C KHOR1, K KEUNG2,3, P SHANMUGASUNDARAM3
1East Coast Renal Network, Sydney, Australia, 2Prince of Wales Hospital, Randwick, Australia, 3St George Hospital , Kogarah, Australia
Background: The prediction of cytomegalovirus (CMV) disease in solid organ transplant recipients would be of significant clinical benefit. Emerging literature supports the use of CMV interferon gamma release assay (CMV-IGRA) to identify those at increased risk of CMV disease post-transplant who may benefit from prolonged valganciclovir prophylaxis.
Case report: A 65-year old female with end stage kidney disease secondary to AL Amyloidosis received a deceased donor renal transplant in July 2018. She received standard induction with Basiliximab and maintenance therapy of prednisone, tacrolimus and mycophenolate mofetil. She was CMV seronegative and the donor CMV seropositive at the time of transplant. Despite receiving six months of prophylactic valganciclovir without interruption, she developed CMV disease with CMV viraemia, fevers and fatigue nine months post-transplant. Despite a reduction in immunosuppression doses, conversion to CMV IgG seropositive status and adherence to international guidelines to treat until two consecutive negative CMV DNA measurements, she developed rebound viraemia within a week of valganciclovir cessation. After a treatment period she received prophylactic valganciclovir for a further 3 months but CMV viraemia recurred within a month of valganciclovir cessation. Commercially available CMV-IGRA was performed with an indeterminate result. Emerging literature suggests patients with an indeterminate result have the highest risk of developing CMV disease, followed by patients with a negative result. A positive CMV-IGRA is associated with the lowest risk. Mycophenolate was subsequently ceased, tacrolimus and prednisone were continued, and in the absence of valganciclovir prophylaxis she has not developed CMV viraemia in the last three months.
Conclusion: CMV-IGRA assay can identify those at high risk of CMV disease post-transplant who may require immunosuppression alteration rather than an extended period of valganciclovir prophylaxis.
Candice Khor is currently a renal advanced trainee in the East Coast Renal Network in New South Wales