Risk-stratified approach to anti-viral prophylaxis against cytomegalovirus disease in glomerulonephritis and renal vasculitis treated with potent immunosuppressants

Abstract

Aim: Cytomegalovirus (CMV) reactivation and disease in immunocompromised individuals is associated with significant morbidity and mortality. Preventive measures such as anti-viral prophylaxis or surveillance and pre-emptive therapy effectively reduced CMV disease in solid organ transplant but have not been evaluated among patients with glomerulonephritis at-risk for CMV disease after immunosuppressive therapy. We evaluated the utility and outcomes of a risk-stratified approach to anti-viral prophylaxis for adults with glomerulonephritis treated with potent immunosuppressants.

Methods: Single-center retrospective cohort study of adults with glomerulonephritis and renal vasculitis prescribed methylprednisolone, cyclophosphamide or rituximab in a tertiary referral centre. A risk-stratified approach to CMV anti-viral prophylaxis was implemented in March 2015. We compared the incidence of CMV disease in the pre-implementation (January 2008–December 2014) and post-implementation (June 2015–June 2017) groups.

Results: We studied 119 individuals: 85 in the pre-implementation group and 34 in the post-implementation group. The post-implementation group had worse kidney function, greater proteinuria, higher prednisolone dose and more received intravenous methylprednisolone and plasma exchanges but CMV disease within 6 months was similar to the pre-implementation group (2.9% vs. 3.5%, p = 1.00). Among individuals in the post-implementation group who satisfied criteria to receive anti-viral prophylaxis (n = 21), CMV disease was more frequent in the group not given prophylaxis compared to those given prophylaxis as recommended (8.3% versus 0%, p = 1.00). Adverse events related to anti-viral prophylaxis occurred in 40%.

Conclusion: This study provided pilot data for future randomized controlled trials to evaluate CMV preventive strategies in selected high-risk patients with glomerulonephritis or renal vasculitis.

Keywords:

• Immunosuppression
• opportunistic infection
• prophylaxis
• surveillance
• valganciclovir

Acknowledgements

We thank our colleagues in the Department of Renal Medicine for their support in the course of the study.

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Disclosure statement

Jason Choo has served on Advisory Boards for Novartis and Pfizer with a donation of honorarium to Singapore General Hospital to support research and education.