Clinical manifestations, diagnosis, and management of cytomegalovirus disease in kidney transplant recipients
- Carlos AQ Santos, MD, MPHS
Carlos AQ Santos, MD, MPHS
- Assistant Professor of Medicine
- Rush University Medical Center
- John Vella, MD, FACP, FRCP, FASN
John Vella, MD, FACP, FRCP, FASN
- Associate Professor of Medicine
- Tufts University School of Medicine
- Daniel C Brennan, MD, FACP
Daniel C Brennan, MD, FACP
- Editor-in-Chief — Nephrology
- Section Editor — Renal Transplantation
- Professor of Medicine
- Washington University School of Medicine
- Section Editors
- Barbara Murphy, MB, BAO, BCh, FRCPI
Barbara Murphy, MB, BAO, BCh, FRCPI
- Section Editor — Renal Transplantation
- Professor of Medicine
- Mount Sinai School of Medicine
- Kieren A Marr, MD
Kieren A Marr, MD
- Section Editor — Compromised Host Infections; Fungal Infections
- Professor of Medicine and Oncology
- Johns Hopkins University School of Medicine
Cytomegalovirus (CMV) is a globally widespread virus that becomes latent following primary infection but reactivates frequently and, in the setting of immunocompromise, causes disease in solid organ transplant patients, including kidney transplant recipients . After kidney transplantation, active CMV infection and disease are associated with increased risk of allograft failure and death; thus, CMV prevention strategies are commonly used in such patients. Preventive therapy decreases reactivation in the setting of latent infection in the transplant recipient and/or acquisition of acute infection in CMV-seronegative recipients of seropositive grafts. However, CMV disease may still occur despite preventive therapies, especially when they are not dosed adequately [2,3]. It also occurs following discontinuation of preventive therapy.
The epidemiology, clinical manifestations, diagnosis, and treatment of CMV disease in kidney transplant recipients are reviewed here. The approach to the prevention of CMV infection in transplant recipients is discussed elsewhere. (See "Prevention of active cytomegalovirus infection and disease in kidney transplant recipients".)
The diagnosis of CMV infection and the epidemiology, clinical manifestations, and treatment of CMV infection and disease in immunocompetent adults are also presented separately. (See "Overview of diagnostic tests for cytomegalovirus infection" and "Approach to the diagnosis of cytomegalovirus infection" and "Epidemiology, clinical manifestations, and treatment of cytomegalovirus infection in immunocompetent adults".)
Like other members of the Herpesvirus family, CMV establishes latent infection after the resolution of acute (or primary) infection. Patients who are CMV seropositive have latent infection. Secondary, symptomatic disease may present later, reflecting either reactivation of latent CMV or, less commonly, reinfection with a novel exogenous strain. The risk of CMV reactivation is highest in the setting of systemic immunosuppression.
CMV can present in kidney transplant recipients as either active CMV infection or CMV disease [1,4,5]:
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- CLINICAL MANIFESTATIONS
- Active CMV infection
- CMV disease
- - Reduction of immunosuppression
- - Antiviral therapy
- Initial therapy
- Duration of therapy
- Adverse effects
- Laboratory monitoring for treatment response
- Resistance testing
- Drug-resistant CMV
- SUMMARY AND RECOMMENDATIONS