1674. Preemptive Strategy for Cytomegalovirus (CMV) Disease Prevention in High Risk (D+/R-) Liver Transplant Recipients Receiving Induction Therapy Effective But Not Optimal
Session: Poster Abstract Session: Pre-emptive Therapy in Transplantation and Immunocompromised Hosts
Saturday, October 5, 2013
Room: The Moscone Center: Poster Hall C
Posters
  • SChuang IDSA 2013.pdf (267.0 kB)
  • Background:

    Current guidelines recommend 3-6 months of valganciclovir for CMV disease prevention in high risk (CMV IgG D+/R-) organ transplant recipients, though a pre-emptive approach is an alternative.  The liver transplant (LT) program at Cleveland Clinic uses a pre-emptive protocol, even after thymoglobulin (rATG) or basiliximab induction.  We sought to assess the efficacy of this strategy.

    Methods:

    For CMV IgG D+/R- LT recipients from 4/09 to 4/12, we retrospectively collected baseline and clinical data for 6 months from LT. Primary outcomes were CMV viremia, symptomatic infection and disease.  Secondary outcomes included patient and allograft survival, rejection, CMV occurrences, viral loads, hospitalizations and CMV resistance. 

    Results:         

    Of 69 D+/R- LT recipients, 58 received induction (9 rATG, 49 basiliximab). CMV infection occurred in 45/58 (77.6%) with induction vs 5/11 (45.4%) without induction (P= 0.06). 9/9 with rATG developed CMV. Analyses of secondary outcomes by induction vs. no induction were not statistically significant (Table 1).  Median initial and peak viral loads were higher with rATG than basiliximab, log 3.33 c/ml (IQR 3.07- 4.17) vs. 2.9 (IQR 2.72- 3.3) (P= 0.005), and log 4.28 c/ml (IQR 3.47- 4.69) vs. 3.7 (IQR 3.34- 4.08) (P< 0.05).  Mean CMV occurrences were greater with rATG than basiliximab or no induction at 2.11, 1.18 and 0.73, respectively (P= 0.008) (Figure 1).  Time to CMV infection was statistically significant between patients with induction and those without (Figure 3).

    Table 1.  Outcomes

    Induction + CMV

    (N= 45)

    No Induction + CMV

    (N=5)

    P

    CMV disease and/ or symptoms

    12 (26.7%)

    2 (40%)

    0.78

    CMV resistance

    2 (4.4%)

    0

    ---

    IV Therapy or Hospitalization

    21 (46.7%)

    2 (40%)

    ---

    Median log initial viral load

    3.01

    2.82

    0.31

    Median log peak viral load

    3.72

    3.22

    0.50

    Death or allograft loss

    1 (2.22%)

    0

    ---

    Rejection after CMV infection

    0

    0

    ---

    Figure 1. Mean CMV occurrences

     

    Figure 2. CMV- free survival

    Conclusion:

    A pre-emptive strategy was effective at preventing invasive CMV disease and early indirect effects in CMV D+/R- LT recipients.  However, this approach does not appear optimal, as evidenced by high rates of CMV infection, many requiring IV therapy or hospitalization, and frequent recurrences. 

    Sally Chuang, MD1, Dympna Kelly, MD2, Jessica Bollinger, PharmD3, Belinda Yen-Lieberman, Ph.D.4, David Van Duin, MD, PhD1 and Christine Koval, MD1, (1)Infectious Disease, Cleveland Clinic, Cleveland, OH, (2)Hepato-Pancreato-Biliary & Transplant Surgery, Cleveland Clinic, Cleveland, OH, (3)Pharmacy, Cleveland Clinic, Cleveland, OH, (4)Clinical Pathology, Cleveland Clinic, Cleveland, OH

    Disclosures:

    S. Chuang, None

    D. Kelly, None

    J. Bollinger, None

    B. Yen-Lieberman, None

    D. Van Duin, None

    C. Koval, None

    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.