Renal cytomegalovirus infection

Patients who have undergone renal transplantation and then require treatment for cytomegalovirus infection are at special risk of renal damage due to foscarnet. 

One renal transplant recipient developed the nephrotic syndrome, with microscopic hematuria and non-ohguric acute renal insufficiency within 15 days after starting foscarnet therapy for cytomegalovirus infection (13). A kidney biopsy showed crystals in aU glomeruh and in the proximal tubules. The crystals consisted of several forms of foscarnet salts. Renal function and proteinuria nevertheless improved progressively, and a second transplant biopsy 8 months after the first one showed... 

A 49-year-old woman taking ciclosporin, prednisolone, and mycophenolate developed acute refractory rejection 4 days after renal transplantation. After an unsuccessful glucocorticoid pulse, her immunosuppressive regimen was successively changed to muromonab and tacrolimus with mycophenolate maintenance. Twelve days after transplantation she had abdominal pain and watery/bloody diarrhea. Colonoscopy showed multiple ulcers with mucosal injection and colon edema. A biopsy suggested ischemic cohtis and cytomegalovirus infection was ruled out. Her sjmptoms persisted until mycophenolate was withdrawn and further colonoscopy showed complete resolution. 

Ringden O, Lonnqvist B, Paulin T, Ahimen J, Klintmalm G, Wahren B, Lernestedt J-0. Pharmacokinetics, safety and preliminary clinical experiences using foscarnet in the treatment of cytomegalovirus infections in bone marrow and renal transplant recipients. J Antimicrob Chemother 1986 17 373-387. 

Justrabo E, Zanetta G, Martin L, Assem M, Mousson C, Maurice-Estepa L, Rifle G,Tanter Y. Irreversible glomerular lesions induced by crystal precipitation in a renal transplant after foscarnet therapy for cytomegalovirus infection. Eiistopathology 1999 34 365-369. 

Roberts TC, Brennan DC, Buller RS, Gaudreault-Keener M, Schnitzler MA, Sternahell KA, et al. Quantitative polymerase chain reaction to predict occurrence of symptomatic cytomegalovirus infection and assess response to ganciclovir therapy in renal transplant recipients. J Infect Dis 1998 178 626-35. 

Kletzmayr J, Kreuzwieser E, Klauser R. New developments in the management of cytomegalovirus infection and disease after renal transplantation. Curr Opin Urol 2001 11 153-158. 

Marker SC, Howard RJ, Groth KE, Mastri AR, Simmons RL, Balfour HH Jr. A trial of vidarabine for cytomegalovirus infection in renal transplant patients. Arch Intern Med 1980 140 1441-1444. 

In liver allograft rejection sIL-2R rises on average 7 days prior to other evidence of rejection or organ dysfunction (P7) and rises higher than sIL-2R in renal allograft rejection (K26). Serum sIL-2R rises to levels comparable to those in rejection by cytomegalovirus infection (P7). Biliary sIL-2R may have some promise as a more sensitive and specific measure. Adams et al. (A5) found that levels above 65 units/ml had a sensitivity of 94% and a specificity of 84% for acute rejection. 

It is broadly employed for the treatment of herpes zoster, herpetic-keratitis, herpes genitalis, chronic hepatitis, common cold and influenza. It also finds its usefulness in limg carcinoma, breast cancer, multiple myelomas. It is also recommended as a prophylactic agent in cytomegalovirus infection in renal transplant patients. 

A man with a kidney transplant taking corticosteroids and ciclosporin developed a cytomegalovirus infection that was treated with foscarnet 85 mg/kg daily. Despite efforts to minimise the nephrotoxic effects of the foscarnet (hydration with 2.5 litres of isotonic saline daily and nifedipine 80 mg the day before and during treatment) the patient developed non-ol-iguric worsening of his renal function after 8 days. Nine days after stopping the foscamet, the former renal function was restored. ... 

Rytel, M. W. and Kauffman, H. M. (1976) Clinical efficacy of adenine arabinoside in therapy of cytomegalovirus infections in renal allograft recipients. J. infect. Dis., 133, 202. 

PFA has recently undergone clinical evaluation in humans for the treatment of recurrent genital herpes, hepatitis B viral infection, and acquired immunodeficiency syndrome (AIDS), as well as cytomegalovirus (CMV) infection of bone marrow and renal transplant patients. 

Wolf DL, Rodriguez CA, Mucci M, et al. Pharmacokinetics and renal effects of cidofovir with a reduced dose of probenecid in HIV-infected patients with cytomegalovirus retinitis. J Clin Pharmacol. 2003 43 43-51. 

Note AIDS is caused by HIV, which impairs both cellular and humoral immune functions, and this results in increased susceptibility to opportunistic infection and certain malignancies. The medical aspects of HIV infection include AIDS-related complex (weight loss, chronic diarrhea, fever, thrush, herpes zoster, fatigue), opportunistic infections and cancer, end-stage renal disease, blindness (cytomegalovirus), HIV encephalopathy, and dementia. The psychological aspects of HIV infection include major depression, regression, and suicidal impulses, delirium, substance abuse, antisocial personality, and bereavement. 

Cheeseman SH, Rubin RH, Stewart JA, Tolkoff-Rubin NE, Cosimi AB, Cantell K, Gilbert J, Winkle S, Herrin JT, Black PH, Russell PS, Hirsch MS. Controlled clinical trial of prophylactic human-leukocyte interferon in renal transplantation. Effects on cytomegalovirus and herpes simplex virus infections. N Engl J Med 1979 300(24) 1345-9. 

In three pivotal clinical trials of mycophenolate mofetil in kidney transplant recipients, adverse effects were in accordance with the known antiproliferative effect of mycophenolate, namely gastrointestinal disorders, leukopenia, and opportunistic infections, in particular cytomegalovirus tissue invasive disease (SED-13, 1130) (SEDA-20,346). Nephrotoxicity was not observed in clinical trials, and renal function significantly improved in six patients converted to mycophenolate for ciclosporin nephrotoxicity (8). 

Opportunistic infections and cancer End-stage renal disease Blindness (cytomegalovirus)... 

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