Cytomegalovirus infection in kidney transplant recipients: Evolution of approach through three eras.
Cytomegalovirus (CMV) prophylaxis is recommended for high-risk patients, while preemptive therapy is considered acceptable for patients at moderate/low risk. After reviewing kidney transplant patients from 1992-1995 and 1996-1999, we decided to replace prophylaxis by preemptive therapy. Herein we have presented our data. From 1996-1999 we treated 129 patients with ganciclovir prophylaxis for 3 months if D+/R- or if they received depleting antibodies. The incidence of CMV was 13.2% versus 3.7% in the 1992-1995 cohort. The increase was associated with mycophenolate mofetil (MMF) use (P = .002). Forty-two percent of the D+/R- developed an infection with 89% of bouts occurring in the first month after cessation of prophylaxis. From 2002-2004, we never gave prophylaxis to 129 patients except when they received thymoglobulin. High-risk D+/R- patients were monitored by polymerase chain reaction (PCR) CMV for 3 months. The incidence of CMV was 17.1% with 54% of the D+/R- developing CMV. CMV infection occurred mostly during the first trimester posttransplantation. Creatinine at 1 year posttransplantation was worse in the presence of CMV infection (154.3 mumol/L-1.75 mg % versus 130.2 mumol/L-1.47 mg %, P = .03). Time to cure CMV infection was longer when MMF was discontinued: 36.7 days versus 69.9 days (P = .026). Our results indicated that CMV incidence is increasing: 3.7% (1992-1995) --> 13.2% (1996-1999) -->17.1% (2002-2004) and that it impairs 1 year graft function. Recovery was faster among patients still receiving MMF compared with those discontinuing MMF. Although MMF inhibits synthesis of anti-CMV IgM, it increases the anti-herpes virus effect of ganciclovir and may protect against chronic allograft nephropathy. Based on our experience, we plan to reintroduce prophylaxis in high-risk patients and to continue MMF when treating CMV infection.
Boucher
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A
Service of Nephrology, Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada. aboucher.hmr@ssss.gouv.qc.ca
Lord
H
H
Collette
S
S
Morin
M
M
Dandavino
R
R
D000212:Acyclovir / Q000627:therapeutic use; D000998:Antiviral Agents / Q000627:therapeutic use; D003586:Cytomegalovirus Infections / Q000188:drug therapy / Q000453:epidemiology* / Q000517:prevention & control; D005500:Follow-Up Studies; D015774:Ganciclovir / Q000627:therapeutic use; D006801:Humans; D015994:Incidence; D016030:Kidney Transplantation / Q000009:adverse effects*; D011183:Postoperative Complications / Q000188:drug therapy / Q000453:epidemiology / Q000821:virology*; D012189:Retrospective Studies; D013997:Time Factors
D000998:Antiviral Agents; D015774:Ganciclovir; D000212:Acyclovir