*Purpose: Guidelines recommend preemptive therapy (PET) as one strategy for prevention of CMV disease in high risk liver transplant recipients (LTR). However, questions have been raised about feasibility and highly precise logistic requirements particularly in active centers with large volumes.

*Methods: Retrospective cohort study in high risk LTR (November 2016 – December 2018). Blood CMV DNA PCR was performed weekly during first 90d; every 1-2 weeks for 3m and then monthly. Antiviral was started for any level of viremia early post-transplant until 2 consecutive negative tests. Primary outcomes were incidence of CMV infection (viremia, regardless of symptoms) and disease (syndrome or end-organ invasive disease).

*Results: 58 LTR were evaluated. Mean age was 55.8±11.3. Mean MELD was 22±7.4. Nonalcoholic steatohepatitis cirrhosis (25.8%) was common followed by alcoholic cirrhosis (20.6%). 51.7% received ATG induction. 55/58 (94.8%) patients met all weekly CMV levels during first 90d. Only 1 LTR missed few measurements during subsequent months. CMV infection occurred in 51/58 (87.9%) during first 90d, 23/56 (41.1%) during subsequent 3 months, and 6/55 (10.9%) after 6 months post-LT. Median time to first detection of CMV was 26d (IQR, 22-32). 12.1% LTRs did not have any CMV infection. The incidence of CMV disease was 6.9% (3 CMV syndromes; 1 CMV hepatitis), with a median time of 32d (IQR, 27.2-36) post-LT. LTR with hepatitis lacked CMV levels for 1 month and had a peak of 1251560 IU/mL upon presentation. No late-onset CMV disease was documented. 100% of LTR with first CMV infection were treated regardless of CMV level. Valganciclovir was the most common therapy. 22.4% (11/49) of subsequent asymptomatic viremias (median CMV level 204, IQR 187-379) were monitored without any treatment and spontaneously resolved after a median time of 7d (IQR 6.5-19). 3 cases of resistant CMV infection were documented with UL97 gene mutations [A594V (2) and deletion 599-601 (1)]. Bacterial/ fungal infection occurred in 13/58 (22.4%). 19/58 (32.7%) LTR developed acute rejection; 13/19 (68.4%) occurred 60d after CMV infection. 1-year mortality and graft failure were 10.3% and 5.1%, respectively.

*Conclusions: PET is feasible even with large numbers of high risk LTR. CMV infection is common early post-LT (3m); however, CMV disease is not. The proportion of LTR with important outcomes such as late-onset CMV disease, resistant CMV, bacterial/ fungal infections, acute rejection, graft failure, and death was favorable in this PET cohort.

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