|Year : 2018 | Volume
| Issue : 2 | Page : 95-102
Epstein–Barr Virus DNAemia and co-occurrence with cytomegalovirus DNAemia in postrenal transplant recipients from a tertiary care center
Ramya Barani1, Yazhini Ravi1, Vigna Seshan1, Sudha Bharathi Reju1, Periasamy Soundararajan2, Gunasekaran Palani3, Padma Srikanth1
1 Department of Microbiology, Sri Ramachandra Medical College and Research Institute, Chennai, Tamil Nadu, India
2 Department of Nephrology, Saveetha Medical College, Chennai, Tamil Nadu, India
3 Deparment of Virology, King Institute of Preventive Medicine and Research, Chennai, Tamil Nadu, India
|Date of Web Publication||29-Jun-2018|
Prof. Padma Srikanth
Department of Microbiology, Sri Ramachandra Medical College and Research Institute, Porur, Chennai - 600 116, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Aim: Co-occurrence of Epstein–Barr virus (EBV) with Cytomegalovirus (CMV) is associated with an increased risk of EBV-associated posttransplant lymphoproliferative disorder (PTLD). Quantitation of EBV by real-time polymerase chain reaction (PCR) can aid the clinicians in the initiation of preemptive measures to improve the survival of the graft. Methods: The study was conducted among postrenal transplant recipients (PRTRs) who were attending the nephrology department from 2011 to 2016. Real-time quantitative PCR for EBV was performed in whole blood. PRTRs were classified into asymptomatic with altered renal parameters (Group A) and symptomatic (Group B), which were further subcategorized into Group B1 (fever with anemia, leukopenia, thrombocytopenia, or altered liver enzymes (any two), Group B2 (Group B1 + end-organ disease or only end-organ disease), and Group B3 (graft dysfunction [GDF]). The posttransplant period was also defined. DNA was extracted (Qiagen, Hilden, Germany) from whole blood, and real-time PCR was performed using QuantiTect multiplex PCR kit. Unpaired t-tests and ANOVA were used to analyze the data. Results: A total of 89 PRTRs were enrolled, of which 39.3% (n = 35) had EBV DNAemia, 43.1% during very late, 41.1% in late and 28.6% in immediate post transplant periods. EBV DNAemia ranged from 324 to 32,436 copies/ml. EBV DNAemia was found in 84% (n = 75) of symptomatic (Group B) and 16% (n = 14) of asymptomatic (Group A). Among the PRTRs with GDF (Group B3), 44% (n = 11/25) had EBV DNAemia of 2893.9 ± 1869 copies/ml. EBV DNAemia was considerably higher in PRTRs without GDF (8700.2 ± 9675.6 copies/ml) than PRTRs with GDF and the difference was statistically significant (P = 0.004). EBV DNAemia with CMV DNAemia among PRTRs was found in 21.3% (n = 19). Conclusion: High EBV DNAemia may precede PTLD or GDF; therefore, regular screening of EBV DNAemia is warranted. CMV and EBV DNAemia may also co-exist in PRTRs. As CMV is an immunomodulating virus, it increases the risk of opportunistic infections, especially EBV.
Keywords: Co-occurrence, cytomegalovirus, Epstein–Barr virus DNAemia, Epstein–Barr virus, real-time quantitative polymerase chain reaction
|How to cite this article:|
Barani R, Ravi Y, Seshan V, Reju SB, Soundararajan P, Palani G, Srikanth P. Epstein–Barr Virus DNAemia and co-occurrence with cytomegalovirus DNAemia in postrenal transplant recipients from a tertiary care center. Indian J Transplant 2018;12:95-102
|How to cite this URL:|
Barani R, Ravi Y, Seshan V, Reju SB, Soundararajan P, Palani G, Srikanth P. Epstein–Barr Virus DNAemia and co-occurrence with cytomegalovirus DNAemia in postrenal transplant recipients from a tertiary care center. Indian J Transplant [serial online] 2018 [cited 2018 Sep 25];12:95-102. Available from: http://www.ijtonline.in/text.asp?2018/12/2/95/235583
| Introduction|| |
Epstein–Barr virus (EBV) is a double-stranded DNA virus, which belongs to subfamily Gammaherpesvirinae of human herpes viruses, with the property of latency in a variety of cell types such as B- and T-lymphocytes, epithelial cells, and smooth muscle cells. Infection in childhood is asymptomatic and remains latent in the B-lymphocytes. Periodic reactivation of latent EBV infections can occur when there is an immunosuppression. EBV is capable of inducing B-cell proliferation to form immortalized cell lines and thereby it increases the risk of developing posttransplant lymphoproliferative disorders (PTLDs). The recent use of immunomodulators in postrenal transplant recipients (PRTRs) has increased the incidence of EBV., However, reactivation can occur anytime during the late posttransplant period.
In developing countries, 90% of the population are exposed to EBV before the age of 40. However, EBV DNAemia occurs only when the immune system is compromised, especially immunosuppressed and immunocompromised individuals. Primary EBV infections are strongly associated with PTLD, and it is reported in 1%–3% of PRTRs and approximately 75% of PTLD cases have been associated with EBV.,
In PRTRs, it can present as chronic active EBV disease (EBVD) or PTLD. The clinical symptoms consist of viral syndrome, history of lethargy, malaise, gastrointestinal (GI) bleeding, obstruction, perforation, back pain, abdominal pain, headache, infiltrative disease of the allograft, and graft dysfunction (GDF). Co-occurrence of cytomegalovirus (CMV) and EBV in solid organ transplant recipients can present with overlapping clinical features resulting in a confusing clinical diagnosis. Co-occurrence of EBV and CMV increases the risk of EBV-associated PTLD by three folds., Age of the patient, serological status of the donor and recipient, and the type of immunosuppression are the risk factors for the development of EBV or CMV disease in PRTRs. Furthermore, both infections can contribute to the disease severity and graft rejection. Only a few studies on EBV associated with PTLD have been reported in pediatric PRTRs. A rise in EBV load could be more informative regarding the risk of developing PTLD.
Published guidelines on PRTRs recommend that quantitation of EBV DNA should be done once within the first week of transplantation and thereafter at 3–6 months and every 3 months in the posttransplantation period in individuals who are at higher risk of developing this disease. In developing countries, irrespective of seropositive or seronegative status of EBV, screening of EBV by serology is not routinely practiced. Our study aimed at the detection of EBV by real-time quantitative polymerase chain reaction (q PCR) in PRTRs and to analyze its co-occurrence with CMV.
There are several methods for diagnosis of EBV which include serology for measuring EBV antiviral capsid antigen IgM and IgG antibodies. However, it is unreliable due to delay or absence of humoral antibodies and high prevalence of seropositivity for EBV. It is preferable for only screening the pretransplant serostatus of the donor and recipients to predict the risk assessment of PTLD. Detection of EBV genome by immunohistochemistry (IHC) in histopathological sections is the gold standard but an invasive procedure. It is used for categorization of PTLD by detecting latent antigen in biopsy using immunophenotyping, EBV clonality studies, molecular genetic markers of antigen, fluorescent in situ hybridization, or gene profiling by micro array. Molecular methods such as conventional and real-time PCR have higher sensitivity and they are used as diagnostic markers for PTLD.
| Materials and Methods|| |
The study was conducted in a tertiary care center after obtaining Institutional Ethics Committee approval (IEC-NI/08/DEC/07/46).
S ample size was calculated by power analysis using the following formula: n = [DEFF (Design effect)×Np(1-p)]/ [(d2/Z2) 1-α/2×(N-1)+p×(1-p)] using Open Epi software.
- PRTRs with complaints such as fever, leukopenia, thrombocytopenia, altered liver enzymes, weight loss, vomiting, abdominal pain, diarrhoea, and symptoms suggestive of end-organ disease or symptoms of GDF were enrolled
- PRTRs with mild elevation of renal parameters without symptoms were also enrolled in view of elevation of renal parameters.
PRTRs with severe combined immunodeficiency disease or asymptomatic PRTRs with normal renal function tests were excluded from the study.
Samples were collected from PRTRs, and written informed consent was obtained from participants above 18 years of age. For the participants between 12 and 18 years of age, a written informed consent along with assent form was obtained. Parent consent form was obtained for PRTRs below 12 years of age.
The study was conducted during 2011–2016 and included participants who had undergone renal transplantation during 1997–2016 and were on follow-up. The clinical details such as year of transplantation, live-related renal transplantation (LRRT), cadaveric or deceased donor renal transplantation (DDRT), clinical manifestations, and laboratory findings were documented in the pro forma during sample collection.
Categorization among postrenal transplant recipients
The PRTRs were categorized as follows:
- Group A: Asymptomatic with altered renal parameters
- Group B: Symptomatic.
Symptomatic participants were further subcategorized into Groups B1, B2, and B3. Group B1: Fever with anemia, leukopenia, thrombocytopenia, or altered liver enzymes (any two); Group B2: B1 + end-organ disease or only end-organ disease and Group B3: Graft dysfunction.
Occurrence of immediate- and late-onset Epstein–Barr virus
The posttransplant period was defined as follows: (1) immediate onset: 0–3 months, (2) late onset: >3–12 months, and (3) very late onset: >1 year.,,
Sample collection and processing
Whole blood (5 ml) was collected in EDTA containers (BD Vacutainer ®) and transported to the clinical virology laboratory at 2°C–4°C. Samples were aliquoted and stored at −80°C until further analysis. Whole blood is an appropriate sample for the estimation of EBV DNAemia by real-time QPCR.,,, Hence, whole blood was used for analysis.
Samples were transferred into multiple storage vials with appropriate labeling and frozen at −80°C before analysis of EBV DNAemia by QPCR.
Quality control measures followed in real-time quantitative polymerase chain reaction
Sterile Milli-Q® water was used as negative control and was included in each run. EBV-specific plasmid DNA was obtained from the Department of Clinical Virology, Christian Medical College, Vellore, for optimization of real-time q PCR for EBV and was used as positive control. Suitable precautions such as handling of pipettes for pre- and post-analysis of PCR, changing of aerosol filter barrier tips, and use of disposable gloves in each step were followed throughout the performance of the assay.
DNA was extracted using QiaAmp DNA blood mini kit (catalog number: 51104, Qiagen, Hilden, Germany). DNA extraction was carried out as per the manufacturer's instructions. Extracted DNA was used for real-time PCR or stored at −20°C for further analysis.
Real-time Epstein–Barr virus quantitative polymerase chain reaction
Real-time PCR for EBV specific to BNT p143 gene was performed using QuantiTect multiplex PCR NoROX kit (catalog number: 20404743, Qiagen, Hilden, Germany) as previously published. The sequences of the forward primer, reverse primer, and probe were as follows: F'-GGAACCTGGTCATCCTTTGC-3', R-5'-ACGTGCATGGACCGGTTAAT-3', and probe ROX-CGCAGGCACTCGTACTGCTCGCT-BHQ. The assay is a 5' nuclease TaqMan technology-based real-time detection of EBV using Rotor-Gene Q real-time PCR analyzer. Real-time PCR was carried out with a 25-μl reaction volume containing 10 μl of DNA template and 12.5 μl of amplification premix with 0.5 μl of (5 pico mole) each forward and reverse primer with 2 pico mole of probe. The standards ranged from 300 copies/ml to 30,000,000 copies/ml, and the lower limit of detection was <100 copies/ml. Samples which showed sigmoid curve amplification with the crossing threshold (Ct) value between 15 and 35 cycles were considered as positive. The amount of DNA was quantified based on the standards. DNA integrity of the samples was confirmed by the presence of internal control DNA. The test sample result was reported as numeric concentration in copies/ml of whole blood. Real-time q PCR for CMV was performed on the same set of samples with a commercial CMVR-gene kit (catalog number: 69-003B, Argene TM, Verniolle, France) using an ABI 7900 Fast real-time PCR instrument (Applied Biosystems, SDSVersion: 2.4). Only data related to co-occurrence presented here.
Estimated glomerular filtration rate calculation among postrenal transplant recipients
Estimated glomerular filtration rate (eGFR) among PRTRs was calculated using Cockcroft–Gault formula.
Unpaired t-tests and ANOVA were used to analyze the quantitative EBV DNAemia using R software (version 3.2.5). EBV DNAemia was also compared with the posttransplant period.
| Results|| |
Demographics of the study participants
A total of 89 PRTRs were enrolled in the study. Among the study participants, 82 (92.1%) were adult PRTRs (>18 years of age) and 7 (7.9%) were pediatric PRTRs (>10–18 years of age). The mean age ± standard deviation (SD) of the participants was 39.2 ± 13.5 years (range: 11–64 years). A total of 49.4% (n = 44) of the PRTRs belonged to the age group of 31–50 years, 20.2% (n = 18) to 51–60 years, 19.1% (n = 17) to 19–30 years, and 7.9% (n = 7) to >10–18 years. Only 3.4% (n = 3) of the PRTRs above the age of 60 had end stage renal disease. Among the participants, 74.2% (n = 66) underwent LRRT and 25.8% (n = 23) underwent DDRT.
Real-time q PCR for Epstein–Barr virus
EBV DNAemia was observed in 39.3% (n = 35) of PRTRs by real-time QPCR, of which 37.1% (n = 33) were adult PRTRs and 2.2% (n = 2) were pediatric PRTRs (>10 to 18 year).
Immediate onset of Epstein–Barr virus (<3 months)
Among twenty one PRTRs who were enrolled in the first 3 months post transplant, six had EBV DNAemia (28.6%). Among the 6 PTRs with EBV DNAemia, in the 1st month of post transplant (n = 12) five (41.6%) had EBV DNAemia and one participant in the Second month post transplant [Figure 1].
|Figure 1: Occurrence of immediate onset (0–3 months) of Epstein–Barr virus among post renal transplant recipients|
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Late onset of Epstein–Barr virus (>3–12 months)
A total of 17 PRTRs were enrolled in the late post transplant period; of which seven (41.1%) had EBV DNAemia. Out of seven, 4 PRTRs (50%) had EBV DNAemia between 3 and 6 months (n = 8) and three (33.3%) in 6–12 months (n = 9) post transplant [Figure 2].
|Figure 2: Occurrence of late onset (>3–12 months) of Epstein–Barr virus among post renal transplant recipients|
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Very late onset of Epstein–Barr virus (>1 year)
Among the total of 51 PRTRs, 43.1% (n = 22/51) had EBV DNAemia. This EBV DNAemia occurred more frequently in 1–3 years post transplant (66.7%; n = 8/12) followed by >9–12 years post transplant (57.1%; n = 4/7) and >6–9 years post transplant (50%; n = 4/8) [Figure 3].
|Figure 3: Occurrence of very late onset (>1 year) of Epstein–Barr virus among post renal transplant recipients|
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Epstein–Barr virus DNAemia range in post transplant period
Among PRTRs with EBV DNAemia, the viral load (VL) ranged from 324 to 32,436 copies/ml [Table 1]. Mean EBV DNAemia ± SD of PRTRs (immediate onset) was found to be 6081 ± 7863.1 copies/ml. During late onset (3–12 months of transplantation), the mean EBV DNAemia ± SD was found to be 3117.7 ± 1358.8 copies/ml and, in very late onset (>1-year ppost transplant), it was 8029.3 ± 9559.9 copies/ml. The occurrence of EBV DNAemia in immediate-, late-, and very late-onset periods is shown in [Figure 4].
|Table 1: Clinical manifestations and Epstein-Barr virus DNAemia in postrenal transplant recipients|
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|Figure 4: Occurrence of Epstein–Barr virus DNAemia in immediate-, late-, and very late-posttransplant period among postrenal transplant recipients|
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Epstein–Barr virus-DNAemia among symptomatic and asymptomatic postrenal transplant recipients
Symptomatic infection (Group B) was found in 84% (n = 75) of the PRTRs and 16% (n = 14) of PRTR were asymptomatic (Group A). EBV DNAemia was observed in 42.6% (n = 32) of symptomatic (Group B) PRTRs, of which 34.4% (n = 11/32) were in Group B3 (graft dysfunction), 34.4% (n = 11/32) in Group B1 (fever with anemia, leukopenia, thrombocytopenia, or altered liver enzymes (any two), and 31.2% (n = 10/32) in Group B2 (Group B1 + end-organ disease or only end-organ disease).
Among 16% (n = 14) of asymptomatic PRTRs (Group A), 21.4% (n = 3/14) had EBV DNAemia [Table 1].
Epstein–Barr virus DNAemia in postrenal transplant recipients with graft dysfunction
Graft dysfunction was documented in 28% (n = 25) of PRTRs, of which 36% (n = 9) had co-occurrence of EBV-CMV DNAemia and 8% (n = 2) had only EBV DNAemia [Table 2].
|Table 2: Epstein-Barr virus DNAemia and cytomegalovirus DNAemia in postrenal transplant recipients with graft dysfunction|
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Among PRTRs with CMV and EBV co-occurrence, 88.9% (n = 8/9) had EBV VL >1000 copies/ml and 11.1% (n = 1/9) had EBV VL <1000 copies/ml. Among the PRTRs with only EBV DNAemia and no co-occurrence of CMV DNAemia (n = 2), EBV DNAemia was found to be more than >1000 copies/ml. Among the PRTRs with GDF (Group B3), 44% (n = 11/25) had EBV DNAemia of 2893.9 ± 1869 copies/ml. EBV DNAemia without GDF was 8700.2 ± 9675.6 copies/ml and was considerably higher and this difference was statistically significant (P = 0.004).
Co-occurrence of cytomegalovirus and Epstein–Barr virus DNAemia among postrenal transplant recipients
Among 89 PRTRs, co-occurrence of EBV and CMV DNAemia was found in 21.3% (n = 19) [Figure 5]. In nineteen PRTRs, EBV CMV co-occurrence was found in 24% (n = 5/21) in the immediate (<3 months), 17.6% (n = 3/17) in late (>3 – 12 months) and 21.6% (n = 11/51) during very late onset (>1 year) post transplantation period [Table 3]. EBV DNAemia ± SD was found to be 4581 ± 6279.20 copies/ml in PRTRs who had co-occurrence with CMV DNAemia, whereas in PRTRs with EBV DNAemia only, it was found to be 9600 ± 10046.3 copies/ml. However, when we compared the difference in DNAemia levels, it was not statistically significant (P = 0.05; Student's t- test).
|Figure 5: Co-occurrence of Epstein–Barr virus DNAemia and cytomegalovirus DNAemia in postrenal transplant recipients|
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|Table 3: Co-occurrence of viral infection among post renal transplant recipients (PRTRs)|
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Graft dysfunction in post transplant period
Among 89 study participants, 50% (n = 6/12) of PRTRs had EBV DNAemia with GDF during very late (>1 year) transplantation, 42.5% (n = 3/7) in immediate (<3 months) transplantation and 33.3% (n = 2/6) in late (>3–12 months) post transplant period.
| Discussion|| |
Laboratory diagnosis of EBV is usually performed by serological tests based on heterophile antibody detection; however, false positivity limits the use of serology in EBV diagnosis.,, IHC is currently used for histopathological examination of EBV and has a reported sensitivity of 44% and specificity of 93%; however, biopsy of the involved lymph node is required for IHC and this is an invasive procedure. Quantitation of EBV DNA by real-time PCR is a rapid and specific test and should be used for assessing EBV DNAemia among PRTRs.
EBV DNAemia was encountered throughout the posttransplant period (immediate-, late-, and very late-onset periods). Out of the 89 PRTRs tested, 39.3% (n = 35) had EBV DNAemia; the rest (n = 54), i.e., 60.7% of the PRTRs did not have EBV DNAemia though most of them were symptomatic. EBV DNAemia was frequently encountered in the 1st month in the immediate-onset group and 1–3 years in very late-onset group. The EBV DNAemia in immediate-, early-, and very late-onset groups was analyzed, and the range of EBV DNAemia was higher in immediate-onset (1084–21,902 copies/ml) and very late-onset (324–32,436 copies/ml) periods.
EBV DNAemia with >1000 copies/ml was documented in 37% (n = 33) and <1000 copies/ml in 2.2% (n = 2) of the PRTRs. Studies have documented EBV VLs of >2000 copies/μg DNA in patients who later developed PTLD. In our study, majority of the PRTRs (71.4%) had VL >2000 copies/ml. Only nine PRTRs had VL <2000 copies/ml; however, they also had clinical evidence of EBVD. Higher EBV DNAemia may be a predictor of PTLD even before the onset of signs and symptoms. Since it was a one-time sampling, it is not clear whether it is a transient DNAemia. A documented high EBV DNAemia of EBV occurring in a time frame of up to 6 weeks is reported to result in PTLD, in 80% of PRTRs. Even before the onset of clinical signs and symptoms of EBV, high EBV level is an indication of developing PTLD; therefore, preemptive treatment can be initiated to prevent illness and halt the disease progression.
Only one-time sampling was done. We did not monitor EBV VL with the change in immunosuppression in our PRTRs. The immunosuppressant used is a reflection of the period when the participants underwent transplantation. Since EBV DNAemia is a predictor of the development of PTLD and as previously shown, we believe that even a single estimation of EBV DNAemia is sufficient to alert the clinician on the line of management and customize treatment. Although serial PCRs would be useful in documenting the changes in EBV DNAemia, the costs of such periodic assays preempt frequent testing. PRTRs with asymptomatic DNAemia are at a higher risk for progression to PTLD, and it is also a predictor of other outcomes such as GDF, acute rejection, or late-onset PTLD.,,, Even in the absence of biopsy-proven PTLD, preemptive treatment may be used to treat the laboratory-detected disease in the context of high EBV DNAemia.
Some studies have reported that EBV-associated PTLD usually occurs after 6 months of transplantation and decreases subsequently and then rises again after 4–5 years of transplantation., Our data show that the participants in the immediate post transplant period had high EBV DNAemia, which suggests that this period may be the window period with high VL which precedes PTLD. Similarly, 1–3 years posttransplant, high EBV DNAemia was documented and PTLD is reported in the 4–5 years posttransplant, which again suggests that high EBV DNAemia precedes PTLD in that period. The limitation of our study is that we have not followed up the participants for progression of PTLD. PRTRs who have GI manifestations or features of GDF and severe anemia or only even a mild alteration in renal parameters need to be monitored for CMV and EBV. Further studies will be conducted to follow up patients with high VL for PTLD. High EBV DNAemia, whether in symptomatic or asymptomatic PRTRs, needs to be monitored or treated to preempt PTLD.
Currently, there are no standard cutoffs to define EBV DNAemia or CMV DNAemia., In our study, the VL among PRTRs for EBV ranged from 324 to 32,436 copies/ml of DNA. All the participants enrolled in the study were either symptomatic or had altered renal parameters. Therefore, we believe that any VL is significant in PRTRs who are symptomatic or have altered renal parameters. Many laboratories have developed their own cutoff values for EBVD. Detection of EBV DNA in whole blood will serve as a noninvasive sample for the prevention of GDF and PTLD.
Both EBV and CMV are associated with GDF in PRTRs. EBV DNAemia and CMV DNAemia in PRTRs with GDF were analyzed. All participants with GDF had eGFR ranging from 3.89 to 72.3 [Table 2], well below the normal range. We believe that DNAemia CMV or EBV or both with altered renal parameters and altered eGFR require treatment irrespective of the VL. Our data have clearly shown that high VL is not necessarily required for GDF.
Cytotoxic T-cell response is essential in controlling the virus in healthy individuals. Up to 50% of the circulating cytotoxic T-cells are activated against EBV-infected B-cells. However, this T-cell response is insufficient to eliminate all the infected B-cells. In PTR, there is a diminished T-cell-mediated immunity which is because of immunosuppressive therapy.,
CMV is an immunomodulating virus, it increases the risk of other opportunistic infections, especially EBV, which may lead to GDF. The association of EBV and PTLD is well known. Co-occurrence of EBV and CMV was 21% in our PRTRs. Graft dysfunction and GI disease may be influenced by CMV or EBV or both viruses. We found 18% of EBV and 21.3% of co-occurrence of EBV and CMV among 89 PRTRs, which shows that CMV is a risk factor for co-infection with EBV.
Is there a need for testing Epstein–Barr virus DNAemia among postrenal transplant recipients?
Our data clearly show how many among the symptomatic (42.6% [n = 32]) and (21.4% [n = 3]) asymptomatic had EBV DNAemia. EBV DNAemia by real-time PCR is routinely used to monitor the EBV DNAemia in response to treatment in PTR with symptoms which include lymphadenopathy or other mass lesions, organ dysfunctions, fever, malaise, or other signs and symptoms suggestive of PTLD. Furthermore, it is required to monitor EBV in post transplant recipients (PTR) with rising serum creatinine in the absence of clinical symptoms or absence of an invasive disease.
| Conclusion|| |
To the best of our knowledge, there is no data in India regarding EBV DNAemia in adult PRTRs. We believe that even a single estimation for EBV DNAemia by quantitative real-time PCR and correlation with the clinical signs, symptoms and renal parameters along with estimation for the co-occurrence of CMV DNAemia will assist the clinician in the selection of treatment protocols and immunosuppressive regimens.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3]