Every-Other-Day Valganciclovir Prophylaxis for Cytomegalovirus Prevention in Kidney Transplant Recipients: A Single-Center Experience

Rapid Communication

Austin J Nephrol Hypertens. 2021; 8(3): 1100.

Every-Other-Day Valganciclovir Prophylaxis for Cytomegalovirus Prevention in Kidney Transplant Recipients: A Single-Center Experience

Bhuwania P*

Department of Nephrology, KG Hospital, Government Arts College Road, Coimbatore, India

*Corresponding author: Puneet Bhuwania, Department of Nephrology, KG Hospital, Government Arts College Road, Coimbatore-641018, India

Received: October 11, 2021; Accepted: November 03, 2021; Published: November 10, 2021


Background: Moderate-risk for Cytomegalovirus (CMV) infection includes patients with donor positive/recipient positive (D+/R+) or donor negative/ recipient positive antibody status (D-/R+). Guidelines recommend high-dose daily Valganciclovir (VGCV) as prophylaxis, which may be due to the paucity of data on the efficacy of every-other-day VGCV.

Methods: Our experience of using every-other-day VGCV as a prophylactic strategy in moderate risk Kidney Transplant Recipients (KTR) has been described. We retrospectively reviewed 86 moderate-risk KTR in our institution between 2018 and 2020. CMV infection at 6 months post-transplant was the primary endpoint. Graft survival, biopsy-proven rejection, opportunistic infections, Haematological adverse events, and mortality were also evaluated.

Results: CMV infection occurrence at 6 months was zero in our cohort. Incidence of leukopenia was 13%, BPAR-31%, OI-33%, and mortality being 3.5%.

Conclusion: Every-Other-Day VGCV dosing can be an effective alternative in moderate risk KTR for CMV prevention.

Keywords: CMV prophylaxis; Valganciclovir; Kidney transplant recipients


ATG-F: Anti-thymocyte globulin-Fresenius; BPAR: Biopsy Proven Acute Rejection; CD3: Cluster of Differentiation-3; CMV: Cytomegalovirus; D+/R-: Donor Positive/Recipient Negative; D-/ R+: Donor Negative/Recipient Positive; D+/R+: Donor Positive/ Recipient Positive; eGFR: Estimated Glomerular Filtration Rate; ug: Microgram; mg.h/L: Milligram.hours per Litre; MMF: Mycophenolate Mofetil; MPA AUC: Mycophenolic Acid Area under the Curve; ng/mL: Nanograms per millilitres; OI: Opportunistic Infection; PCR: Polymerase Chain Reaction; r-ATG: Rabbit Anti Thymocyte Globulin; TAC: Tacrolimus; VGCV: Valganciclovir; VZV: Varicellazoster


Cytomegalovirus (CMV) is a well-established opportunistic infection confronted in the post-transplant setting. Its impact on graft survival, morbidity, and mortality in renal transplant recipients has always remained very significant [1,2]. Anti-CMV Immunoglobulin G (IgG) is detected in plasma in renal donors with prior CMV exposure when being evaluated for transplantation and so it is one of the multiple factors that can influence CMV emergence, others being CMV serological status of the recipient, the usage of pre-emptive therapy or prophylaxis and immune-suppressants [3]. None of the given guidelines accepts the prescription of Every-Other-Day dose of VGCV for Cytomegalovirus (CMV) prophylaxis, which is partly due to the lack of published data [1]. However, in a survey conducted internationally, nearly 30-40% of centers have reported using the low-dose regimen of 450mg/day in the moderate-risk population [4]. The safety and efficacy of low-dose VGCV for CMV prophylaxis in 478 intermediate-risk Kidney Transplant Recipients (KTR) has been reported by Heldenbrand et al. [5], who found no significant difference in the 12-month incidence of CMV disease (3.4% vs. 3.5%), rejection (11.2% vs. 10.3%) or graft loss (6.7% vs. 5.0%) between patients receiving high vs. low-dose VGCV prophylaxis respectively. Khan et al. [6], also described a low incidence of CMV in 316 KTR i.e. 2.7% in D+/R+, 4% in the D-/R+ and 3% in R+, where they used 450mg/day (adjusted to renal functions) of VGCV as prophylaxis. We used even lower doses of VGCV prophylaxis (defined as 450mg on Every-Other-Day with renal dose adjustment if needed) in moderate risk KTR at our institution and have presented our findings.


A retrospective analysis utilizing our institutional electronic medical record system of a cohort of 86 CMV D+/R+ KTR between 2018 and 2020 was done. The analysis was conducted following the Declaration of Helsinki, the International Conference on Harmonization, and Good Clinical Practice guidelines. Recipients included were live (related/directed - near and not near) or deceased complement-dependent cytotoxicity cross-match negative, HLA match or mismatch patients, along with ABO-incompatible recipients, who underwent desensitization. All transplant recipients received a single dose of Anti-thymocyte globulin - Fresenius (ATG-F) IV (2-5 mg/kg) as a part of induction therapy along with methylprednisolone 500mg IV on postoperative days 0, 1, 2 days as per unit protocol. Maintenance Immunosuppression included a combination of Anti proliferative agent i.e. mycophenolate mofetil (30mg/kg), Calcineurin inhibitor i.e. Cyclosporine (3-5 mg/kg) or Tacrolimus (0.15mg/kg) and Prednisolone (initially initiated at 20mg/day then was tapered to 2.5-5 mg/d at around 4 weeks post-transplant and remained the same during the study period.

The recipients received VGCV (defined as 450mg on every other day adjusted for renal function if needed) for CMV prophylaxis. Following transplantation, prophylaxis was given for the first 90- 100 days. The primary endpoint being CMV infection incidence till 6 months (max incidence of CMV during this period) posttransplant defined as (i) Positive CMV Deoxyribonucleic acid (DNA) determination by Polymerase Chain Reaction (PCR) - which was performed based on clinical suspicion of the treating doctor (ii) Evidence of CMV with positive immunohistochemistry staining or viral inclusions on histology. The secondary endpoints included leucopenia episodes during the period of prophylaxis, graft survival, Biopsy-Proven Acute Rejection (BPAR), Opportunistic Infection (OI), and mortality.


A total of 86 of moderate risk KTR were a part of our analysis. 80% of the patients were male and their mean age was 39 years (Table 1). All received VGCV prophylaxis for 90-100 days.