*Purpose: Opportunistic infections remain a significant burden after liver transplantation, particularly cytomegalovirus (CMV) infection. With the use of valganciclovir (VGCV), the incidence of CMV infection post-liver transplantation has reduced significantly, however the optimal time to initiate CMV prophylaxis (ppx) in liver transplant recipients is unclear and VGCV use is limited by cost and side effects including leukopenia and thrombocytopenia. This study evaluates timing to CMV ppx initiation and outcomes in liver transplant recipients.

*Methods: In this single center retrospective cohort study of adult liver transplant recipients between August 2018 and May 2019, patients who received immediate VGCV (within 6 days post-transplantation) were compared to those who received delayed VGCV (7-10 days post-transplantation) for CMV ppx. Patients included in this study received VGCV within 10 days of transplant and continued through at least 3 months. Exclusion criteria included patients with a prior history of transplantation, simultaneous kidney and liver transplantation, VGCV initiation greater than 10 days after liver transplant, and patients with unknown recipient CMV serologies. The primary outcome evaluated was the incidence of CMV viremia. Secondary endpoints included CMV syndrome, CMV tissue-invasive disease, biopsy proven acute rejection episodes (BPAR), allograft loss, and 6-month all-cause mortality.

*Results: The average time to initiation of VGCV ppx in the immediate group was 3.71 days ± 1.65, compared to 7.76 days ± 0.96 in the delayed group. CMV viremia occurred in 14.3% and 12.1% of patients in the immediate and delayed ppx groups respectively (p > 0.99). No differences were found in secondary outcomes. We estimated a cost savings of $429.62 per patient.

*Conclusions: Our study demonstrates that timing to CMV ppx initiation with valganciclovir does not influence the incidence of CMV viremia in adult patients after liver transplantation, and is an area for cost containment for transplant centers.

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