Acyclovir prophylaxis for cytomegalovirus disease in high-risk renal transplant recipients: is it effective?

Cytomegalovirus (CMV) is a significant cause of post-transplantation morbidity and mortality in renal transplant recipients. The risk of CMV infection is between 60 to 88% in CMV seronegative patients who receive kidneys from CMV seropositive donors (D+, R-). In order to evaluate the efficacy of oral acyclovir in prevention of CMV infection after transplantation, we retrospectively reviewed the records of 25 patients (D+, R-) who were transplanted between January 1993 and December 1995. Eighteen of 25 patients received prophylaxis with variable doses of acyclovir (600 to 4000 mg/day, adjusted for their renal function) for 4 to 7 months. CMV disease was defined as fever (> or = 38 degrees C) for at least three days which could not be attributed to other causes with positive cultures or seroconversion for CMV, and presence of either leukopenia, pneumonitis, gastroenteritis or elevated liver enzymes. Twelve of the 18 patients (66.6%) who received acyclovir prophylaxis developed CMV disease. Seven patients were hospitalized and treated with i.v. ganciclovir. One patient died from CMV pneumonia associated with invasive fungal infection five months after transplantation. Of the 7 patients who did not receive prophylactic acyclovir, 5 (71.4%) developed CMV disease (2 patients were hospitalized and treated with ganciclovir). Our results failed to confirm the efficacy of oral acyclovir as a prophylaxis against CMV disease in a small group of high-risk patients. We conclude that other strategies should be tested.