Active CMV infection before lung transplantation: Risk factors and clinical implications

Background: Cytomegalovirus (CMV) infection is a major cause of morbidity f ollowing lung transplantation, but active CMV infection has not been descri bed before transplantation. Methods: Since 1990, we have screened all lung-transplant recipients for CM V infection with viral urine cultures on the day of transplantation. We ret rospectively reviewed the medical records of all 102 lung-allograft recipie nts transplanted between March 1990 and September 1998. Patients with posit ive urine cultures for CMV were compared to culture negative patients for a ge, gender, pretransplant diagnosis, time from diagnosis to transplantation , CMV serostatus, use of pretransplant immunosuppression, T-lymphocyte subs ets, and presence of fever. Posttransplant outcomes assessed were duration of intubation and hospitalization, acute rejection, frequency of CMV diseas e. duration of Nashville rabbit antithymocyte serum or globulin (N-RATS/G) and ganciclovir, and survival. Results: Five (5%) of 102 patients had positive urine cultures for CMV; non e had symptoms of CMV infection. All 5 had idiopathic pulmonary fibrosis (I PF) (5/5 vs 27/97; p = 0.002). The age, gender, and CMV serostatus of these patients did not differ from the 97 patients in the culture negative group . Four (80%) of the 5 patients with positive cultures were receiving treatm ent with azathioprine or cyclophosphamide vs only 18 (19%) of the 97 patien ts with negative cultures (p = 0.007), and all 5 (100%) were receiving ster oids compared to 50 (52%) of 97 patients with negative cultures (p = 0.06). Culture-positive IPF patients, when compared with the 27 culture-negative IPF patients, did not differ in any demographic variable or in the use of i mmunosuppression, but culture-positive patients were more likely to have a CD4/CD8 T-cell subset ratio <1.0 (p = 0.02), Following transplantation, 3 ( 60%) of 5 TPF patients with positive CMV cultures developed CMV disease com pared to 3 (11%) of 27 TPF patients with negative cultures (p = 0.03), Pati ents with positive cultures also received more days of parenteral antiviral therapy (mean 44 +/- 11 days vs 16 +/- 10 days; p < 0.001). Conclusion: Utilizing pretransplant screening, we have discovered that 16% of patients with IPF had active CMV infection, which was associated with bo th alterations in their T-cell subsets and a greater risk for CMV disease a fter transplantation. This occurrence sf occult CMV infection in patients w ith TPF has not been previously recognized, and has important implications.