高危移植患者（D+/R-）巨细胞病毒疾病的预防策略及长期预后：来自RESITRA-REIPI队列的经验

Prevention strategies for cytomegalovirus disease and long-term outcomes in the high-risk transplant patient (D+/R-): experience from the RESITRA-REIPI cohort.

作者信息

Meije Y, Fortún J, Len Ó, Aguado J M, Moreno A, Cisneros J M, Gurguí M, Carratalà J, Muñoz P, Montejo M, Blanes M, Bou G, Pérez J L, Torre-Cisneros J, Ramos A, Pahissa A, Gavaldà J

机构信息

Infectious Diseases Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain.

出版信息

Transpl Infect Dis. 2014 Jun;16(3):387-96. doi: 10.1111/tid.12226. Epub 2014 May 8.

DOI:10.1111/tid.12226

PMID:24807640

Abstract

BACKGROUND

Cytomegalovirus (CMV)-negative recipients of a graft from a CMV-positive donor (D+/R-) are at high risk of CMV disease. Current preventive strategies include universal prophylaxis (UP) and preemptive therapy (PT). However, the best strategy to prevent CMV disease and achieve better long-term outcomes remains a matter of debate.

METHODS

We analyzed the incidence of CMV disease and long-term outcomes including graft dysfunction and patient mortality at 5 years after transplantation with both preventive strategies. High-risk (D+/R-) kidney and liver transplant recipients from the RESITRA cohort were included.

RESULTS

Of 2410 kidney or liver transplant patients, 195 (8.3%) were D+/R-. The final cohort included 58 liver and 102 kidney recipients. UP was given in 92 patients and 68 received PT; 10.9% and 36.8% developed CMV disease, respectively (P < 0.01). The independent risk factors for CMV disease were PT strategy (hazard ratio [HR], 3.30; 95% confidence interval [CI], 1.6-6.9), kidney transplantation (HR, 3.8; 95% CI, 1.4-9.9), and cyclosporine immunosuppression (HR, 2.4; 95% CI, 1.2-4.7). PT strategy was also a risk factor for CMV disease in both liver transplantation (HR, 11.0; 95% CI, 1.2-98.7) and kidney transplantation (HR, 2.7; 95% CI, 1.3-6.0), independently. The development of CMV replication during the first 2 years after transplantation was a risk factor for graft dysfunction at 5 years after transplantation (odds ratio, 3.4; 95% CI, 1.3-9.0). Nevertheless, no significant differences were seen in either graft dysfunction or mortality between the 2 strategies.

CONCLUSIONS

The study supports the benefit of the UP strategy to prevent CMV disease in D+/R- liver or kidney transplant patients. The development of CMV replication during the first 2 years after transplantation was associated with graft dysfunction at 5 years after transplantation.

摘要

背景

接受来自巨细胞病毒（CMV）阳性供体的移植物的CMV阴性受者（D+/R-）发生CMV疾病的风险很高。当前的预防策略包括普遍预防（UP）和抢先治疗（PT）。然而，预防CMV疾病并实现更好的长期预后的最佳策略仍存在争议。

方法

我们分析了采用这两种预防策略进行移植后5年时CMV疾病的发生率以及包括移植物功能障碍和患者死亡率在内的长期预后情况。纳入了RESITRA队列中的高危（D+/R-）肾移植和肝移植受者。

结果

在2410例肾移植或肝移植患者中，195例（8.3%）为D+/R-。最终队列包括58例肝移植受者和102例肾移植受者。92例患者接受了UP，68例接受了PT；分别有10.9%和36.8%发生了CMV疾病（P<0.01）。CMV疾病的独立危险因素为PT策略（风险比[HR]，3.30；95%置信区间[CI]，1.6-6.9）、肾移植（HR，3.8；95%CI，1.4-9.9）和环孢素免疫抑制（HR，2.4；95%CI，1.2-4.7）。PT策略也是肝移植（HR，11.0；95%CI，1.2-98.7）和肾移植（HR，2.7；95%CI，1.3-6.0）中CMV疾病的独立危险因素。移植后前2年期间CMV复制的发生是移植后5年时移植物功能障碍的危险因素（比值比，3.4；95%CI，1.3-9.0）。然而，两种策略在移植物功能障碍或死亡率方面均未观察到显著差异。