Based on last international guidelines, both universal prophylaxis and preemptive strategies are viable approaches for the prevention of cytomegalovirus (CMV) disease after organ transplantation. Universal prophylaxis is used in most of the centers but leads to higher incidence of late-onset CMV disease (l-od), which has been associated with poor patient and graft survival in kidney transplant recipients (KTR). The purpose of this retrospective study was to reappraise the impact of l-od in KTR with the highest risk for CMV infection, i.e. CMV seronegative recipients transplanted with a seropositive donor (D+R-). CMV DNAemia was measured using a whole blood CMV quantitative nucleic acid amplification assay. CMV disease was defined as CMV DNAemia with viral syndrome or tissue invasive disease. Early-onset disease (e-od) was defined as occurring before 3 months and l-od after 3 months post-transplantation. Recurrence was defined as a new CMV DNAemia with clinical symptoms, after a successfully treated disease. According to the period, either universal prophylaxis for 3 to 6 months or preemptive treatment was used for CMV prevention. 168 D+R- KTR were included between 2003 and 2011, 40 with l-od, 36 with e-od and 92 without disease. 87.5% of l-od occurred after universal prophylaxis whereas 89% of e-od occurred after preemptive strategy (χ2 ; p<0.0001). Compared to patients with e-od, patients with l-od had significantly less recurrences (Odd Ratio=0.2; 95 % CI=0.08-0.5; p=0.001). Furthermore, when we compared the outcomes at three year post-transplantation of KTR with respectively l-od, e-od and no disease, the incidence of biopsy-proven acute rejection (30% vs. 18% vs. 25%, p=0.6), graft survival (90% vs. 82% vs. 93%, p=0.2) and patient survival (95% vs. 100% vs. 100%, p=0.06) were not significantly different. In D+R- KTR, universal prophylaxis is associated with late-onset disease that has better infection outcomes, and has no detrimental effect on graft and patient outcomes at three year post transplantation. These results support the use of a universal prophylaxis over a preemptive strategy in D+R- KTR.

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