Cytomegalovirus Immune Globulin (CMV-Ig): An Old Drug with Fewer Tricks - Removal of Prophylactic CMV-Ig Administration in CMV Mismatched Lung Transplant Recipients

Abstract

The routine use of cytomegalovirus immune globulin (CMV-Ig) to provide passive immunity to cytomegalovirus (CMV) in patients is not supported in published literature. International guidelines do not advocate for the use of CMV-Ig alone in thoracic transplant and provide only weak recommendations for its role in combination with antiviral therapy for prevention of CMV. The utilization of CMV-Ig incurs significant cost, and carries the potential for infusion related toxicities. Furthermore, in 2012, an international survey reported only 38 % of thoracic transplant centers utilized CMV-Ig as part of a universal prophylaxis protocol. We evaluated the safety and cost efficiency of the removal of CMV-Ig from standard practice. Prior to September 2018, CMV-Ig 150mg/kg x1 was given to all CMV high-risk lung transplant recipients on postoperative day two in conjunction with intravenous ganciclovir (GCV) followed by prophylaxis with oral valganciclovir (vGCV) for 12 months per institution protocol. After September 2018, CMV-Ig was removed from our institution protocol and high-risk patients received GCV/vGCV prophylaxis alone. Serum CMV PCRs were monitored per institution protocol. All patients post-intervention were retrospectively reviewed for occurrence of CMV viremia, seroconversion, and a cost savings analysis was performed. Twelve CMV high-risk lung transplant recipients were observed after the removal of CMV-Ig administration from standard practice. None of these patients experienced a detectable serum CMV PCR. Median follow up time was 163 days (IQR 111-301) post-transplant. All patients received antiviral prophylaxis immediately post-operatively, and had at least 8 weeks of follow up. Seroconversion was observed in three patients at post-operative day 7, 76, and 80 respectively. Using average wholesale price, the calculated cost savings was approximately $5,700 per patient and $68,400 across the entire cohort. Our results demonstrate that removal of CMV-Ig administration from standard practice, even in CMV high-risk patients, did not increase the risk of CMV viremia and led to significant cost savings. These data allude to the decreasing utility of CMV-Ig for CMV prophylaxis in the GCV/vGCV era.