1. An audit of CMV disease in renal transplant recipients transplanted at the Queen Elizabeth Hospital Birmingham Gemma Banham, Shazia Shabir, Richard Borrows

2. Cytomegalovirus infection
Direct effects
Viral syndrome
Tissue invasive disease
Indirect effects
Acute and chronic rejection
Post transplantation diabetes
Opportunistic infections

3. IMPACT Trial
Humar A et al. American Journal of Transplantation 2010; 10: 1228–1237
Humar A et al, Transplantation 2010; 90: 1427–1431

4. RCT of oral prophylactic ganciclovir vs intravenous pre-emptive therapy
FULL ITT population
D+/R-
D+/R+
D-/R+
Kliem V et al, American Journal of Transplantation 2008; 8: 975–983

5. British Transplantation Society Guidelines (2011)
CMV prophylaxis to seronegative recipients who receive a transplant from a seropositive donor (D+/R-)
CMV prophylaxis where either the donor or recipient is seropositive if patient is treated with T-cell depleting antibodies
Choice of prophylaxis strategies
Audit standards
Rate of CMV disease in 1st year in D+/R- patients <8%
Rate of CMV disease in 1st year in D+/R+ patients <8%
Rate of CMV disease in 1st year in D-/R+ patients <8%

6. CMV status (Donor/Recipient)
Audit Methods
Patients transplanted at QEHB between 1st August 2007 and 30th June 2011
Patients identified from Surgery Department’s database
Total of 569 patients
PICS microbiology tab for CMV PCR results
Electronic clinical notes for those with CMV viraemia
Heartland’s Hospital Virology Department results database
Stoke audit
NHS Blood and Transplant
CMV status (Donor/Recipient)
Number (%)
D-/R-
150 (26.4)
D-/R+
121 (21.3)
D+/R+
178 (31.3)
D+/R-
116 (20.4)
Unknown
4 (0.7)

7. Audit Questions?
Should we offer extended prophylaxis (200 days) to D+/R- recipients?
Should we offer prophylaxis to D+/R+ recipients?
Should we offer prophylaxis to D-/R+ recipients?
£ for 30 day supply of 900mg once daily dose

8. CMV Syndrome CMV Disease
Number at risk
100
200
300
365
150
137
127
119
111
121
104 96 94 89
116
109 86 75 67
178
128
115
107
105
Number at risk
100
200
300
365
150
140
130
121
113
110
104
102 97
116 98 91 85
178
154
143
136
133

9. Audit Standards 
Rate of CMV disease in the first year post transplantation in D+/R- patients <8%
Rate of CMV disease in the first year post transplantation in D+/R+ patients <8%
Rate of CMV disease in the first year post transplantation in D-/R+ patients <8%  

10. Early CMV in D+/R- 3/23 cases CMV syndrome during 1st 100 days
Subtherapeutic dose of valganciclovir in 2/3
Creatinine clearance (ml/min)
Cockcroft-Gault Formula
Recommended valganciclovir prophylaxis
>60
900mg once daily
450mg once daily
450mg alternate days
450mg twice weekly
<10
Not recommended

11. Consequences of CMV Syndrome
Syndrome cases (%)
D-/R-
3/150 (2.0)
D-/R+
12/122 (9.9)
D+/R+
39/178 (21.9)
D+/R-
23/116 (19.8)
Total
77/569 (13.5)
Disease
1 (33.0)
2 (16.7)
5 (12.8)
4 (17.4)
12 (15.6)
Histology
0 (0.0)
2 (5.1)
1 (4.3)
5 (6.5)
Death during CMV episode
1 (2.6)
2 (2.6)
Viraemia level
(median, range)
2.2x107, 1.6x x107
1.1x104, x105
1.3x104, x108
3.1x105, x106
2.2x104, x108
Requiring treatment*
- Total
Intravenous
3 (100.0)
2 (66.7)
11 (91.7)
2 (1.7)
37 (94.9)
12 (30.8)
21 (91.3)
8 (34.8)
72 (93.5)
24 (31.2)
Patients requiring CMV related hospitalisation
- QEHB
- Stoke
8 (66.7)
27 (69.2)
23 (59.0)
4 (10.3)
17 (73.9)
14 (60.9)
3 (13.0)
55 (71.4)
48 (62.3)
7 (9.1)
Days in QEHB
8, 6-10
21, 2-42
9, 2-48
10.5, 3-26
Total days in QEHB 24
175
343
168
710
*5 additional patients received treatment with no evidence of CMV Syndrome or Disease

12. Conclusions Meeting targets for CMV ‘Disease’
Large amounts CMV ‘Syndrome’ with significant morbidity and cost
Highest burden in D+/R+, followed by D+/R- then D-/R+
Majority D+/R- disease is late
Early D+/R- disease may be due to inappropriate dosing of valganciclovir

13. Acknowledgments Everyone at other transplant units Kerry Tomlinson
Caroline Clark
Hari Krishnan
Husum Osman

14. Who should receive prophylaxis?
Number at risk
200
400
600
730
150
127
110 97 81
121 96 87 74 59
116 86 62 51 40
178
115
102 90 77