Abstract
BackgroundIn the absence of an adequate prevention strategy, up to 20% of CMV IgG+ liver transplant recipients (LTR) will develop CMV disease. Despite improved reporting in CMV-DNAemia, there is no consensus as to what the ideal CMV-DNAemia cutoff for a successful preemptive strategy is. Each transplant centre establishes their own threshold. We aimed to determine the effectiveness of our preventive strategy in CMV IgG+ LTR, and evaluate CMV replication kinetics.MethodsIn this retrospective study we determined the incidence of CMV disease in the first 6 months following transplantation in CMV seropositive LTR in a tertiary-care centre in Mexico. Secondary outcomes were determining the number of patients who required preemptive therapy (treatment cutoff ≥ 4000 UI/ml), adherence to the centre’s prevention protocol and calculation of viral replication kinetics.ResultsOne-hundred and twenty-four patients met inclusion criteria. Four patients (3.2%) developed CMV disease. Ninety-six (85%) had detectable DNAemia and 25 (22%) asymptomatic patients received preemptive therapy, none of them developed CMV disease. The highest viral loads were observed on the second posttransplant month. The number of viral load measurements decreased over time. Patients with DNAemia ≥ 4000 UI/ml had a faster viral load growth rate, shorter viral load duplication time, and higher basic reproductive number. Viral load growth rate and autoimmune hepatitis were associated with development of DNAemia ≥ 4000 UI/ml.ConclusionCytomegalovirus disease occurred in 3.2% of the study subjects. Preemptive therapy using a threshold of CMV ≥ 4000 UI/ml was effective in reducing the incidence of end-organ disease. The viral replication parameters described in this population highlight the importance of frequent monitoring, a challenging feat for transplant programs in low- and middle-income countries.
Highlights
Periodical measurement of CMV DNAemia and initiation of treatment once a threshold is reached is known as preemptive therapy [2]
Study design and outcomes This was a retrospective cohort study of CMV IgG-positive adult liver transplant recipients managed under preemptive therapy for prevention of CMV disease
Viral load growth rate and autoimmune hepatitis were associated with development of DNAemia ≥ 4000 UI/ml on multivariate analysis
Summary
In the absence of an adequate prevention strategy, up to 20% of CMV IgG+ liver transplant recipi‐ ents (LTR) will develop CMV disease. Each transplant centre establishes their own threshold. We aimed to determine the effectiveness of our preventive strategy in CMV IgG+ LTR, and evaluate CMV replication kinetics. Cytomegalovirus (CMV) is a major pathogen affecting solid organ transplant (SOT) recipients. Up to 20% of CMV IgG-positive liver transplant recipients develop disease in the absence of a prevention strategy. Periodical measurement of CMV DNAemia and initiation of treatment once a threshold is reached is known as preemptive therapy [2]. Despite standardization by the World Health Organization (WHO) in 2010 there is no universal DNAemia threshold at which therapy should be initiated. Transplant centres establish and monitor their own criteria to initiate antiviral therapy in SOT recipients
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