During a period of four years, heart transplantations were performed in 77 patients. The immunosuppressive regimen consisted of cyclosporin A (CsA) and prednisone. The dose of CsA was adjusted according to plasma trough levels. Endomyocardial biopsies were performed at regular intervals. In case of a biopsy-proven rejection three times, 1 g of methylprednisolone was administered intravenously. In steroid-unresponsive rejections, rabbit anti-thy- mocyte globulin (RATG) was given. During this treatment peripheral T cells (CD3+) were kept below 150/cu mm3 for three weeks.
The CMV serostatus of the transplant recipients was screened for anti-CMV IgG by an ELISA. Recipients with a pretransplant ELISA titer <100 were considered to be CMV seronegative. Serum of allograft donors was retrospectively screened for CMV IgG antibodies too. Blood donors were not screened for CMV IgG antibody, but peri-, per- and posttransplantation only bufly-coat depleted blood was given.
After the ninth transplantation, all CMV seronegative recipients received anti-CMV immunoglobulins, irrespective of the CMV serostatus of the allograft donor. A commercially available immunoglobulin preparation was used (Cytotect). It was produced by cold ethanol precipitation of plasma pools with high titers of antibodies to CMV Sterilization was performed by (3-propiolactone treatment. The preparation contained 100 mg protein per milliliter and had a specific IgG antibody level of 40,000 ELISA units/ml (50 U/ml ELISA against the Paul Ehrlich standard). The CMV neutralizing antibody titer was 1:3,ООО. The first gift of immunoglobulin was infused in a dose of 150 mg/kg body weight during transplantation before recirculation started. Thereafter, on day 2, 7, 14, 35, 56, and 77, the same preparation was given in a dose of 100 mg/kg. This regimen resulted in median anti-CMV IgG levels of 1,200 ELISA units during the first three months after transplantation.
Before each infusion of globulin, samples of urine, throat wash, and blood were collected for virus isolation. When indicated, more specimens were obtained for diagnosis. The isolation of CMV was performed by a low-speed centrifugation assay in combination with immunofluorescence using a monoclonal antibody against early antigen of СМУ as described in detail elsewhere. Bufly-coat samples were also cultured on human embryonic lung fibroblasts and screened for cytopathic change. Specific anti-CMV immunofluorescence studies were done on all cultures. From the CMV seropositive recipients and from the untreated CMV seronegative recipients, clinical specimens were obtained monthly or more frequently when infection was suspected.
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Symptomatic CMV infection was defined as illness with two of the following symptoms without other possible explanations: fever (>38.5°C) for at least three consecutive days; gastrointestinal, lung or central nervous system involvement; leukocytopenia (<3.0 X lO^/L); thrombocytopenia (<100 X lOVL); elevated serum alanine or aspartate aminotransferases (>2.5 times the upper limit of normal). This viral syndrome had to be confirmed by concomitant isolation of CMV. Organ involvement had to be confirmed by culture or biopsy from the diseased organ. In case of serious CMV disease, therapy with ganciclovir (9-[2-hydroxy 1-(hydroxymethyl) ethoxymethyl] guanine), (DHPG), was instituted.
The incidence of CMV disease in the untreated CMV seropositive and seronegative recipients and the expected incidence based on the data from the literature were used as the reference group. For differences between the globulin and the reference group the point estimate and its 95 percent confidence interval are given. To test the hypothesis that there was no difference between these groups, the chi-square test was used. The results of tests of significance are reported as two tailed.