Cytomegalovirus disease in lung transplantation: impact of recipient seropositivity and duration of antiviral prophylaxis

Abstract

A recent randomized trial demonstrated that 1year of antiviral prophylaxis for cytomegalovirus (CMV) after lung transplantation is superior to 3months of treatment for prevention of CMV disease. However, it is uncertain if a shorter duration of prophylaxis might result in a similar rate of CMV disease among select lung transplant (LT) recipients who are at lower risk for CMV disease, based on baseline donor (D) and recipient (R) CMV serologies. We retrospectively assessed incidence, cumulative probability, and predictors of CMV disease and viremia in LT recipients transplanted between July 2004 and December 2009 at our center, where antiviral CMV prophylaxis for 6-12months is standard. Of 129 LT recipients, 94 were at risk for CMV infection based on donor CMV seropositivity (D+) or recipient seropositivity (R+); 14 developed CMV disease (14.9%): 11 with CMV syndrome, 2 with pneumonitis, and 1 with gastrointestinal disease by the end of follow-up (October 2010); 17 developed asymptomatic CMV viremia (18.1%). The cumulative probability of CMV disease was 17.4% 18months after transplantation. CMV D+/R- recipients who routinely received 1year of prophylaxis were more likely to develop CMV disease compared with D+/R+ or D-/R+ recipients, who routinely received 6months of prophylaxis (12/45 vs. 2/25 vs. 0/24, P=0.005). Recipients who stopped CMV prophylaxis before 12months (in D+/R- recipients) and 6months (in R+ recipients) tended to develop CMV disease more than those who did not (9/39 vs. 3/41, P=0.06). On a 6-month CMV prophylaxis protocol, few R+ recipients developed CMV disease in this cohort. In contrast, despite a 12-month prophylaxis protocol, D+/R- LT recipients remained at highest risk for CMV disease.