than two years after transplant, N=401) was even more likely to be of monomorphic pathology (55.9% vs. 31.4%, 12.7% unknown). Early-onset PTLD was predominantly of B-cell origin (72.3% B-cell versus 4.2% T-cell, 23.6% unknown). Late-onset PTLD showed a slightly higher proportion of T-cell PTLD (64.3% B-cell versus 9.7% T-cell, 25.9% unknown).

Figure 1
Incidence of post-transplant lymphoproliferative disorder (PTLD) among kidney recipients during 1999–2007. Incidence and 95% confidence intervals are shown as a function of time since transplantation. PTLD incidence is displayed as PTLD events ...
Table 1
Demographic and transplant characteristics of kidney recipients followed during 1999–2007 in the United States (N=156,740)

We examined PTLD risk factors stratified by onset time (Table 2). Gender was not associated with early-onset PTLD risk, but males had significantly higher late-onset PTLD risk than females (hazard ratio [HR] 1.23). Young age was more strongly associated with risk of early-onset PTLD than late-onset PTLD (HRs 6.59 and 2.98, respectively, compared to age 20–50 years at transplant; p<0.0001 for difference in HRs), while older age (>50 years) was significantly associated only with late-onset PTLD risk (HR 1.29). Non-Hispanic whites were at significantly higher risk of early-onset and late-onset PTLD than other racial/ethnic groups (HRs 2.09 and 1.76, respectively). EBV serongegativity was associated with significantly increased risk of both early-onset and late-onset PTLD, although the association was much stronger for early-onset PTLD (HRs 4.76 vs. 1.52, p<0.0001). CMV seronegativity was also associated with increased early-onset PTLD risk more strongly than late-onset PTLD risk (HRs 2.44 vs. 1.25, p=0.0001).

Table 2
PTLD risk factors among U.S. kidney transplant recipients during 1999–2007

Steroid maintenance therapy did not impact early-onset PTLD risk, but significantly decreased the risk of late-onset PTLD (HR 0.64). Use of antibody induction or anti-rejection therapies was not associated with PTLD risk, even when restricted to T-cell based therapies (Table 2). The degree of HLA mismatch was also not associated with PTLD risk, regardless of the timing of PTLD onset.

Results of separate multivariate models for early-onset and late-onset PTLD are shown in Table 3. When EBV and CMV serostatus were not included (model 1), young age was significantly associated with both early-onset and late-onset PTLD risk (HRs 6.47 and 2.92, respectively, compared to age 20–50 years), and non-Hispanic whites were at significantly increased risk of both early-onset PTLD and late-onset PTLD, compared to other racial/ethnic groups (HRs 2.11 and 1.73, respectively). The association with young age was stronger for early-onset than for late-onset PTLD (p<0.0001).

Table 3
Multivariate analysis of risk factors for PTLD among U.S. kidney transplant recipients during 1999–2007

With addition of information for EBV and CMV serostatus (model 2), young age remained significantly associated with both early-onset and late-onset PTLD risk (HRs 3.97 and 2.68, respectively, compared to age 20–50 years), although the association was attenuated for early-onset PTLD compared to the results of model 1. Non-Hispanic whites continued to be at significantly increased risk of both early-onset PTLD and late-onset PTLD compared to other racial/ethnic groups (HRs 1.82 and 1.77, respectively). EBV and CMV seronegativity were significantly associated with increased risk of early-onset PTLD only (HRs 3.13 and 1.49, respectively). In both multivariate models, gender was no longer associated with risk of either early-onset or late-onset PTLD. When added to model 2, steroid maintenance therapy remained a significant predictor of decreased late-onset PTLD risk (HR 0.66).

This large retrospective cohort study of kidney transplant recipients showed a clear bimodal pattern in onset for PTLD, and there were distinct differences in pathology and risk factors between early-onset PTLD and late-onset PTLD. Independent risk factors for early-onset PTLD included young age at transplantation, and EBV and CMV seronegativity. By comparison, independent risk factors for late-onset PTLD included older age at transplantation, and non-Hispanic white race/ethnicity. Although the differences in risk factors were not large, the results suggest that early-onset and late-onset PTLD comprise different entities with somewhat different etiologies.

The cumulative incidence of PTLD in our study was similar to that reported previously (9;10;15;16). As in prior studies (10;11), we also observed a “U-shaped” pattern of PTLD incidence with time since transplantation. This pattern identifies early-onset PTLD, occurring in the 1–2-year period immediately following transplantation, and late-onset PTLD, occurring some years later. In our study, a greater proportion of late-onset PTLDs than early-onset PTLDs were of monomorphic pathology and of T-cell origin. Other studies have found similar biological differences between early-onset PTLD and late-onset PTLD (13;17). While early-onset PTLD is more likely than late-onset PTLD to be localized in the transplanted organ (12;13), we were unable to examine this pattern in our study due to insufficient data on tumor location.

The increased risk of PTLD seen in young recipients (9;18) is likely due to the high percentage who are EBV naive at transplantation, leaving them susceptible to primary infection immediately following transplantation. Supporting this interpretation, we found that the association of young age at transplant with early-onset PTLD became weaker when we included EBV serostatus in a multivariate model (model 2 vs. model 1, Table 3). Primary infection during the period of intense immunosuppression immediately following transplantation allows for uncontrolled EBV-driven lymphoproliferation (4;7;19). The vast majority of early-onset PTLDs express EBV proteins (13). The role of CMV infection is less well understood. An earlier study pointed to a possible synergistic role of CMV disease with primary EBV infection in causing PTLD (20). Nonetheless, the association that we observed between CMV serostatus and risk of early-onset PTLD could be the result of uncontrolled confounding, since CMV serostatus is related to age, EBV serostatus, and perhaps other unmeasured factors. In our study EBV seronegativity was not an independent risk factor for late-onset PTLD, although this has been suggested in other work (21).

We did not find an association between antibody induction therapy and early-onset PTLD risk, in contrast to earlier reports (9;19;22;23). The discrepancy could relate to calendar period differences, because we focused on a later calendar period (1999–2007), well after widespread introduction of antibody induction therapy during the mid to late 1990s (24). When new therapies are introduced, the rate of PTLD has been observed to increase as transplant centers work to establish the appropriate dosing regimen to ensure a balance of efficacy and safety (“learning-curve” effect) (1). We hypothesize that transplant centers had had sufficient time by 1999 to gain experience with antibody-based induction therapies, leading to an attenuation of associated PTLD risk.

In terms of pathology and clinical features, compared to early-onset PTLDs, late-onset PTLDs more closely resemble lymphomas seen in the general population (8). In the general population, NHL incidence is higher among non-Hispanic whites than other races/ethnicities and increases monotonically with age (25;26), which may explain the observed associations of these two factors with late-onset PTLD. While the association with increasing age has been described previously (9;27), the protective effect of steroid-based maintenance therapy on late-onset PTLD risk is a new finding. Of interest, research on NHLs in the general population has yielded inconsistent results on the possible effect of steroid-based medications, with some studies showing that they increase NHL risk and other studies showing no relationship (28).

Our study had several important strengths, including its large size and inclusion of both malignant and non-malignant PTLDs Limitations to our study also need to be considered. We likely did not have complete ascertainment of PTLD, especially for diagnoses that occurred late after transplantation. Transplant centers are typically able to follow a very high percentage of recipients in the first 1–2 years after transplantation, but this percentage decreases with time, and by 5 years post-transplant, up to 25% of kidney transplant recipients may be lost to follow-up (29). Losses to follow-up would have led to underestimation of PTLD incidence but should not have differed across the risk factors we examined. Missing data on EBV and CMV serology for a large percentage of transplant recipients required that we impute the data using demographic and other characteristics, so that these findings need to be interpreted with some caution. In addition, our data on immunosuppressive medications were limited to baseline and did not include specific dosing information. Thus, we could not assess the effect of immunosuppressive intensity or changes in the immunosuppressive regimen on PTLD risk.

In conclusion, the bimodal timing of PTLD after transplant and the observed differences in pathology and risk factors provide evidence that early-onset PTLD and late-onset PTLD are either distinct disease entities or, perhaps more likely, are composed of a variable mixture of subtypes with different etiologies. PTLD remains an important source of morbidity associated with solid organ transplantation, and additional research on the risk factors and clinical features of PTLD, particularly late-onset PTLD, is required to better understand the role of prolonged immunosuppression and immune dysfunction in lymphomagenesis.


We conducted a retrospective cohort study of U.S. kidney transplant recipients using SRTR data. Data on all U.S. kidney transplants since 1986 are provided by transplantation centers and organ procurement organizations that together comprise the Organ Procurement and Transplantation Network (OPTN). Baseline data are collected at the time of registration and at transplantation, and follow-up data are collected 6 and 12 months after transplantation and annually thereafter. Recipients of first kidney transplants conducted between October 1, 1987, and August 31, 2007 were eligible for the present study. Included recipients had no evidence of human immunodeficiency virus infection and had at least 30 days of follow-up after transplantation.

For each transplant recipient, SRTR data included demographic characteristics, human leukocyte antigen (HLA) mismatches with the donor at the A, B, and DR loci, and serology results for EBV (EBV IgG) and cytomegalovirus (CMV IgG). Information on the initial immunosuppressive regimen prescribed prior to hospital discharge was obtained.

Transplant centers reported on the occurrence of PTLD during follow-up, which were categorized according to pathology (polymorphic including hyperplasia, monomorphic, or unknown) and cell type (B-cell, T-cell, or unknown). Cases of multiple myeloma and Hodgkin lymphoma were excluded. Reporting of PTLD to the SRTR changed over time. OPTN did not routinely collect PTLD data on kidney transplant recipients until March 1, 1997. In 1999, the SRTR transitioned from a paper-based to a web-based system for filing follow-up reports.

Statistical analysis

Recipients were followed from 30 days after transplant until the earliest of PTLD diagnosis, graft failure, re-transplantation, death, loss to follow-up, or 10 years post-transplantation. To ensure uniform reporting of PTLD, we included only follow-up time and PTLD events from January 1, 1999 onwards.

Based on the pattern of PTLD risk in relation to time since transplant, we divided cases into early-onset PTLD (within 2 years of transplantation) and late-onset PTLD (2 or more years from transplantation). Risk factors for these two periods were evaluated using separate proportional hazards regression models. In these analyses, recipients contributed to each model during their person-time within the window of interest. To determine if the strength of association differed for each risk factor between early-onset and late-onset PTLD, we tested the significance of an interaction term between the variable of interest and a time-dependent indicator variable that distinguished early and late follow-up periods. In multivariate models, we included variables that were significant in univariate models or seemed relevant based on earlier work.

Baseline EBV and CMV data were missing for 62.1% and 41.9% of recipients, respectively. We therefore used a multiple imputation approach to assign EBV and CMV baseline serostatus based on demographic and transplant characteristics for recipients initially missing this information. This full dataset including the imputed values was used to estimate hazard ratios associated with EBV and CMV serostatus. The imputation and estimation was repeated 10 times and the results were combined using the Rubin method in the MIANALYZE procedure (SAS, Version 9.1, Cary, NC) (30).

Supplementary Material

Supp Table 01-02


The Scientific Registry of Transplant Recipients (SRTR) is supported by contract 231–00-0116 from the U.S. Department of Health Resources and Services Administration (HRSA), U.S. Department of Health and Human Services.

The data reported here have been supplied by the contractor for the SRTR. The interpretation and reporting of these data are the responsibility of the authors and should not be seen as an official policy of or interpretation by the SRTR or the U.S. Government.

Reference List

1. Penn I. Post-transplant malignancy: the role of immunosuppression. Drug Saf. 2000 Aug;23(2):101–113. [PubMed]
2. Harris NL, Swerdlow SH, Frizzera G, Knowles DM. Post-transplant lymphoproliferative disorders. In: Jaffe ES, Harris NL, Stein H, Vardiman JW, editors. Pathology and Genetics - Tumours of Haematopoietic and Lymphoid Tissues. Lyon, France: IARC Press; 2001. pp. 264–269.
3. Epstein-Barr virus and lymphoproliferative disorders after transplantation. Am J Transplant. 2004 Nov;4 Suppl 10:59–65. [PubMed]
4. Andreone P, Gramenzi A, Lorenzini S, Biselli M, Cursaro C, Pileri S, Bernardi M. Posttransplantation lymphoproliferative disorders. Arch Intern Med. 2003 Sep 22;163(17):1997–2004. [PubMed]
5. Cockfield SM. Identifying the patient at risk for post-transplant lymphoproliferative disorder. Transpl Infect Dis. 2001 Jun;3(2):70–78. [PubMed]
6. LaCasce AS. Post-transplant lymphoproliferative disorders. Oncologist. 2006 Jun;11(6):674–680. [PubMed]
7. Opelz G, Daniel V, Naujokat C, Dohler B. Epidemiology of pretransplant EBV and CMV serostatus in relation to posttransplant non-Hodgkin lymphoma. Transplantation. 2009 Oct 27;88(8):962–967. [PubMed]
8. Taylor AL, Marcus R, Bradley JA. Post-transplant lymphoproliferative disorders (PTLD) after solid organ transplantation. Crit Rev Oncol Hematol. 2005 Oct;56(1):155–167. [PubMed]
9. van Leeuwen MT, Grulich AE, Webster AC, McCredie MR, Stewart JH, McDonald SP, Amin J, Kaldor JM, Chapman JR, Vajdic CM. Immunosuppression and other risk factors for early and late non-Hodgkin lymphoma after kidney transplantation. Blood. 2009 Jul 16;114(3):630–637. [PubMed]
10. Faull RJ, Hollett P, McDonald SP. Lymphoproliferative disease after renal transplantation in Australia and New Zealand. Transplantation. 2005 Jul 27;80(2):193–197. [PubMed]
11. Morton LM, Landgren O, Chatterjee N, Castenson D, Parsons R, Hoover RN, Engels EA. Hepatitis C virus infection and risk of posttransplantation lymphoproliferative disorder among solid organ transplant recipients. Blood. 2007 Dec 15;110(13):4599–4605. [PubMed]
12. Bakker NA, van Imhoff GW, Verschuuren EA, van Son WJ, Homan van der Heide JJ, Veeger NJ, Kluin PM, Kluin-Nelemans HC. Early onset post-transplant lymphoproliferative disease is associated with allograft localization. Clin Transplant. 2005 Jun;19(3):327–334. [PubMed]
13. Ghobrial IM, Habermann TM, Macon WR, Ristow KM, Larson TS, Walker RC, Ansell SM, Gores GJ, Stegall MD, McGregor CG. Differences between early and late posttransplant lymphoproliferative disorders in solid organ transplant patients: are they two different diseases? Transplantation. 2005 Jan 27;79(2):244–247. [PubMed]
14. Leblond V, Davi F, Charlotte F, Dorent R, Bitker MO, Sutton L, Gandjbakhch I, Binet JL, Raphael M. Posttransplant lymphoproliferative disorders not associated with Epstein-Barr virus: a distinct entity? J Clin Oncol. 1998 Jun;16(6):2052–2059. [PubMed]
15. Caillard S, Lelong C, Pessione F, Moulin B. Post-transplant lymphoproliferative disorders occurring after renal transplantation in adults: report of 230 cases from the French Registry. Am J Transplant. 2006 Nov;6(11):2735–2742. [PubMed]
16. Opelz G, Dohler B. Lymphomas after solid organ transplantation: a collaborative transplant study report. Am J Transplant. 2004 Feb;4(2):222–230. [PubMed]
17. Nelson BP, Nalesnik MA, Bahler DW, Locker J, Fung JJ, Swerdlow SH. Epstein-Barr virus-negative post-transplant lymphoproliferative disorders: a distinct entity? Am J Surg Pathol. 2000 Mar;24(3):375–385. [PubMed]
18. Dharnidharka VR, Tejani AH, Ho PL, Harmon WE. Post-transplant lymphoproliferative disorder in the United States: young Caucasian males are at highest risk. Am J Transplant. 2002 Nov;2(10):993–998. [PubMed]
19. Caillard S, Dharnidharka V, Agodoa L, Bohen E, Abbott K. Posttransplant lymphoproliferative disorders after renal transplantation in the United States in era of modern immunosuppression. Transplantation. 2005 Nov 15;80(9):1233–1243. [PubMed]
20. Manez R, Breinig MC, Linden P, Wilson J, Torre-Cisneros J, Kusne S, Dummer S, Ho M. Posttransplant lymphoproliferative disease in primary Epstein-Barr virus infection after liver transplantation: the role of cytomegalovirus disease. J Infect Dis. 1997 Dec;176(6):1462–1467. [PubMed]
21. Shahinian VB, Muirhead N, Jevnikar AM, Leckie SH, Khakhar AK, Luke PP, Rizhalla KS, Hollomby DJ, House AA. Epstein-Barr virus seronegativity is a risk factor for late-onset posttransplant lymphoproliferative disorder in adult renal allograft recipients. Transplantation. 2003 Mar 27;75(6):851–856. [PubMed]
22. Bustami RT, Ojo AO, Wolfe RA, Merion RM, Bennett WM, McDiarmid SV, Leichtman AB, Held PJ, Port FK. Immunosuppression and the risk of post-transplant malignancy among cadaveric first kidney transplant recipients. Am J Transplant. 2004 Jan;4(1):87–93. [PubMed]
23. Swinnen LJ, Costanzo-Nordin MR, Fisher SG, O'Sullivan EJ, Johnson MR, Heroux AL, Dizikes GJ, Pifarre R, Fisher RI. Increased incidence of lymphoproliferative disorder after immunosuppression with the monoclonal antibody OKT3 in cardiac-transplant recipients. N Engl J Med. 1990 Dec 20;323(25):1723–1728. [PubMed]
24. Meier-Kriesche HU, Li S, Gruessner RW, Fung JJ, Bustami RT, Barr ML, Leichtman AB. Immunosuppression: evolution in practice and trends, 1994–2004. Am J Transplant. 2006;6(5 Pt 2):1111–1131. [PubMed]
25. Alexander DD, Mink PJ, Adami HO, Chang ET, Cole P, Mandel JS, Trichopoulos D. The non-Hodgkin lymphomas: a review of the epidemiologic literature. Int J Cancer. 2007;120 Suppl 12:1–39. [PubMed]
26. Grulich AE, Vajdic CM. The epidemiology of non-Hodgkin lymphoma. Pathology. 2005 Dec;37(6):409–419. [PubMed]
27. Caillard S, Lelong C, Pessione F, Moulin B. Post-transplant lymphoproliferative disorders occurring after renal transplantation in adults: report of 230 cases from the French Registry. Am J Transplant. 2006 Nov;6(11):2735–2742. [PubMed]
28. Ekstrom-Smedby K. Epidemiology and etiology of non-Hodgkin lymphoma--a review. Acta Oncol. 2006;45(3):258–271. [PubMed]
29. Levine GN, McCullough KP, Rodgers AM, Dickinson DM, Ashby VB, Schaubel DE. Analytical methods and database design: implications for transplant researchers, 2005. Am J Transplant. 2006;6(5 Pt 2):1228–1242. [PubMed]
30. Rubin DB. Multiple Imputation for Nonresponse in Surveys. New York: J. Wiley & Sons; 1986.