title: Use of leflunomide in renal transplant recipients with ganciclovir-resistant/refractory cytomegalovirus infection: a case series from the University of Chicago.
abstract: BACKGROUND
  Although antiviral prophylaxis for cytomegalovirus (CMV) is widely used, CMV infection remains common in renal transplant recipients with adverse consequences.
  
  
  METHODS
  We report 5 cases of renal transplant recipients with resistant CMV infection who were successfully managed with leflunomide at the University of Chicago Medical Center.
  
  
  RESULTS
  Five renal transplant recipients (2 simultaneous pancreas/kidney transplants, 3 deceased donor kidney transplants) were diagnosed with GCV-resistant CMV infection from 2003 to 2011. Of the 4 patients who had resistance genotype testing, 3 showed a UL97 mutation and 1 patient had a clinically resistant CMV infection. All patients received CMV prophylaxis with valganciclovir for 3 months. The number of days from the date of transplant to viremia ranged from 38 to 458 days (median 219). All 5 patients received other antiviral agents (e.g. ganciclovir, foscarnet), and in 4 patients, viremia was cleared before leflunomide was initiated as consolidation (or maintenance) therapy.
  
  
  CONCLUSIONS
  Leflunomide was well tolerated and successful in preventing recurrence of viremia in renal transplant recipients with resistant CMV infection. The beneficial effect of leflunomide in this setting warrants further investigation.
authors.affiliation: Section of Nephrology, University of Chicago, Chicago, Ill., USA.
authors.forename: W James
authors.initials: WJ
authors.lastname: Chon
authors.affiliation: Division of Nephrology and Transplant Medicine, University of Arizona, Tucson, Ariz., USA.
authors.forename: Pradeep V
authors.initials: PV
authors.lastname: Kadambi
authors.affiliation: Section of Nephrology, University of Chicago, Chicago, Ill., USA.
authors.forename: Chang
authors.initials: C
authors.lastname: Xu
authors.affiliation: Section of Transplant Surgery, University of Chicago, Chicago, Ill., USA.
authors.forename: Yolanda T
authors.initials: YT
authors.lastname: Becker
authors.affiliation: Section of Transplant Surgery, University of Chicago, Chicago, Ill., USA.
authors.forename: Piotr
authors.initials: P
authors.lastname: Witkowski
authors.affiliation: Section of Infectious Disease, University of Chicago, Chicago, Ill., USA.
authors.forename: Kenneth
authors.initials: K
authors.lastname: Pursell
authors.affiliation: Department of Pharmacy Services, University of Chicago, Chicago, Ill., USA.
authors.forename: Brenna
authors.initials: B
authors.lastname: Kane
authors.affiliation: Section of Nephrology, University of Chicago, Chicago, Ill., USA.
authors.forename: Michelle A
authors.initials: MA
authors.lastname: Josephson
keywords: Cytomegalovirus infection; Leflunomide; Renal transplant recipients