Background:

Cytomegalovirus is a common opportunistic infection after transplant. Relapse may occur after treatment of the initial episode of viremia or disease and secondary prophylaxis is commonly used to prevent this. However, risk factors for recurrence are not fully defined and there are limited data assessing the utility of secondary antiviral prophylaxis (AVP).

Methods:

SOT patients with first episode of CMV disease or asymptomatic viremia (≥1000 copies/mL) and starting on antiviral therapy were identified by chart review encompassing a 5-year period. Data including baseline demographics, type of transplant and immunosuppression, antiviral therapy, viral loads, and use of secondary AVP (used at the discretion of the treating physician) were collected. The primary outcome was recurrence of CMV viremia or disease within 6 months of treatment discontinuation.

Results:

The first episode of CMV viremia requiring antiviral therapy was assessed in 100 patients (52 CMV disease and 48 asymptomatic viremia). Mean age was 50±14.6 years and transplant types were kidney (n=25), liver (n=25), lung (n=29), heart (n=10), kidney/pancreas(n=7), combined (n=4). CMV viremia or disease occurred at 6.5 (0.66-235.7) months post-transplant and 23% were classified as late onset CMV (>1 year post-tx). All patients received antiviral therapy until viral load was negative. Recurrent CMV occurred in 23% patients at a median of 56 (14-343) days after discontinuation of therapy. Factors predictive of relapse were absolute lymphocyte count <1000/μL at the end of therapy (mean lymphocyte count 810 in recurrence vs. 1410 in no recurrence, p=0.02). Patients with lung transplant were also more likely to have recurrence (41.9% in lung vs. 14.5% in nonlung, p=0.004). Age, immunosuppression, acute rejection, initial and peak viral load, CMV D+/R- serostatus, and presence of CMV disease were not significantly associated with CMV recurrence. Secondary AVP was given to 63% of patients. Recurrence occurred in 15/63 (23.8%) of patients that received secondary AVP vs. 8/37 (21.6%) in those with no prophylaxis (p=NS). Time to recurrence from end of therapy was 160.6 vs. 123.9 days in patients who received secondary AVP vs. no prophylaxis (p=0.004).

Conclusions:

Recurrent CMV occurs in a significant percentage of patients after treatment of the first episode of CMV viremia/disease. Lymphopenia and lung transplant were significant predictors of recurrence. Secondary antiviral prophylaxis was not associated with a reduced risk of recurrence.

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