Reduction by combination prophylactic therapy with CMV hyperimmune globulin and acyclovir of the risk of primary CMV disease in renal transplant recipients

Vitamin D Levels After Kidney Transplantation and the Risk of Cytomegalovirus Infection

Background:

Some studies reported an association between low levels of vitamin D and the risk of infections, especially viral infections. Kidney transplant patients are at risk of opportunistic infections; however, no study has been conducted on the association between vitamin D levels and the risk of CMV infection.

Objectives:

The aim of this study was to compare the level of vitamin D in two groups of patients with and without CMV infection within four months after the transplantation. Moreover, we aimed to find a relation between vitamin D level, before and after transplantation in each group.

Patients and Methods:

This prospective cohort study was conducted in Baqiyatallah hospital in Tehran in 2013. A total of 82 kidney transplant patients were enrolled and vitamin D levels were measured in them before transplantation. The kidney transplant patients had been followed up for four months and monitored for the presence of cytomegalovirus antigen (CMV Ag) in their blood. In patients with positive CMV Ag, vitamin D level was measured again when they became positive but in other patients it was measured at the end of follow-up; at the end, characteristics of patients and vitamin D levels were compared between the two groups.

Results:

Of all, 40 patients were CMV Ag positive and 42 patients were negative. In most patients transplanted organs were taken from cadaver (66%) and the most common type of dialysis was hemodialysis (92%). Most participants did not undergo antithymocyte globulin therapy (69%) and pulse corticosteroid therapy (83%). Vitamin D level before transplantation was 17.2 ± 11.6 ng/mL. In patients with positive results or at the end of follow-up in patients without CMV Ag, vitamin D level was 16.3 ± 11.4 ng/mL. Only 11% of kidney transplant patients, within four months after transplantation, had a normal level of vitamin D (> 30 ng/mL). There was no significant difference between the two groups for patients’ characteristics (P > 0.05). Vitamin D levels, before transplantation and at the time of detecting CMV Ag or at the end of follow-up period in patients without CMV, were not significantly different between the two groups (P > 0.05). However, vitamin D levels decreased in patients with CMV, while it increased in CMV Ag negative patients, which was statistically significant (P = 0.037).

Conclusions:

Only 11% of kidney transplant patients, even with a successful transplantation of the kidney and with an acceptable performance of the transplanted kidney, had an adequate level of vitamin D. Although, we did not find any significant association between vitamin D levels and CMV infection during a 4-month follow-up after kidney transplantation. It was observed that, compared with the time before transplantation, vitamin D levels decreased in patients with CMV, while it increased in CMV negative patients.

Prophylaxis of cytomegalovirus disease in mismatched patients after heart transplantation using combined antiviral and immunoglobulin therapy

BACKGROUND

Cytomegalovirus (CMV) is a common cause of infection and morbidity after heart transplantation. Seronegative recipients (R-) of seropositive donor hearts (D+) are at high risk for CMV disease. We compared three different CMV prophylaxis regimens using combined antiviral and immunoglobulin therapy.

METHODS

In 99 patients who survived more than 30 days after heart transplant, all received induction with antilymphocytic therapy and triple-drug therapy. In group A, D+R- patients received one dose of intravenous immunoglobulin (IVIG) followed by one dose of CMV-specific immunoglobulin (CMV-IVIG), and intravenous ganciclovir (GCV) for 4 weeks followed by 11 months of oral acyclovir (ACV). In group B, D+R- patients received one dose IVIG followed by five doses of CMV-IVIG and intravenous GCV for 14 weeks followed by 9 months of oral ACV. In group C, D+R- patients were treated with the same regimen as for group B, except oral ACV was replaced with oral GCV.

RESULTS

The actuarial freedom from CMV disease for D+R- patients at 1 month, 1 year, and 2 years after transplantation in group A was 100%, 25% ± 15%, and 25% ± 15%, respectively; group B was 100%, 67% ± 27%, and 67% ± 27%; group C was 100%, 83% ± 15%, and 83% ± 15% (P < .01, groups B and C vs group A). By comparison, the actuarial freedom from CMV disease for seropositive recipients (D-R+ or D+R+) at 1 month, 1 year, and 2 years in group A was 100%, 87% ± 7%, and 82% ± 8%, respectively; group B was 100%, 88% ± 8%, and 75% ± 11%; group C was 100%, 72% ± 9%, and 72% ± 9% (P = NS among groups). Rejection rates did not differ among the three groups.

CONCLUSIONS

A longer course of intravenous GCV with multiple doses of CMV-IVIG was a more effective prophylaxis regimen against CMV disease for the high-risk group of seronegative recipients of seropositive donor hearts.

WITHDRAWN: Cytomegalovirus prophylaxis with antiviral agents for solid organ transplantation

BACKGROUND

Cytomegalovirus (CMV) disease is a major cause of morbidity and mortality in solid organ transplantation. It is also associated with an increased risk of opportunistic infections, allograft injury and higher transplantation costs. CMV infection also seems to increase the risk of acute and chronic rejection of allografts via immune-mediated vascular injury. These serious consequences of CMV disease have lead to the development of effective strategies for the prevention, early diagnosis and treatment. However, there is no consensus on the necessity and the efficacy of CMV prophylaxis.

OBJECTIVES

To assess the efficacy of antiviral agents in solid organ transplant recipients in the prevention of cytomegalovirus infection and symptomatic disease and in the reduction of the incidence of acute rejection, graft loss and death.

SEARCH STRATEGY

A computerised search was conducted on Medline, Embase and Pascal. The reference lists of the current review articles and some congress proceedings were searched manually (Transplantation Proceedings, American Thoracic Society, European Society of Organ Transplantation).

SELECTION CRITERIA

Prospective, randomised studies in adults or paediatric recipients of a solid organ transplant, in which one arm received a prophylactic treatment with acyclovir and/or ganciclovir, started before cytomegalovirus infection, and the control arm received placebo or no treatment.

DATA COLLECTION AND ANALYSIS

Data were extracted from each trial and a letter sent to the authors to ask them to verify the data extracted, and to provide any data that was missing. For each outcome, several methods were used to calculate the chi-square for association and the estimate for the treatment effect with its 95% CI, with an additive model (rate difference), or a multiplicative model (odds ratio, relative risk). We considered the test of association to be significant when the p value was less than 0.01 and the homogeneity test to be significant when the p value was less than 0.1.

MAIN RESULTS

Prophylactic treatment was found to be associated with a significant decrease in cytomegalovirus disease compared with placebo or no treatment, using the logarithm of relative risk method (RR 0.51, 95% CI 0.41-0.64, p value for X(2) association < 0.001). Prophylactic treatment also decreased the rate of cytomegalovirus infection (RR 0.62, 95%CI 0.53-0.73, p < 0.001). Our analysis failed to show a significant decrease in graft loss, acute rejection or death in the prophylactic treatment group. Sub-group analysis based on the type of antiviral agent (acyclovir or ganciclovir) and on the type of organ (kidney or liver) gave comparable results.

AUTHORS' CONCLUSIONS

The use of antiviral agents for the prevention of cytomegalovirus disease and cytomegalovirus infection in solid organ transplantation is supported by this meta-analysis.

Early adequate mycophenolic acid exposure is associated with less rejection in kidney transplantation

This study examines the importance of early mycophenolic acid (MPA) exposure in the cyclosporine- and mycophenolate mofetil (MMF)-treated kidney transplant population. We prospectively evaluated 94 first solitary kidney transplant patients treated with cyclosporine (Neoral), MMF, and prednisone. Basiliximab was also given to 72 recipients. MPA exposure was measured by HPLC using a limited sampling estimate of 12 h area under the curve (AUC [0-12]) within the first week. Efficacy was determined by the occurrence of acute rejection and toxicity by the need to reduce MMF doses within the first 3 months post-transplantation. Acute rejection was observed in 14 (15%) and MMF toxicity in 27 (29%). Receiver operator curve analysis shows that MPA AUC [0-12] on day 3 was predictive of efficacy (c = 0.72, p = 0.007) but not toxicity (c = 0.57, p = 0.285). A separate analysis of only patients on basiliximab shows that the MPA AUC [0-12] on day 3 was also predictive of efficacy (c = 0.80, p = 0.01). Therefore early adequate exposure to MPA by day 3 is associated with low acute rejection but cannot predict toxicity. Adequate MPA exposure is also important with basiliximab induction therapy.

Therapeutic monitoring of cyclosporine in kidney transplantation: the Halifax experience

Appropriate dosing of an immunosuppressive agent is critical to its efficacy and tolerability. Finding a simple and effective method of monitoring cyclosporine (CsA/CyA) has been formidable despite a long history of widespread usage. Earlier reports linked CsA dosing to trough levels (C0), whereas later more elaborate systems have evaluated efficacy linked to 12-hour area-under-the-curve (AUC(0-12)) as a measure of total drug exposure. Recent work done at our center and elsewhere has shown that the 2-hour postdose concentration (C2) to be simple and more effective than the C0 or the AUC. With C2 monitoring as a guide to CsA dosing, acute rejection (AR) and nephrotoxicity (NT) can be effectively reduced. Furthermore, absorption profile as per C2 levels further emphasizes the importance of achieving the targeted peak concentration in the first week of transplantation. The C2 concentration strategy is discussed in light of newer induction agents and other immunosuppression.

Neutralising human recombinant antibodies to human cytomegalovirus glycoproteins gB and gH

A phage antibody display library of single chain fragment variable (scFv) was applied to develop anti-HCMV glycoprotein B (gB) and glycoprotein H (gH) neutralising libraries. To enrich for specific scFvs, the phage antibody was panned against cytomegalovirus epitopes derived from the N-terminal part of gB, the C-terminal part of gB and the N-terminal part of gH (NETIYNTTLKYGDV, VTSGSTKD and AASEALDPHAFHLLLNTYGR). A number of clones were differentiated by Bst N1 fingerprinting. After isolation of specific clones against each peptide, the neutralising effect of each clone was assessed by plaque reduction assay. This resulted in the isolation of eight neutralising scFv antibodies with 51-63% neutralising effects. Sequence analysis of three neutralising clones revealed the amino acids specificity changes in heavy and light chains of antibody molecules.

Viral infections after renal transplantation

Viral infections are a leading cause of posttransplantation morbidity and mortality. A number of recent developments have altered our understanding and management of these disorders. The pathogenetic roles of several viruses, including human herpesviruses 6 and 8, have been newly established. Molecular-based diagnostic tests now make more rapid diagnosis possible. The licensing of new potent antiviral agents offers a wider choice of drugs for viral prophylaxis and treatment. The use of more potent immunosuppressive agents is responsible in part for the increasing incidence of some viral infections, but this varies among drugs, and individual viruses differ in their sensitivity to immunosuppressive agents. This review summarizes the natural history, diagnosis, prevention, and treatment of many common viral infections after renal transplantation.

Prevention of recurrent cytomegalovirus disease in renal and liver transplant recipients: effect of oral ganciclovir

BACKGROUND

Although the primary treatment of symptomatic cytomegalovirus (CMV) disease in organ transplant recipients is successful in >90% of individuals, relapsing disease, particularly in those with primary infection, remains an important problem. Previously, we had observed that the rate of symptomatic recurrence was >60% in those with primary disease (seronegative for CMV prior to transplant), and approximately 20% in those who were seropositive prior to transplant. The present study was undertaken to determine whether a maintenance regimen of oral ganciclovir for 2-3 months added to the routine 14-21 days of intravenous ganciclovir would further prevent symptomatic CMV recurrence.

METHODS

From May 1995 until June 1998, all kidney and liver transplant recipients with confirmed tissue-invasive CMV disease or CMV syndrome were treated with 14-21 days of intravenous ganciclovir (5 mg/kg b.i.d. with dose adjusted for renal dysfunction) followed by 2-3 months of oral ganciclovir (2 g daily). The incidence of recurrence of CMV disease and/or viremia during and after oral therapy was then determined over a mean follow-up of 530.6 days.

RESULTS

Thirty-seven patients, 19 kidney and 18 liver transplant recipients, were studied; 5 had biopsy-proven tissue-invasive disease (13.5) and 32 suffered a CMV syndrome (86.5). Twenty-one of these patients (58.6) were seronegative for CMV prior to transplant and received an allograft from a seropositive donor (D+/R-). Overall, 10 patients (27.0) developed CMV recurrence. Eight of 21 patients who were D+/R- for CMV (38.1) developed recurrence as opposed to 2 of 16 patients with other serologic status (12.5) (P=0.14). Patients with recurrent CMV disease and/or viremia had a peak antigenemia assay titer during their initial CMV event of 319.2 positive cells/2 slides compared with 109.8 positive cells/2 slides for patients without recurrent CMV infection (P=0.14); the trend of having a higher peak antigenemia assay titer among patients who recurred occurred both in patients who were at risk of primary CMV infection (D+/R- for CMV) and in those who were not. Two patients developed recurrent infection with strains of CMV that were resistant to ganciclovir.

CONCLUSIONS

This new therapeutic regimen of oral ganciclovir following intravenous ganciclovir slightly reduced the overall rate of recurrent CMV disease and/or viremia, but it still did not adequately prevent CMV recurrence in patients who are at risk of primary infection prior to transplant. Of particular concern, 2 patients with primary infection treated with this regimen developed ganciclovir-resistant recurrent disease.

Cytomegalovirus prophylaxis with antiviral agents for solid organ transplantation

OBJECTIVES

To assess the efficacy of antiviral agents in solid organ transplant recipients in the prevention of cytomegalovirus infection and symptomatic disease and in the reduction of the incidence of acute rejection, graft loss and death.

SEARCH STRATEGY

A computerised search was conducted on Medline, Embase and Pascal. The reference lists of the current review articles and some congress proceedings were searched manually (Transplantation Proceedings, American Thoracic Society, European Society of Organ Transplantation).

SELECTION CRITERIA

Prospective, randomised studies in adults or paediatric recipients of a solid organ transplant, in which one arm received a prophylactic treatment with acyclovir and/or ganciclovir, started before cytomegalovirus infection, and the control arm received placebo or no treatment.

DATA COLLECTION AND ANALYSIS

Data were extracted from each trial and a letter sent to the authors to ask them to verify the data extracted, and to provide any data that was missing. For each outcome, several methods were used to calculate the chi-square for association and the estimate for the treatment effect with its 95% confidence interval, with an additive model (rate difference), or a multiplicative model (odds ratio, relative risk). We considered the test of association to be significant when the p value was less than 0.01 and the homogeneity test to be significant when the p value was less than 0.1.

MAIN RESULTS

Prophylactic treatment was found to be associated with a significant decrease in cytomegalovirus disease compared with placebo or no treatment, using the logarithm of relative risk method (relative risk 0.51, 95% confidence interval 0. 41-0.64, p value for X(2) association < 0.001). Prophylactic treatment also decreased the rate of cytomegalovirus infection (RR 0. 62, 95%CI 0.53-0.73, p < 0.001). Our analysis failed to show a significant decrease in graft loss, acute rejection or death in the prophylactic treatment group. Sub-group analysis based on the type of antiviral agent (acyclovir or ganciclovir) and on the type of organ (kidney or liver) gave comparable results.

REVIEWER'S CONCLUSIONS

The use of antiviral agents for the prevention of cytomegalovirus disease and cytomegalovirus infection in solid organ transplantation is supported by this meta-analysis.

Effect of oral acyclovir or ganciclovir therapy after preemptive intravenous ganciclovir therapy to prevent cytomegalovirus disease in cytomegalovirus seropositive renal and liver transplant recipients receiving antilymphocyte antibody therapy

BACKGROUND

Organ transplant recipients who are seropositive for cytomegalovirus (CMV) and who are treated with antilymphocyte antibody (ALA) therapy have a high rate of symptomatic CMV disease. The intravenous administration of ganciclovir therapy once daily during ALA therapy decreased the incidence from 24% to 10% in patients receiving ALA as an induction therapy and from 64% to 22% in those treated for rejection. The present study was undertaken to determine whether a more intensive and sustained antiviral regimen could be more effective.

METHODS

From April 1995 to December 1997, all CMV seropositive renal and liver transplant recipients who received ALA therapy were treated with intravenously administered ganciclovir (5 mg/kg/day with dose adjusted for renal dysfunction) for the length of ALA therapy and then with orally administered acyclovir (400 mg three times/day) or ganciclovir (1 gm twice/day) for 3 to 4 months. The incidence of CMV viremia and of CMV disease was determined during the 6 months after completion of ALA therapy.

RESULTS

Forty-one patients (35 renal and 6 liver transplant recipients) were studied. CMV disease occurred in 2 patients (4.9%), both of whom were treated for rejection; it occurred in 1 of 21 patients (4.8%) treated with orally administered acyclovir, and in 1 of 20 patients (5%) treated with orally administered ganciclovir. The only patient who developed CMV disease in the ganciclovir group had received only 26 days of oral antiviral therapy. No CMV disease was documented in the group of patients receiving ALA therapy as induction therapy. CMV viremia occurred in three patients in the acyclovir group (14.3%) and in one patient in the ganciclovir group (5%). Among renal transplant recipients only, 1 of 35 patients developed CMV disease (2.9%) and no case of CMV disease was documented in patients treated with orally administered ganciclovir. All six patients receiving two courses of ALA therapy each were free of CMV disease. Toxicity of the regimen was minimal, and antiviral resistance did not develop.

CONCLUSIONS

Preemptive antiviral therapy with intravenously administered ganciclovir during ALA therapy and then orally administered ganciclovir for 3 to 4 months provides virtually complete protection against the excessive rate of CMV disease that occurs in CMV seropositive allograft recipients receiving ALA therapy.

A randomized prospective controlled trial of oral acyclovir versus oral ganciclovir for cytomegalovirus prophylaxis in high-risk kidney transplant recipients

BACKGROUND

Posttransplantation cytomegalovirus (CMV) infection remains a significant cause of morbidity in kidney transplant recipients. We performed a randomized prospective controlled trial of oral acyclovir versus oral ganciclovir for CMV prophylaxis in a group of renal allograft recipients considered at high risk for CMV disease due to the use of OKT3 induction therapy.

METHODS

A total of 101 recipients of cadaveric (83) and zero haplotype-matched live donor (18) kidney transplants were entered into the trial. A total of 22 D-R- patients received no prophylaxis. Twenty-seven D+R-, 29 D+R+, and 23 D-R+ patients were randomized to receive 3 months of either oral acyclovir (800 mg q.i.d.) or oral ganciclovir (1000 mg t.i.d.). Doses were adjusted according to the level of renal function. The D+R- patients were also given CMV immune globulin biweekly for 16 weeks. Surveillance blood cultures were obtained at transplantation, at months 1, 2, 3, and 6, and when clinically indicated. The primary study end points were time to CMV infection and disease the first 6 months after transplantation.

RESULTS

The mean follow up was 14.4 months. Both agents were well tolerated, and no drug interruptions for toxicity occurred. CMV was isolated in 14 of 39 (35.9%) acyclovir-treated and 1 of 40 (2.5%) ganciclovir-treated recipients by 6 months (P=0.0001). Symptomatic CMV disease occurred in 9 of 14 (64%) of the acyclovir patients, two with tissue-invasive disease. Infection rates for acyclovir vs. ganciclovir, respectively, stratified by CMV serology were: D+R-, 54 vs. 0%, P=0.0008; D+R+, 43 vs. 6.6%, P=0.01; D-R+, 8.3 vs. 0%, P=NS. No patient developed CMV infection while taking oral ganciclovir, however three delayed infections occurred 2-7 months after finishing therapy. Each patient had been previously treated for acute rejection.

CONCLUSIONS

Oral acyclovir provides effective CMV prophylaxis only for recipients of seronegative donor kidneys. Oral ganciclovir is a superior agent providing effective CMV prophylaxis for recipients of seropositive donor kidneys. Recipients who are treated for acute rejection are at risk for delayed CMV infection during the first posttransplantation year.

Cytomegalovirus viremia in lung transplant recipients receiving ganciclovir and immune globulin

BACKGROUND

Cytomegalovirus (CMV) disease is an important cause of organ transplant-related morbidity and mortality. During the last 5 years at our institution, prophylactic ganciclovir and hyperimmune globulin have been routinely administered to lung transplant recipients whenever the donor or the recipient was CMV antibody-positive. We sought to assess the efficacy of prophylaxis on viremia, CMV disease, and bronchiolitis obliterans syndrome (BOS).

METHODS

A retrospective chart review of 61 consecutive lung transplants performed between recipients between January 1993 and August 1995 was performed. Fifty-six patients who survived at least 1 month were analyzed. Patients were considered at risk for CMV disease whenever pretransplant donor or recipient serology was positive.

RESULTS

Fourteen of the 39 patients at risk (36%) had viremia while on prophylaxis. The rate of CMV disease was 13% during the first 6 months following transplantation. A donor whose CMV serology was positive appeared to increase the risk of BOS in a Cox regression model (relative risk=2.4; 95% confidence interval=0.86-6.74; p=0.0957). Neither age, CMV infection (viremia or a positive specimen from BAL), recipient's serology at the time of transplantation, or CMV disease was associated with BOS. None of these variables was associated with mortality on Cox regression analysis or univariate analysis.

CONCLUSIONS

Administration of combination ganciclovir and hyperimmune globulin prophylactic therapy to lung transplant recipients at risk for CMV infection and disease is associated with a relatively low incidence of disease, which appears only after prophylaxis treatment with ganciclovir is completed. Ganciclovir prophylaxis does not prevent CMV viremia; however, viremia while on prophylaxis is not predictive of disease.

Eradication of cytomegalovirus reactivation disease using high-dose acyclovir and targeted intravenous ganciclovir in kidney and kidney/pancreas transplantation

BACKGROUND

The attack rate of cytomegalovirus (CMV) is over 50% in solid organ transplant recipients at risk for primary CMV infection and in those receiving antilymphocyte antibody therapy. Various CMV prophylaxis regimens over the last few years have reduced the attack rate to around 20% overall.

METHODS

We report our results using high-dose acyclovir for 3 months after transplant, with targeted intravenous ganciclovir for the duration of any antilymphocyte antibody therapy, in our kidney and simultaneous pancreas/kidney transplant recipients. Records of 109 consecutive patients over a 2-year period were reviewed.

RESULTS

Six cases of CMV disease were identified. Five cases occurred in 21 patients at risk for primary CMV disease (24%), whereas only one case occurred in 73 patients at risk for CMV reactivation (1.4%).

CONCLUSION

We conclude that high-dose acyclovir and targeted ganciclovir is excellent prophylaxis against CMV reactivation in kidney and simultaneous pancreas/kidney transplantation.

Infections in solid-organ transplant recipients

Solid-organ transplantation is a therapeutic option for many human diseases. Infections are a major complication of solid-organ transplantation. All candidates should undergo a thorough infectious-disease screening prior to transplantation. There are three time frames, influenced by surgical factors, the level of immunosuppression, and environmental exposures, during which infections of specific types most frequently occur posttransplantation. Most infections during the first month are related to surgical complications. Opportunistic infections typically occur from the second to the sixth month. During the late posttransplant period (beyond 6 months), transplantation recipients suffer from the same infections seen in the general community. Opportunistic bacterial infections seen in transplant recipients include those caused by Legionella spp., Nocardia spp., Salmonella spp., and Listeria monocytogenes. Cytomegalovirus is the most common cause of viral infections. Herpes simplex virus, varicella-zoster virus, Epstein-Barr virus and others are also significant pathogens. Fungal infections, caused by both yeasts and mycelial fungi, are associated with the highest mortality rates. Mycobacterial, pneumocystis, and parasitic diseases may also occur.

Cytomegalovirus antibody status and renal transplantation: 1987-1994

We examined graft and patient survival rates of 47,146 patients in the United Network for Organ Sharing registry following transplants between donors and recipients who were cytomegalovirus (CMV) antibody negative and positive. CMV positivity increased with age to about 80% in patients over 60. Seropositivity was seen in 80% of Asians, 71% of African Americans, and 56% of Caucasians. In all age groups, females had a slightly higher incidence of positivity than males. Transplants involving CMV-positive donors resulted in lower graft survival rates than those with CMV-negative donors. This occurred regardless of whether the recipient was CMV negative or positive. The greatest effect was on patient survival rate, which, in turn, adversely affected graft survival rate. The CMV-positive-donor effect was primarily noted in (1) Caucasian recipients, (2) patients with HLA-A,B,DR mismatches, and (3) patients older than 15 years of age. In contrast, CMV-positive donors were not a risk factor for African American and Hispanic patients, CMV-positive Asian patients, patients younger than 16 years of age, and patients with no HLA-A,B,DR antigen mismatches. In conclusion, a kidney from a CMV-positive donor is a risk factor for certain patients and currently yields about a 4% overall lower graft survival rate at 3 years than a kidney from a CMV-negative donor.

A cost-effectiveness analysis of OKT3 induction therapy in cadaveric kidney transplantation

We evaluated the cost-effectiveness of a standard immunosuppressive regimen versus an OKT3 induction regimen in cadaveric kidney transplant recipients. Cost estimates were based on results from a five-center randomized trial comparing the safety and efficacy of OKT3 induction with a conventional triple-drug regimen and financial data from the National Cooperative Transplantation Study, the Medicare Provider and Analysis Review database, and other sources. Patients received OKT3 (5 mg/day) by intravenous (IV) bolus injection for 10 to 14 consecutive days in conjunction with azathioprine, prednisone, and the delayed addition of cyclosporine (CsA) on day 11 (n = 105) or a conventional immunosuppressive regimen consisting of CsA, azathioprine, and prednisone (n = 102). The following measures were used to evaluate the two regimens: costs incurred between transplantation and graft failure; the effectiveness of the two regimens as defined by length of graft survival; and cost-effectiveness ratios through 5 years of observed follow-up and modeled through the expected duration of graft survival. Results showed that OKT3 induction uniformly adds $8,219 to the cost of the transplant hospitalization. However, most of this cost is offset by a reduction in the cost of treating rejection episodes in the OKT3 group (P = 0.002). A trend toward improved graft survival was detected in the OKT3 group (P = 0.158). Through 5 years of observed follow-up, costs per year of graft survival are $30,474 with OKT3 versus $32,687 with the conventional regimen. Modeled through the expected duration of graft survival, OKT3 induction costs $8,335 for each additional year of graft survival. Results are fairly insensitive to wide variations in baseline assumptions. We conclude that OKT3 induction improves the cost-effectiveness of kidney transplantation.

Overview of the present and future of clinical transplantation

An historical overview of kidney transplantation including the rehabilitation status of long-term survivors, the ethical issues related to current American transplantation, and projections for the future are presented.

Small intestinal transplantation in humans with or without the colon

Under FK506-based immunosuppression, 16 cadaveric small bowel transplantations were performed in 15 recipients with (n = 5) or without (n = 11) the large bowel. Twelve (80%) patients are alive after 1.5 to 19 months, 11 bearing their grafts, of which 4 include colon. The actuarial one-year patient and graft survivals are 87.5% and 65.9%, respectively. Five grafts were lost to acute (n = 4) or chronic (n = 1) rejection, and 3 of these patients subsequently died after 376, 440, and 776 days total survival. Six recipients developed severe CMV infection that was strongly associated with seronegative status preoperatively and receipt of grafts from CMV positive donors; 3 died, and the other 3 required prolonged hospitalization. Currently, 9 patients are free from TPN 1-18 months postoperatively, 2 require partial TPN, and one has returned to TPN after graft removal. The results show the feasibility of small bowel transplantation but emphasize the difficulty of managing these recipients not only early but long after their operation.