Comparing Therapeutic Efficacy and Safety of Epoetin Beta and Epoetin Alfa in the Treatment of Anemia in End-Stage Renal Disease Hemodialysis Patients.

BACKGROUND: Anemia is one of the most prevalent complications in patients with chronic kidney disease, which is believed to be caused by the insufficient synthesis of erythropoietin by the kidney. This phase III study aimed to compare the efficacy and safety of CinnaPoietin® (epoetin beta, CinnaGen) with Eprex® (epoetin alfa, Janssen Cilag) in the treatment of anemia in ESRD hemodialysis patients. METHODS: In this randomized, active-controlled, double-blind, parallel, and non-inferiority trial, patients were randomized to receive either CinnaPoietin® or Eprex® for a 26-week period. The primary endpoints of this study were to assess the mean hemoglobin (Hb) change during the last 4 weeks of treatment from baseline along with the evaluation of the mean weekly epoetin dosage per kilogram of body weight that was necessary to maintain the Hb level within 10-12 g/dL during the last 4 weeks of treatment. As the secondary objective, safety was assessed along with other efficacy endpoints. RESULTS: A total of 156 patients were included in this clinical trial. There was no statistically significant difference between treatment groups regarding the mean Hb change (p = 0.21). In addition, the mean weekly epoetin dosage per kg of body weight for maintaining the Hb level within 10-12 g/dL showed no statistically significant difference between treatment arms (p = 0.63). Moreover, both products had comparable safety profiles. However, the incidence of Hb levels above 13 g/dL was significantly lower in the CinnaPoietin® group. CONCLUSION: CinnaPoietin® was proved to be non-inferior to Eprex® in the treatment of anemia in ESRD hemodialysis patients. The trial was registered in Clinicaltrials.gov (NCT03408639).

Infective endocarditis after renal transplantation.

BACKGROUND: Infective endocarditis (IE) is a serious complication in immunosuppressive patients that has adverse effects. OBJECTIVES: The aim of this study was to define the characteristics, outcomes, and correlating factors of mortality in renal transplant recipients. PATIENTS AND METHODS: Infective endocarditis was diagnosed in 22 patients from three renal transplant centers in Iran between 2000 and 2010. Modified Duke criteria were applied to confirm the diagnosis. RESULTS: Twenty-two renal transplant patients with IE were evaluated. Blood culture results were positive in 81%. Enteroccous and group D non-enterococcal were the causative microorganisms in 31% and 25% of patients, respectively. In-hospital and 12-month mortality was 41% and the mortality rate was higher in older patients in comparison to younger patients. Overall, the rates of one-year disease-free patient and graft survival were 49% and 88%, respectively. CONCLUSIONS: Despite the availability of different and potent antibiotics, the mortality caused by IE remains considerably high. These patients are significantly prone to endovascular infections that affect the mortality and survival.

Incidence of malignancy after living kidney transplantation: a multicenter study from iran.

Malignancy is a common complication after renal transplantation. However, limited data are available on post-transplant malignancy in living kidney transplantation. Therefore, we made a plan to evaluate the incidence and types of malignancies, association with the main risk factors and patient survival in a large population of living kidney transplantation. We conducted a large retrospective multicenter study on 12525 renal recipients, accounting for up to 59% of all kidney transplantation in Iran during 22 years follow up period. All information was collected from observation of individual notes or computerized records for transplant patients. Two hundred and sixty-six biopsy-proven malignancies were collected from 16 Transplant Centers in Iran; 26 different type of malignancy categorized in 5 groups were detected. The mean age of patients was 46.2±12.9 years, mean age at tumor diagnosis was 50.8±13.2 years and average time between transplantation and detection of malignancy was 50.0±48.4 months. Overall tumor incidence in recipients was 2%. Kaposis' sarcoma was the most common type of tumor. The overall mean survival time was 117.1 months (95% CI: 104.9-129.3). In multivariate analysis, the only independent risk factor associated with mortality was type of malignancy. This study revealed the lowest malignancy incidence in living unrelated kidney transplantation.

Prophylactic fluid therapy in crushed victims of Bam earthquake.

BACKGROUND: Acute kidney injury (AKI) is a severe and preventable problem of crushed earthquake victims. Early hydration therapy started before fully removing earthquake rubbles has been claimed to play a decisive role in AKI prevention, which saves the necessity of later dialysis. However, the extent, quality, and appropriateness of its know-how are controversial. METHODS: Processing clinical and paraclinical data gathered from Bam earthquake victims older than 15 years, we tried to determine correlations between the time of being under the rubbles (TUR), the level of serum creatine phosphokinase (CPK), the delayed onset of fluid therapy (DFT), and finally the volume of intravenous fluid received per day (VFR) with the formation of AKI and the need for dialysis. RESULTS: There is a direct and significant relation between the intensity of the trauma (TUR and CPK) and DFT with the occurrence of AKI and need for dialysis (P < .001). However, as the VFR increases, the occurrence of AKI and the need for dialysis significantly decrease (P = .005). Based on multivariate analysis, the occurrence of AKI and the need for dialysis are primarily affected by CPK, TUR, and VFR; and DFT has been dropped out. The analysis showed the preventive role of VFR more than 6 L in severe rhabdomyolysis patients and of at least 3 L in moderate ones in development of AKI and dialysis. CONCLUSIONS: In the severely rhabdomyolized patients (CPK ≥ 15,000), higher volumes of prophylactic fluid (VFR >6 L) are required, whereas in less-traumatized patients, lower volumes (3-6 L) would be effective.

Melioidosis: It is not Far from here.

In the modern world, with developed traveling facilities, tourism is an important factor in emerging new infectious diseases in non-endemic areas. Therefore, the epidemiology of infections is a considerable issue for physicians and should be taken into account. We report a case of melioidosis in a 69-year-old Iranian man during his trip to Southeast Asia. On admission, he was febrile with tachycardia and tachypnea and had diabetes mellitus and hypertension since eleven years ago. Bronchoscopy and bronchoalveolar lavage (BAL) were performed. Blood and BAL cultures revealed heavy growth of Burkholderia pseudomallei. According to the aforementioned culture results, the patient was treated with meropenem and TMP-SMX, while other antibiotics were discontinued. After 3 weeks, the patient was discharged with stable status and normal pulmonary function; and eradication therapy with TMP-SMX continued for about 3 months. The control lung CT scan after one month demonstrated significant improvement.

Skin cancer after renal transplantation: Results of a multicenter study in Iran.

BACKGROUND: Incidence and risk factors for skin tumors following renal transplantation can vary geographically; therefore, a retrospective study was performed to determine the incidence of and potential risk factors for skin cancer at 14 Transplant Centers in Iran between 1984 and 2008. MATERIAL/METHODS: We enrolled 11,255 kidney transplant recipients who were examined for all skin tumors. All skin cancers were established by histological examination. The data collection included the patient's age and sex, immunosuppressive regimen before and after diagnosis of tumor, rejection episodes, post-transplant latency period, other concurrent neoplastic problems, renal allograft function and outcome. RESULTS: One hundred and twenty-eight (1.14%) renal recipients had skin tumor, representing half of all post-transplant malignancies (128 out of 245 cases). Kaposi's sarcoma was the most common post-transplant cancer compared with other skin tumors. Male recipients had more tumors than did females (P=0.04); the male-to-female ratio in the affected patients was 2.5:1. The age at transplantation of patients with skin tumor was higher compared to RTRs without skin tumor (47±11 vs. 38±15 years, P=0.000), and individuals older than 45 years were at higher risk (odds ratio=3.8, 95%CI 2.6-5.5) of skin cancers. Patients consuming azathioprine were at risk more of skin cancer compared with those were on MMF (odds ratio =2.9, 95%, CI 2.0-4.2). The overall mortality was low (7.8%) in cases with skin cancer. CONCLUSIONS: This study showed that male sex, increased age, prolonged immunosuppression and azathioprine increased the risk of skin tumors after renal transplantation.

Assessment of sleep disturbance in renal transplant recipients and associated risk factors.

Sleep disturbances are highly prevalent in ESRD patients. In this study we sought to evaluate the associations of poor sleep with several genetic, laboratory, treatment and demographic factors in renal allograft recipients using a validated sleep quality questionnaire. A cross-sectional study was conducted on renal transplant patients over 18 years of age with stable current stable graft function. All patients completed PSQI and Ifudu questionnaires for assessment of sleep quality and morbidity measures. Kolmogorov-Smirnov test was used for evaluation of distributions besides Student's t-test, and Fisher's exact test for analyses. Mean total PSQI score for the whole patients was 6.5 +/- 2.6. Overall 26 (67%) of patients were diagnosed as "poor sleepers" (PSQI total score > or =5) and the reminding 13 (33%) were "good sleepers". Compared to "good sleepers", "poor sleepers" significantly had higher serum phosphate levels and ESRD duration (P = 0.05). Hematological disorders were more seen in "poor sleepers" and musculoskeletal disorders had a significant worsening impact on PSQI total score (beta = 0.28, P = 0.05). In conclusion our study showed that sleep disturbance is common in renal transplant patients is surprisingly common, and ESRD duration prior to transplant was significantly associate with sleep quality. Future studies with larger sample sizes are necessary for confirming our results.

Mycophenolate sodium increases cyclosporine blood levels in renal transplant recipients.

Cyclosporine is an immunosuppressive agent that displays a broad intra- and inter-individual pharmacokinetic variability. To evaluate the factors, which significantly influence cyclosporine blood levels in our renal transplant recipients, we studied 611 consecutive patients transplanted from living donors in Baqiyatallah hospital, Tehran, Iran from 1984 to 2005. The patients were divided into two groups: Group I included patients treated with mycophenolate sodium (MS) as an adjunctive immunosuppressive agent and Group II treated with azathioprine (AZA) as an adjunctive agent. Measurements of cyclosporine blood tough levels (C0) were performed 12 hours after the morning dose (just before the night dose). The mean age of the study population at time of transplantation was 38.7 +/- 13.7 years and males formed 67% of it. Univariate analysis and multivariable linear regression model showed that older age at transplantation, treatment with MS, and time interval from time of transplantation were significantly related with higher C0 levels. We conclude that there is an interaction of immunosuppressive agents in renal transplant patients with higher cyclosporine levels in the recipients of MS.

Is pulmonary histoplasmosis a risk factor for acute renal failure in renal transplant recipients?

Prolonged use of immunosuppressive medication is associated with an increased susceptibility to viral, bacterial and fungal infections. This paper reports a 42 year old kidney transplant recipient with 10 years of stable allograft function who developed pulmonary histoplasmosis and consequently lost his kidney. This report corroborates the previously proposed threat of infection with H. capsulatum for kidney allograft rejection.

Practical strategies to reduce morbidity and mortality of natural catastrophes: a retrospective study based on Bam earthquake experience.

BACKGROUND: Critical analysis of shortcomings of emergency medical management of earthquake casualties will provide an invaluable insight to improve outcomes for future events. Using a critical analysis methodology to evaluate the quality of emergency medical management after Bam earthquake, we suggest a practical strategic approach to decrease morbidity and mortality after such events. METHODS: We designed a questioner to register the basic demographic data and the key biologic parameters of all rescued victims arriving in hospitals. Based on that questioner a data bank was created and used for different analyses. In addition, published official reports and on the scene observations of our nephrologist colleagues were other sources of our data. RESULTS: Bam earthquake was publicly announced more than six hours after its occurrence. The earliest time when local and international rescue teams arrived at the scene was 12 hours after the disaster. Fifty-four percent of hospital inpatients had been admitted on the second or third day after the earthquake. The mean time of being under the rubble was 4.8+/-4.9 hours. The mean time between extrication and initiation of intravenous fluid infusion was 18.9 hours (min: 10 minutes, max: 96 hours). CONCLUSION: Problems encountered in the aftermath of the Bam earthquake were related to the lack of prepared action plan and data management system. Here, we present a specifically designed earthquake chart. By following the chart, rescue paramedic personnel and emergency medical teams will be able to recognize high-risk victims, in order to provide timely medical management.

Costs and length of hospitalizations following kidney transplantation.

INTRODUCTION: We assessed the costs of hospital admissions and length of hospital stay in kidney allograft recipients admitted to our center, in order to rank hospitalization causes in terms of costly and prolonged admissions, to bring to light the respective correlates of costly and prolonged admissions, and to investigate the relationship between costs and length of rehospitalizations. MATERIALS AND METHODS: In a retrospective study at Baqyiatallah Hospital, in Tehran, records of 358 posttransplant hospitalizations were reviewed for the costs and duration of hospital stay. The causes of rehospitalizations, relative frequency of prolonged stays in costly rehospitalizations, and also relative frequency of costly admissions in short and prolonged stays were evaluated. RESULTS: Among rehospitalizations, 83.3% of those due to cerebrovascular accident were costly and 51% of those with graft rejection resulted in prolonged hospital stays. Costly admissions had a high regularity in cases of patients older than 60 years, end-stage renal disease due to diabetes mellitus, graft loss, intensive care unit admission, and hospitalizations accompanied by in death. Prolonged stays were more common in those who were admitted to intensive care unit and those who ultimately died. The Costs showed a significant correlation with the length of rehospitalization (r = 0.626, P = .001). CONCLUSIONS: The strong correlation between the length of hospitalization and posttransplant hospitalization costs means that the former should be curtailed by focusing on such correlates of high-cost admissions as high age and diabetes mellitus as the cause of kidney failure.

Approach to a target value for 2-hours post dose cyclosporine (C2) during the first week post renal transplantation.

BACKGROUND: There is not a wide consensus on whether recommended target ranges for 2-hours post dose cyclosporine (CsA) blood level (C2) are generalizeable to all kidney recipient populations worldwide. In this study we aimed to assess in which C2 level we can obtain the least acute rejection (AR) episodes in our kidney transplanted patients. MATERIAL/METHOD: In a retrospective cross-sectional study, we investigated all our renal recipients with at least a valid C2 blood level at the days between 5-9 post transplantation. All patients were under immunosuppressive therapy with CsA (Neoral), prednisolone and MMF. RESULTS: Hundred forty-four patients were eligible for inclusion in the study. Mean age of the study subjects at the time of transplantation was 36.8+/-16.6 years. 99 (69%) of the patients were male. Overall, 16 (11%) patients experienced AR during the first two weeks post-transplantation. Mean C2 blood levels for patients experiencing AR was 793+/-335 compared with 1028+/-391 for patients without AR (p=0.023). We found that none of the patients with a C2 level of higher than 1300 ng/mL experienced an episode of AR. CONCLUSIONS: According to our findings, we recommend that for minimization purpose of the incident AR episodes among LURD kidney, a C2 blood level of higher than 1300 ng/mL to be obtained during the first week post-transplantation. Alongside, approaching specific C2 targets for patients with different drug regimen or genetic polymorphisms seem necessary.

Does CMV infection increase the incidence of infective endocarditis following kidney transplantation?

BACKGROUND: Infective endocarditis (IE) is a rare but life threatening infection after renal transplantation. In addition, coinfection of CMV and IE has not been reported. Therefore, the current study was initiated to determine whether CMV infection is a risk factor for developing of IE after kidney transplantation. MATERIAL/METHODS: In a retrospectively study, we analyzed the medical records of 3700 kidney recipients at two transplant centers in Iran, between January 2000 and June 2008 for infective endocarditis. RESULTS: During the study, 15 patients with IE hospitalized in our centers were included. The predominant causative microorganisms (60%) were group D non-enterococcal streptococci and enterococci. Patient survival rate in all recipients was 66% at 6 months. Data analysis showed no significant differences in 6 months patient survival from hospitalization between both groups with and without CMV infection (P=0.2). The presentation time of infective endocarditis in recipients with CMV coinfection was more likely to be early when compared to CMV negative coinfection patients (P=0.03). CONCLUSIONS: The present study indicates that CMV infection may lead to predispose to infective endocarditis after kidney transplantation. Rapid diagnosis, effective treatment, and prompt recognition of complications in kidney transplant recipients are essential to good patient outcome.

Ramadan fasting in kidney transplant recipients with normal renal function and with mild-to-moderate renal dysfunction.

BACKGROUND: Fasting during Ramadan is prescribed for every healthy Muslim after the age of puberty. However, many patients ask their physicians whether it is safe for them to fast. AIM: The aim of this study was to evaluate the influence of voluntary Ramadan fasting on patients with transplanted kidneys. METHODS: We conducted a prospective study on 41 kidney transplant recipients who chose to fast during Ramadan and 41 recipients who had not fasted at five transplant centers in the month of Ramadan (September-October 2007). All 82 recipients underwent transplantation at least 1 year prior to the study, and all had had stable renal function for at least 6 months prior to the study. RESULTS: The mean ages of the fasting and control groups were 42 +/- 12 years and 43 +/- 12 years, respectively, and the corresponding duration since transplantation was 10-210 (average: 65) months and 11-180 (average: 69) months. Our results showed that estimated GFR did not significantly change during Ramadan for either group (mean estimated GFRs pre- and post-Ramadan were 72.8 +/- 27.8 and 73.1 +/- 29.3 ml/min in the fasting group, and 73.4 +/- 18.8 and 73.1 +/- 18.5 ml/min in non-fasters, respectively). In patients with GFR < 60 ml/min, renal function remained stable during Ramadan. CONCLUSION: The results did not show any adverse effects of fasting, especially on allograft function, in kidney recipients who had normal as well as mild to moderate impaired but stable renal function prior to fasting.

Kaposi's sarcoma following living donor kidney transplantation: review of 7,939 recipients.

INTRODUCTION: Kaposi's sarcoma (KS) is one of the most common tumors to occur in kidney recipients, especially in the Middle East countries. Limited data with adequate sample size exist about the development of KS in living kidney recipients. METHODS: Therefore, we made a plan for a multicenter study, accounting for up to 36% (n = 7,939) of all kidney transplantation in Iran, to determine the incidence of KS after kidney transplantation between 1984 and 2007. RESULTS: Fifty-five (0.69%) recipients who developed KS after kidney transplantation were retrospectively evaluated with a median follow-up of 24 (1-180) months. KS occurred more often in older age when compared to patients without KS (49 +/- 12 vs. 38 +/- 15 years, P = 0.000). KS was frequently found during the first 2 years after transplantation (72.7%). Skin involvement was universal. Furthermore, overall mortality rate was 18%, and it was higher in patients with visceral involvement compared to those with mucocutaneous lesions (P = 0.01). However, KS had no adverse affect on patient and graft survival rates compared to those without KS. Forty-four patients with limited mucocutaneous disease and four with visceral disease responded to withdrawal or reduction of immunosuppression with or without other treatment modalities. Renal function was preserved when immunosuppression was reduced instead of withdrawn in patients with and without visceral involvement (P = 0.001 and 0.008, respectively). CONCLUSION: The high incidence of KS in this large population studied, as compared to that reported in other transplant patient groups, suggests that genetic predisposition may play a pathogenetic role.

Burden among care-givers of kidney transplant recipients and its associated factors.

Burden among care-givers of chronically ill patients has been widely investigated. However, there is no study evaluating perceived pressure on care-givers of kidney transplant recipients. This study aimed to evaluate the effect of care-giving to renal transplant recipients in Iranian Muslim population and to analyze factors associated with it. A cross-sectional study was carried out involving 41 care-givers of renal recipients. The Care-giver Burden Scale (CB Scale) was used to evaluate the care-giver's perceived burden and its correlates. Statistical analysis was performed using software SPSS v.13.0. P (p 0.05), and being a parent or spouse to the patient (p 0.05). We also found significant adverse effects of patients' second transplantation and gender (male) on care-givers' burden. There was no significant relationship between care-giver burden score and patients' marital status, education level, operation time, age, donor type (cadaveric or living), and dialysis history before and after transplantation. In conclusion, care-givers experience strain, which has implications for research and service provision. Service providers need to identify those care-givers at risk of greater strain and help them in situations that cannot be altered. Future research should be conducted to identify the effects of interventions, on care-givers' burden perception.

Hepatitis C virus infection among patients on hemodialysis: a report from a single center in Iran.

The aim of this study is to evaluate the incidence of hepatitis C virus (HCV) infec-tion among the hemodialysis (HD) patients at the Nephrology and Urology Research Center, Tehran, Iran, and identify the potential risk factors. A total of 112 patients on HD in our two dia-lysis units were studied. The mean duration of follow-up was 27 +/- 27 months (range, 6-132). All study subjects were HCV-negative at entry to the study and were tested for anti-HCV antibody by ELISA II every six months thereafter. Positive samples were re-examined by RT/PCR for confir-mation. Factors that might be implicated in HCV transmission were evaluated. Six patients (5.3%) were labeled as HCV infected, at the end of the follow-up period. Thus, the incidence of HCV infection in our dialysis units was 1.8 per 100 person years. A total of 64.5% of the study popu-lation had previous history of blood transfusion(s) and 8% had undergone prior transplantation. Univariate analysis showed a significant relationship between number of blood transfusions and duration on dialysis and HCV infection. Multivariate analysis revealed that only duration on HD was significantly associated with HCV positivity (OR: 1.03, p=0.008). Our study further suggests that nosocomial transmission plays a major role in HCV transmission among patients on HD. Meticulous practice of preventive measures is essential to eradicate the spread of HCV in HD units.

Invasive fungal infections following renal transplantation: a review of 2410 recipients.

BACKGROUND: Organ transplant recipients, on long-term graft preserving immunosuppressive therapy, are at increased risk for life threatening opportunistic fungal infections. MATERIAL/METHODS: In order to evaluate the incidence of invasive fungal infections (IFIs) and to identify the most common fungal pathogens, we conducted a retrospective study on 2410 ESRD cases undergone living kidney transplantation in three transplant centers between 1998 and 2008. RESULTS: IFIs developed in 21 recipients (0.87%), 17 male and 4 female. Their immunosuppression was cyclosporine based. The mean age of patients was 48+/-10 (ranged from 32 to 67) years. Diagnosis was made by radiological findings, positive blood or bronchoalveolar lavage (BAL) cultures and tissue biopsies. Mucormycosis was the most common cause of IFIs in population studied (n=11), followed by disseminated candidiasis (n=4), aspergillosis (n=3), nocardiasis (n=2) and histoplasmosis (n=1). Pulmonary involvement was dominant (47.6%). The treatment was successful in only 10 patients and the rest died. CONCLUSIONS: In our large series of kidney transplant recipients, mucormycosis was found to be the most common cause of invasive fungal infection. Prompt diagnosis and treatment are necessary to avoid the life threatening complications and may greatly improve prognosis.

Immunogenicity of pneumococcal vaccination in renal transplant recipients and hemodialysis patients: a comparative controlled trial.

BACKGROUND: The objectives of this study were: to assess and compare the antibody responses of renal allograft recipients and dialysis patients to pneumococcal vaccination. MATERIAL/METHODS: 14 stable dialysis patients as well as 37 kidney transplant recipients were eligible for inclusion in this trial. Participated patients receive a single 0.5-mL of 23-valent vaccine Pneumovax administered intramuscularly in the upper extremities. The efficacy of vaccination was evaluated by measuring the antibody response to the whole vaccine. Sera were obtained prior to vaccination and 4 weeks, 6 months and 1 year after the vaccination. RESULTS: Prior to vaccination, mean IgG and IgG2 titers were equivalent in Dx and KTx patients (p>0.1 in both). Four weeks after vaccination, 49 out of 51 participated patients (96%) represented an increase in their anti pneumococcal IgG levels (mean 99+/-66) compared to 48 out of 51 (94%) for month 6 (mean 90+/-59), and 38 out of 45 (85%) for the first year after vaccination (mean 73+/-69). KTx patients kept significantly more serum IgG2 levels at months 6 and 12 after vaccination (p=0.001, p=0.03, respectively; Table 1). Mean IgG values for month 6 was 9+/-41 units lesser than month 1 post vaccination serum IgG levels. CONCLUSIONS: We found that patients with renal failure on hemodialysis and kidney transplantation well respond to immunization by anti pneumococcal vaccination. But, they rapidly loss their serum antibody levels during the one year after vaccination. Specifying protective levels for serum IgG and IgG2 levels in these patients would help us to more precisely follow these patients and to consider a revaccination when they failed to save the protective serum antibody level.

Cytomegalovirus disease in renal transplant recipients: an Iranian experience.

BACKGROUND: Cytomegalovirus is considered the most important infectious cause of mortality and morbidity in organ transplant recipients. In the current study, we evaluate the potential impact of cytomegalovirus infection and cytomegalovirus disease on the outcomes of renal allograft recipients under different conditions. MATERIALS AND METHODS: We retrospectively analyzed the data from 48 renal transplant recipients who had undergone a transplant at the Baqiyatallah Hospital in Tehran, Iran, between 1984 and 2007. We included all patients with valid laboratory test results for cytomegalovirus infection. Values for P less than .05 were considered statistically significant. RESULTS: Overall, 48 patients (2.1%) were documented as developing cytomegalovirus disease. From these, 1 patient (2%) died, and 3 (6%) lost their allograft function. Compared with mycophenolic-acid-based triple immunosuppressive therapy, azathioprine was less likely to induce cytomegalovirus disease and also promised better survival (P < .0001 and P < .001). Being negative for the anti-cytomegalovirus IgG antibody and receiving an allograft from a positive donor also were associated with cytomegalovirus disease development and poorer patient survival (P = .03 and P < .0001). CONCLUSIONS: Cytomegalovirus infection induces unfavorable outcomes in renal allograft recipients, especially when the infection occurs early on in the posttransplant phase. We suggest close monitoring of cytomegalovirus-positive patients and the use of less-intensive immunosuppressive treatments. Future prospective studies seem necessary.