1668. The clash of the titans: Prophylaxis vs. Preemptive strategies for CMV infections after solid organ transplantation. A meta-analysis
Session: Poster Abstract Session: Pre-emptive Therapy in Transplantation and Immunocompromised Hosts
Saturday, October 5, 2013
Room: The Moscone Center: Poster Hall C
  • CMV Infections.pdf (217.9 kB)
  • Background:  Prophylactic and preemptive strategies are  used to prevent cytomegalovirus infections after solid organ transplantation (SOT). Many randomized trials directly comparing these strategies have been published. We assessed the safety and efficacy of both strategies for CMV prevention after SOT.

    Methods:  DerSimonian and Laird random-effects model was used for pooling and Q statistic method and I-squared methods were used to assess statistical heterogeneity

    Results:  Twenty studies (2744 patients) were selected. The odds of CMV syndrome (OR=1.10;95%CI:0.60-2.03;p=0.76;I2=51.49%) and disease (OR=0.77;0.41-1.47;p=0.43;I2=44.97%.) were not significantly different  between strategies. The odds of developing late-onset CMV infections were higher for the prophylactic compared to the preemptive strategy (OR=6.21;2.55-15.20;p<0.0001;I2=37.9%). The odds of CMV viremia were lower for prophylaxis (OR=0.42;0.24-0.74;p=0.003;I2=75.1%). The analysis by drug type for prophylaxis showed that all drugs caused similar reductions  in CMV viremia: acyclovir and valacyclovir (OR=0.37;0.04-3.70;p=0.40;I2=82.51%), ganciclovir (OR=0.45;0.12-1.65;p=0.23;I2=69.08%) and valganciclovir (OR=0.47;0.22-0.99;p=0.05;I2=79.80%). Compared to preemptive strategy, prophylaxis prevented more CMV viremia when duration was 5.7 -14.3 weeks (OR=0.37;0.20 0.71;p=0.003;I2=78.60%), but not when duration was 17.1-25.7 weeks (OR=0.76;0.31-1.87;p=0.55;I2=0%). No differences between strategies were noted for: graft loss (OR=0.88;0.37-2.13;p=0.78;I2=38.62%), graft loss censored for death (OR=0.73;0.17-3.21;p=0.68;I2=55.32%), acute rejection (OR=0.93;0.70-1.24;p=0.64;I2=7.61%) and mortality (OR=0.80;0.56-1.14;p=0.22;I2=0%). More  patients on prophylaxis had leukopenia (OR=1.97;1.39-2.79;p=0.0001;I2=0%) and neutropenia (OR=2.07;1.13-3.78;p=0.02;I2=11.40%) compared to patients on preemptive strategy. The odds for other infections (HSV, VZV, bacterial and fungal infections) were not significantly different between both strategies.

    Conclusion:  The prophylactic and preemptive strategies have similar efficacy in preventing CMV syndrome and disease. Prophylaxis was associated with less viremia early after transplantation, but with significantly more late-onset CMV infections and side effects (leukopenia and neutropenia). Rates of rejection, graft loss, death and other infections were similar.

    Diana F. Florescu, MD, Transplant Surgery Division, University of Nebraska Medical Center, Omaha, NE; Infectious Diseases, University of Nebraska Medical Center, Omaha, NE, Fang Qiu, PhD, Biostatistics Department, Nebraska Medical Center, Omaha, NE, Cynthia Schmidt, MD, MLS, University of Nebraska Medical Center, Omaha, NE and Andre C. Kalil, MD, MPH, Internal Med., Univ. of Nebraska Med. Ctr., Omaha, NE


    D. F. Florescu, Behring: Consultant and Investigator, Consulting fee, Research grant and Research support
    Chimerix: Consultant and Grant Investigator, Consulting fee and Research grant

    F. Qiu, Chimerix: Grant Investigator, Research support
    Behring: Grant Investigator, Research support

    C. Schmidt, None

    A. C. Kalil, Chimerix: Grant Investigator, Research support

    Findings in the abstracts are embargoed until 12:01 a.m. PST, Oct. 2nd with the exception of research findings presented at the IDWeek press conferences.