Brennan D C, Garlock K A, Lippmann B A, Buller R S, Gaudreault-Keener M, Lowell J A, Miller S B, Shenoy S, Howard T K, Storch G A
Department of Internal Medicine, Washington University School of Medicine, St. Louis, Missouri, USA.
J Am Soc Nephrol. 1997 Jan;8(1):118-25. doi: 10.1681/ASN.V81118.
The objective of this randomized, prospective study was to compare preemptive to deferred treatment of cytomegalovirus (CMV) infection in high-risk renal transplant recipients. Conducted at a university-affiliated transplant center, the study included 36 renal allograft recipients with donor or recipient CMV-seropositivity who received anti-thymocyte induction therapy. Ganciclovir was administered intravenously for 21 days upon detection of CMV viremia (preemptive, N = 15) or detection of CMV viremia associated with a CMV syndrome (deferred, N = 21). Shell vial culture, conventional culture, and polymerase chain reaction (PCR) were performed upon buffy-coat specimens weekly for 12 to 16 wk. CMV and non-CMV-associated charges were calculated. The comparative sensitivities of PCR, shell vial culture, and conventional culture were 91%, 44%, and 47%, respectively. A delay in specimen processing of > 24 h severely compromised the sensitivity of culture techniques but not that of PCR. Preemptive therapy tended to decrease symptomatic CMV episodes (0.4 versus 0.6 episodes per patient randomized; P = 0.22). One patient in each group had organ involvement, and no patient died. Allograft function and survival were similar. Ganciclovir use was increased in the preemptive group (1.2 versus 0.6 courses per patient randomized; P = 0.02). CMV-associated charges were $10,368 (preemptive) versus $5,752 (deferred); P = 0.13. PCR is superior to conventional monitoring to detect CMV viremia. Culture cannot be considered the "gold standard" for detection of CMV viremia, especially when transport of specimens over distances results in processing delays. Preemptive therapy may reduce symptomatic CMV infections in renal transplant recipients. It was associated with higher CMV-related charges but equivalent overall charges versus deferred treatment with intensive monitoring. Either strategy can achieve control of CMV infection after renal transplantation.
这项随机、前瞻性研究的目的是比较高危肾移植受者中巨细胞病毒（CMV）感染的抢先治疗与延迟治疗。该研究在一所大学附属医院的移植中心进行，纳入了36名接受抗胸腺细胞诱导治疗的肾移植受者，其供体或受体CMV血清学呈阳性。一旦检测到CMV病毒血症（抢先治疗组，N = 15）或检测到与CMV综合征相关的CMV病毒血症（延迟治疗组，N = 21），即静脉给予更昔洛韦21天。对血沉棕黄层标本每周进行12至16周的空斑试验培养、传统培养和聚合酶链反应（PCR）检测。计算CMV及非CMV相关费用。PCR、空斑试验培养和传统培养的比较敏感性分别为91%、44%和47%。标本处理延迟> 24小时会严重损害培养技术的敏感性，但不会影响PCR的敏感性。抢先治疗倾向于减少有症状的CMV发作（随机分组的患者中，每位患者发作0.4次与0.6次；P = 0.22）。每组各有1例患者出现器官受累，无患者死亡。移植肾功能和存活率相似。抢先治疗组更昔洛韦的使用量增加（随机分组的患者中，每位患者使用1.2个疗程与0.6个疗程；P = 0.02）。CMV相关费用为10368美元（抢先治疗组）对5752美元（延迟治疗组）；P = 0.13。在检测CMV病毒血症方面，PCR优于传统监测方法。培养不能被视为检测CMV病毒血症的“金标准”，尤其是当标本远距离运输导致处理延迟时。抢先治疗可能会减少肾移植受者中有症状的CMV感染。与强化监测的延迟治疗相比，它与更高的CMV相关费用相关，但总体费用相当。两种策略均可实现肾移植后CMV感染的控制。
