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Review
. 2015 Jan-Mar;13(1):142-8.
doi: 10.1590/S1679-45082015RW3175.

Cytomegalovirus infection in renal transplantation: clinical aspects, management and the perspectives

[Article in English, Portuguese]
Lúcio Roberto Requião-Moura  1 , Ana Cristina Carvalho deMatos  1 , Alvaro Pacheco-Silva  2
Affiliations
Review

Cytomegalovirus infection in renal transplantation: clinical aspects, management and the perspectives

[Article in English, Portuguese]
Lúcio Roberto Requião-Moura et al. Einstein (Sao Paulo). 2015 Jan-Mar.

Abstract
in English, Portuguese

Cytomegalovirus infection is one of most frequent infectious complications after renal transplantation, and can be classified as primo-infection, when the transmission occurs through the graft, or reactivation, when the recipient is cytomegalovirus seropositive. After transplantation, cytomegalovirus can appear as an infection, when the patient presents with evidence of viral replication without symptoms or disease, which has two clinical spectra: typical viral syndrome or invasive disease, which is a less common form. Their effects can be classified as direct, while the disease is developed, or indirect, with an increase of acute rejection and chronic allograft dysfunction risks. Diagnosis must be made based on viremia by one of the standardized methods: antigenemia or PCR, which is more sensitive. The risk factors related to infection after transplantation are the serologic matching (positive donor and negative recipient) and anti-lymphocyte antibody drugs. One of the strategies to reduce risk of disease should be chosen for patients at high risk: preemptive treatment or universal prophylaxis. Recent clinical research has described ganciclovir resistance as an emergent problem in management of cytomegalovirus infection. Two types of mutation that cause resistance were described: UL97 (most frequent) and UL54. Today, sophisticated methods of immunologic monitoring to detect specific T-cell clones against cytomegalovirus are used in clinical practice to improve the management of high-risk patients after renal transplantation.

A infecção pelo citomegalovírus é uma das principais complicações após o transplante de rim, podendo ser classificada em primoinfecção, quando a transmissão ocorre por meio do enxerto, ou em reativação, quando o receptor é soropositivo. Do ponto de vista clínico, pode se apresentar como infecção, na ausência de sintomas, ou como doença, com dois diferentes espectros: a síndrome viral típica ou, menos comumente, a doença invasiva. Os efeitos podem ser diretos, que é o desenvolvimento da doença, ou indiretos, como aumento no risco de rejeição aguda e de disfunção crônica do enxerto. O diagnóstico deve ser feito por pesquisa de viremia por meio de um dos dois métodos padronizados: antigenemia ou PCR − sendo essa última a mais sensível. Os fatores de risco relacionados com a infecção após o transplante são o match sorológico (doador positivo e receptor negativo) e o uso de anticorpos antilinfócitos. Uma das estratégias de redução de risco de doença deve ser escolhida após o transplante nos pacientes de alto risco: tratamento preemptivo ou profilaxia. Recentemente, linhas de pesquisa clínica têm apontado a resistência ao ganciclovir como um problema emergente no manejo da infecção pelo citomegalovírus. Duas formas de mutação que causam resistência são descritas: UL97, que é a mais frequente, e a UL54. Atualmente, sofisticados métodos de monitorização imunológica, como a detecção de clones específicos de células T contra o citomegalovírus podem ser utilizados na prática clínica para o melhor manejo após o transplante renal dos pacientes de alto risco.

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Figures

Figure 1
Figure 1. Spectra of cytomegalovirus infection in transplant
Figure 2
Figure 2. Clinical presentation and need for retreatment of cytomegalovirus infection in the Kidney Transplant Program of the Hospital Israelita Albert Einstein
Figura 1
Figura 1. Espectros da infecção pelo citomegalovírus no transplante
Figura 2
Figura 2. Apresentação clínica e necessidade de retratamento da infecção pelo citomegalovírus no Programa de Transplante de Rim do Hospital Israelita Albert Einstein
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