Low dose valganciclovir as cytomegalovirus prophylaxis in post-renal transplant recipients induced with alemtuzumab: A single-center study

Transpl Immunol. 2019 Oct;56:101226. doi: 10.1016/j.trim.2019.101226. Epub 2019 Jul 22.

Abstract

Objectives: Alemtuzumab (Ale) is a recombinant monoclonal antibody which binds to CD52 causing profound lymphodepletion, thus allowing its use in renal transplantation induction therapy. However, patients may be at increased risk for opportunistic infections, such as Cytomegalovirus (CMV). We analyzed CMV infection in renal allograft recipients administered low-dose valganciclovir (VGCV) prophylaxis with alemtuzumab induction and steroid minimization.

Materials and methods: In this retrospective analysis, 678 kidney transplant recipients were evaluated, with 606 included for analysis. Patients were excluded for receiving induction therapy other than Ale, or for lack of follow-up within 1 year. VGCV prophylaxis was stratified by recipient CMV risk status and low-dose (450 mg) VGCV was given 3 times a week to low and moderate risk patients and daily to high risk individuals. Subject records were examined for recipient demographics, donor and recipient CMV serostatus, CMV viremia, and invasive infection.

Results: Of the 606 recipients, 154 were defined as low risk for CMV infection (donor and recipient both negative, or D-/R-), 236 as moderate risk without mismatch (D+/R+), 122 as moderate risk with mismatch (D-/R+), and 94 as high risk (D+/R-). Twenty-nine (29) individuals (4.8%) tested positive by PCR for CMV viremia and 10 (1.7%) patients developed invasive CMV disease, including colitis (n = 4), esophagitis (n = 1), enteritis (n = 1), nephritis (n = 1), and pneumonia (n = 3). High risk recipients (D+/R-) accounted for the majority of invasive CMV disease (n = 5), followed by moderate risk (n = 4). CMV viremia was also more common in high risk and moderate risk (D+/R+) individuals. Overall rejection rate for our study population was 27%.

Conclusion: In this institution's experience, CMV incidence was reduced compared to historically reported data by using low-dose (450 mg) VGCV prophylaxis in combination with Ale induction and steroid minimization. However, overall rejection rate was significantly higher in our population, possibly influenced by the degree of steroid minimization.

Keywords: Alemtuzumab; CMV; Renal transplantation; Valganciclovir.

MeSH terms

  • Adult
  • Aged
  • Alemtuzumab / adverse effects
  • Alemtuzumab / therapeutic use*
  • Antiviral Agents / therapeutic use*
  • CD52 Antigen / immunology
  • Cytomegalovirus / physiology*
  • Cytomegalovirus Infections / etiology
  • Cytomegalovirus Infections / prevention & control*
  • Drug Dosage Calculations
  • Graft Rejection / drug therapy*
  • Humans
  • Kidney Transplantation*
  • Lymphocyte Depletion
  • Middle Aged
  • Postoperative Period
  • Retrospective Studies
  • Risk
  • Steroids / therapeutic use
  • Transplantation, Homologous
  • Treatment Outcome
  • Valganciclovir / therapeutic use*

Substances

  • Antiviral Agents
  • CD52 Antigen
  • Steroids
  • Alemtuzumab
  • Valganciclovir