Risk Factors for Posttransplant Lymphoproliferative Disorder in Pediatric Liver Transplant Recipients With Cytomegalovirus Antigenemia

Epstein-Barr virus (EBV) infections, associated with posttransplant lymphoproliferative disorder (PTLD) are known to develop in cytomegalovirus (CMV)-infected transplant recipients due to the indirect effects of CMV. This study evaluated risk factors for PTLD among pediatric liver transplant recipients with CMV infections. We reviewed the medical records of 119 patients ≤18 years old who underwent liver transplantation between September 1996 and April 2009. Sixty-six subjects (55.5%) displayed CMV antigenemia during the study period; 15 (12.6%) developed PTLD. Of these, 10 developed PTLD after CMV antigenemia. The other patients (n = 5) were excluded due to negative CMV antigenemia. The incidence of PTLD influenced by CMV infection was not significantly different from the incidence of PTLD without underlying CMV (P = .258). There were no differences in age, gender, antiviral prophylaxis, type of liver transplantation, or acute rejection episodes in the incidence of between patients with versus without PTLD. EBV but not CMV high-risk groups were a predictor for the development of PTLD (P = .035). CMV syndrome, tissue-invasive CMV disease, and CMV peak titer were not associated with an increased risk of PTLD. The primary risk factor for PTLD was EBV high-risk patients (donor positive/recipient negative). CMV disease was not associated with PTLD in pediatric liver transplant recipients with CMV infections.     

Incidence and Risk Factors for Cytomegalovirus Disease in a Colombian Cohort of Kidney Transplant Recipients

Incidence and risk factors for cytomegalovirus (CMV) disease in a Colombian cohort of kidney transplant recipients. CMV infection and disease are important causes of morbidity and mortality in kidney transplant recipients, and its prevalence varies with economic, geographic, and ethnic factors. Among 1620 records from a Colombian reference center, CMV immunoglobulin (Ig)G seroprevalence was found to be 90.9% among recipients and 90.2% among donors. In 86% (n = 264) of the cases, CMV disease occurred during the first 6 months after the transplantation, and the most frequent clinical presentation was CMV syndrome, followed by gastrointestinal disease. The following parameters were independent predictors of CMV disease: serological status of D+/R+ (hazard ratio [HR], 1.64; 95% confidence interval [CI], 1.03–2.63) and D+/R− (HR, 2.72; 95% CI, 1.49–4.93), age of the recipient (HR, 1.02; 95% CI, 1.01–1.03), and receiving more than 30 mg of prednisolone by the end of the first month after transplantation (HR, 1.59; 95% CI, 1.22–2.07). Acyclovir prophylaxis or other antiviral agents significantly decreased the risk of disease (HR, 0.41; 95% CI, 0.29–0.58 and HR, 0.34; 95% CI, 0.20–0.58, respectively). In conclusion, we found a high prevalence of CMV infection in a cohort of Latin American transplant recipients. In accord with findings from other regions, serological status is the main risk factor, prophylaxis with acyclovir is effective, and induction with alemtuzumab does not increase the risk of CMV disease.     

Cytomegalovirus Infection Renal Transplant Recipients: Risk Factors and Outcome

Objective

Cytomegalovirus (CMV) is the most common viral infection after allotransplantation; it can be a major cause of morbidity and mortality. Our aim was to analyze the main risk factors that lead to development of CMV infection and disease.

Patients and Methods

We retrospectively analyzed 207 patients who received a renal allograft from May 2003 to December 2007. Three patients (D−/R−) were excluded. CMV infection was defined by the detection of 2 or more positive tests for pp65 antigenemia and CMV disease by evidence of attributable symptoms in need of antiviral treatment.

Results

Thirty-two patients (15.7%) presented active CMV infections and another 35 (17.2%), CMV disease. The mean follow-up was 27.8 ± 17 months. Prior to transplantation, 9.2% of patients were seronegative (D+/R−) and 77.9% seropositive (D+/R+). Compared with noninfected patients, those with CMV infection/disease were older and received an allograft from an older donor. Upon logistic regression analysis, recipient age older than 55 years, induction therapy with Thymoglobulin, and maintenance immunosuppression with cyclosporine were the major risk factors to develop CMV disease. An early acute rejection episode was more frequent and renal function measured by serum creatinine poorer until 18 months posttransplantation among CMV-infected versus noninfected patients.

Conclusions

Our data showed that CMV infection is a common complication after kidney transplantation associated with older age, induction treatment with antilymphocyte globulin, worse renal function, and increased patient morbidity.     

Risk Factors for Mortality in Liver Transplant Recipients With ESKAPE Infection

BackgroundAlthough infections caused by the pathogens Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter spp (ESKAPE) have recently been identified as serious emerging problems in solid organ transplant, no information in liver transplant (LT) recipients is available. We sought to investigate the risk factors for associated mortality in LT recipients with ESKAPE infections.MethodsA retrospective analysis of infection after LT was reviewed. Risk factors for mortality caused by ESKAPE infection were identified.ResultsFifty-three episodes of infections caused by ESKAPE were documented in 51 LT recipients. The main sites of infection were the bloodstream (49.0%), the lungs (33.3%), and the intra-abdominal/biliary tract (17.6%). The risk factors for mortality independently associated with ESKAPE infection were female sex (odds ratio [OR] = 6.6, 95% confidence interval [CI] = 1.1–40.8, P = .042), septic shock (OR = 30.1, 95% CI = 3.7–244.8, P = .001), and lymphocyte counts <300/mm³ (OR = 20.2, 95% CI = 2.9–142.2, P = .003).ConclusionsTo improve the results of LT, more effective therapeutic treatments are of paramount importance when female LT recipients with ESKAPE infection present with septic shock and decreased lymphocyte counts.     

Association of Cytomegalovirus Infection and Disease With Death and Graft Loss After Liver Transplant in High‐Risk Recipients

In the era of effective antiviral chemoprophylaxis, cytomegalovirus (CMV) disease has been inconsistently associated with increased mortality in liver transplant (LT) recipients. A retrospective study evaluating the association of CMV infection and disease occurring within 1 year of transplant with the endpoints of death or the combined endpoint of graft loss or death was undertaken in a cohort of 227 CMV donor seropositive, recipient seronegative first LT recipients. Associations were evaluated using Cox proportional hazards regression models. CMV infection and disease occurred in 91 (40%) and 43 (19%) patients, respectively. Forty‐eight (21%) died while 58 (26%) sustained graft loss or death. In multivariable analysis, CMV infection was associated with an increased risk of death (RR: 2.24, p = 0.008) and graft loss or death (RR: 2.85, p < 0.001). CMV disease was also associated with an increased risk of death (RR: 2.73, p = 0.003) and graft loss or death (RR: 3.04, p = 0.001). CMV infection and disease occurring within the first year after LT in high‐risk recipients is associated with increased risk of death and of graft loss or death. Investigation of strategies to further reduce the risk of CMV infection and disease in high‐risk LT recipients is warranted.     

Cytomegalovirus Status of Kidney Transplant Recipients and Cardiovascular Risk

Background

Cytomegalovirus (CMV) infection is associated with an increased risk of cardiac complications in kidney transplant recipients (KTRs). Some data suggest that CMV may be involved in atherogenesis. The aim of the study was the analysis of CMV medical history in KTRs and its influence on cardiovascular (CV) incidents.

Preemptive Therapy for Cytomegalovirus Disease in Allogeneic Stem Cell Transplant Recipients

Cytomegalovirus (CMV) infection causes high morbidity and mortality among allogeneic stem cell transplant recipients. Preemptive therapy with oral valganciclovir or intravenous ganciclovir has replaced universal prophylaxis. We prospectively studied 19 consecutive adult recipients of allogeneic peripheral blood stem cell transplants from May 2005 through February 2007 to analyze the safety and efficacy of preemptive therapy for the treatment of CMV infection. The antigenemia test was persistently negative in 8 patients (42%) and positive at least once in 11 (58%). Eight patients were treated with oral valganciclovir on an outpatient basis and they all became CMV negative after the first week of treatment. The other 3 patients received intravenous ganciclovir and were also CMV negative after the first week of treatment. No patient abandoned treatment, no severe secondary toxicity was noted, and there was no CMV-associated mortality.     

Clinical Course of Renal Disease in Recipients of Liver Transplant Who Required Peritransplant Dialysis

PurposeRenal dysfunction is a common complication and one of the factors that affects the outcomes of liver transplantation (LT). The aim of this study was to review the clinical course of recipients of LT who needed peritransplant dialysis at our center.MethodsWe compared the clinical demographics, morbidity, and mortality between patients who required and those who did not require peritransplant dialysis among 26 recipients of LT from May 2015 to February 2018 at our center.ResultsAmong the recipients, 9 had pretransplant or posttransplant dialysis and 17 did not. The patients who underwent dialysis had a higher pretransplant Model for End-Stage Liver Disease score (42 vs 13; P < .001), older donor age (41 vs 24 years; P < .001), and longer post-LT hospital stay (37 vs 20 days; P < .001). However, there was no significant difference in the serum creatinine level between the 2 groups (1.36 vs 0.93 mg/dL; P = .187) at 2 weeks (1.10 vs 0.96 mg/dL; P = .341), 1 month (1.06 vs 0.86 mg/dL; P = .105), and 3 months after LT (0.92 vs 0.94 vs 0.89 mg/dL; P = .825). Mortality was higher in the peritransplant dialysis group (P = .043). The pre-LT dialysis duration was significantly related to post-LT dialysis (P = .028) and mortality (P = .011).ConclusionsThe pre-LT dialysis duration is considered an important factor in the survival and recovery of kidney function after LT. Therefore, if the patient has started dialysis, it may be beneficial to proceed to LT as soon as possible.     

Cytomegalovirus Disease in Renal Transplant Recipients: A Single-Center Experience

Cytomegalovirus (CMV) disease is an important complication and an independent risk factor for acute rejection and recipient morbidity-mortality. The aim of this study was to review the results of CMV disease in renal transplant recipients. Method. We have retrospectively analyzed CMV disease in 120 renal transplant recipients and recorded the demographic features, clinical manifestations, and immunosuppressive regimens. Results. Twenty-nine recipients (24.1%) developed CMV disease after a median interval of 2.8 ± 2,6 months from transplantation. CMV disease developed in 36.3% of recipients who received basiliximab as induction therapy and 21.4% of recipients who were treated with anti-thymocyte globulin (ATG). The most commonly used immunosuppressive regimen was cyclosporine-A (CsA)-based (79.3%). The mean cumulative steroid dose until the diagnosis was 3,600 mg methyl prednisolone per patient. Malaise, fever, and diarrhea were the most common symptoms. Gastritis, pneumonia, and transaminitis were the most commonly seen end-organ involvements. Frequent laboratory findings were leukopenia (34.5%), increased serum creatinine level (34.5%), and leukocytosis (20.7%). We performed renal biopsy to seven patients and detected acute rejection in four patients. In 25 patients, immunosuppressive treatment was modified. Relapsing CMV disease was seen in seven patients. Conclusion. In our study, CMV disease was seen in recipients who were treated with basiliximab, a finding similar to recipients who were treated with ATG.     

Posttransplant Lymphoproliferative Disease in Pediatric Liver Transplant Recipients

Posttransplant lymphoproliferative disease was first reported in 1968. Posttransplant lymphoproliferative disease encompasses a range of abnormalities from benign infectious mononucleosis-like illnesses to non-Hodgkin's lymphomas with nodal and extranodal site involvement. We evaluated five children who had posttransplant lymphoproliferative disease after liver transplantation. Since 2001, we have performed 118 liver transplantations in 115 children. Five children (4.6%), including three girls and two boys of overall mean age, 3.9 year, developed posttransplant lymphoproliferative diseases. The indications for liver transplant were hepatoblastoma in one recipient and cholestatic liver disease in the remaining four subjects. Posttransplant lymphoproliferative disease was diagnosed at 6, 11, 17, 22, and 27 months after the liver transplantation. Imaging modalities identified generalized lymphadenopathy in one, multiple liver masses in one, a large portal mass in one, multiple stomach ulcers in one, and a large mediastinal mass in one recipient. At diagnosis, the recipient with the large mediastinal mass displayed cough; the remaining four recipients were asymptomatic. Histological findings showed B-cell lymphomas in three recipients and T-cell lymphomas in two. The results of in situ hybridization for Epstein-Barr virus were negative in one recipient and positive in four. Four recipients were treated with chemotherapy; the remaining recipient was treated with anti-CD20 monoclonal antibodies. The one recipient who had a large mediastinal mass died at 2 months after receiving the diagnosis of chemotherapy-related sepsis; the remaining four children are alive at 9, 11, 18, and 34 months after treatment. Our rate of posttransplant lymphoproliferative disease was similar to that in the literature. From a few months to several years after liver transplantation, radiologists must be alert to the possibility of posttransplant lymphoproliferative disease. Thorough imaging is required to detect the wide variety of potential presentations.     

Infected Bilomas in Liver Transplant Recipients, Incidence, Risk Factors and Implications for Prevention

Bilomas, infected hepatic fluid collections, are a frequent complication of liver transplantation. We report a case-control cohort study to determine the incidence and microbiologic profile of bilomas and risk factors for biloma formation in 492 patients undergoing liver transplantation from 1994 to 2001. Fifty-seven patients (11.5%) developed one or more bilomas; 95% in the first year post-transplantation. The most common initial infecting pathogens were enterococci (37%), one-half resistant to vancomycin (VRE); coagulase-negative staphylococci (26%); and Candida species (26%). Infection by coagulase-negative staphylococci was strongly associated with the presence of a T-tube (OR 9.60, p=0.02). In stepwise logistic regression multivariable analyses, hepatic artery thrombosis (OR 90.9, p<0.0001), hepatic artery stenosis (OR 13.2, p<0.0001) and Roux-en-Y choledochojejunostomy (OR 5.8, p=0.03) were independent risk factors for biloma formation; ursodeoxycholic acid use was highly protective (OR 0.1, p=0.002). Strategies to prevent biloma formation must focus on measures to prevent hepatic artery thrombosis and colonization of liver transplant patients by multiresistant nosocomial pathogens. T-tube drainage post-transplantation bears reassessment. The protective effect of ursodeoxycholic acid found in this study warrants confirmation in a prospective multicenter, randomized trial.     

Risk Factors for Septic Complications in Kidney Transplant Recipients

Introduction

Septic complications following kidney transplantation are a leading cause of therapeutic failure. An early diagnosis may protect the recipient from the severe consequences of sepsis. We sought to determine the risk factors influencing the occurrence of septic complications among kidney transplant recipients.

Materials and methods

The 146 potential donors included in the study were evaluated for brain stem death criteria. Supportive management included mechanical ventilation to normocapnia, rewarming, as well as fluid and electrolyte replacement. Dopamine infusions and desaminovasopressin were titrated to predetermined mean arterial pressure (MAP). Central venous pressure (CVP) was maintained at 8 to 11 mm Hg. Hemodynamic data were acquired by the thermodilution method prior to organ procurement: MAP, CVP, pulmonary capillary wedge pressure (PCWP), and systemic vascular resistance index (SVRI). Recipient data included age, gender, period of prior hemodialysis, panel reactive antibodies, cold ischemia time, and cause of renal insufficiency. The 232 kidney recipients were examined for occurrence of septic complications including septicemia, pneumonia, peritonitis, or graft infection.

Results

Kidney transplants from donors with MAP < 70 mm Hg and SVRI < 1200 dyne × s/cm⁵ × m² showed a significantly higher occurrence of septic complications in recipients (P < .05) where mortality rate was also significantly greater (P < .01).

Conclusions

MAP < 70 mm Hg and SVRI < 1200 dyne × s/cm⁵ × m² among organ donors predicted greater occurrence of septic complications and increased mortality among kidney transplant recipients.     

Survival Benefit in Heart Transplant Recipients Who Have Coronary Artery Disease Confirmed Using Angiography and Are Receiving Sirolimus

Introduction

The aim of this study was to assess efficacy and safety of sirolimus (SIR) in heart transplant recipients to prevent further development of coronary artery disease (TxCAD) already confirmed by using coronary angiography.

Material and Methods

We performed a retrospective case-control study involving all 60 heart transplant recipients receiving SIR in a number of combinations with other immunosuppressive drugs, and 60 matched individuals after heart transplantation treated without SIR. TxCAD was diagnosed using elective coronary angiography in 9 subjects in the study group (8 males and 1 female) of mean age 44 ± 11 years, including ischemic cardiomyopathy in 4 members. The control group of 15 individuals 15 males of mean age 47 ± 7 years, including ischemic cardiomyopathy in 8. We compared time to develop significant TxCAD and death caused by TxCAD, and all-cause deaths. Significance was assessed using log-rank and chi-square tests, when applicable.

Results

Significant TxCAD (critical coronary lesions, myocardial infarction or death) was observed in 5 (56%) patients receiving SIR and 11 (73%) without SIR (P = not significant [NS]). Time to develop significant TxCAD was comparable. There were 2 (22%) deaths in the SIR group and 8 (53%) in the control group (P = NS). Survival time was significantly longer among subjects receiving SIR (P = .02). None of deaths in the study group was caused by TxCAD compared with 6 (40%) deaths among controls (P = .09). Time of freedom from death caused by TxCAD was significantly longer in the study group (P = .023).

Conclusion

SIR prolonged survival in heart transplant recipients with TxCAD confirmed using coronary angiography.     

Incidence,Risk Factors,and Outcomes of Delayed-Onset Cytomegalovirus Disease in a Large,Retrospective Cohort of Heart Transplant Recipients

BackgroundDelayed-onset cytomegalovirus (CMV) disease can occur among heart transplant recipients after stopping anti-CMV prophylaxis. We evaluated a large, retrospective cohort of heart transplant recipients in the United States through the use of billing data from 3 Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SID) to determine the epidemiology of delayed-onset CMV disease coded during hospital readmission.MethodsWe identified 2280 adult heart transplant recipients from 2004 to 2010 through the use of the California, Florida, and New York SID. Demographics, comorbidities, heart failure etiology, CMV disease, and inpatient death were identified. CMV disease was classified as early-onset (≤100 days) or delayed-onset (>100 days after transplant). Possible tissue invasion by CMV was determined through the use of codes for CMV pneumonitis, hepatitis, and gastrointestinal endoscopy. Multivariate analysis was performed with the use of Cox proportional hazards models.ResultsDelayed-onset CMV disease occurred in 7.5% (170/2280) and early-onset CMV disease occurred in 2.0% (45/2280) of heart transplant recipients. Risk factors for delayed-onset CMV disease included residence in a non-metropolitan locale (aHR. 1.8; 95% confidence interval [CI], 1.0–3.3) and ischemic cardiomyopathy as heart failure etiology (aHR, 1.8; 95% CI, 1.3–2.5). Inpatient death >100 days after transplant was associated with delayed-onset CMV disease with possible tissue invasion (aHR, 2.0; 95% CI, 1.1–3.8), transplant failure or rejection (aHR, 4.0; 95% CI, 2.7–5.8), and renal failure (aHR, 1.5; 95% CI, 1.1–2.0).ConclusionsDelayed-onset CMV disease is more common than early-onset CMV disease among heart transplant recipients. These results suggest that delayed-onset tissue-invasive CMV disease may be associated with an increased risk of death.     

Intrauterine Growth Restriction in Pregnant Renal and Liver Transplant Recipients: Risk Factors Assessment

Background

Nowadays pregnancy after organ transplantation is possible due to advances in surgical and immunosuppressive therapies. One of the possible complications in pregnancy after organ transplantation is intrauterine growth restriction (IUGR). This may lead to various adverse perinatal outcomes. Prevalence of IUGR in the general population is estimated at 3%–10% with smoking being the most frequent maternal risk factor. The aim of this study was to determine the risk factors of IUGR in pregnant renal transplant recipients (RTR) or liver transplant recipients (LTR) in comparison with healthy pregnant women.

Methods

Retrospective analysis included 48 RTR and 52 LTR. IUGR was defined as estimated fetal weight less than the 10th percentile for gestational age. IUGR was diagnosed in 15 (31.3%) pregnant RTR and in 10 (19.2%) LTR. The control group consisted of 60 healthy pregnant women diagnosed with IUGR. Fisher exact test and Student t test were used to assess the differences in fractions and means, respectively, between distinguished groups of patients. Test for fractions based on asymptotic normal distribution was used to compare the proportion of patients with IUGR with the proportion of 10% in the general population. The logistic regression model was used to assess the statistical significance of correlations between the assumed risk factors and the prevalence of IUGR in multivariate settings.

Results

Hypertension, anemia, and proteinuria were the most frequent complications in the study group. They were more prominent in RTR than in LTR. Hypertension was diagnosed in all RTR, whereas severe anemia requiring erythropoietin treatment or blood transfusion was found in 4 RTR and in 1 LTR.

Conclusion

IUGR is more common in organ recipients. Therefore, vigilant obstetric care is highly recommended in pregnant patients after renal or liver transplantation. Hypertension, severe anemia, and proteinuria proved not to be statistically significantly correlated with the prevalence of IUGR among patients after transplantation.     

Cytomegalovirus Disease in High-Risk Transplant Recipients Despite Ganciclovir or Valganciclovir Prophylaxis

The clinical patterns and predictors of cytomegalovirus (CMV) disease in kidney and/or pancreas transplant patients on ganciclovir (1.0 g po t.i.d.) or valganciclovir (450 mg po q.d.) prophylaxis were studied. This is a retrospective analysis of 129 transplant recipients. Median follow up was 12 months (range, 6-18 months). The overall incidence of CMV disease at 1-year post-transplant was 14% (4% tissue-invasive, 10% noninvasive). Seventeen of 18 patients were diagnosed with CMV after completion of 3 months' prophylaxis (median 8 weeks, range, 2-28 weeks). Induction treatment with thymoglobulin, and Donor +/Recipient - CMV status were the strongest predictors for the development of CMV disease. Cytomegalovirus incidence was not different between patients treated with ganciclovir or valganciclovir (15 vs. 17%, respectively). Valganciclovir (450 mg q.d.) is as effective as oral ganciclovir in CMV prophylaxis. High-risk individuals might require higher doses or longer duration of valganciclovir treatment.     

Risk Factors of Prolonged ICU Stay in Liver Transplant Recipients in a Single-Center Experience

Background

Prolonged initial intensive care unit (ICU) stay after liver transplantation (LT) is associated with prolonged total hospitalization, increased hospital mortality, and impaired patient and graft survival. Recent data suggested that model for end-stage liver disease (MELD) score at the time of LT and the length of surgery were the two independent risk factors for an ICU stay longer than 3 days after LT. We further identified factors influencing prolonged ICU stay in single-center liver graft recipients.

Early and Delayed Onset Cytomegalovirus Infection of Liver Transplant Recipients in Endemic Areas

Background

The delayed onset of cytomegalovirus (CMV) infection after liver transplantation can place patients at risk for graft failure and mortality.

Methods

We compared early versus delayed onset of CMV infection to identify risk factors for mortality among liver transplant recipients in an endemic area.

Results

Among 710 consecutive adult liver transplant recipients, incidence of CMV infection was 47.5% (337/710). Male gender, biliary complications, acute rejection episodes, antilymphocyte antibodies high hemoglobin, and high total bilirubin were significantly different among patients with delayed versus early onset CMV infections. The overall incidence of early versus delayed CMV infections was 43.1% (306/710) versus 4.4% (31/710). Among them, 11.1% (34/306) and 25.8% (8/31) of patients developed CMV disease.

Conclusion

These results showed that a higher proportion of patients developed disease among delayed CMV infected patients (P = .039). The overall and graft survival curves for patients with early onset CMV infections were better than those of patients who had delayed onset CMV infections (P = .026 and P = .014). Recurrence of hepatitis B virus, hepatic dysfunction, and retransplantation were associated with increased mortality among patients who had a delayed CMV infection.     

Osteoporosis and Related Risk Factors in Renal Transplant Recipients

Decreased bone mineral density is a common problem after kidney transplantation. Osteoporosis has a major role in morbidity in these patients. We evaluated the incidence of osteoporosis and determined risk factors in 77 patients aged 17 to 50 years who had undergone renal transplantation 6 months to 2 years previously. Bone mineral densitometry was performed using dual-energy x-ray absorptiometry. The incidence of osteoporosis was 26% (20 of 77 patients). Mean (SD) age of affected patients was 34.6 (8.7) years. The most common sites of osteoporosis were the hip (osteoporotic in 19 patients [24.7%] and osteopenic in 42 [54.5%]) and the spine (osteoporotic in 6 patients [7.8%] and osteopenic in 52 [67.5%]). There was a significant relationship between posttransplantation creatinine concentration and hip osteoporosis (P = .01). No relationship was observed between osteoporosis and age, sex, body mass index, duration of hemodialysis therapy, cumulative dosage of any drugs, or use of pulsed methylprednisolone therapy. A hip or spine z score of 1 or less had no relationship to the number of steroid pulse sessions but was significantly related to the total dosage of cyclosporine (P < .001), prednisolone (P < .001), and mycophenolate mofetil (P < .05). A hip z score of less than 1 was related to the posttransplantation period (P = .02). In conclusion, osteoporosis is a frequent complication that requires detection and treatment to reduce morbidity.     

Cell-Mediated Immunity to Predict Cytomegalovirus Disease in High-Risk Solid Organ Transplant Recipients

Late-onset cytomegalovirus (CMV) disease commonly occurs after discontinuation of antiviral prophylaxis. We determined the utility of testing CD8+ T-cell response against CMV as a predictor of late-onset CMV disease after a standard course of antiviral prophylaxis. Transplant patients at high-risk for CMV disease were enrolled. CD8+ T-cell-mediated immunity (CMI) was tested using the QuantiFERON-CMV assay at baseline, 1, 2 and 3 months posttransplant by measurement of interferon-γ response to whole blood stimulation with a 21-peptide pool. The primary outcome was the ability of CMI testing to predict CMV disease in the first 6 months posttransplant. There were 108 evaluable patients (D+/R+ n = 39; D-/R+ n = 34; D+/R- n = 35) of whom 18 (16.7%) developed symptomatic CMV disease. At the end of prophylaxis, CMI was detectable in 38/108 (35.2%) patients (cutoff 0.1 IU/mL interferon-γ). CMV disease occurred in 2/38 (5.3%) patients with a detectable interferon-γ response versus 16/70 (22.9%) patients with a negative response; p = 0.038. In the subgroup of D+/R- patients, CMV disease occurred in 1/10 (10.0%) patients with a detectable interferon-γ response (cutoff 0.1 IU/mL) versus 10/25 (40.0%) patients with a negative CMI, p = 0.12. Monitoring of CMI may be useful for predicting late-onset CMV disease.