COMPLICATIONS - INFECTIONS

G. Paget, S. Naicker
Division Of Nephrology, Charlotte Maxeke Johannesburg Academic Hospital, South Africa, Johannesburg/SOUTH AFRICA

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Introduction The majority of transplants in South Africa take place in “high risk” patients, necessitating the use of sequential induction immunosuppression. Whether to give CMV prophylaxis to particularly CMV D+/R+ transplant patients is controversial and expensive in a resource-limited setting like South Africa. Methods We undertook a retrospective analysis of CMV disease in 47 CMV D+/R+ adult renal transplant patients (> 80% African Blacks) from February 2000 to November 2004 who had received Basiliximab/MMF/Steroid and Cyclosporine induction immunosuppression. Available for comparison were historical data with previous immunosuppressive therapy (CMV incidence of 12% with Azathioprine/CyA/Steroid and 33% with addition of ATG induction to this regimen) and 22 D-/R+ transplants with the same induction therapy and very similar demographics. Patients were only included if diagnosis of CMV was confirmed by detection of PP65 antigenaemia or histology. We commenced routine valganciclovir prophylaxis for 3 months post renal transplant in January 2007 and looked at incidence of CMV in at risk patients until October 2009. Patients received sequential induction and some were given tacrolimus or rapamycin. Results Before prophylaxis - In the D+/R+ group, 15 (32%) developed a total of 17 episodes of CMV disease (2 with recurrent disease) over a mean follow up period of 25.6 months (+/- 14.33 months). Incidence of CMV disease was not statistically different between D+/R+ and D-/R+ groups (32% vs 27%; p=0.46). In the D+/R+ group, average time to occurrence of CMV disease was 4.78 months post induction (range of 2 to 24 months). The variables that predicted CMV disease in Cox proportional hazard regression were age and time to reach a prednisone dose of 7.5 mg/day. Ethnicity, transfusion, rejection or therapy for rejection were not significant risk factors in this study, differing from previous reports published in literature. Importantly, concomitant sepsis occurred in 40% of patients with CMV disease (p=0.0005). Graft survival analysis adjusted for CMV disease showed that D+/R+ recipients had a hazard ratio of 2.8 compared to D-/R+ transplants (p=0.03) for a poor graft outcome over the follow up period. Patient survival was similar between the groups. After prophylaxis – The files of 45 patients (11 live donor and 34 deceased donor) that were eligible for review were studied. Among live donor recipients (82% D+/R+) there were no episodes of CMV disease over mean follow up period of 20 months. Among deceased donor recipients (85% D+/R+), the incidence of CMV disease over a mean follow up of 17.3 months was only 5.8% (n=2), and these episodes occurred at 7 and 10 months after high dose steroid use. Graft outcomes are also good although follow up is shorter. Conclusion It would appear that the use of sequential induction therapy in our patients results in CMV disease in approximately a third of patients and is associated with poorer graft outcomes in those with CMV disease. It would seem that CMV prophylaxis has been highly effective at reducing incidence of CMV disease in our patients, despite “potent” immunosuppression.

Disclosure: All authors have declared no conflicts of interest.