title: A stringent preemptive protocol reduces cytomegalovirus disease in the first 6 months after kidney transplantation.
abstract: BACKGROUND
  The optimal strategy to prevent cytomegalovirus (CMV) disease after kidney transplantation continues to be open to debate. The preemptive approach requires regular determination of CMV viremia and prompt initiation of therapy.
  
  
  METHODS
  We retrospectively compared the incidence of CMV disease during two periods at our center: A first phase (P1, n = 84 kidney recipients), during which time the intensity of surveillance was determined by the responsible physician, was compared to a second phase (P2, n = 74), when a stringent protocol of CMV surveillance was required for all patients. The preemptive approach was applied for all CMV risk groups; prophylaxis was optional in the case of treatment for rejection or delayed graft function in the intermediate- and high-risk group. Follow-up was truncated at 6 months after transplant surgery. CMV syndrome was differentiated from asymptomatic replication by the presence of at least one systemic symptom, while diagnosis of CMV end-organ disease required histological confirmation.
  
  
  RESULTS
  Immunosuppression was similar in the two periods. CMV prophylaxis was used equally (26 %) in both periods. The probability for asymptomatic viremia episodes was not different for patients in P1 and P2 regardless of the prevention strategy. For patients following the preemptive strategy, the probability for CMV disease was increased during P1 (p = 0.016), despite fewer PCR assays being performed in phase 2. Protocol violations were only observed during P1.
  
  
  CONCLUSIONS
  The probability of CMV disease episodes (CMV syndrome and CMV end-organ disease) was substantially reduced using a very stringent protocol. This study highlights the crucial importance of a stringent protocol with optimal adherence by all caregivers if the preemptive strategy is to be successful.
authors.affiliation: Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, Rämistrasse 100/RAE U 70, 8091, Zürich, Switzerland.
authors.forename: M
authors.initials: M
authors.lastname: Greiner
authors.forename: A
authors.initials: A
authors.lastname: Cusini
authors.forename: M
authors.initials: M
authors.lastname: Ruesch
authors.forename: M
authors.initials: M
authors.lastname: Schiesser
authors.forename: B
authors.initials: B
authors.lastname: Ledergerber
authors.forename: T
authors.initials: T
authors.lastname: Fehr
authors.forename: N J
authors.initials: NJ
authors.lastname: Mueller
mesh_terms: D000328:Adult; D003587:Cytomegalovirus / Q000302:isolation & purification*; D003586:Cytomegalovirus Infections / Q000517:prevention & control*; D005260:Female; D006801:Humans; D007166:Immunosuppressive Agents / Q000627:therapeutic use*; D016030:Kidney Transplantation; D008297:Male; D008875:Middle Aged; D016133:Polymerase Chain Reaction / Q000379:methods; D011183:Postoperative Complications / Q000517:prevention & control*; D017410:Practice Guidelines as Topic; D012189:Retrospective Studies; D012307:Risk Factors; D013557:Switzerland; D013997:Time Factors; D019562:Viral Load; D014766:Viremia / Q000175:diagnosis*
chemical_list: D007166:Immunosuppressive Agents