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Prevention of active cytomegalovirus infection and disease in kidney transplant recipients

Carlos AQ Santos, MD, MPHS
Daniel C Brennan, MD, FACP
Section Editors
Barbara Murphy, MB, BAO, BCh, FRCPI
Kieren A Marr, MD
Deputy Editors
Albert Q Lam, MD
Sheila Bond, MD


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 [1]. 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.

This topic reviews the risk factors, clinical significance, and prevention of CMV infection among kidney transplant recipients. The management of active CMV infection and disease in transplant recipients is discussed elsewhere. (See "Clinical manifestations, diagnosis, and management of cytomegalovirus disease in kidney transplant recipients".)

The diagnosis of CMV infection and the epidemiology, clinical manifestations, and treatment of CMV infection immunocompetent adults are also discussed elsewhere. (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 CMV infection or CMV disease [1,4,5].

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Literature review current through: Nov 2017. | This topic last updated: Oct 18, 2017.
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  1. Razonable RR, Humar A, AST Infectious Diseases Community of Practice. Cytomegalovirus in solid organ transplantation. Am J Transplant 2013; 13 Suppl 4:93.
  2. Arthurs SK, Eid AJ, Pedersen RA, et al. Delayed-onset primary cytomegalovirus disease and the risk of allograft failure and mortality after kidney transplantation. Clin Infect Dis 2008; 46:840.
  3. Santos CA, Brennan DC, Fraser VJ, Olsen MA. Delayed-onset cytomegalovirus disease coded during hospital readmission after kidney transplantation. Transplantation 2014; 98:187.
  4. Santos CA, Brennan DC, Olsen MA. Accuracy of Inpatient International Classification of Diseases, Ninth Revision, Clinical Modification Coding for Cytomegalovirus After Kidney Transplantation. Transplant Proc 2015; 47:1772.
  5. Kotton CN, Kumar D, Caliendo AM, et al. Updated international consensus guidelines on the management of cytomegalovirus in solid-organ transplantation. Transplantation 2013; 96:333.
  6. Abbott KC, Hypolite IO, Viola R, et al. Hospitalizations for cytomegalovirus disease after renal transplantation in the United States. Ann Epidemiol 2002; 12:402.
  7. Kumar D, Chernenko S, Moussa G, et al. Cell-mediated immunity to predict cytomegalovirus disease in high-risk solid organ transplant recipients. Am J Transplant 2009; 9:1214.
  8. Hartmann A, Sagedal S, Hjelmesaeth J. The natural course of cytomegalovirus infection and disease in renal transplant recipients. Transplantation 2006; 82:S15.
  9. Harvala H, Stewart C, Muller K, et al. High risk of cytomegalovirus infection following solid organ transplantation despite prophylactic therapy. J Med Virol 2013; 85:893.
  10. Khoury JA, Storch GA, Bohl DL, et al. Prophylactic versus preemptive oral valganciclovir for the management of cytomegalovirus infection in adult renal transplant recipients. Am J Transplant 2006; 6:2134.
  11. Luan FL, Samaniego M, Kommareddi M, et al. Choice of induction regimens on the risk of cytomegalovirus infection in donor-positive and recipient-negative kidney transplant recipients. Transpl Infect Dis 2010; 12:473.
  12. Sarmiento JM, Dockrell DH, Schwab TR, et al. Mycophenolate mofetil increases cytomegalovirus invasive organ disease in renal transplant patients. Clin Transplant 2000; 14:136.
  13. Eid AJ, Razonable RR. New developments in the management of cytomegalovirus infection after solid organ transplantation. Drugs 2010; 70:965.
  14. Hibberd PL, Tolkoff-Rubin NE, Conti D, et al. Preemptive ganciclovir therapy to prevent cytomegalovirus disease in cytomegalovirus antibody-positive renal transplant recipients. A randomized controlled trial. Ann Intern Med 1995; 123:18.
  15. Conti DJ, Freed BM, Singh TP, et al. Preemptive ganciclovir therapy in cytomegalovirus-seropositive renal transplants recipients. Arch Surg 1995; 130:1217.
  16. Schachtner T, Zaks M, Otto NM, et al. Simultaneous pancreas/kidney transplant recipients are predisposed to tissue-invasive cytomegalovirus disease and concomitant infectious complications. Transpl Infect Dis 2017; 19.
  17. Sagedal S, Nordal KP, Hartmann A, et al. The impact of cytomegalovirus infection and disease on rejection episodes in renal allograft recipients. Am J Transplant 2002; 2:850.
  18. Sagedal S, Hartmann A, Nordal KP, et al. Impact of early cytomegalovirus infection and disease on long-term recipient and kidney graft survival. Kidney Int 2004; 66:329.
  19. Hakimi Z, Aballéa S, Ferchichi S, et al. Burden of cytomegalovirus disease in solid organ transplant recipients: a national matched cohort study in an inpatient setting. Transpl Infect Dis 2017; 19.
  20. Birk PE, Chavers BM. Does cytomegalovirus cause glomerular injury in renal allograft recipients? J Am Soc Nephrol 1997; 8:1801.
  21. Vichot AA, Formica RN Jr, Moeckel GW. Cytomegalovirus glomerulopathy and cytomegalovirus interstitial nephritis on sequential transplant kidney biopsies. Am J Kidney Dis 2014; 63:536.
  22. Liapis H, Storch GA, Hill DA, et al. CMV infection of the renal allograft is much more common than the pathology indicates: a retrospective analysis of qualitative and quantitative buffy coat CMV-PCR, renal biopsy pathology and tissue CMV-PCR. Nephrol Dial Transplant 2003; 18:397.
  23. Borchers AT, Perez R, Kaysen G, et al. Role of cytomegalovirus infection in allograft rejection: a review of possible mechanisms. Transpl Immunol 1999; 7:75.
  24. Reischig T, Jindra P, Hes O, et al. Valacyclovir prophylaxis versus preemptive valganciclovir therapy to prevent cytomegalovirus disease after renal transplantation. Am J Transplant 2008; 8:69.
  25. Hodson EM, Jones CA, Webster AC, et al. Antiviral medications to prevent cytomegalovirus disease and early death in recipients of solid-organ transplants: a systematic review of randomised controlled trials. Lancet 2005; 365:2105.
  26. Strippoli GF, Hodson EM, Jones C, Craig JC. Preemptive treatment for cytomegalovirus viremia to prevent cytomegalovirus disease in solid organ transplant recipients. Transplantation 2006; 81:139.
  27. Kalil AC, Levitsky J, Lyden E, et al. Meta-analysis: the efficacy of strategies to prevent organ disease by cytomegalovirus in solid organ transplant recipients. Ann Intern Med 2005; 143:870.
  28. Brennan DC, Garlock KA, Singer GG, et al. Prophylactic oral ganciclovir compared with deferred therapy for control of cytomegalovirus in renal transplant recipients. Transplantation 1997; 64:1843.
  29. Lowance D, Neumayer HH, Legendre CM, et al. Valacyclovir for the prevention of cytomegalovirus disease after renal transplantation. International Valacyclovir Cytomegalovirus Prophylaxis Transplantation Study Group. N Engl J Med 1999; 340:1462.
  30. Paya C, Humar A, Dominguez E, et al. Efficacy and safety of valganciclovir vs. oral ganciclovir for prevention of cytomegalovirus disease in solid organ transplant recipients. Am J Transplant 2004; 4:611.
  31. Humar A, Lebranchu Y, Vincenti F, et al. The efficacy and safety of 200 days valganciclovir cytomegalovirus prophylaxis in high-risk kidney transplant recipients. Am J Transplant 2010; 10:1228.
  32. Kliem V, Fricke L, Wollbrink T, et al. Improvement in long-term renal graft survival due to CMV prophylaxis with oral ganciclovir: results of a randomized clinical trial. Am J Transplant 2008; 8:975.
  33. Witzke O, Hauser IA, Bartels M, et al. Valganciclovir prophylaxis versus preemptive therapy in cytomegalovirus-positive renal allograft recipients: 1-year results of a randomized clinical trial. Transplantation 2012; 93:61.
  34. Jung C, Engelmann E, Borner K, Offermann G. Preemptive oral ganciclovir therapy versus prophylaxis to prevent symptomatic cytomegalovirus infection after kidney transplantation. Transplant Proc 2001; 33:3621.
  35. Singh N, Yu VL, Mieles L, et al. High-dose acyclovir compared with short-course preemptive ganciclovir therapy to prevent cytomegalovirus disease in liver transplant recipients. A randomized trial. Ann Intern Med 1994; 120:375.
  36. Zhang LF, Wang YT, Tian JH, et al. Preemptive versus prophylactic protocol to prevent cytomegalovirus infection after renal transplantation: a meta-analysis and systematic review of randomized controlled trials. Transpl Infect Dis 2011; 13:622.
  37. Zuckerman RA, Limaye AP. Varicella zoster virus (VZV) and herpes simplex virus (HSV) in solid organ transplant patients. Am J Transplant 2013; 13 Suppl 3:55.