Accurate prediction of cytomegalovirus disease through optimized viral load cut-offs in intermediate-risk kidney transplant recipients.

BACKGROUND

Cytomegalovirus (CMV) infection remains a major complication in kidney transplant recipients (KTRs), particularly among donor-negative/recipient-positive (D-/R+) individuals, who are at intermediate risk for viral reactivation. Although CMV DNAemia monitoring allows for preemptive therapy, the optimal threshold to predict disease remains uncertain. This study aimed to determine a clinically relevant CMV DNAemia cut-off for predicting CMV disease in D-/R+ KTRs and evaluate associated clinical outcomes.

METHODS

A retrospective cohort of 192 D-/R+ KTRs was followed for one year post-transplantation. Patients were stratified by peak CMV DNAemia levels. Clinical, laboratory, and graft-related outcomes were assessed. Logistic regression identified independent predictors of CMV disease. Receiver operating characteristic (ROC) analysis determined the optimal DNAemia threshold.

RESULTS

CMV DNAemia ≥1001 IU/mL occurred in 71% of patients and was associated with earlier infection onset, higher peak viral loads, increased use of thymoglobulin, and prolonged delayed graft function (DGF). CMV disease developed in 15% of patients and was independently associated with Kidney Donor Profile Index (KDPI) >80%, elevated DNAemia, longer DGF, lymphopenia, thrombocytopenia, graft loss, and acute rejection. A DNAemia threshold of 14,200 IU/mL (log > 4.15) predicted CMV disease with 63.1% sensitivity and 66.0% specificity (AUC = 0.62). Moreover, recipients of high-KDPI grafts had higher rates of CMV recurrence and peak DNAemia.

CONCLUSIONS

Elevated CMV DNAemia, poor donor organ quality, and prolonged DGF are key predictors of CMV disease in D-/R+ KTRs. A DNAemia threshold >14,200 IU/mL was associated with an increased risk of CMV disease and may support risk stratification within preemptive management strategies in this intermediate-risk group.