title: Effect of the immunosuppressive regimen on the incidence of cytomegalovirus infection in 378 heart transplant recipients: A single centre, prospective cohort study.
abstract: BACKGROUND
  Cytomegalovirus (CMV) infection is a major complication of immunosuppression after heart transplant. Recent studies suggest the actual immunosuppressive regimen may affect the risk of CMV infection.
  
  
  OBJECTIVE
  To evaluate incidence, risk factors and clinical consequences of CMV infection and assess the possible differential effect of distinct immunosuppressive protocols.
  
  
  METHODS
  Single centre, prospective cohort study of 378 consecutive heart transplant recipients undergoing CMV monitoring. Preemptive treatment was the standard of care. Patients were grouped as follows: group A, without any CMV infection; group B, with CMV infection not requiring pre-emptive treatment; group C, treated for CMV infection or disease.
  
  
  RESULTS
  Most recipients never required antiviral therapy because of no CMV infection/disease (group A, 31%) or CMV levels below the cut-off for pre-emptive treatment (group B, 28%). Group C recipients (41%) were significantly older than group A patients (49.1±13.2 vs. 44.8±15.1 years; p=0.028). Most cases occurred within the second month post-transplant. CMV viremia was detected in 77% and 62% of patients primed with thymoglobulin or ATG Fresenius, respectively, (OR 2.06, 95% C.I. 1.27-3.34; p=0.0034). Use of everolimus was associated with a significantly lower rate of CMV infection compared to azathioprine or mycophenolate (OR 0.19, 95% C.I. 0.09-0.39; p<0.0001). Major opportunistic infections were significantly more common in groups B and C.
  
  
  CONCLUSIONS
  In a large and homogeneous cohort of heart transplant recipients, we observed a strong relationship between the immune suppressive regimen and CMV infection, as well as an increased incidence of other opportunistic infections in recipients with CMV infection/disease.
authors.affiliation: Internal Medicine Section, Department of Cardiothoracic Sciences, and Division of Infectious and Transplant Medicine, Second University of Naples at Monaldi Hospital, Napoli, Italy. Electronic address: emanuele.durante@unina2.it.
authors.forename: Emanuele
authors.initials: E
authors.lastname: Durante-Mangoni
authors.affiliation: Internal Medicine Section, Department of Cardiothoracic Sciences, and Division of Infectious and Transplant Medicine, Second University of Naples at Monaldi Hospital, Napoli, Italy.
authors.forename: Roberto
authors.initials: R
authors.lastname: Andini
authors.affiliation: Internal Medicine Section, Department of Cardiothoracic Sciences, and Division of Infectious and Transplant Medicine, Second University of Naples at Monaldi Hospital, Napoli, Italy.
authors.forename: Daniela
authors.initials: D
authors.lastname: Pinto
authors.affiliation: Internal Medicine Section, Department of Cardiothoracic Sciences, and Division of Infectious and Transplant Medicine, Second University of Naples at Monaldi Hospital, Napoli, Italy.
authors.forename: Domenico
authors.initials: D
authors.lastname: Iossa
authors.affiliation: Internal Medicine Section, Department of Cardiothoracic Sciences, and Division of Infectious and Transplant Medicine, Second University of Naples at Monaldi Hospital, Napoli, Italy.
authors.forename: Rosa
authors.initials: R
authors.lastname: Molaro
authors.affiliation: Internal Medicine Section, Department of Cardiothoracic Sciences, and Division of Infectious and Transplant Medicine, Second University of Naples at Monaldi Hospital, Napoli, Italy.
authors.forename: Federica
authors.initials: F
authors.lastname: Agrusta
authors.affiliation: Internal Medicine Section, Department of Cardiothoracic Sciences, and Division of Infectious and Transplant Medicine, Second University of Naples at Monaldi Hospital, Napoli, Italy.
authors.forename: Roberta
authors.initials: R
authors.lastname: Casillo
authors.affiliation: Internal Medicine Section, Department of Cardiothoracic Sciences, and Division of Infectious and Transplant Medicine, Second University of Naples at Monaldi Hospital, Napoli, Italy.
authors.forename: Maria
authors.initials: M
authors.lastname: Grimaldi
authors.affiliation: Internal Medicine Section, Department of Cardiothoracic Sciences, and Division of Infectious and Transplant Medicine, Second University of Naples at Monaldi Hospital, Napoli, Italy.
authors.forename: Riccardo
authors.initials: R
authors.lastname: Utili
mesh_terms: D000328:Adult; D000368:Aged; D003586:Cytomegalovirus Infections / Q000453:epidemiology* / Q000473:pathology; D005260:Female; D016027:Heart Transplantation; D006801:Humans; D007166:Immunosuppressive Agents / Q000009:adverse effects / Q000627:therapeutic use*; D015994:Incidence; D008297:Male; D008875:Middle Aged; D009894:Opportunistic Infections / Q000453:epidemiology* / Q000473:pathology; D011446:Prospective Studies; D012307:Risk Factors; D066027:Transplant Recipients
chemical_list: D007166:Immunosuppressive Agents
keywords: Cytomegalovirus; Immunosuppression; Opportunistic infection; Prognosis; Transplant