Late cytomegalovirus (CMV) infections after kidney transplantation under the preemptive strategy: Risk factors and clinical aspects

Abstract

Background Late cytomegalovirus infections (LCMV) after the cessation of prophylaxis are well described. We aimed to assess clinical and epidemiological data on late‐occurring cytomegalovirus (CMV) infections in the absence of CMV prophylaxis in a cohort of kidney transplant patients. Methods In a cohort of kidney transplant recipients not employing CMV‐specific prophylaxis, patients with CMV infections occurring after 6 months of transplantation were compared to patients with CMV infections diagnosed within the first 6 months (early infections). The main objectives were to compare clinical outcomes and evaluate risk factors for late CMV infection. Results A total of 556 patients were evaluated. Forty‐three patients with LCMV infections were compared to 513 patients with early CMV infections. LCMV infections occurred after a median of 473 days of transplantation and had a more severe course, with a statistically significant higher rate of invasive disease and graft loss (60.5% vs 21.6% and 11.6% vs 3.1% respectively). Thirty‐day mortality was twice as high for patients with LCMV, but did not reach statistical significance (9.3% vs 4.3%). By multivariate analysis, employment of antilymphocyte therapy early after transplantation and tacrolimus as initial immunosuppressive therapy were significantly protective for the occurrence of LCMV infections. Conclusion Late CMV infections in the absence of specific prophylaxis after kidney transplantation have a more severe outcome when compared to early infections and occur in patients less immunosuppressed early after transplantation.

Cytomegalovirus Retinitis in HIV and Non-HIV Individuals

“…In immunocompetent individuals, CMV remains asymptomatic but has the potential to reactivate when the immune system is compromised [19]. In immunocompromised patients, primary CMV infection causes severe complications such as pyrexia, viremic-septicemia, pneumonitis and in rare cases CMV induced immunosuppression [23,24]. CMV may also disseminate to the gastrointestinal tract and cause ulcerations.…”

“…Active CMV in the eye primarily infects vascular endothelial cells followed by retinal pigment epithelial cells in the retina causing viral cytopathic effect and subsequent retinal necrosis, as characterized in CMVR [25]. The large viral genome of CMV quickly translocates to the infected cell nucleus and starts production of viral progeny in a lytic lifecycle [24,25,32]. Viral progeny then bud out of the infected cell to infect neighboring cells and repeat the process.…”

Late vs early‐onset CMV infections in kidney transplantation, still a topical issue, reply to Ono et al

“…We read with great interest the recently published article entitled "Late cytomegalovirus (CMV) infections after kidney transplantation under the preemptive strategy: Risk factors and clinical aspects" by of G. Ono et al 1 The authors found that these late-onset CMV infections were associated with a higher rate of invasive disease and graft loss than earlier infections occurring in the first 6 months following the transplantation. In a previous article, we found that lateonset CMV diseases were associated with a lower DNAemia peak, a shorter CMV therapy and fewer recurrences than early-onset diseases because of a faster anti-CMV immune response.…”

Comparison of prophylactic versus preemptive treatments in the management of cytomegalovirus infection in renal transplant recipients

“…Therefore, in general, prophylactic treatment for CMV infection is administered to recipients in the high and moderate risk groups [6]. Over recent years, as the CMV PCR diagnostic method has started to be used to rapidly and correctly reveal CMV viral replication, a preemptive treatment strategy has come to prominence [7,8]. Prophylactic treatment is antiviral therapy applied for 3-6 months from 10 days after transplantation [9].…”

“…These two approaches are similar in respect of CMV infection but studies have shown differences in respect of side-effects [7,[9][10][11][12]. However, these studies have been conducted with limited numbers of patients, and there has been variability in the follow-up periods and the antivirals used.…”