Cytomegalovirus Infection After Kidney Transplantation: From Recent Guidelines to Feasible Strategies in Resource-Limited Settings

By Amantia IMERAJ, Nevi PASKO, Ariana STRAKOSHA

Abstract
Cytomegalovirus (CMV) remains one of the most frequent and clinically relevant opportunistic infections after kidney transplantation. Its importance is related not only to direct viral effects, including asymptomatic viremia, CMV syndrome and tissue-invasive disease, but also to indirect immunomodulatory effects that may contribute to acute rejection, graft dysfunction and other opportunistic infections. In recent years, CMV management has progressively moved toward a more individualized and risk-adapted approach, based on donor and recipient serostatus, net status of immunosuppressive therapy, recipient-related risk factors, quantitative viral-load monitoring and early recognition of refractory or resistant disease. Current guidelines provide a detailed framework for prevention, diagnosis and treatment of CMV after solid organ transplantation. However, their application may be difficult in resource-limited settings, where access to standardized realtime quantitative PCR, repeated viral-load monitoring, rapid laboratory reporting, antiviral drugs and resistance testing may be limited. In this context, kidney transplant programs need feasible strategies able to translate guideline recommendations into daily clinical practice. This review summarizes the clinical impact of CMV after kidney transplantation, focusing on risk stratification, diagnostic monitoring, prevention strategies, treatment of CMV infection and disease, antiviral resistance and toxicity. Particular attention is given to the practical management of CMV in resource-limited settings. In these contexts, CMV care should be based on a structured but adaptable approach, integrating donor–recipient serostatus, net state of immunosuppression, clinical presentation and locally available diagnostic resources. A practical risk-based algorithm may help clinicians identify patients who require universal prophylaxis, closer viral monitoring or early therapeutic intervention, improving CMV management while considering real-world limitations.
Key Words: Cytomegalovirus Infection (CMV), Kidney Transplantation, Immunosuppressive therapy, CMV prophylaxis, resource limited-setting