Usefulness of valacyclovir prophylaxis for cytomegalovirus infection after anti-thymocyte globulin as rejection therapy
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Background/Aims: Anti-thymocyte globulin (ATG) treatment for acute T-cell mediated rejection (TCMR) can increase the risk of cytomegalovirus (CMV) infection. We aimed to evaluate the effect of valacyclovir prophylaxis against CMV infection after ATG administration as anti-rejection therapy. Methods: We retrospectively analyzed 55 kidney transplant recipients (KTRs) receiving ATG for steroid resistant TCMR. In all KTRs, we used intravenous ganciclovir during ATG injection. In 34 KTRs treated before July 2013, we performed preemptive therapy for CMV infection after ATG therapy. They were regarded as the historic control group (CONT). After July 2013, we used valacyclovir maintenance for 1 month after ATG therapy in 21 patients (VAL). The primary outcome was the incidence of CMV infection, and the secondary outcomes were subsequent acute rejection, and graft and patient outcome. Results: Valacyclovir prophylaxis significantly reduced the incidence of CMV infection (VAL, 9.6% vs. CONT, 67.6%; p < 0.001), and CMV-free survival rate was higher in the VAL group compared to the CONT group (p = 0.009). In the VAL group, two cases of CMV infection were limited to CMV viremia, but CMV disease or syndrome (n = 3) was detected in the CONT group. There was no difference in graft failure (CONT, 70.5% vs. VAL, 47.6%; p = 0.152), incidence of subsequent rejection after ATG treatment (CONT, 41.1% vs. VAL, 33.3%; p = 0.776), and graft or patient survival between the two groups. There were no major adverse events associated with valacyclovir prophylaxis. Conclusions: In conclusion, valacyclovir prophylaxis is effective in the prevention of CMV infection after ATG treatment for steroid resistant TCMR.
Abstract
Background/Aims: Anti-thymocyte globulin (ATG) treatment for acute T-cell mediated rejection (TCMR) can increase the risk of cytomegalovirus (CMV) infection. We aimed to evaluate the effect of valacyclovir prophylaxis against CMV infection after ATG administration as anti-rejection therapy. Methods: We retrospectively analyzed 55 kidney transplant recipients (KTRs) receiving ATG for steroid resistant TCMR. In all KTRs, we used intravenous ganciclovir during ATG injection. In 34 KTRs treated before July 2013, we performed preemptive therapy for CMV infection after ATG therapy. They were regarded as the historic control group (CONT). After July 2013, we used valacyclovir maintenance for 1 month after ATG therapy in 21 patients (VAL). The primary outcome was the incidence of CMV infection, and the secondary outcomes were subsequent acute rejection, and graft and patient outcome. Results: Valacyclovir prophylaxis significantly reduced the incidence of CMV infection (VAL, 9.6% vs. CONT, 67.6%; p < 0.001), and CMV-free survival rate was higher in the VAL group compared to the CONT group (p = 0.009). In the VAL group, two cases of CMV infection were limited to CMV viremia, but CMV disease or syndrome (n = 3) was detected in the CONT group. There was no difference in graft failure (CONT, 70.5% vs. VAL, 47.6%; p = 0.152), incidence of subsequent rejection after ATG treatment (CONT, 41.1% vs. VAL, 33.3%; p = 0.776), and graft or patient survival between the two groups. There were no major adverse events associated with valacyclovir prophylaxis. Conclusions: In conclusion, valacyclovir prophylaxis is effective in the prevention of CMV infection after ATG treatment for steroid resistant TCMR.
참고문헌 (26)
- Kliem V, "Improvement in long-term renal graft survival due to CMV prophylaxis with oral ganciclovir : results of a randomized clinical trial", Am J Transplant, 8, pp.975~983 (2008)
- Reischig T, "Valacyclovir for cytomegalovirus prophylaxis reduces the risk of acute renal allograft rejection", Transplantation, 79, pp.317~324 (2005)
- Issa NC, "Infectious complications of antilymphocyte therapies in solid organ transplantation", Clin Infect Dis, 48, pp.772~786 (2009)
- Couzi L, "Preemptive therapy versus valgancyclovir prophylaxis in cytomegalovirus-positive kidney transplant recipients receiving antithymocyte globulin induction", Transplant Proc, 44, pp.2809~2813 (2012)
- Said T, "Cytomegalovirus prophylaxis with ganciclovir in kidney transplant recipients receiving induction antilymphocyte antibodies", Transplant Proc, 36, pp.1847~1849 (2004)
- Hellemans R, "Cost analysis in favor of a combined approach for cytomegalovirus after kidney transplantation : a single-center experience", Transpl Infect Dis, 15, pp.70~78 (2013)
- Reischig T, "Prospective comparison of valacyclovir and oral ganciclovir for prevention of cytomegalovirus disease in high-risk renal transplant recipients", Kidney Blood Press Res, 28, pp.218~225 (2005)
- Reischig T, "Long-term outcomes of pre-emptive valganciclovir compared with valacyclovir prophylaxis for prevention of cytomegalovirus in renal transplantation", J Am Soc Nephrol, 23, pp.1588~1597 (2012)
- Racusen LC, "The Banff 97working classification of renal allograft pathology", Kidney Int, 55, pp.713~723 (1999)
- Chung BH, "Clinical significance of the ratio between FOXP3 positive regulatory T cell and interleukin-17 secreting cell in renal allograft biopsies with acute T-cell-mediated rejection", Immunology, 136, pp.344~351 (2012)
- Gaber AO, "Results of the double-blind, randomized, multicenter, phase III clinical trial of thymoglobulin versus Atgam in the treatment of acute graft rejection episodes after renal transplantation", Transplantation, 66, pp.29~37 (1998)
- Brennan DC, "A randomized, double-blinded comparison of thymoglobulin versus Atgam for induction immunosuppressive therapy in adult renal transplant recipients", Transplantation, 67, pp.1011~1018 (1999)
- Levey AS, "A new equation to estimate glomerular filtration rate", Ann Intern Med, 150, pp.604~612 (2009)
- Ljungman P, "Definitions of cytomegalovirus infection and disease in transplant recipients", Clin Infect Dis, 34, pp.1094~1097 (2002)
- Turgeon N, "Effect of oral acyclovir or ganciclovir therapy after preemptive intravenous ganciclovir therapy to prevent cytomegalovirus disease in cytomegalovirus seropositive renal and liver transplant recipients receiving antilymphocyte antibody therapy", Transplantation, 66, pp.1780~1786 (1998)
- Hibberd PL, "Preemptive ganciclovir therapy to prevent cytomegalovirus disease in cytomegalovirus antibody-positive renal transplant recipients : a randomized controlled trial", Ann Intern Med, 123, pp.18~26 (1995)
- Kotton CN, "Updated international consensus guidelines on the management of cytomegalovirus in solid-organ transplantation", Transplantation, 96, pp.333~360 (2013)
- Ormrod D, "Valaciclovir : a review of its long term utility in the management of genital herpes simplex virus and cytomegalovirus infections", Drugs, 59, pp.839~863 (2000)
- Sagedal S, "The impact of cytomegalovirus infection and disease on rejection episodes in renal allograft recipients", Am J Transplant, 2, pp.850~856 (2002)
- Ciancio G, "Randomized trial of dual antibody induction therapy with steroid avoidance in renal transplantation", Transplantation, 92, pp.1348~1357 (2011)
- Kuypers DR, "Secondary effects of immunosuppressive drugs after simultaneous pancreas-kidney transplantation", Nephrol Dial Transplant, (20 Suppl 2), pp.ii33~ii39 (2005)
- Zafrani L, "Incidence, risk factors and clinical consequences of neutropenia following kidney transplantation : a retrospective study", Am J Transplant, 9, pp.1816~1825 (2009)
- Lowance D, "Valacyclovir for the prevention of cytomegalovirus disease after renal transplantation. International Valacyclovir Cytomegalovirus Prophylaxis Transplantation Study Group", N Engl J Med, 340, pp.1462~1470 (1999)
- Grafals M, "Immunophenotyping and efficacy of low dose ATG in non-sensitized kidney recipients undergoing early steroid withdrawal : a randomized pilot study", PLoS One, 9, pp.e104408~ (2014)
- Marfo K, "Clinical and economic analysis of short-course versus standard-course antithymocyte globulin(rabbit)induction therapy in deceased-donor renal transplant recipients", Am J Health Syst Pharm, 68, pp.2276~2282 (2011)
- Kute VB, "Post-renal transplant cytomegalovirus infection : study of risk factors", Transplant Proc, 44, pp.706~709 (2012)