The current burden of cytomegalovirus infection in kidney transplant recipients receiving no pharmacological prophylaxis / O fardo atual da infecção por citomegalovírus em receptores de transplante renal que não recebem profilaxia farmacológica

Abstract Cytomegalovirus (CMV) infection in kidney transplantation has changed its clinical spectrum, mostly due to the current and more effective immunosuppression. In the absence of preventive strategies it is associated with significant morbi-mortality. Objective: This study evaluated the incidence of CMV events and its effect on outcomes of kidney transplantation in recipients without pharmacological prophylaxis or targeted preemptive treatment. Results: The study cohort comprised 802 recipients of kidney transplants between 04/30/2014 and 04/30/2015. The majority received induction with anti-thymocyte globulin (81.5%), tacrolimus and prednisone in combination with either mycophenolate (46.3%) or azathioprine (53.7%). The overall incidence of CMV events was 42% (58.6% infection and 41.4% disease). Patients with CMV showed higher incidence of first treated acute rejection (19 vs. 11%, p = 0,001) compared with those without CMV but no differences in graft loss, death or loss to follow-up. The incidence of delayed graft function was higher (56% vs. 37%, p = 0.000) and the eGFR at 1 (41 ± 21 vs. 54 ± 28 ml/min, p = 0.000) and 12 months (50 ± 19 vs. 61 ± 29 ml/min, p = 0.000) were lower in patients with CMV. Recipients age (OR = 1.03), negative CMV serology (OR = 5.21) and use of mycophenolate (OR = 1.67) were associated with increased risk of CMV. Changes in immunosuppression was more often in patients with CMV (63% vs. 31%, p = 0.000). Conclusion: the incidence of CMV events was high and associated with higher incidence of acute rejection and changes in immunosuppression. Besides traditional risk factors, renal function at 1 month was independently associated with CMV infection.

Resumo A infecção por citomegalovírus (CMV) no transplante renal mudou seu espectro clínico, principalmente devido à atual e mais efetiva imunossupressão. Na ausência de estratégias preventivas, está associado a significativa morbimortalidade. Objetivo: este estudo avaliou a incidência de eventos de CMV e seu efeito nos desfechos do transplante renal em receptores sem profilaxia farmacológica ou tratamento preventivo direcionado. Resultados: A coorte do estudo envolveu 802 receptores de transplantes de rim entre 30/04/2014 e 30/04/2015. A maioria recebeu indução com globulina anti-timocitária (81,5%), tacrolimus e prednisona em combinação com micofenolato (46,3%) ou azatioprina (53,7%). A incidência global de eventos de CMV foi de 42% (58,6% de infecção e 41,4% de doença). Os pacientes com CMV apresentaram maior incidência de rejeição aguda do primeiro tratamento (19 vs. 11%, p = 0,001), em comparação com aqueles sem CMV, mas sem diferenças na perda de enxerto, morte ou perda de seguimento. A incidência de função retardada de enxerto foi maior (56% vs. 37%, p = 0,000) e a TFGe a 1 (41 ± 21 vs. 54 ± 28 ml/min, p = 0,000) e 12 meses (50 ± 19 vs. 61 ± 29 ml/min, p = 0.000) foram menores em pacientes com CMV. A idade dos receptores (OR = 1,03), a sorologia negativa para CMV (OR = 5,21) e o uso de micofenolato (OR = 1,67) foram associados ao aumento do risco de CMV. As alterações na imunossupressão foram mais frequentes em doentes com CMV (63% vs. 31%, p = 0,000). Conclusão: a incidência de eventos relacionados a CMV foi alta e associada a maior incidência de rejeição aguda e alterações na imunossupressão. Além dos fatores de risco tradicionais, a função renal com 1 mês foi associada de forma independente à infecção por CMV.

The current burden of cytomegalovirus infection in kidney transplant recipients receiving no pharmacological prophylaxis.

Cytomegalovirus (CMV) infection in kidney transplantation has changed its clinical spectrum, mostly due to the current and more effective immunosuppression. In the absence of preventive strategies it is associated with significant morbi-mortality. OBJECTIVE: This study evaluated the incidence of CMV events and its effect on outcomes of kidney transplantation in recipients without pharmacological prophylaxis or targeted preemptive treatment. RESULTS: The study cohort comprised 802 recipients of kidney transplants between 04/30/2014 and 04/30/2015. The majority received induction with anti-thymocyte globulin (81.5%), tacrolimus and prednisone in combination with either mycophenolate (46.3%) or azathioprine (53.7%). The overall incidence of CMV events was 42% (58.6% infection and 41.4% disease). Patients with CMV showed higher incidence of first treated acute rejection (19 vs. 11%, p = 0,001) compared with those without CMV but no differences in graft loss, death or loss to follow-up. The incidence of delayed graft function was higher (56% vs. 37%, p = 0.000) and the eGFR at 1 (41 ± 21 vs. 54 ± 28 ml/min, p = 0.000) and 12 months (50 ± 19 vs. 61 ± 29 ml/min, p = 0.000) were lower in patients with CMV. Recipients age (OR = 1.03), negative CMV serology (OR = 5.21) and use of mycophenolate (OR = 1.67) were associated with increased risk of CMV. Changes in immunosuppression was more often in patients with CMV (63% vs. 31%, p = 0.000). CONCLUSION: the incidence of CMV events was high and associated with higher incidence of acute rejection and changes in immunosuppression. Besides traditional risk factors, renal function at 1 month was independently associated with CMV infection.

Randomized Trial of Machine Perfusion Versus Cold Storage in Recipients of Deceased Donor Kidney Transplants With High Incidence of Delayed Graft Function

BACKGROUND: This study compared the use of static cold storage versus continuous hypothermic machine perfusion in a cohort of kidney transplant recipients at high risk for delayed graft function (DGF). METHODS: In this national, multicenter, and controlled trial, 80 pairs of kidneys recovered from brain-dead deceased donors were randomized to cold storage or machine perfusion, transplanted, and followed up for 12 months. The primary endpoint was the incidence of DGF. Secondary endpoints included the duration of DGF, hospital stay, primary nonfunction, estimated glomerular filtration rate, acute rejection, and allograft and patient survivals. RESULTS: Mean cold ischemia time was high but not different between the 2 groups (25.6 ± 6.6 hours vs 25.05 ± 6.3 hours, 0.937). The incidence of DGF was lower in the machine perfusion compared with cold storage group (61% vs. 45%, P = 0.031). Machine perfusion was independently associated with a reduced risk of DGF (odds ratio, 0.49; 95% confidence interval, 0.26-0.95). Mean estimated glomerular filtration rate tended to be higher at day 28 (40.6 ± 19.9 mL/min per 1.73 m2 vs 49.0 ± 26.9 mL/min per 1.73 m2; P = 0.262) and 1 year (48.3 ± 19.8 mL/min per 1.73 m2 vs 54.4 ± 28.6 mL/min per 1.73 m2; P = 0.201) in the machine perfusion group. No differences in the incidence of acute rejection, primary nonfunction (0% vs 2.5%), graft loss (7.5% vs 10%), or death (8.8% vs 6.3%) were observed...