Comparison of Outcomes in Heart Transplant Recipients Receiving CMV Prophylaxis with CMV IVIG with Valganciclovir versus Valganciclovir Alone

Abstract

Cytomegalovirus (CMV) remains one of the most common opportunistic infections affecting orthotopic heart transplant (OHT) patients, with seronegative (R-) recipients receiving transplants from seropositive donors (D+) being at the highest risk. CMV intravenous immune globulin (CMV IVIG) use for prophylaxis has been limited since the release of valganciclovir (VGC) due to efficacy, infusion-related toxicities, and cost. The ISHLT guidelines for the care of heart transplant recipients state there may be a role for CMV IVIG in high risk (D+/R-) OHT in combination with VCG, but it is not clearly defined. The goal of this study is to evaluate if adding CMV IVIG to VGC impacts the rates of CMV infection. This is a retrospective, pre-post study of CMV high risk adult OHT recipients transplanted between 1/1/2015-12/31/2018 (n=51). In 9/2017, the institutional protocol for prophylaxis of high risk CMV OHT recipients changed. Previously, high risk patients were given CMV IVIG for 3 months in addition to VGC 900 mg daily for 6 months (or renal dose equivalent). After the protocol change, patients received VGC alone for 6 months. CMV infection was defined as evidence of CMV replication regardless of symptoms. CMV disease was defined as evidence of CMV infection with attributable symptoms. Of the CMV high risk OHT recipients, 29 received CMV IVIG+VGC and 22 received VGC alone. There were no differences in baseline characteristics, immunosuppressive regimens, renal function, or VGC dosing between cohorts (Table 1). There was no difference in the rates of CMV infection at 1 year between cohorts (34.5% vs. 18.2%; p=0.225). Furthermore, there was no difference in rates of CMV pneumonia (6.9% vs 0%, p=0.499) or CMV colitis (0% vs 4.5%, p=0.431) between cohorts. Overall, only one patient had breakthrough CMV and that patient was on VGC therapy alone. CMV IVIG appears to have no added benefit in preventing CMV infections in the era of VGC therapy.