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Gardiner BJ, Nierenberg NE, Chow JK, Ruthazer R, Kent DM, Snydman DR. Absolute Lymphocyte Count: A Predictor of Recurrent Cytomegalovirus Disease in Solid Organ Transplant Recipients. Clin Infect Dis 2019; 67:1395-1402. [PMID: 29635432 DOI: 10.1093/cid/ciy295] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Accepted: 04/06/2018] [Indexed: 12/21/2022] Open
Abstract
Background Recurrent cytomegalovirus (CMV) disease in solid organ transplant recipients frequently occurs despite effective antiviral therapy. We previously demonstrated that patients with lymphopenia before liver transplantation are more likely to develop posttransplant infectious complications including CMV. The aim of this study was to explore absolute lymphocyte count (ALC) as a predictor of relapse following treatment for CMV disease. Methods We performed a retrospective cohort study of heart, liver, and kidney transplant recipients treated for an episode of CMV disease. Our primary outcome was time to relapse of CMV within 6 months. Data on potential predictors of relapse including ALC were collected at the time of CMV treatment completion. Univariate and multivariate hazard ratios (HRs) were calculated with a Cox model. Multiple imputation was used to complete the data. Results Relapse occurred in 33 of 170 participants (19.4%). Mean ALC in relapse-free patients was 1.08 ± 0.69 vs 0.73 ± 0.42 × 103 cells/μL in those who relapsed, corresponding to an unadjusted hazard ratio of 1.11 (95% confidence interval, 1.03-1.21; P = .009, n = 133) for every decrease of 100 cells/μL. After adjusting for potential confounders, the association between ALC and relapse remained significant (HR, 1.11 [1.03-1.20]; P = .009). Conclusions Low ALC at the time of CMV treatment completion was a strong independent predictor for recurrent CMV disease. This finding is biologically plausible given the known importance of T-cell immunity in maintaining CMV latency. Future studies should consider this inexpensive, readily available marker of host immunity.
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Affiliation(s)
- Bradley J Gardiner
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center and Tufts University School of Medicine, Boston, Massachusetts.,Department of Infectious Diseases, Alfred Hospital and Monash University, Melbourne, Victoria, Australia
| | - Natalie E Nierenberg
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center and Tufts University School of Medicine, Boston, Massachusetts
| | - Jennifer K Chow
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center and Tufts University School of Medicine, Boston, Massachusetts
| | - Robin Ruthazer
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts.,Tufts Clinical and Translational Science Institute, Tufts University, Boston, Massachusetts
| | - David M Kent
- Tufts Clinical and Translational Science Institute, Tufts University, Boston, Massachusetts.,Predictive Analytics and Comparative Effectiveness Center, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center and Tufts University School of Medicine, Boston, Massachusetts
| | - David R Snydman
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center and Tufts University School of Medicine, Boston, Massachusetts.,Tufts Clinical and Translational Science Institute, Tufts University, Boston, Massachusetts
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2
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Natori Y, Alghamdi A, Tazari M, Miller V, Husain S, Komatsu T, Griffiths P, Ljungman P, Orchanian-Cheff A, Kumar D, Humar A, Alexander B, Avery R, Baldanti F, Barnett S, Baum P, Berrey MM, Birnkrant D, Blumberg E, Boeckh M, Boutolleau D, Bowlin T, Brooks J, Chemaly R, Chou S, Cloherty G, Cruikshank W, Dropulic L, Einsele H, Erdman J, Fahle G, Fallon L, Gillis H, Gonzalez D, Griffiths P, Gunter K, Hirsch H, Hodowanec A, Humar A, Hunt P, Josephson F, Komatsu T, Kotton C, Krause P, Kuhr F, Lademacher C, Lanier R, Lazarus T, Leake J, Leavitt R, Lehrman SN, Li L, Ljungman P, Lodding PI, Lundgren J, Martinez-Murillo F(P, Mayer H, McCutcheon M, McKinnon J, Mertens T, Miller V, Modarress K, Mols J, Mossman S, Murata Y, Murawski D, Murray J, Natori Y, Nichols G, O’Rear J, Peggs K, Pikis A, Prichard M, Razonable R, Riches M, Roberts J, Saber W, Sayada C, Singer M, Stamminger T, Wijatyk A, Yu D, Zeiher B. Use of Viral Load as a Surrogate Marker in Clinical Studies of Cytomegalovirus in Solid Organ Transplantation: A Systematic Review and Meta-analysis. Clin Infect Dis 2019; 66:617-631. [PMID: 29020339 DOI: 10.1093/cid/cix793] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Accepted: 09/01/2017] [Indexed: 12/22/2022] Open
Abstract
Symptomatic cytomegalovirus (CMV) disease has been the standard endpoint for clinical trials in organ transplant recipients. Viral load may be a more relevant endpoint due to low frequency of disease. We performed a meta-analysis and systematic review of the literature. We found several lines of evidence to support the validity of viral load as an appropriate surrogate end-point, including the following: (1) viral loads in CMV disease are significantly greater than in asymptomatic viremia (odds ratio, 9.3 95% confidence interval, 4.6-19.3); (2) kinetics of viral replication are strongly associated with progression to disease; (3) pooled incidence of CMV viremia and disease is significantly lower during prophylaxis compared with the full patient follow-up period (viremia incidence: 3.2% vs 34.3%; P < .001) (disease incidence: 1.1% vs 13.0%; P < .001); (4) treatment of viremia prevented disease; and (5) viral load decline correlated with symptom resolution. Based on the analysis, we conclude that CMV load is an appropriate surrogate endpoint for CMV trials in organ transplant recipients.
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Affiliation(s)
- Yoichiro Natori
- Multi-Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Ali Alghamdi
- Multi-Organ Transplant Program, University Health Network, Toronto, Ontario, Canada.,King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Mahmood Tazari
- Multi-Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Veronica Miller
- Forum for Collaborative Research, University of California, Berkeley
| | - Shahid Husain
- Multi-Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Takashi Komatsu
- Division of Antiviral Products, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland
| | - Paul Griffiths
- Institute for Immunity and Transplantation, University College London Medical School, United Kingdom
| | - Per Ljungman
- Division of Hematology, Department of Medicine Huddigne, Karolinksa Institutet, Stockholm, Sweden
| | - Ani Orchanian-Cheff
- Library and Information Services, University Health Network, Toronto, Ontario, Canada
| | - Deepali Kumar
- Multi-Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Atul Humar
- Multi-Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
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3
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Kabbani D, Hirji A, Hernandez C, Malhi H, Mabilangan C, Chandrarathne S, Halloran K, Weinkauf J, Kapasi A, Lien D, Preiksaitis J, Cervera C. High incidence of clinically significant cytomegalovirus infection in CMV D+/R+ lung transplant recipients receiving 3 months of antiviral prophylaxis. Transpl Infect Dis 2019; 21:e13094. [PMID: 30985048 DOI: 10.1111/tid.13094] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Revised: 02/27/2019] [Accepted: 03/31/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Universal antiviral prophylaxis is the preferred preventive strategy for lung transplant recipients (LTRs) at risk of CMV infection. We compared the risk of CMV infection between CMV D+/R + and D-/R + LTRs after 3 months of prophylaxis. METHODS This was a retrospective review of CMV R + LTRs transplanted between 2005 and 2013. Patients dying before completing 3 months, or receiving >180 days of prophylaxis were excluded. The primary outcome was proportion of LTRs who developed CMV infection and clinically significant CMV infection defined as CMV infection leading to preemptive therapy or CMV disease. RESULTS We analyzed 90 D+/R + and 72 D-/R + with a median follow up of 730 days. CMV infection and disease was more common in D+/R + compared to D-/R+ (CMV infection 66% vs 40%; P = 0.001; CMV disease 13% vs 4% P = 0.045). Fifty-nine patients developed at least one episode of clinically significant CMV infection (41/90 [46%] D+/R + and 18/72 [25%] D-/R + P=0.007) with recurrence occurring in 29 LTRs (49% of patients with previous CMV infection), of which 22 (76%) were CMV D+/R+. Thirty percent had side effects related to CMV therapy. CONCLUSION Three months prophylaxis in D+/R + LTRs was associated with high rates of clinically significant CMV infection and recurrences.
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Affiliation(s)
- Dima Kabbani
- Department of Medicine, Division of Infectious Diseases, University of Alberta, Edmonton, AB, Canada
| | - Alim Hirji
- Department of Medicine, Division of Pulmonary Medicine, University of Alberta, Edmonton, AB, Canada
| | - Cristina Hernandez
- Department of Medicine, Division of Infectious Diseases, University of Alberta, Edmonton, AB, Canada
| | - Harjot Malhi
- Department of Medicine, Division of Pulmonary Medicine, University of Alberta, Edmonton, AB, Canada
| | - Curtis Mabilangan
- Department of Medicine, Division of Infectious Diseases, University of Alberta, Edmonton, AB, Canada
| | - Sanjaya Chandrarathne
- Department of Medicine, Division of Pulmonary Medicine, University of Alberta, Edmonton, AB, Canada
| | - Kieran Halloran
- Department of Medicine, Division of Pulmonary Medicine, University of Alberta, Edmonton, AB, Canada
| | - Justin Weinkauf
- Department of Medicine, Division of Pulmonary Medicine, University of Alberta, Edmonton, AB, Canada
| | - Ali Kapasi
- Department of Medicine, Division of Pulmonary Medicine, University of Alberta, Edmonton, AB, Canada
| | - Dale Lien
- Department of Medicine, Division of Pulmonary Medicine, University of Alberta, Edmonton, AB, Canada
| | - Jutta Preiksaitis
- Department of Medicine, Division of Infectious Diseases, University of Alberta, Edmonton, AB, Canada
| | - Carlos Cervera
- Department of Medicine, Division of Infectious Diseases, University of Alberta, Edmonton, AB, Canada
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4
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Camargo JF, Anderson AD, Rosa R, Kimble E, Komanduri KV, Morris MI. Use of maintenance therapy and incidence of recurrent Cytomegalovirus DNAemia among allogeneic hematopoietic cell transplant recipients. Transpl Infect Dis 2019; 21:e13054. [PMID: 30689300 DOI: 10.1111/tid.13054] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 11/28/2018] [Accepted: 01/15/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Cytomegalovirus (CMV) infection is the most common infection following hematopoietic cell transplantation (HCT). Preemptive antiviral therapy is highly effective at halting viral replication and preventing CMV disease; however, recurrence rates after clearance of CMV DNAemia are high (50-70%). Current treatment guidelines recommend maintenance therapy after initial clearance. Yet, the effectiveness of this intervention to prevent recurrence is not well defined. OBJECTIVES We aimed to assess the impact of maintenance therapy on the probability of recurrent CMV in allogeneic HCT recipients with early CMV reactivation. STUDY DESIGN Sixty-six patients with an initial episode of early CMV reactivation who achieved viral clearance in response to preemptive therapy were included. We compared the incidence of recurrent CMV DNAemia in patients who received maintenance therapy vs those who underwent early discontinuation of antiviral therapy. RESULTS Recurrence occurred in 47/64 (73%) patients, including 11/14 (79%) patients without maintenance therapy and 36/50 (72%) of patients who received maintenance therapy (P = 0.74). The propensity score adjusted risk ratio for the effect of maintenance therapy on recurrence was 0.89 (95% CI 0.64-1.25; P = 0.41). In a time to event analysis using the unweighted cohort, the 90-day probability of CMV recurrence was similar between patient groups independent of maintenance therapy administration (54% vs 64% for maintenance vs non-maintenance groups, respectively; log-rank P = 0.37). CONCLUSION These data suggest that maintenance antiviral therapy does not reduce the incidence of CMV recurrence while off therapy and is of limited value in HCT recipients who have successfully eradicated CMV DNAemia in response to preemptive therapy. Larger studies in this area are needed.
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Affiliation(s)
- Jose F Camargo
- Department of Medicine, Division of Infectious Diseases, University of Miami Miller School of Medicine, Miami, Florida
| | - Anthony D Anderson
- Department of Pharmacy, Sylvester Comprehensive Cancer Center, Miami, Florida
| | - Rossana Rosa
- Department of Medicine, Jackson Memorial Hospital, Miami, Florida
| | - Erik Kimble
- Department of Medicine, Jackson Memorial Hospital, Miami, Florida
| | - Krishna V Komanduri
- Adult Stem Cell Transplant Program, Sylvester Comprehensive Cancer Center, Miami, Florida
| | - Michele I Morris
- Department of Medicine, Division of Infectious Diseases, University of Miami Miller School of Medicine, Miami, Florida
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5
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Serrano-Alonso M, Guillen-Grima F, Martin-Moreno P, Rabago G, Manrique J, Garcia-del-Barrio M, Reina G, Torre-Cisneros J, Fernandez-Alonso M, Herrero J. Reduction in mortality associated with secondary cytomegalovirus prophylaxis after solid organ transplantation. Transpl Infect Dis 2018; 20:e12873. [DOI: 10.1111/tid.12873] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 01/02/2018] [Accepted: 01/14/2018] [Indexed: 01/06/2023]
Affiliation(s)
| | - F. Guillen-Grima
- Preventive Medicine Department; Clínica Universidad de Navarra; Pamplona Spain
- Department of Health Sciences; Public University of Navarra; Pamplona Spain
- Navarra's Health Research Institute (IdiSNA); Pamplona Spain
| | - P. Martin-Moreno
- Navarra's Health Research Institute (IdiSNA); Pamplona Spain
- Nephrology Department; Clínica Universidad de Navarra; Pamplona Spain
| | - G. Rabago
- Cardiac Surgery Department; Clínica Universidad de Navarra; Pamplona Spain
| | - J. Manrique
- Navarra's Health Research Institute (IdiSNA); Pamplona Spain
- Nephrology Department; Complejo Hospitalario de Navarra; Pamplona Spain
| | | | - G. Reina
- Navarra's Health Research Institute (IdiSNA); Pamplona Spain
- Microbiology Department; Clínica Universidad de Navarra; Pamplona Spain
| | - J. Torre-Cisneros
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC); Reina Sofía University Hospital; University of Cordoba; Cordoba Spain
| | - M. Fernandez-Alonso
- Navarra's Health Research Institute (IdiSNA); Pamplona Spain
- Microbiology Department; Clínica Universidad de Navarra; Pamplona Spain
| | - J.I. Herrero
- Navarra's Health Research Institute (IdiSNA); Pamplona Spain
- Liver Unit; Clínica Universidad de Navarra; Pamplona Spain
- Biomedical Research Networking Center in Hepatic and Digestive Diseases (CIBERehd); Madrid Spain
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6
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Recurrence of CMV Infection and the Effect of Prolonged Antivirals in Organ Transplant Recipients. Transplantation 2017; 101:1449-1454. [DOI: 10.1097/tp.0000000000001338] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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7
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Cortés JA, Yomayusa N, Arias YR, Arroyave IH, Cataño JC, García P, Guevara FO, Mesa L, Montero C, Rios MF, Robayo A, Rosso F, Torres R, Uribe LG, González L, Alvarez CA. Consenso colombiano para la estratificación, diagnóstico, tratamiento y prevención de la infección por citomegalovirus en pacientes adultos con trasplante renal. INFECTIO 2016. [DOI: 10.1016/j.infect.2015.10.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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8
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The Role of Secondary Cytomegalovirus Prophylaxis for Kidney and Liver Transplant Recipients. Transplantation 2015; 99:855-9. [DOI: 10.1097/tp.0000000000000386] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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9
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Kotton CN, Kumar D, Caliendo AM, Asberg A, Chou S, Danziger-Isakov L, Humar A. Updated international consensus guidelines on the management of cytomegalovirus in solid-organ transplantation. Transplantation 2013; 96:333-60. [PMID: 23896556 DOI: 10.1097/tp.0b013e31829df29d] [Citation(s) in RCA: 554] [Impact Index Per Article: 50.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Cytomegalovirus (CMV) continues to be one of the most common infections after solid-organ transplantation, resulting in significant morbidity, graft loss, and adverse outcomes. Management of CMV varies considerably among transplant centers but has been become more standardized by publication of consensus guidelines by the Infectious Diseases Section of The Transplantation Society. An international panel of experts was reconvened in October 2012 to revise and expand evidence and expert opinion-based consensus guidelines on CMV management, including diagnostics, immunology, prevention, treatment, drug resistance, and pediatric issues. The following report summarizes the recommendations.
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Affiliation(s)
- Camille N Kotton
- Transplant and Immunocompromised Host Infectious Diseases, Infectious Diseases Division, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA.
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10
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Kotton CN. CMV: Prevention, Diagnosis and Therapy. Am J Transplant 2013; 13 Suppl 3:24-40; quiz 40. [PMID: 23347212 DOI: 10.1111/ajt.12006] [Citation(s) in RCA: 182] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2012] [Revised: 07/05/2012] [Accepted: 07/25/2012] [Indexed: 01/25/2023]
Abstract
Cytomegalovirus (CMV) is the most common infection after organ transplantation and has a major impact on morbidity, mortality and graft survival. Optimal prevention, diagnosis and treatment of active CMV infection enhance transplant outcomes, and are the focus of this section. Methods to prevent CMV include universal prophylaxis and preemptive therapy; each has its merits, and will be compared and contrasted. Diagnostics have improved substantially in recent years, both in type and quality, allowing for more accurate and savvy treatment; advances in diagnostics include the development of an international standard, which should allow comparison of results across different methodologies, and assays for cellular immune function against CMV. Therapy primarily involves ganciclovir, now rendered more versatile by data suggesting oral therapy with valganciclovir is not inferior to intravenous therapy with ganciclovir. Treatment of resistant virus remains problematic, but is enhanced by the availability of multiple novel therapeutic agents.
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Affiliation(s)
- C N Kotton
- Transplant and Immunocompromised Host Infectious Diseases, Infectious Diseases Division, Massachusetts General Hospital, Boston, MA, USA.
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11
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Florescu DF, Langnas AN, Grant W, Mercer DF, Botha J, Qiu F, Shafer L, Kalil AC. Incidence, risk factors, and outcomes associated with cytomegalovirus disease in small bowel transplant recipients. Pediatr Transplant 2012; 16:294-301. [PMID: 22212495 DOI: 10.1111/j.1399-3046.2011.01628.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Despite improved prophylaxis, monitoring, and more efficient immunosuppression, CMV infection remains a common opportunistic infection in transplant recipients. We assessed the incidence of CMV disease in pediatric SBT recipients, the timing of CMV disease after transplantation, and its impact on patient outcome. The medical records of 98 SBT recipients were reviewed. We performed descriptive analysis, regression analysis, and Kaplan-Meier curves to determine the time-to-event after transplantation. Fifty-three percent patients were male and 47% female, with a mean age of 38.3 months. Thirty-five percent of patients received prophylactic VGC, 55% GCV, 10% a combination of GCV/VGC, and 99% CMV immunoglobulins. A total of 24.5% recipients were CMV D+/R- (CMV serostatus donor positive/recipient negative). Seven (c. 7%) patients developed CMV disease. CMV disease was associated with 2.5 times (0.52-12.1; p = 0.25) higher rate of CMV mismatch and 11.1 times (1.3-95.9; p = 0.03) higher risk of death. CMV prophylaxis increased time-to-death (p = 0.074). Time-to-CMV disease was shorter in patients with enteritis (p < 0.0001), and CMV disease was associated with shorter time-to-death after transplantation (p = 0.001). CMV disease in SBT recipients was associated with an 11-fold mortality increase and a fourfold faster time-to-death. Time-to-death was significantly shorter with CMV enteritis.
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Affiliation(s)
- D F Florescu
- Infectious Diseases Division, Transplant Infectious Diseases Program, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE 68198-5400, USA.
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12
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García-Testal A, Olagüe Díaz P, Bonilla Escobar BA, Criado-Álvarez JJ, Sánchez Plumed J. Análisis de infección por citomegalovirus y sus consecuencias en el trasplante renal: revisión de una década. Med Clin (Barc) 2011; 137:335-9. [DOI: 10.1016/j.medcli.2010.12.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2010] [Revised: 12/02/2010] [Accepted: 12/09/2010] [Indexed: 10/17/2022]
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