Reciprocal Relationship Between Cytomegalovirus Infection and Graft Rejection in Intestinal/Multivisceral Transplantation: Impact on Survival and Ideal Immunosuppression Protocol
Transplant Surgery, Indiana University School of Medicine, Indianapolis, IN.
Meeting: 2015 American Transplant Congress
Abstract number: 413
Keywords: Antilymphocyte antibodies, Ganciclovir, Graft survival, Risk factors
Session Information
Session Name: Concurrent Session: Small Bowel Transplantation
Session Type: Concurrent Session
Date: Tuesday, May 5, 2015
Session Time: 2:15pm-3:45pm
Presentation Time: 2:27pm-2:39pm
Location: Room 117
Background: Cytomegalovius (CMV) infection and graft rejection are opposing complications of isolated intestinal/multivisceral transplantation (IIT/MVT), a procedure requiring precise balance of immunosuppression. The aim of this study is to evaluate the occurrence of CMV infection and rejection, to investigate their association and impact on survival, and to assess our induction immunosuppression protocol.
Methods: Medical records of 210 IIT/MVT patients transplanted between 2003 and 2014 were evaluated. Occurrence of CMV infection and rejection was reviewed. Induction immunosuppression consisted of rituximab and rabbit anti-thymocyte globulin (RATG) ranging from 6 to 10 mg/kg. All detectable CMV PCR values were considered to be CMV viremia. Incidence and onset of CMV infection, including viremia and/or tissue invasive disease, was assessed. Pathologically proven moderate or severe rejection was evaluated. Cox regression model with CMV infection and rejection as time dependent covariates was used for the evaluation of impact on survival.
Results: CMV infection occurred in 34 of 210 (16%) with median onset of 347 days and rejection occurred in 71 of 210 (34%) with median onset of 158 days. Eighteen had both episodes, of whom 14 had rejection followed by CMV infection and in four, the opposite. Incidence of CMV infection and rejection were significantly associated with each other (P=0.01, odds ratio=2.61). The adverse impact on patient and graft survival was significant for both CMV infection (p = 0.001, hazard ratio = 2.71 and p = 0.007, hazard ratio = 2.29) and rejection (p < 0.001, hazard ratio = 3.63 and p < 0.001, hazard ratio = 4.73). The dose of RATG induction showed a protective effect on patient survival in a continuous manner (P=0.005, HR=0.88 per mg/kg). Induction with higher doses of RATG (≥10mg/kg) tended to lower CMV infection incidence (p = 0.06, hazard ratio = 0.26 [Ref. <6mg/kg]), but was not associated with rejection.
Conclusion: CMV infection and rejection are associated, but each is also an independent prognostic factor in IIT/MVT. While further investigation is required, the use of higher doses of RATG induction may be the first part of the equation resulting in a favorable balance of immunosuppression and infection.
To cite this abstract in AMA style:
Nagai S, Mangus R, Anderson E, Doan K, Ekser B, Kubal C, Fridell J, Tector A. Reciprocal Relationship Between Cytomegalovirus Infection and Graft Rejection in Intestinal/Multivisceral Transplantation: Impact on Survival and Ideal Immunosuppression Protocol [abstract]. Am J Transplant. 2015; 15 (suppl 3). https://atcmeetingabstracts.com/abstract/reciprocal-relationship-between-cytomegalovirus-infection-and-graft-rejection-in-intestinalmultivisceral-transplantation-impact-on-survival-and-ideal-immunosuppression-protocol/. Accessed May 17, 2025.« Back to 2015 American Transplant Congress