*Purpose: Evaluate epidemiology and outcomes of cytomegalovirus infection (CMV) in pancreas transplant recipients (PTR) in the current era of valganciclovir (VGC) prophylaxis (PPX)

*Methods: Adult PTRs were divided into a current era (1/1/2011-12/31/17; 6 month VGC for high risk, D+/R-) and a historic era (1/1/2003-12/31/09; 3 month VGC for D+/R-). Primary objective: describe epidemiology of CMV in PTRs in the current era. Secondary objective: evaluate the effect of D+/R- PPX extension on CMV and patient/graft survival.

*Results: There were 590 PTRs in the study period; 307 in the historic era/283 in the current era. In the current era 27.9% of patients were D+/R-, 23.7% were D+/R+, 20.1% were D-/R+ and 28.3% were D-/R-. Serostatus distribution was similar in the historic era (p=0.15). In the current era one year rates of CMV varied significantly by serostatus (D+/R- 36%, D+/R+ 20.3%, D-/R+ 11.1%, D-/R- 1.4%; p<0.0001), however incidence of end organ CMV was not significantly different (D+/R- 6.9%, D+/R+ 1.6%, D-/R+ 3.6%, D-/R- 0%; p=0.1).

There were 177 D+/R- PTRs in the study period; 98 in the historic era/79 in the current era. Patients in the current era were older (40.4±7.5 vs 44.7±10.7, p=0.003), with higher BMI (24.9±3.9 vs 27±4.2 p=0.0009). There were significantly more pancreas alone PTRs in the current era (8.2% vs 41.8% p<0.0001). Although use of lymphocyte depleting induction was not different between eras (p=0.1), the agent varied significantly (historic: 59% alemtuzumab vs current: 52% thymoglobulin, p<0.0001).Overall rates of CMV (historic: 37% vs current 39%, p=0.93) and end-organ CMV (historic: 14% vs current 8.3%, p=0.44) were not different between eras. Extension of D+/R- PPX from 3 to 6 months resulted in reduction of overall CMV from 25.4% at 6 months in the historic era to 10.9% in the current era (p=0.021). However, by 1 year rates of CMV (historic: 31% vs current: 36%) and end organ CMV (historic: 7.7% vs current: 6.9%) were no longer different. There was also no significant difference in graft/death censored graft survival (p=0.16, p=0.08) or patient survival (p=0.79). The current era was not associated with reduced rates of CMV (HR 1.0, p=0.99) or end organ CMV (HR 0.5, p=0.3) in D+/R- on multivariable analysis adjusted for allograft type, induction, age and BMI. Additionally, after adjustment, the current era was not significantly associated with improved graft survival (p=0.08), death censored graft survival (p=0.07) or patient survival (p=0.6).

*Conclusions: CMV in PTRs follows classical serostatus dependent distribution. Despite current era PPX, rates approach 40% in D+/R-. While extension of PPX from 3 to 6 months reduced CMV at 6 months, overall incidence was not different between eras. These results suggest PPX extension only delays CMV development. Surveillance after PPX in PTRs may be indicated; it could lead to earlier detection which may result in improved outcomes. Month 6-12 will likely be associated with the highest yield.

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