Expanding Kidney Transplant Donor Criteria: Safe Transplantation from a Donor with Active CMV Infection
In the best of all possible worlds, the supply of donor organs for everyone in need of a life-saving transplant meets the demand. In the meantime, the quest continues to alleviate the chronic shortage of viable organs for transplantation. Medical centers and transplant programs combine technological advances and other medical breakthroughs to provide new solutions and options. One such emerging solution, explores options previously deemed too high-risk by reconsidering donor criteria.
At University of Maryland Medical Center (UMMC), a recent case report highlights a successful kidney transplant using organs from a donor with high-grade cytomegalovirus (CMV) viremia. The report, published online in July 2024 in The Lancet Infectious Diseases, provides insights into managing such transplants and expands the discussion on viable ways to use expanded donor criteria while ensuring patient safety, efficacy, and optimal long-term outcomes.
The UMMC transplantation team faced the challenge of utilizing kidneys from a donor with severe CMV viremia and probable CMV pneumonitis. The donor, a woman with systemic lupus erythematosus (SLE) and interstitial lung disease, exhibited CMV viral loads exceeding 100,000 IU/mL. Despite these findings, histological analysis confirmed the absence of CMV in the kidneys, enabling the transplant team to proceed under strict monitoring protocols.
An important detail of this case includes the modification of standard immunosuppressive protocols by the UMMC team to mitigate the risk of CMV reactivation in the recipient. The patient received basiliximab induction therapy and standard maintenance with tacrolimus. Valganciclovir prophylaxis resumed after initial clearance of CMV, with as-needed adjustments to the patient’s antiviral medications based on regular tests of his viral load.
UMMC remains committed to advancing research in transplant immunology and infectious diseases, ensuring that even patients with complex medical histories have the opportunity to receive lifesaving organs.
At University of Maryland Medical Center (UMMC), a recent case report highlights a successful kidney transplant using organs from a donor with high-grade cytomegalovirus (CMV) viremia. The report, published online in July 2024 in The Lancet Infectious Diseases, provides insights into managing such transplants and expands the discussion on viable ways to use expanded donor criteria while ensuring patient safety, efficacy, and optimal long-term outcomes.
Background
CMV, a common herpesvirus, is a long-known potential complication in solid organ transplantation. CMV infections can cause significant morbidity through direct infection or reactivation in the recipient. While routinely transplanting organs from CMV-seropositive donors, the use of organs from donors with active, high-grade CMV infections is a rare occurrence due to the potential risks. To this point, the relative scarcity of outcomes data and best practices on the use of organs from donors with active CMV infections hampered clinical decision-making, which is one reason this new case report and review from UMMC particularly provides value for the transplant medicine community.The UMMC transplantation team faced the challenge of utilizing kidneys from a donor with severe CMV viremia and probable CMV pneumonitis. The donor, a woman with systemic lupus erythematosus (SLE) and interstitial lung disease, exhibited CMV viral loads exceeding 100,000 IU/mL. Despite these findings, histological analysis confirmed the absence of CMV in the kidneys, enabling the transplant team to proceed under strict monitoring protocols.
About the Case and Outcomes
The recipient, a 61-year-old male CMV-seropositive patient with end-stage renal disease in the setting of SLE, received a dual kidney transplant from the aforementioned high-risk donor. Following the transplant surgery, the patient experienced delayed graft function but showed improvement after one week. Antiviral treatment with ganciclovir and valganciclovir began immediately post-transplant and continued for the first month.An important detail of this case includes the modification of standard immunosuppressive protocols by the UMMC team to mitigate the risk of CMV reactivation in the recipient. The patient received basiliximab induction therapy and standard maintenance with tacrolimus. Valganciclovir prophylaxis resumed after initial clearance of CMV, with as-needed adjustments to the patient’s antiviral medications based on regular tests of his viral load.
Clinical Takeaways for Providers
The case report from the UMMC transplant team demonstrates that kidney transplantation from donors with high-grade CMV viremia is feasible in CMV-seropositive recipients when managed with appropriate antiviral and immunosuppressive protocols. At one-year post-transplant, the patient’s kidney function remains stable without evidence of virus reactivation after pausing his prophylactic therapy. The success of this case shows the importance of personalized antiviral and immunosuppressive strategies, essential to minimizing the risk of CMV disease and optimizing patient outcomes. The approach designed by the UMMC team, including modifying the immunosuppressive regimen and implementing robust antiviral therapy, led to a successful management of this transplant. The findings from this case also suggest that with rigorous protocols and monitoring, organs from donors with active CMV infections may be safely utilized in well-selected candidates. The use of these organs when feasible demonstrates the potential to be another option for expanding the pool of donor organs safely and with good outcomes.Impact on Clinical Practice
"This case demonstrates that with proper protocols and vigilant monitoring, we can successfully use organs from donors previously considered high-risk, thereby helping to alleviate the organ shortage while maintaining patient safety," says Raphael P. H. Meier, MD, PhD, the lead surgeon and researcher from UMMC involved in the transplant.UMMC remains committed to advancing research in transplant immunology and infectious diseases, ensuring that even patients with complex medical histories have the opportunity to receive lifesaving organs.
Future Directions
The successful management of this case highlights the need for additional research into optimizing antiviral and immunosuppressive protocols when using organs from donors with active infections. Further studies seek to validate these initial findings and develop standardized approaches for similar transplants.
“University of Maryland Medical Center explores novel approaches to expand the donor pool, ensuring that patients receive timely and effective transplants, even in challenging clinical scenarios. UMMC remains committed to advancing research in transplant immunology and infectious diseases to optimize patient outcomes.” says Dr. Meier.
For more information or referrals, please visit the University of Maryland Medical Center Transplant Center at Baltimore website or contact the transplant center at 410-328-5408 (Kidney and Pancreas transplant) or 410-328-3444 (Liver Transplant).
Reference
Shirini K, Kamberi S, Drachenberg C, Haririan A, Saharia K, Meier RPH. Renal transplantation using kidneys from a donor with high-grade cytomegalovirus viraemia: case report and literature review. Lancet Infect Dis. Published online July 8, 2024. doi: 10.1016/S1473-3099(24)00359-1.