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Abstract: FR-PO773

Symptomatic Cytomegalovirus (CMV) Infection and Antibody-Mediated Rejection (ABMR) of Kidney Allograft

Session Information

Category: Transplantation

  • 2102 Transplantation: Clinical


  • Schmitz, Lucas, Ascension Health, St Agnes, Baltimore, Maryland, United States
  • Alotaibi, Manal, Johns Hopkins University, Baltimore, Maryland, United States
  • Kant, Sam, Johns Hopkins University, Baltimore, Maryland, United States

CMV infection is a common complication after transplantation, occurring in up to 30% of kidney transplant recipients. The main risk factor for CMV viremia is serological mismatch between the donor and the recipient. Infection can lead to direct virus-induced cytopathic effect on host cells in various systems, such as pneumonia, gastrointestinal disease, hepatitis, and even invasion of the transplanted organ. However, mechanisms of allograft injury are not limited to direct viral cytotoxicity only, as CMV infection has been shown to promote immune-mediated transplant rejection. We present a patient with symptomatic CMV infection leading to antibody-mediated allograft rejection requiring dialysis, with complete renal recovery after antiviral treatment.

Case Description

A 59 year-old male CMV D+/R- kidney transplant recipient presented seven months after transplantation with fever, chills, fatigue and acute kidney injury. Within four days, creatinine worsened to 4.6 from a baseline of 1.3. He was found to have CMV viremia with a peak of 8350 copies/mL and was started on intravenous ganciclovir. He had previously been on valganciclovir as prophylaxis. Kidney allograft biopsy demonstrated features of antibody mediated rejection, albeit with anti HLA antibodies only against third party antigens. Despite intravenous methylprednisolone and five sessions of plasmapheresis, renal function continued to deteriorate to a creatinine of 11.3, along with signs and symptoms of uremia and volume overload prompting initiation of dialysis two weeks after the initial presentation

The patient continued to receive intravenous ganciclovir throughout hospitalization and CMV viral load decreased to 104 copies/mL by the time of dialysis initiation.After 1 week of dialysis, kidney recovery ensued and CMV viral load was undetectable. Repeat allograft biopsy three weeks after initiation of antiviral treatment showed signs of resolving ABMR. Patient has been off dialysis and showed complete recovery of function, with creatinine levels back at baseline two months after initial presentation


The immune nature of antibody-mediated allograft rejection may mislead clinicians into overlooking viral infections as a potential underlying etiology. This case highlights the importance of identifying CMV viremia as a trigger of ABMR in kidney transplant recipients, as adequate treatment can lead to complete allograft recovery