Prophylaxis of Cytomegalovirus Primary Infection With Short-Term Ganciclovir Theraphy R. Lauzurica, B. Baye ´s, C. Frı´as, A. Herna ´ ndez, A. Jimenez, N. Fontsere ´ , and R. Romero C YTOMEGALOVIRUS (CMV) remains one of the most important pathogens in kidney and other solid organ transplantation. It produces greater morbility nowa- days rather than the significant mortality rates in the past. CMV not only produces direct damage due to the infection, but also indirect complications including excessive immu- nosuppression and augmented acute rejection as well as decreasing patient and allograft survivals and increasing economic costs. 1 The most important risk factors for CMV infection are recipient CMV serologic status in relation to organ donor serology (D + /R - ), and the use of antilympho- cyte antibodies either for induction or for acute rejection therapy. 1,2 There are two major forms of CMV infection; prophylaxis by administration of antiviral drugs or gamma- globulins at the time of transplantation and for a variable period after transplantation, and preemptive therapy, namely giving antiviral drugs when there is evidence of the virus replication after kidney transplantation. 1,3 We report our experience with a group of high risk patients (D + /R - ) who received low-dose and short-term gancyclovir prophylaxis. PATIENTS AND METHODS Definitions Between July 1997 and July 2002, 156 kidney transplants were performed at our Kidney Transplantation Unit. Fifteen seronega- tive recipients received a kidney allograft from a seropositive donor. Prophylaxis included intravenous (IV) gancyclovir (1.25–5 mg/kg/d adjusted by kidney function) for 1 week, followed by oral (PO) gancyclovir (500 mg/8 –12 hours according to the body mass index) for 3 more weeks (total treatment period of 4 weeks). The diagnosis of CMV infection was established by seroconversion and/or pp65 antigenemia. Asymptomatic CMV infection was diagnosed when evidence of seroconversion and/or positive antigenemia occurred without any clinical features. Symptomatic CMV infection occurred when se- roconversion and/or positive antigenemia were associated with fever and/or leukopenia without organ or tissue involvement. CMV disease was established when there was evidence of CMV infection with involvement of one or more organs. RESULTS Fourteen of the 15 patients were men. Mean age was 41 years (range 19 – 69). Only 2 received induction with anti- lymphocyte antibodies; all received prednisone; 12 tacroli- mus; 3 cyclosporine; 11 mycophenolate mofetil; and 3 azathioprine. Two experienced an acute rejection episode that was treated (and resolved) with methylprednisolone pulses (250 –500 mg IV for 3 days). Thirteen of 15 devel- oped a primary infection; two (2 and 25 months after KT) have not seroconverted yet. CMV diagnosis was established between 3 and 78 days after KT (mean 48 days). Asymp- tomatic CMV infection was detected in two patients who did not receive therapy. Symptomatic infection occurred in seven patients with CMV disease in four patients, including (mild transaminitis in three; and only one patient with transaminitis, pneumonitis and superinfection) with Pneu- mocystis carinii. In 12 patients, diagnosis was achieved by positive antigenemia and in 1 by seroconversion. Only three patients required hospital admission (for 2, 10, and 30 days, respectively). In all but one subject therapy consisted of ganciclovir (PO 500 mg/3 times a day for 1 month). In two patients with CMV disease, ganciclovir was initiated IV followed by PO delivery and in one (with pneumonitis) was combined with specific gammaglobulin. There were no deaths. Neither infection recurrences nor drug resistances occurred. Up to now all patients but one have functional kidneys (serum creatinine below 140 mol/L) without clin- ical, biological, or histologic criteria of chronic allograft nephropathy. One patient lost the kidney due to active alcoholism after kidney transplantation with noncompli- ance to immunosuppresion medications. DISCUSSION Strategies for CMV infection prophylaxis are diverse: CMV hyperimmune globulins, which are more effective than unselected globulin treatment, acyclovir, valacyclovir, and ganciclovir. 1,4 The best results have been obtained with ganciclovir but the doses and lengths of treatment are quite different from those described in our protocol. 1,4,5 The From the Nephrology Department, Kidney Transplant Unit (R.L., B.B., N.F., R.R.) and Microbiology Department (C.F., A.H., A.J.), Hospital Universitari Germans Trias i Pujol, Badalona, Spain. Address reprint requests to Dr Ricardo Lauzurica, Kidney Transplant Unit, Hospital Universitari Germans Trias i Pujol, Crta.del Canyet, s/n -08916 Badalona, Spain. E-mail: rlauzu@ns.hugtip.scs.es © 2003 by Elsevier Inc. All rights reserved. 0041-1345/03/$–see front matter 360 Park Avenue South, New York, NY 10010-1710 doi:10.1016/s0041-1345(03)00714-0 Transplantation Proceedings, 35, 1751–1752 (2003) 1751