Cytomegalovirus infection as a complication of OKT3 therapy in kidney transplant recipients

Effect of cytomegalovirus prophylaxis with acyclovir on renal transplant survival

It is recognized that cytomegalovirus (CMV) infection in transplant recipients may lead to graft loss. Prophylaxis with acyclovir has therefore gained widespread acceptance, but the debate on whether this intervention improves long term graft survival continues. All patients who received renal grafts at the National Renal Transplant Centre, Dublin, between January 1992 and December 1999 were retrospectively analyzed. During this time period, patients who were CMV positive and/or had received grafts from CMV-positive donors were administered prophylactic oral acyclovir 800 mg thrice daily, adjusted for calculated creatinine clearance, from the first day post-transplantation. This treatment was continued for three months unless the graft failed or the patient developed CMV disease or died. Graft and patient outcomes were compared in recipients who received acyclovir with those who did not. Over the study period, 935 patients received renal transplants in our center, of whom 487 were administered acyclovir. The incidence of CMV disease was 3.3 cases per 100 patients per annum in those who required prophylaxis. Despite prophylaxis, graft outcomes were found to be significantly worse (p value < 0.001) in the group that qualified for acyclovir. We conclude that acyclovir provides incomplete protection from the negative impact of CMV on graft survival.

OKT3 muromonab as second-line and subsequent treatment in recipients of stem cell allografts with steroid-resistant acute graft-versus-host disease

We retrospectively evaluated response to monoclonal antibody directed against CD3 (OKT3) treatment in 43 patients with steroid-resistant acute graft-versus-host disease (aGvHD) following allogeneic hematopoietic cell transplantation. Median duration of OKT3 therapy was 9 (range, 1-20) days. In all, 20 cycles were administered as second-line and 28 as third-plus line treatment. Side effects were mild to moderate. Overall response rate was 69 with 12% complete remissions and best response in skin involvement. Proportional reduction of concomitant steroids was higher in responding patients. Five patients (12%) achieved durable responses. Pharmacokinetic studies of OKT3 showed adequate plasma levels (> or = 1000 ng/ml) in 13 of 17 evaluable patients after a median of 6 (1-11) days on treatment. OKT3 became undetectable shortly after discontinuation of therapy. Median survival for all patients was 80 (2 to 2474+) days. There was a trend for better survival for patients on second-line vs third-plus line treatment (146 vs 46 days; P=0.07) and significant longer survival for patients with grade II when compared to those with grade III/IV aGvHD (206 vs 47 days; P=0.039). We conclude that salvage treatment with OKT3 shows considerable efficiency, however, sometimes of transient nature, and is well tolerated in patients with corticosteroid-resistant aGvHD.