[The significance of risk-adapted antiviral prophylaxis and modern virus diagnosis for organ survival after kidney transplantation].
OBJECTIVE
Viral, especially cytomegalovirus (CMV), infections are after rejection reaction the most serious problem following organ transplantation. The risk of disease correlates with the CMV donor/recipient constellation and the degree of immunosuppression. The importance of antiviral prophylaxis remains unresolved. Whether drug prophylaxis adapted to the individual risk is of clinical value was investigated in a prospective study.


METHODS
A risk-adapted stepwise antiviral prophylactic regimen was given to 62 patients with renal transplants. All patients at risk of CMV infection were given acyclovir, 200 mg four times daily for 3 months. Patients with rejection reaction for which they were receiving i.v. immunosuppressive treatment additionally received CMV hyperimmunoglobulin (2 ml/kg body weight on days 1 and 14). High-risk patients (donor CMV positive and recipient CMV negative) were given as basic prophylaxis CMV hyperimmunoglobulin i.v. on days 1 and 14 after transplantation, and additionally i.v. ganciclovir during any rejection treatment. The results were compared with those of a retrospectively selected patient cohort (n = 52) who had received only acyclovir as basic prophylaxis. The diagnosis of CMV infection was made by demonstrating CMVpp65 antigen in blood. In the prospectively studied patients measurement of beta 2 microglobulin concentration was used to determine viruria in 24-hour urine.


RESULTS
Among the high-risk group (donor CMV positive/recipient CMV negative) the additional prophylactic regimen significantly reduced the proportion of CMV-associated cases of rejection (14% compared with 42%, P < 0.05) in the basic prophylaxis only group. Similar results were obtained for CMV-caused transplant loss within the first 3 years (19% vs 50%, P < 0.05). The additional prophylaxis had no influence on the incidence of CMV infection. In case of active infection an isolated rise of beta 2-microglobulin in urine occurred in active infection at a mean of 6 days before CMVpp65 antigenaemia (sensitivity of 89%).


CONCLUSIONS
These results indicate that risk-adapted antiviral prophylaxis can decisively influence the long-term prognosis for a renal transplant, but not the incidence of CMV infection. The early and reliable diagnosis of active CMV infection is made possible by the combined use of beta 2-microglobulinuria and pp65 antigenaemia.
Fricke
L
L
Klinik für Innere Medizin I, Medizinischen Universität zu Lübeck.
Steinhoff
J
J
Hartwig-Weber
I
I
Bein
G
G
D000212:Acyclovir / Q000627:therapeutic use; D000328:Adult; D000998:Antiviral Agents / Q000627:therapeutic use*; D015331:Cohort Studies; D003586:Cytomegalovirus Infections / Q000175:diagnosis / Q000453:epidemiology / Q000517:prevention & control*; D005260:Female; D015774:Ganciclovir / Q000627:therapeutic use; D006084:Graft Rejection / Q000188:drug therapy; D006085:Graft Survival; D006801:Humans; D016756:Immunoglobulins, Intravenous / Q000627:therapeutic use; D007165:Immunosuppression Therapy; D015994:Incidence; D016030:Kidney Transplantation; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012189:Retrospective Studies; D012307:Risk Factors
D000998:Antiviral Agents; D016756:Immunoglobulins, Intravenous; D015774:Ganciclovir; D000212:Acyclovir