Cytomegalovirus Infection in Seropositive Kidney Transplant Recipients With Diverse Immunological Risks Under Preemptive Strategy

Cytomegalovirus (CMV) infection remains the most prevalent viral infection in kidney transplant recipients. Despite effective preventive strategies, the use of desensitization therapies and potent immunosuppressive agents in patients with high immunological risks underscores the continued importance of CMV as a major concern. This study aims to determine the incidence and outcomes of CMV infection in patients with diverse immunological risks under preemptive stategies. We analyzed 614 CMV-seropositive kidney transplant recipients managed under preemptive strategies. Of them, 231 patients (37.6%) underwent immunologically incompatible transplantation, including 75 ABO- and 156 HLA-incompatible transplants. During the median follow-up of 60 months, 354 patients (57.7%) experienced CMV infection. Multivariable analysis identified older recipient age, deceased donor, rituximab, and anti-thymocyte globulin as independent risk factors for CMV infection, while the use of mammalian target of rapamycin inhibitor was protective. Multivariable Cox regression analysis confirmed that CMV infection was independently associated with increased risks of death-censored graft loss (adjusted hazard ratio [aHR], 2.05; 95% confidence interval [CI], 1.17-3.59) and all-cause mortality (aHR, 3.40; 95% CI, 1.60-7.23). CMV infection adversely affects graft and patient outcomes in seropositive recipients managed under preemptive strategies. These findings emphasize the need for optimized CMV prevention strategies in recipients with high immunological risks, hereby intensified preemptive strategies or immunological risk-adapted antiviral prophylaxis are key options.