Blood Rheology and Renal Transplantation: An Intriguing Relationship for Assessing Cardiovascular Risk

Abstract

Introduction: Cytomegalovirus (CMV) is still a major morbidity of organ transplantation. One of the strategies to deal with it is routine prophylaxis. This can be prohibitively expensive in a self financed health care system like in India. We planned to evaluate the efficacy and cost effectiveness of pre-emptive therapy (over routine prophylaxis) in donor and recipient seropositive (D+/R+) renal transplant patients at our centre. Methods: After appropriate consent, D+/R+ patients undergoing renal transplant at our centre were not given routine CMV prophylaxis. They were closely monitored with CMV quantitative DNA PCR every 15 days for six months post transplant. If PCR reported DNA copies of > 600, patients were started on pre-emptive therapy with 14 day therapy of intravenous (IV) gancyclovir (5 mg/kg) followed by oral vangancyclovir (900 mg per day adjusted according to GFR) given for 3 months (or till titres were below 600 copies). Incidence of CMV infection, DNA copies >600 and cost of therapy were analyzed. Results: Over a two year period (2007-09) we included 21 D+/R+ patients in this study. One patient was lost to follow up one month after transplant after detection of onset of humoral rejection. Another patient was excluded from the study since he received ATG for induction (delayed graft function) and therefore was shifted on routine prophylaxis. Of the 19 patients included for analysis, mean age was 36 years (range 22-55 years). Of these 14 were males and five were females. Twelve (63.15%) patients received induction therapy with IL2 receptor blocker (Simulect) while the remaining seven (36.85%) did not receive any induction therapy. All patients received triple immunosuppressive therapy with a combination of tacrolimus (serum level monitoring and dose adjustments), mycophenolate (fixed dose therapy) and prednisolone. We had one case of biopsy proven acute cellular rejection which was treated successfully with three bolus doses of 250 mg prednisolone. We noted a raised CMV DNA titre >600 copies in only one patient (5.26%). This patient had no clinical evidence of disease and was successfully treated with the pre-emptive protocol for the study. At our centre routine prophylaxis with oral vangancyclovir (450 mg twice daily) for 3 months costs INR 84,000 (US $ 1,807) while the cost of CMV DNA PCR monitoring for six months was INR 48,000 (US $ 904). The cost of pre-emptive therapy in the single patient needing this was INR 124,000 (US $ 2668). Conclusions: In this pilot study of D+/R+ renal transplant patients we noted a low incidence of significant CMV viremia (5.26%). The cost of CMV DNA PCR monitoring is more rational compared to routine prophylaxis (half the cost spread over twice the time period) for self financing patients. Thus, in living related renal transplant programme it is both safe and economical to use close monitoring with pre-emptive therapy instead of routine prophylaxis for D+/R+ patients. We need larger studies to confirm these preliminary results.