Minimal impact of CMV infection on long-term survival after liver transplantation

The Impact of Pretransplant Cytomegalovirus Infection on Acute Renal Allograft Rejection

BACKGROUND

The role of cytomegalovirus (CMV) infection in renal allograft rejection remains controversial; moreover, there are few studies on pretransplant infections. This study sought to investigate whether pretransplant CMV infections had negative effects on acute rejection episodes (ARE) and to evaluate the effect of preemptive treatment.

METHODS

This retrospective single-center study of 416 transplant recipients from October 1, 2000 to September 1, 2003 had CMV infections diagnosed by CMV antigenemia tests. The incidences of ARE were compared between CMV-infected and noninfected groups. Risk factors for ARE were analyzed. Based on preemptive treatment, pretransplant CMV-infected recipients were divided into ganciclovir-treated and nontreated groups and the incidence of ARE was compared between the two groups.

RESULTS

One hundred eighty four recipients had CMV infections pretransplant; the infection rate was 44.2%. Fifty five recipients had ARE among the pretransplant CMV-positive group, which was significantly higher than that in the noninfected group (29.9% vs 19.5%, P = .014). But the rejection subgroups and renal function recovery had no significant differences. While the presence of pretransplant infection was an independent predictor of ARE (RR = 1.807), severity showed no significant impact on ARE. Among 184 pretransplant CMV infection recipients, the incidences of ARE were 14.3% and 18.0% in ganciclovir-treated versus nontreated patients, respectively (P = .650).

CONCLUSIONS

Pretransplant CMV-positive recipients were at greater risk of ARE. Pretransplant CMV infection was an independent risk factor for ARE. Preemptive antiviral treatment did not show protective effects against ARE related to CMV infection-mediated immunological injuries.

Prospective evaluation of the clinical utility of different methods for the detection of human cytomegalovirus disease after liver transplantation

Standardized human cytomegalovirus (HCMV) assays were prospectively evaluated to predict HCMV disease. In 135 consecutive adult liver transplantations, pp65-antigenemia, quantitative HCMV-DNA and qualitative pp67-messenger-RNA were determined weekly. No ganciclovir prophylaxis or preemptive treatment was used. One hundred and ten (81.5%) patients showed no HCMV-infection, 25 patients were positive in at least one of the HCMV-tests (18.5%). Four suffered from HCMV viral syndrome (3.0%) and another four from tissue invasive disease. In total, pp65-antigenemia was detected in 18, HCMV-DNA in 22 and pp67-mRNA in 18 patients. The sensitivity and negative predictive value (NPV) for HCMV-disease was 100% for all tests. The PPV for symptomatic HCMV-infection was 47% for pp67 mRNA. In contrast, the PPV of pp65-antigenemia (using a threshold of > 2/200 000 cells) and quantitative PCR (using a cutoff of > 5000 copies/mL) were 80% and 89%, respectively. A cost analysis revealed symptom-triggered or preemptive treatment was less expensive than general ganciclovir prophylaxis, if the incidence of CMV disease was low (<30%). Quantitative human cytomegalovirus (HCMV)-DNA and pp65-antigen assays have a comparable sensitivity and can therefore predict the onset of HCMV symptoms at an early stage. Compared with general prophylaxis, symptom-triggered or preemptive treatment based on one of these assays might reduce the costs and also the danger of ganciclovir resistance.

Cytomegalovirus infection as a common complication following liver transplantation

The aim of our study was to assess the incidence course, influence on liver function, diagnostic methods, prophylaxis of, and cost treatment effectiveness of CMV infection among 123 consecutive liver transplant recipients. All patients received immunoglobulin and parenterall gancyclovir as prophylaxis. CMV IgM and IgG antibodies were determined using an ELISA method. Thirty seven patients (30.0%) developed CMV infection. Main indications for primary LTX were: immune liver disease (n = 22), viral hepatitis (n = 5), and other (n = 10). CMV infection occurred between the days 5 and 416. Ten patients (27.0%) developed more than one infection (52 infections in total). Asymptomatic CMV infection was diagnosed in six cases (16.2%), CMV syndrome in 11 cases (29.7%), and hepatitis in 35 cases. All patients were treated with gancyclovir and immunoglobulin (18 cases). The intensity of infection was mild or moderate. There was no case of pneumonia or neurological disease, nor the need to use foscarnet. The correlations between the incidence of CMV infection and acute rejection, tacrolimus versus cyclosporine regimens, dual versus triple immunosupressive schemes were not statistically significant, whereas anti-IL-2R-ab antibodies markedly reduced the incidence of CMV infection (P <.05). The values of CMV IgM significantly differred before/during infection (P <.001) and before/after infection (P <.05). In conclusion, prophylaxis and antiviral treatment result in a mild or moderate intensity of CMV infection with acceptable costs. Among immunosuppressive drugs, only anti-IL-2Rab was proved to significantly reduce the incidence of CMV.