In a recently published article on low-dose ganciclovir prophylaxis. Hibberd and colleagues [1] found a markedly reduced incidence of CMV disease in renal transplant recipients receiving antilymphocyte globulin. When antilymphocyte globulin was given to treat acute rejection, the incidence of CMV disease was as high as 64% in the 11 placebo recipients. Daily administration of ganciclovir (2.5 mg/kg of body weight) reduced the incidence of CMV disease to 22% (5 of 23 patients). At our institution, eight patients seropositive for CMV were treated with antilymphocyte globulin for steroid-resistant rejection and received higher doses of ganciclovir three times per week, to a total of nine doses, in an outpatient clinic. If a patient's creatinine clearance was less than 50 mL/min, the dose was reduced (creatinine clearance, 25 to 50 mL/min: 7.5 mg/kg of ganciclovir; 10 to 25 mL/min: 5 mg/kg; less than 10 mL/min: 2.5 mg/kg).

The clinical follow-up included weekly monitoring of leukocyte counts, creatinine clearance, and liver variables as well as CMV testing by detection of viral antigens in peripheral leukocytes (antigenemia assay) for as long as 12 weeks. None of the patients developed CMV disease as defined by Hibberd and colleagues. Only one patient developed low-level antigenemia (7 positive cells/100 000 leukocytes) without symptoms of CMV disease. No side effects required the discontinuation of preemptive ganciclovir therapy.

These preliminary results suggest that the incidence of CMV disease in high-risk patients receiving antilymphocyte globulin for rejection can be further reduced using higher doses of ganciclovir for longer intervals.