Recurrent Cytomegalovirus Infections in Heart Transplant Recipients in the Current Era of Immunosuppression

Abstract

Society guidelines recommend prophylaxis for patients at high risk (D+/R−) of developing cytomegalovirus (CMV) infection following heart transplantation. We sought to quantify the burden of CMV viraemia in intermediate-risk patients (R+). We reviewed 150 consecutive heart transplant recipients (2013–2017). Intermediate-risk patients had regular laboratory monitoring to detect early viral replication. High-risk patients received ganciclovir prophylaxis within 24 hours of transplantation with subsequent valganciclovir. Patients received induction immunosuppression with basiliximab if serum creatinine >120 μmol/L (n = 118); all patients received maintenance tacrolimus and mycophenolate mofitil. Cytomegalovirus viraemia was defined as serum CMV polymerase chain reaction >712 IU/mL; sustained increase in CMV titre despite oral valganciclovir was considered persistent viraemia. There was a high prevalence of CMV viraemia in intermediate-risk patients with 55% (n = 59/107) having 31 episodes of CMV viraemia; it was 39% (n = 9/23; p = 0.163) in high-risk patients. There was no difference in the proportion of viraemic patients with persistent viraemia or clinical CMV infection requiring hospitalisation for IV ganciclovir in intermediate-risk versus high-risk patients (46% [n = 27/59] vs 67% [n = 6/9]; p = 0.242). However, presence of clinical CMV disease requiring hospitalisation was lower in intermediate-risk than in high-risk patients (17% [n = 10/59] vs 57% [n = 6/9]; p = 0.001). Mean highest CMV titre was lower in intermediate-risk than in high-risk patients (372,070 IU/mL vs 1,324,1779 IU/mL; p = 0.002). There was no observed difference in mortality, allograft rejection, or vasculopathy between groups. We identified at least an equivalent risk of CMV viraemia and hospitalisation for intravenous ganciclovir in intermediate-risk and high-risk patients, when the former are managed by pre-emptive therapy.