Background:

There is little information on the incidence, risk factors and outcomes associated with cytomegalovirus (CMV) and BK infections in sensitized patients

Methods:

We examined 254 kidney transplant recipients with positive DSA and negative flow crossmatch .We defined the primary endpoint as the incidence of CMV or BK infection or nephropathy (BKVN).

Results:

Mean age at time of transplant was 49; 60% were male, number of kidney transplant varied from one to five, with 77 (30.3%) multiple transplant recipients. Mean follow up was 42.6±14 months. Mean three-month eGFR was 55.1 ± 19.5, while mean eGFR at last follow-up (42.5 months) was 54.2 ±22.6 ml/min.

There were total of 110 cases of BK or CMV infection (43%). Four patients (1.5%) had both infections. Specifically, there were 79 (31.1%) patients with BK infection, 19 (7.5%) with BKVN and 31 (12.2%) with CMV infection. At the time of diagnosis, mean serum BK and CMV PCR levels were 121,001±94,246 and 519,926±1,431,740 copies/mL, respectively. One patient had CMV colitis. Mean time to diagnosis for BK and CMV was 4.5±3.4 and 9.1±5.49 months respectively. There were 25 (9.8%) deaths and 36 (14.2%) graft losses.

In Cox regression analyses the following were associated with increased incidence of BK or CMV infection: African American race (HR 2.64, 95%CI 1.3774 to 5.0719, p=0.003), Thymoglobulin (HR 2.18, 95%CI 1.3863 to 3.4310, p=0.0008), DSA at transplant > 500 MFI (HR 1.64, 95%CI, 1.0504 to 2.57, p=0.03) and history of diabetes (HR 1.62, 95%CI, 1.0092 to 2.6, p=0.04). The following were associated with reduced risk of BK or CMV infection: Rituximab (HR 0.47, 95%CI 0.2421 to 0.9197, p=0.02), peak PRA > 80% (HR 0.48, 95%CI 0.2747 to 0.8404, p=0.01), live donor transplant (HR 0.57, 95%CI, 0.3622 to 0.8764, p=0.01). Out of these 7 variables, stepwise multiple regression analyses only retained Thymoglobulin induction (HR 2.76, 95%CI 1.7154 to 4.4435, p<0.0001) and peak PRA > 80% (HR 0.36, 95%CI 0.2033 to 0.6479, p=0.0006) as significant predictors of infection.

Conclusion:

We found the incidence of CMV and BK infections were higher in immunological high risk patients who received thymoglobulin, however, highly sensitized patients were less likely to develop these infections. Close monitoring for these infections are essential.

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