*Purpose:  Preemptive therapy  (PET)  has  demonstrated superiority to antiviral prophylaxis  for  prevention of  cytomegalovirus (CMV)  disease  in  CMV  donor seropositive/recipient seronegative (D+R-)  liver transplant recipients  (LTxRs)  in clinical trials. However, logistical challenges may preclude PET implementation  in  clinical practice  and  the feasibility  of PET has  not been assessed  in real-world settings.  

*Methods: We  retrospectively assessed a  cohort of consecutive  adult  CMV D+R- LTxRs  receiving PET for CMV prevention  between 4/4/2019 and 4/18/2021 at a single center (real-world  cohort, N=48) and compared measures of adherence to PET protocols and clinical outcomes to  a cohort of  CMV D+R-  LTxRs   randomized to PET as part of a clinical trial (CAPSIL,  N=100). PET consisted of weekly CMV plasma PCR  for 3 months  post-transplant  with initiation of valganciclovir 900mg twice daily at any detectable level of viremia. Adherence to PET was measured by proportion of  required  CMV PCRs  actually  performed,  proportion  of  patients  with >80% of scheduled  PCRs  completed,  and time to initiation of antivirals  in viremic patients. Clinical outcomes included incidence of CMV disease, allograft rejection, re-transplant and mortality within 6 months of transplant. Chi-square and Fisher’s exact tests were used to compare proportions between groups.   

*Results:  Incidence of viremia was similar in the real-world and CAPSIL cohorts (88% vs  81%, respectively).   There was no significant difference in the proportion of successfully completed  CMV  plasma PCRs  between the real-world (584/686, 85%) and CAPSIL (1207/1313, 92%) cohorts (p=0.28). Antivirals were initiated at a median of 3 days (IQR 2-3.75) in the real-world group versus 2 days (IQR 1-4) in the CAPSIL cohort. CMV  syndrome or end-organ  disease occurred in 8% of real-world  cohort  and 7% of  LTxRs  in the CAPSIL group (p=0.75). There was no significant difference in the incidence of allograft rejection, re-transplantation, or death between groups (Figure  1). 

*Conclusions: Adherence to viral load monitoring and timely initiation of antivirals is feasible in  LTxRs  receiving PET for CMV disease prevention in a real-world setting.  Further research is needed to  assess  the  generalizability  of these findings in  broader  clinical  contexts. 

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