Ask the Experts - Renal Transplant Recipients With Elevated Liver...
Ask the Experts - Renal Transplant Recipients With Elevated Liver...
A 30-year-old male living-related renal transplant recipient (2 months posttransplant) has mild elevation of liver enzymes. He is negative for hepatitis B virus infection, hepatitis C virus infection, and is asymptomatic. His cytomegalovirus (CMV) status was IgG+ pretransplantation and now is IgM+. He is on standard triple immunosuppression and received 2 doses of basiliximab. Should this patient receive treatment for CMV and if so, what dosage? CMV therapy is expensive in our setting.
Sanjay Sinha, MS, DNB, MCh, MAMS
There are some data missing from your question. Does your patient have other clinical signs or symptoms of CMV disease (ie, fever, leukopenia, general malaise, etc.)? In the setting of clinical signs and the elevation of liver enzymes, I would treat for CMV disease. In the absence of other signs and symptoms, consider confirming your suspicions with a diagnostic test. Consider a blood specimen for "rapid antigen," which, if positive in the setting of elevated liver enzymes, would confirm your suspicion. If your patient is leukopenic, consider a quantitative PCR assay. Some would suggest that this patient should have received prophylactic therapy anyway, as the likelihood of developing CMV disease was 5-7 times greater than a seronegative recipient/donor combination (within the first 3 months posttransplantation). Finally, the gold standard of diagnostic tests would be a liver biopsy. This would typically reveal "oak eye" cells consistent with CMV infection and replication. Of course, also consider other culprits that cause hepatitis such as certain drugs your patient may be receiving, and as always, try to minimize the immunosuppression to afford prevention of rejection without the unnecessary effect of opportunistic infection.
A 30-year-old male living-related renal transplant recipient (2 months posttransplant) has mild elevation of liver enzymes. He is negative for hepatitis B virus infection, hepatitis C virus infection, and is asymptomatic. His cytomegalovirus (CMV) status was IgG+ pretransplantation and now is IgM+. He is on standard triple immunosuppression and received 2 doses of basiliximab. Should this patient receive treatment for CMV and if so, what dosage? CMV therapy is expensive in our setting.
Sanjay Sinha, MS, DNB, MCh, MAMS
There are some data missing from your question. Does your patient have other clinical signs or symptoms of CMV disease (ie, fever, leukopenia, general malaise, etc.)? In the setting of clinical signs and the elevation of liver enzymes, I would treat for CMV disease. In the absence of other signs and symptoms, consider confirming your suspicions with a diagnostic test. Consider a blood specimen for "rapid antigen," which, if positive in the setting of elevated liver enzymes, would confirm your suspicion. If your patient is leukopenic, consider a quantitative PCR assay. Some would suggest that this patient should have received prophylactic therapy anyway, as the likelihood of developing CMV disease was 5-7 times greater than a seronegative recipient/donor combination (within the first 3 months posttransplantation). Finally, the gold standard of diagnostic tests would be a liver biopsy. This would typically reveal "oak eye" cells consistent with CMV infection and replication. Of course, also consider other culprits that cause hepatitis such as certain drugs your patient may be receiving, and as always, try to minimize the immunosuppression to afford prevention of rejection without the unnecessary effect of opportunistic infection.
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