Purpose: There is interest in reduced dosing and duration of valganciclovir (VGCV) for cytomegalovirus (CMV) prophylaxis in liver transplant (LT) recipients to minimize side effects and cost. Our center has implemented reduced-dose VGCV 450 mg for intermediate-risk recipients and 900 mg daily for high-risk recipients, both with a duration of 3 months. This study aimed at evaluating the efficacy of these dosing strategies.

Methods: We conducted a retrospective chart review of patients > 18 years of age who received a LT between 2/1/2013 and 3/31/2016. We included patients at high and intermediate-risk for CMV with at least 6 months of follow up time from prophylaxis discontinuation. Excluded were patients without at least one year of follow up laboratory data or receipt of a multi-organ transplant. The primary outcome was rate of CMV infection. Secondary outcomes included rates of biopsy-proven acute rejection (BPAR), time to CMV infection from transplant and time to CMV infection from discontinuation of antiviral prophylaxis.

Results: Forty-four patients met the criteria. Majority were male (70%) with mean age of 56.6 ± 10.5 years. Sixty-one percent received basiliximab induction and 52% received mycophenolate maintenance. Out of the 17 high-risk patients, 14 developed CMV infection (82%), 5 of which developed CMV disease (29%). Of the 27 intermediate-risk patients, 4 developed CMV infection (15%), with only 1 developing CMV disease (4%). Rate of BPAR for the cohort was 18% (n=8). BPAR occurred in 4 patients with CMV infection prior to the diagnosis of CMV. CMV infection occurred in the high and intermediate-risk groups at a median of 170 and 69 days post-transplant and 62 and 372 days post-discontinuation of prophylaxis, excluding 1 case of breakthrough CMV in the high-risk group and 2 cases of breakthrough CMV in the intermediate-risk group, respectively. All cases of breakthrough CMV received appropriate VGCV dosing.

Conclusion: While half-dose antiviral prophylaxis for 3 months resulted in acceptable rates of CMV infection in intermediate-risk patients, CMV disease, particularly tissue-invasive disease, remains a burden in the high-risk population. This study highlights the potential role of preemptive CMV monitoring post-discontinuation of prophylaxis as the majority of cases occurred within 3 months of VGCV discontinuation.

CITATION INFORMATION: Belfield K., Malinis M., Cohen E. Efficacy of Two Valganciclovir Dosing Strategies in Intermediate and High-Risk Liver Transplant Recipients Am J Transplant. 2017;17 (suppl 3).

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