CMV INFECTION

I. Helanterä¹, L. Kyllönen², I. Lautenschlager³, K. Salmela², P. Koskinen^1
1Department Of Medicine, Division Of Nephrology, Helsinki University Hospital, Helsinki/FINLAND, ²Department Of Surgery, Division Of Transplantation, Helsinki University Hospital, Helsinki/FINLAND, ³Department Of Virology, Helsinki University Hospital, Helsinki/FINLAND

Body: Introduction: CMV seronegative recipients of a kidney from a seropositive donor (D+/R-) are at highest risk for CMV infection, and antiviral prophylaxis for at least 3 months is recommended. However, late-onset primary infections commonly occur after the cessation of prophylaxis. Prolonging CMV prophylaxis to 6 months is suggested to reduce the incidence of late infections. All D+/R- kidney transplant recipients at our centre have received 6 months valganciclovir prophylaxis since the beginning of 2004. We analyzed late-onset primary CMV infections in our patients. Methods: Data from all adult D+/R- patients who received a kidney transplant between January 2004 and December 2008 were analyzed. Patients with a functioning graft at six months after transplantation and who received valganciclovir prophylaxis according to our current policy of 6 months were included (N=127). Immunosuppression was usually a triple-drug regimen with Cyclosporine A, mycophenolate mofetil (MMF) and steroid. In immunologically high-risk patients cyclosporine was replaced by tacrolimus, and/or induction therapy with basiliximab was administered. Valganciclovir prophylaxis was given orally, 900mg once daily, for 6 months after transplantation. CMV-DNAemia was diagnosed with quantitative PCR. Results: Prophylaxis was completed in 119 patients. Prophylaxis was stopped prematurely at 3-5 months due to leukopenia or gastrointestinal side effects in 8 patients. Late-onset primary CMV infection developed in 47/127 (37%) patients mean 289 days after transplantation (range 150-655) and mean 115 days after the cessation of prophylaxis (range 1-475). Only four infections were asymptomatic. Most common symptoms included fever (N=28), gastrointestinal symptoms (nausea, vomiting, diarrhea) (N=24), respiratory tract symptoms (N=12), and hepatopathy (N=6). Mean peak viral load was 162063 copies/ml (range 400-2831000). Of the infections, 24 were treated initially with IV ganciclovir followed by valganciclovir, and 18 were treated with only oral valganciclovir. Recurrent CMV infection developed in 9/47 (19%) patients after 1.5- 6 months of secondary prophylaxis. Of the recurrent infections, 5 were asymptomatic, and in 4 patients symptoms included fever and gastrointestinal symptoms. In logistic regression analysis, no significant risk factors for late primary CMV infections were identified. Patient or graft survival, or graft function did not differ in patients with or without CMV infections. Conclusion: Incidence of late-onset primary CMV infections in our population was higher than previously reported, and infections occurred also late after transplantation. Most of the infections were symptomatic, and most common symptoms were from the gastrointestinal tract. As side-effects and increased costs are associated with 6 months valganciclovir prophylaxis, CMV prevention strategies in our population require further consideration.

Disclosure: All authors have declared no conflicts of interest.