THE SIGNIFICANCE OF RISK-ADAPTED ANTIVIRA L PROPHYLAXIS AND MODERN VIROLOGICAL DIAGNOSIS FOR THE SURVIVAL OF A RENAL-TRANSPLANT

Basic problem and objective: Viral, especially cytomegalovirus (CMV), infections are after rejection reaction the most serious problem follo wing organ transplantation. The risk of disease correlates with the CM V donor/recipient constellation and the degree of immunosuppression. T he importance of antiviral prophylaxis remains unresolved. Whether dru g prophylaxis adapted to the individual risk is of clinical value was investigated in a prospective study. Patients and methods: A risk-adap ted stepwise antiviral prophylactic regimen was given to 62 patients w ith renal transp lants. All patients at risk of CMV infection were giv en aciclovir, 200 mg four times daily for 3 months. Patients with reje ction reaction for which they were receiving i. v. immunosuppressive t reatment additionally received CMV hyperimmunoglobulin (2 ml/kg body w eight on days 1 and 14). High-risk patients (donor CMV positive and-re cipient CMV negative) were given as basic prophylaxis CMV hyperimmunog lobulin i.v. on days 1 and 14 after transplantation, and additionally i.v. ganciclovir during any rejection treatment. The results were comp ared with those of a retrospectively selected patient cohort (n = 52) who had received only aciclovir as basic prophylaxis. The diagnosis of CMV infection was made by demonstrating CMVpp65 antigen in blood. In the prospectively studied patients measurement of (3, microglobulin co ncentration was used to determine viruria in 24-hour urine. Results: A mong the high-risk group (donor CMV positive/recipient CMV negative) t he additional prophylactic regimen significantly reduced the proportio n of CMV-associated cases of rejection (14% compared with 42%, P < 0.0 5) in the basic prophylaxis only group. Similar results were obtained for CMV-caused transplant loss within the first 3 years (19% vs 50%, P < 0.05). The additional prophylaxis had no influence on the incidence of CMV infection. In case of active infection an isolated rise of (be ta(2)-microglobulin in urine occurred in active infection at a mean of 6 days before CMVpp65 antigenaemia (sensitivity of 89%). Conclusions: These results indicate that risk-adapted antiviral prophylaxis can de cisively influence the long-term prognosis for a renal transplant, but not the incidence of CMV infection. The early and reliable diagnosis of active CMV infection is made possible by the combined use of beta(2 )-microglobulinuria and pp65 antigenaemia.