CLINICAL-PRACTICE GUIDELINES - PREVENTION OF CYTOMEGALOVIRUS DISEASE AFTER RENAL-TRANSPLANTATION

Objective: To develop a set of comprehensive, standardized, evidence-b ased guidelines for the use of antiviral therapy to prevent cytomegalo virus disease in adult patients having undergone renal transplantation . Options: The use of medication, at the time of induction therapy or at the earliest sign of viremia, Treatments were evaluated by patient and donor serologic groups and the induction regimen used. Outcomes: T he control of symptoms and features of cytomegalovirus disease over th e first 6 mo to 1 yr after transplantation. Evidence: Articles, compil ed using a MEDLINE search from 1976 to July 1997, were reviewed by rep resentatives of nephrology, microbiology, pharmacy, and epidemiology. Additional information was obtained from recent review articles and co nference abstracts, and from experts in the field. Values: The evidenc e-based methods and values of the Canadian Task Force on the Periodic Health Examinations were used. High value was placed on studies with a randomized controlled design and blinded outcome observers. Study qua lity was classified as poor when cointervention was present (especiall y with regard to immunosuppressive regimens), when more than 20% of pa tients were lost to follow-up, and when intention to treat analysis wa s not performed. Recommendations were made with a graded system (grade s A and B: Use of the intervention advised, based on high or fair qual ity evidence, respectively; grades D and E: Use of the intervention no t advised, based on high or fair quality evidence, respectively; grade C: No recommendation made because of insufficient or conflicting evid ence). Recommendations: (I) Seropositive recipient, donor seropositive or seronegative; immunosuppression with antilymphocyte products. Prop hylaxis with antiviral therapy recommended (grade A recommendation). ( 2) Seronegative recipient; seropositive donor; immunosuppression with antilymphocyte products. Prophylaxis with antiviral therapy recommende d (grade A recommendation) (3) Seronegative recipient; seropositive do nor; conventional immunosuppression. Prophylaxis with antiviral therap y recommended (grade B recommendation). (4) Seronegative recipient; se ronegative donor; any immunosuppressive regimen. Na prophylaxis with a ntiviral therapy required (grade D/E recommendation). (5) Seropositive recipient: donor seropositive or seronegative; conventional immunosup pression. Prophylaxis left to the discrimination of the physician in c harge (grade C recommendation).