Intensive strategy to prevent CMV disease in seropositive umbilical cord blood transplant recipients

Abstract

Seropositive umbilical cord blood transplant (UCBT) recipients are at increased risk for CMV complications. To reduce CMV complications, we adopted an intensive strategy that consisted of ganciclovir administered before transplantation (5 mg/kg intravenously daily from day -8 to day -2), high-dose acyclovir (2 g, 3 times daily) after transplantation, and biweekly monitoring with a serum CMV PCR for preemptive therapy. Hazard rates and cumulative incidence of CMV complications along with days treated were compared in high-risk CMV-seropositive UCBT recipients who received the intensive strategy and a historical cohort who received a standard strategy. Of 72 seropositive patients, 29 (40%) received standard prophylaxis and 43 (60%) the new intensive approach. The hazard rate (HR) for CMV reactivation was lower for patients receiving the intensive strategy (HR 0.27, 95% confidence interval 0.15-0.48; P < .001) and led to fewer cases of CMV disease by 1 year (HR 0.11, 95% confidence interval 0.02-0.53; P = .006). In patients who reactivated, the intensive strategy also led to fewer days on CMV-specific antiviral therapy (median 42% [interquartile range 21-63] vs 70% [interquartile range 54-83], P < .001). Use of an intensive CMV prevention strategy in high-risk CMVseropositive UCBT recipients results in a significant decrease in CMV reactivation and disease.

Figure 1

Schema of seropositive UCBT study population.

Figure 2

Cumulative incidence of CMV reactivation to day +100 by prevention strategy in seropositive UCBT recipients (n = 72). Competing risk for CMV reactivation considered death or retransplantation; P value determined by the Gray test.

Figure 3

Mean observed CMV viral load in UCBT recipients during the first 100 days after transplantation by type of prevention strategy (n = 72). Whiskers equal 95% CIs for weekly mean value.

Figure 4

Use of anti-CMV antiviral therapy by type of prevention strategy. Anti-CMV therapy was considered ganciclovir and foscarnet; induction therapy was the period during which patients received the equivalent of twice-daily dosing of anti-CMV therapy. Only patients with proven CMV reactivation included. Total percentage was determined by days on anti-CMV therapy divided by total days alive during the first 100 days after transplantation. Whiskers equal 10th to 90th percentile, and solid dots equal outliers.