Acyclovir prophylaxis against cytomegalovirus in high risk paediatric kidney transplant recipients

Abstract

Aims Cytomegalovirus (CMV) is an important infectious pathogen after kidney transplantation causing significant morbidity and mortality. Several prophylactic antiviral treatments are used and the aim of this study was to review the efficacy of acyclovir prophylaxis to prevent CMV infection in paediatric kidney transplant recipients. Methods The clinical records of kidney transplant recipients over a 20 year period were reviewed. Details of recipient and donor CMV serostatus were recorded together with information regarding prophylaxis received, evidence of CMV infection, and CMV related complications. All patients were scheduled to receive 5 mg/kg loading dose acyclovir peri-operatively and then acyclovir 200 mg qds for 90 days. Results 192 kidney transplants were performed in 177 children between 1991 and 2010. Only first grafts were considered in subsequent analysis. 36 recipients were identified as being at risk of CMV after transplant (i.e. recipient CMV IgG negative, donor CMV IgG positive). All of these patients received oral acyclovir prophylaxis and 58% received an intravenous loading dose. Of these 36 patients, 9 (25%) developed CMV viraemia with a positive CMV PCR. 7 patients met the criteria for CMV disease. 8 of the 9 patients developed viraemia whilst on acyclovir indicating active CMV replication despite treatment. There were no cases of severe infection or tissue invasive disease. There was no graft loss as a consequence of CMV infection. Conclusions The evidence supporting the choice of prophylactic treatment for CMV in paediatric kidney transplant recipients is limited. Recent data from the adult population indicate rates of disease are substantially lower in kidney transplant recipients treated with valganciclovir. These data indicate that in high risk individuals there is substantial risk of CMV disease despite prophylaxis with acyclovir and suggest that prophylaxis with valganciclovir is likely to result in significantly lower rates of CMV disease.