Late‐onset allograft rejection, cytomegalovirus infection, and renal allograft loss: Is anti‐CMV prophylaxis required following late‐onset allograft rejection?

Abstract

Renal transplant recipients remain at risk of delayed‐onset cytomegalovirus (CMV) infection occurring beyond a complete course of prophylaxis. In this retrospective cohort, all 278 patients who received renal allografts from deceased donors from 2014 to 2016 were followed until September 1, 2019. We determined the effect of early–vs late‐onset acute rejection (EAR vs LAR [ie, occurring beyond 12 months after transplantation]) on CMV infection and subsequently long‐term allograft outcome. Median (IQR) duration of follow‐up was 1186.0 (904.7‐1531.2) days. Seventy patients including 49 patients with EAR and 21 with LAR received augmented immunosuppression. In the same interval, 40 patients developed CMV infection (36 patients beyond 90 days after transplantation [90%]). In logistic regression analysis, D+/R‐ CMV serostatus (OR: 5.5, 95% CI: 2.5‐12.2) and LAR (OR: 7.9, 95% CI: 2.8‐22.2) significantly increased the risk of CMV infection. In Cox proportional hazard model, delayed‐onset CMV infection (HR: 2.51, 95% CI: 1.08‐5.86) and LAR (HR: 5.46, 95% CI: 2.26‐13.14) significantly increased the risk of allograft loss. Patients with LAR are at risk of late‐onset CMV infection. Post‐LAR, targeted prophylaxis may reduce the risk of CMV infection and subsequently allograft loss. Further studies are required to demonstrate the effect of targeted prophylaxis following LAR.

Incidence and Outcomes Associated With Clostridioides difficile Infection in Solid Organ Transplant Recipients

“…36 However, infectious complications occurring beyond 3 months following transplant may be associated with graft dysfunction, late-onset allograft rejection, and cumulative immunosuppression. 9,37 To our knowledge, ours is the first study to quantify the risk of death in patients who have undergone SOT and developed CDI early vs later after transplant.…”

“…However, the outcome of late-onset CDI has been rarely investigated . Although early-onset infectious complications may affect allograft function, late-onset infectious diseases may be associated with allograft loss and death . To our knowledge, post-CDI mortality has not been compared between patients who underwent SOT developing early- vs late-onset CDI.…”

Cytomegalovirus in the transplant setting: Where are we now and what happens next? A report from the International CMV Symposium 2021

“…36 It is also important to consider the risk of organ rejection as CMV may be associated with allograft loss. 37,38 Although some data indicate that graft survival is improved with prophylaxis in kidney transplant recipients 39,40 the same conclusion has not been associated with pre-emptive therapy. 32 Fausto Baldanti reminded delegates that the individuals most at risk of negative outcomes from CMV in the SOT setting were those who were highly immunocompromised.…”

“…It is also important to consider the risk of organ rejection as CMV may be associated with allograft loss. 37 , 38 Although some data indicate that graft survival is improved with prophylaxis in kidney transplant recipients 39 , 40 the same conclusion has not been associated with pre‐emptive therapy. 32 …”

Long-term CMV monitoring and chronic rejection in renal transplant recipients

“…Even though the late-onset CMV infection is an important issue after KTx, the data about the CMV infection in the chronic phase are lacking. Previous reports regarding late-onset CMV infection and CMV viremia had short observation periods (< 2.0 years after KTx in most studies), and the details of CMV monitoring were missing or limited ( Viot et al., 2015 ; Selvey et al., 2017 ; Rahimishahmirzadi et al., 2021 ; Chaudhari et al., 2022 ). A previous study retrospectively analyzed the long-term impact of CMV infection over a period of 10 years after KTx ( Browne et al., 2010 ), however, CMV monitoring was performed only when the patients had signs or symptoms, which was the same selection condition as in other reports.…”