Effectiveness of Preemptive Therapy for Cytomegalovirus Disease in Pediatric Liver Transplantation

Abstract

Background: Most pediatric liver transplantation (LT) centers administer long courses of prophylaxis against cytomegalovirus (CMV) without evidence of benefit and with significant drug exposure and costs. We aimed at evaluating overall outcomes, direct and putative indirect effects of CMV, possible impact of viremia and risk factors for CMV infection in pediatric LT recipients managed with ganciclovir-based preemptive therapy (PET).

Methods: The records of all the children who underwent LT between 2008 and 2014 were retrospectively analyzed.

Results: One hundred children were included. Three children had CMV disease; no CMV-related death or graft loss was recorded. The only identified risk factor for CMV infection was the donor/recipient serostatus (odds ratio, 17.23; 95% confidence interval, 1.88-157.87; P = 0.012), while viremia per se did not worsen LT outcomes, such as the incidence of acute rejection, Epstein-Barr virus infection, sepsis, biliary and vascular complications, nor graft dysfunction/loss or death at 3 and 5 years after LT. When compared with a historical cohort of children receiving ganciclovir prophylaxis, PET did not differ from prophylaxis for any of the selected outcomes, but was rather associated with lower antiviral drug exposure (6.4 ± 13 days vs 38.6 ± 14 days, P < 0.0001) and cost per patient (2.2 ± 3.9 k&OV0556; vs 6.6 ± 8.2 k&OV0556;, P = 0.001).

Conclusions: PET is effective in controlling CMV in children receiving LT, with lower costs and lower exposure to antivirals.

FIGURE 1.

Patient selection and inclusion in the study.

FIGURE 2.

Kaplan-Meier curve comparison of patients managed with preemptive therapy: CMV infection-free survival according to donor (D)/recipient (R) serostatus: D−/R− (N = 5); Dany/R+ (N = 64); D+/R− (N = 16).

FIGURE 3.

Kaplan-Meier curve comparison of patients managed with preemptive therapy and prophylaxis. A, CMV infection-free survival at 200 days post-LT; proportion of patients without graft dysfunction (B), biliary complications (C), and vascular complications (D) at 3 years after LT.