Kalil AC et al. (2005) Meta-analysis: the efficacy of strategies to prevent organ disease by cytomegalovirus in solid organ transplant recipients. Ann Intern Med 143: 870–880

In a systematic review of data from randomized, controlled trials, researchers at the University of Nebraska Medical Center have compared two strategies for preventing CYTOMEGALOVIRUS (CMV) infection and its complications in solid organ transplant recipients.

The analysis included kidney and liver transplant recipients from 11 trials that assessed universal prophylaxis (n = 1,582) and 6 trials that evaluated a pre-emptive strategy (n = 398). Universal prophylaxis involved administration of aciclovir ≥2 g/day or ganciclovir ≥3 g/day for at least 60 days to all CMV seropositive patients and recipients of grafts from seropositive donors. The pre-emptive strategy involved at least 14 days of treatment for patients in whom CMV was detected during routine monitoring. Median follow-up was 6 months.

Both approaches significantly reduced the risk of developing CMV organ disease (defined as histological or clinical manifestation of CMV viremia) and acute allograft rejection, but only universal prophylaxis decreased bacterial and fungal infections and death (P <0.05 for all). Neither strategy reduced the risk of graft loss. There were insufficient data to assess CMV recurrence and resistance, or occurrence of late-onset CMV disease.

Subgroup analyses showed that aciclovir and ganciclovir were both effective in reducing CMV organ disease when used for universal prophylaxis. This finding contradicts recent guidelines, which advise that only newer agents, such as ganciclovir and valganciclovir, be used in the solid organ transplant setting. The authors of this meta-analysis recommend that aciclovir remains an option for universal prophylaxis until a large, randomized, controlled trial resolves which anti-CMV drug is superior and most cost-effective.