Department of Nephrology, Antwerp University Hospital, Edegem, Belgium.
Laboratory of Experimental Medicine and Pediatrics, University of Antwerp, Antwerpen, Belgium.
Transpl Infect Dis. 2021 Apr;23(2):e13467. doi: 10.1111/tid.13467. Epub 2020 Oct 22.
Cytomegalovirus (CMV) remains an important challenge after kidney transplantation. Current Transplantation Society International Consensus Guidelines recommend antiviral prophylaxis or pre-emptive therapy for high-risk CMV-seronegative recipients with a CMV-seropositive donor (D+/R-) and moderate-risk CMV-seropositive recipients (R+). However, a split strategy according to CMV serostatus is not specifically mentioned.
We evaluated a split strategy to prevent CMV infection after kidney transplantation in which D+/R- patients received valganciclovir (VGC) prophylaxis for 200 days, and R + patients were treated pre-emptively according to CMV DNAemia. Patients were followed until 1-year post-transplant.
Between April 2014 and March 2018, 40 D+/R- and 92 R + patients underwent kidney transplantation. Forty-six percent received antithymocyte globulin (ATG) induction, and 98% was treated with calcineurin inhibitors, mycophenolic acid (MPA), and steroids. No D+/R- patient developed CMV disease during prophylaxis (median 200 days), but 15% developed post-prophylaxis or late-onset disease. Fifty-three percent developed neutropenia during prophylaxis, including 16/40 (40%) grade 3 or 4 neutropenia requiring reduction/discontinuation of MPA (30%) and/or VGC (35%), and an occasional need for granulocyte colony-stimulating factor (5%). In the R + group, 40% received antiviral therapy for a median duration of 21 days; 5% developed early-onset CMV disease. Only 5% developed neutropenia. D+/R + status (hazard ratio (HR) 2.09,P = .004) and ATG use (HR 2.81, P < .0001) were risk factors for CMV reactivation.
Prophylaxis leads to acceptable CMV control in high-risk patients but comes with a high risk of neutropenia. Pre-emptive therapy is effective and limits drug exposure in those at lower risk of CMV.
巨细胞病毒（CMV）仍然是肾移植后的一个重要挑战。目前，移植学会国际共识指南建议对 CMV 阴性受者（D+/R-）和中度风险 CMV 阳性受者（R+）接受 CMV 阳性供体（D+/R+）进行抗病毒预防或先发治疗。然而，并没有特别提到根据 CMV 血清状态进行的分割策略。
我们评估了一种肾移植后预防 CMV 感染的分割策略，其中 D+/R-患者接受缬更昔洛韦（VGC）预防治疗 200 天，而 R+患者则根据 CMV DNA 血症进行先发治疗。患者随访至移植后 1 年。
2014 年 4 月至 2018 年 3 月，40 例 D+/R-和 92 例 R+患者接受了肾移植。46%的患者接受了抗胸腺细胞球蛋白（ATG）诱导，98%的患者接受了钙调磷酸酶抑制剂、霉酚酸（MPA）和类固醇治疗。在预防期间，没有 D+/R-患者发生 CMV 疾病（中位数 200 天），但 15%的患者发生了预防后或迟发性疾病。53%的患者在预防期间发生中性粒细胞减少症，包括 16/40（40%）例 3 或 4 级中性粒细胞减少症，需要减少/停用 MPA（30%）和/或 VGC（35%），偶尔需要使用粒细胞集落刺激因子（5%）。在 R+组中，40%的患者接受了抗病毒治疗，中位时间为 21 天；5%的患者发生了早发性 CMV 疾病。只有 5%的患者发生中性粒细胞减少症。D+/R+状态（风险比（HR）2.09，P=0.004）和 ATG 使用（HR 2.81，P<0.0001）是 CMV 再激活的危险因素。
预防治疗可在高危患者中实现可接受的 CMV 控制，但会带来中性粒细胞减少症的高风险。先发治疗在 CMV 风险较低的患者中是有效的，并限制了药物暴露。
