Ask the Experts - CMV in Living-Donor Kidney Candidate?
The initial cytomegalovirus (CMV) serology for a living-donor kidney allograft candidate was negative. Six months later, he became CMV immunoglobulin M (IgM) positive. Although he never developed symptoms of CMV disease, his IgM serology has remained persistently positive for the last 2 years. His donor is CMV negative. Would you proceed with this patient for transplantation? If so, would you consider CMV prophylaxis necessary in this case?

Ronaldo M. Esmeraldo, MD

The question here is: what is the risk of developing CMV disease in a CMV seropositive recipient, after the addition of exogenous immunosuppression? It is unclear to me why this patient has remained persistently IgM positive for 2 years. Serologic status remains an insensitive means of following immunosuppressed patients for CMV disease. CMV disease, as opposed to infection, is defined as fever, neutropenia, and 1 or more of the following: (1) biopsy evidence of tissue invasive disease, (2) a positive CMV rapid antigen test, shell vial assay, or body fluid polymerase chain reaction test, (3) a positive fluid or tissue culture, and/or (4) some "-it is" (eg, hepatitis, retinitis, gastroenteritis). If your patient has persistent CMV disease, as defined above, then it needs to be treated first and the transplant should be delayed. If your patient is simply infected, the virus remains latent and the relative risk of reactivation after exogenous immunosuppression is roughly 2-5 times that of a donor negative-recipient negative combination. So, in answer to your question, if your patient is asymptomatic, I would use standard prophylaxis with perioperative intravenous ganciclovir, followed by oral ganciclovir for at least 12 weeks posttransplantation, especially if induction immunotherapy is used in this patient.