Effect of oral acyclovir or ganciclovir therapy after preemptive intravenous ganciclovir therapy to prevent cytomegalovirus disease in cytomegalovirus seropositive renal and liver transplant recipients receiving antilymphocyte antibody therapy

Background. Organ transplant recipients who are seropositive for cytomegalo virus (CMV) and who are treated with antilymphocyte antibody (ALA) therapy have a high rate of symptomatic CMV disease. The intravenous administration of ganciclovir therapy once daily during ALA therapy decreased the inciden ce from 24% to 10% in patients receiving ALA as an induction therapy and fr om 64% to 22% in those treated for rejection. The present study was underta ken to determine whether a more intensive and sustained antiviral regimen c ould be more effective. Methods. From April 1995 to December 1997, all CMV seropositive renal and l iver transplant, recipients who received ALA therapy were treated with intr avenously administered ganciclovir (5 mg/kg/day with dose adjusted for rena l dysfunction) for the length of ALA therapy and then with orally administe red acyclovir (400 mg three times/day) or ganciclovir (1 gm twice/day) for 3 to 4 months. The incidence of CMV viremia and of CMV disease was determin ed during the 6 months after completion of ALA therapy. Results. Forty-one patients (35 renal and 6 liver transplant recipients) we re studied. CMV disease occurred in 2 patients (4.9%), both of whom were tr eated for rejection; it occurred in 1 of 21 patients (4.8%) treated with or ally administered acyclovir, and in 1 of 20 patients (5%) treated with oral ly administered ganciclovir. The only patient who developed CMV disease in the ganciclovir group had received only 26 days of oral antiviral therapy. No CMV disease was documented in the group of patients receiving ALA therap y as induction therapy. CMV viremia occurred in three patients in the acycl ovir group (14.3%) and in one patient in the ganciclovir group (5%). Among renal transplant recipients only, 1 of 35 patients developed CMV disease (2 .9%) and no case of CMV disease was documented in patients treated with ora lly administered ganciclovir. All six patients receiving two courses of ALA therapy each were free of CMV disease. Toxicity of the regimen was minimal , and antiviral resistance did not develop. Conclusions. Preemptive antiviral therapy with intravenously administered g anciclovir during ALA therapy and then orally administered ganciclovir for 3 to 4 months provides virtually complete protection against the excessive rate of CMV disease that occurs in CMV seropositive allograft recipients re ceiving ALA therapy.