Universal CMV Prophylaxis Mitigates the Risks of Basiliximab Induction in Heart Transplant Recipients at Intermediate Risk (R+) for Post-Transplant CMV Complications

Abstract

Purpose Induction therapy with either thymoglobulin or basiliximab is used in approximately 50% of patients at the time of heart transplant. While the use of thymoglobulin has been reported to increase the risk of CMV reactivation, it remains unclear if this risk is also seen with basiliximab. In the present analysis, we compared post-transplant CMV outcomes in patients receiving basiliximab vs. no induction in a multicenter, retrospective analysis. We also assess the effects of universal prophylaxis on any attendant risk. Methods Retrospective analysis of 439 intermediate risk (CMV R+) HTx recipients from 6 U.S. centers between 2010-2018 treated with either basiliximab induction (63%, n = 276) or no induction (37%, n = 163). The primary endpoint was the development of CMV viremia or end-organ disease resulting in the escalation of anti-CMV therapy. The secondary endpoint was hospitalization for CMV-related infection. Results Of 439 patients in the analysis, 18.9% (n = 83) developed CMV viremia or end-organ infection requiring escalation of anti-CMV therapy, and 5.7% (n = 25) were hospitalized for CMV infection. Patients who received induction with basiliximab were more likely to meet the primary endpoint (22.8% vs. 12.3%, p = 0.006) and had a trend towards higher risk for CMV hospitalization (7.2% vs. 3.1%, p = 0.068) in the overall group. However, in patients receiving universal CMV prophylaxis, there was no difference in the primary (14.7% vs. 13.1%, p = 0.672) or secondary endpoint (4.1% vs. 3.3%, p = 0.687) when basiliximab was used compared to no induction. Alternatively, 36% of patients receiving basiliximab induction reached the primary endpoint when a preemptive therapy approach to prophylaxis was used (vs. 0% in no induction, p = 0.021). Conclusion Although basiliximab induction increases the risk of CMV viremia/end organ damage and CMV-related hospitalizations, this risk is eliminated when a universal CMV prophylaxis strategy is used.