Table 2.

Reported cases of systemic cytomegalovirus-associated thrombotic microangiopathy in kidney transplant recipients.

Author, Year	Country	Age (Years), Sex	Time after Transplant	Immunosuppression	CMV manifestation	CMV blood diagnostic tests	TMA features	Renal involvement	Other extrarenal involvement of TMA	Treatment	Dialysis required	Outcome
Jeejeebhoy et al. (1998) (29)	Canada	57, Female	6 weeks	Cyclosporine + azathioprine + prednisone	CMV pneumonitis, BAL viral culture; inclusion bodies	CMV IgM positive	MAHA, thrombocytopenia, ↑LDH, schistocytes	Acute kidney injury, no biopsy	Neurologic symptoms (headache, seizures)	CsA withdrawal, plasmapheresis (failed), IV ganciclovir	Not reported	Complete resolution
Waiser et al. (1999) (28)	Germany	28, Male	2 months	Tacrolimus + MMF + steroids	Primary CMV disease with CMV esophagitis	PCR+, pp65 antigenemia+	MAHA, ↑LDH, ↓haptoglobin, schistocytes	Acute renal failure; biopsy-proven TMA in allograft	None reported	Ganciclovir + plasmapheresis + reduction of immunosuppression	Yes	Graft failure; chronic hemodialysis
Waiser et al. (1999) (28)	Germany	33, Male	8 years	Cyclosporine + steroids	Primary CMV disease with fever and leukopenia	PCR+, pp65 antigenemia+	MAHA, thrombocytopenia, ↑LDH, schistocytes	Acute renal failure; biopsy-proven TMA	Gastrointestinal TMA (jejunal lesions)	Ganciclovir + plasmapheresis	Yes	Recovery of hemolysis but graft loss
De Keyzer et al. (2010) (30)	Belgium	46, Male	25 years	Azathioprine + prednisolone	CMV syndrome	CMV PCR: 1,600,000 copies/mL	MAHA, thrombocytopenia, ↑LDH, schistocytes	Acute graft failure; biopsy-proven TMA	None reported	Valganciclovir → IV ganciclovir + foscarnet + plasma Exchange	Yes	Persistent graft loss; chronic hemodialysis
Macesic et al. (2015) (31)	Australia	61, Male	9 months	Tacrolimus + MMF + prednisone	CMV colitis followed by CMV viremia and CMV glomerulopathy	CMV DNA PCR positive	MAHA with thrombocytopenia, elevated LDH, low haptoglobin, rare schistocytes	Biopsy-proven TMA	None reported	Plasma exchange, withdrawal of tacrolimus, CMV immunoglobulin, leflunomide, artesunate, adoptive CMV-specific T-cell therapy	Yes	Recovery of hemolysis but graft loss; chronic hemodialysis
Naidu et al. (2023) (32)	Australia	76, Female	3 years	Tacrolimus, everolimus, prednisone	CMV viremia with prior CMV colitis	CMV PCR > 300,000 copies/mL	MAHA with thrombocytopenia, elevated LDH (815 U/L), schistocytes	Acute graft failure; biopsy-proven TMA	None reported	Methylprednisolone, IVIG, plasma exchange, tacrolimus withdrawal, IV ganciclovir	Yes	Irreversible graft loss; chronic hemodialysis
Current case	Colombia	78, Female	6 years	Tacrolimus, mycophenolate mofetil, prednisone.	CMV viremia with gastrointestinal symptoms	Quantitative CMV PCR positive (54,000 copies/mL)	MAHA, thrombocytopenia, elevated LDH, undetectable haptoglobin, schistocytes; ADAMTS13 normal	Acute kidney injury without biopsy	None reported	Discontinuation of tacrolimus; IV ganciclovir followed by valganciclovir; RBC transfusion; switch to belatacept-based immunosuppression	No	Complete resolution of TMA with recovery of graft function

CMV, cytomegalovirus; TMA, thrombotic microangiopathy; MAHA, microangiopathic hemolytic anemia; LDH, lactate dehydrogenase; PCR, polymerase chain reaction; BAL, bronchoalveolar lavage; IgM, immunoglobulin M; CsA, cyclosporine A; MMF, mycophenolate mofetil; IV, intravenous; IVIG, intravenous immunoglobulin; RBC, red blood cells; ADAMTS13, a disintegrin and metalloproteinase with thrombospondin type 1 motif, member 13.