A Nationwide Survey of Cytomegalovirus Prevention Strategies in Kidney Transplant Recipients in a Resource-Limited Setting

Jackrapong Bruminhent; Asalaysa Bushyakanist; Surasak Kantachuvesiri; Sasisopin Kiertiburanakul

doi:10.1093/ofid/ofz322

A Nationwide Survey of Cytomegalovirus Prevention Strategies in Kidney Transplant Recipients in a Resource-Limited Setting

Open Forum Infect Dis. 2019 Jul 8;6(9):ofz322. doi: 10.1093/ofid/ofz322. eCollection 2019 Sep.

Authors

Jackrapong Bruminhent^{1

2}, Asalaysa Bushyakanist¹, Surasak Kantachuvesiri^{2

3}, Sasisopin Kiertiburanakul¹

Affiliations

¹ Division of Infectious Diseases, Department of Medicine, Mahidol University, Bangkok, Thailand.
² Excellence Center of Organ Transplantation, Mahidol University, Bangkok, Thailand.
³ Division of Nephrology, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.

Abstract

Objective: Strategies to prevent cytomegalovirus (CMV) infection in resource-limited settings have been under-explored. We investigated CMV prevention strategies utilized among transplant centers in Thailand.

Method: A questionnaire on CMV prevention strategies for kidney transplant (KT) recipients was developed using a web-based electronic survey website (www.surveymonkey.com). The survey was delivered to 31 transplant centers in Thailand. One infectious disease physician (ID) and 1 nephrologist (NP) from each center were included.

Results: There were 43 respondents from 26 of the 31 transplant centers (84%), including 26 (60%) IDs and 17 (40%) NPs. Forty-one 95% (41/43) physicians agreed on the necessity of CMV prevention. Of these, 77% (33/43) physicians implemented prevention strategies for their patients. Interventions included preemptive approaches (48%), prophylaxis (45%), hybrid approaches; surveillance after prophylaxis (3%), and CMV-specific immunity-guided approaches (3%). For CMV-seropositive KT recipients, use of preemptive approaches (84%) exceeded prophylaxis (12%). However, 81% of the former preferred targeted prophylaxis in patients receiving antithymocyte globulin therapy. Sixty-five percent and 93% of physicians started preemptive therapy when plasma CMV DNA loads reached 2000 and 3000 copies/mL (1820 and 2730 IU/mL), respectively. A significantly greater percentage of NPs initiated preemptive therapy at a plasma CMV DNA load of 1820 IU/mL compared with IDs (88% vs 50%; P = .02). The most common barrier to prevention strategy implementation was financial inaccessibility of oral valganciclovir (67%) and quantitative CMV DNA testing (12%).

Conclusions: Most physicians agreed on a need for preemptive approaches, although prophylaxis was targeted in those receiving intense immunosuppression. The financial implication is the main barrier for CMV prevention in Thailand.

Keywords: burden; cut-off; cytomegalovirus; hybrid approach; preemptive therapy; prophylaxis; threshold; viral load.