CMV Discordance in Elderly Kidney Transplant Recipients

Previous studies have linked high-risk CMV (cytolmegavirus) discordance (R-/D+) with adverse outcomes following kidney transplantation. Due to severe immunosenescence, elderly transplant recipients are at increased risk for CMV infections. A. Dinesh and colleagues conducted a retrospective analysis to examine survival outcomes in kidney transplant recipients ≥60 years of age by CMV concordance status.

Results of the analysis were reported during a virtual session at the 2021 American Transplant Congress. The presentation was titled Does High-Risk CMV Discordance Affect Elderly Kidney Transplant Recipient Survival? A Multivariable Analysis.

The review included all primary kidney transplant recipients ≥60 years of age at the University of Minnesota, Minneapolis, from 2008 to 2019. The center uses thymoglobulin (r-ATG) as induction with early steroid withdrawal followed by calcineurin inhibitor (CNI) plus mycophenolate mofetil (MMF) maintenance. Typically, patients receive CMV prophylaxis with valganciclovir for 90 days for recipients with low-risk (CMV immunoglobulin G [IgG] R+/D+, R+/D-, or R-/D-) status and 180 days for recipients with high-risk (CMV IgG R-/D+) status.

The researchers stratified the study population into two groups: clinically high risk (CMV IgG R-/D+) status recipients (n=85) and low-risk (CMV IgG R+/D+. R+/D-, or R-/D-) status recipients (n=376). Recipient survival, death-censored graft survival, and CMV-infection-free survival with follow-up censored at 5 years were assessed using Kaplan-Meier curves. Multivariable Cox proportional hazards model adjusted for age, sex, race, body mass index, maintenance immunosuppression, donor type, and donor age were used to examine the effect of CMV high-risk status on the outcomes of interest. Due to severe proportional hazard violations, CMV-free survival was not modeled.

There was no difference observed in patient survival or death-censored graft survival between the two groups in univariate analysis (log-rank, P=.372 and log-rank. P=.844, respectively). CMV-survival was significantly lower in the high-risk group (log-rank, P<.001). At 2 years from engraftment, the cumulative incidence of CMV infection in the high-risk group was 42% compared with 21% in the low-risk group. In the multivariable model, CMV status was not a predictor of patient survival (hazard ratio [HR], 1.10; 95% confidence interval [CI], 0.54-2.23; P=.80) or graft survival (HR, 0.90; 95% CI, 0.28-2.86; P=.86).

In conclusion, the researchers said, “In primary kidney transplant recipients ≤60 of age receiving r-ATG induction immunosuppression followed by CNI plus MMF maintenance with early steroid withdrawal, the incidence of post-transplant CMV viremia is significantly higher in the high-risk CMV discordant recipients. However, we did not detect an association between CMV discordance and patient or graft survival.”

Source: Dinesh A, Jackson S, Riad S, Pruett T. L. Does high-risk CMV discordance affect elderly kidney transplant recipient survival? A multivariable analysis. Abstract of a presentation at the virtual 2021 American Transplant Congress (Abstract #784), June 5, 2021.