Evaluation of a change in cytomegalovirus prevention strategy following pediatric solid organ transplantation

Abstract

Background: An optimal cytomegalovirus (CMV) prevention strategy following solid organ transplantation (SOT) remains uncertain. This study reports on the rates of CMV events following a change in a local prevention guideline involving increased surveillance, earlier transition to oral valganciclovir, and decreased CMV-immunoglobulin use.Methods: A retrospective cohort study utilizing historical controls evaluated the rates of CMV invasive disease pre-and post-intervention among pediatric heart, liver, and kidney recipients. Outcomes were recorded for the 4 years pre-and post-intervention, 9/2009-10/2017. Logistic regression was used to estimate the risk of a CMV event.Results: There was no difference in the rates of CMV invasive disease between the two study groups (P = 1). An increase in the detection of CMV events occurred (P = .04), predominantly asymptomatic CMV infection. This increase was independently associated with increased surveillance testing among high-risk heart and liver recipients, aOR 1.08(1. 06-1.12). Surprisingly, 28.9% of CMV events occurred during antiviral prophylaxis. Conclusions:Modification of the local CMV prevention guideline did not result in an increase in CMV invasive disease. CMV events occurred while on prophylaxis, highlighting a potential difference from adult solid organ transplant (SOT) and emphasizing the potential need for monitoring on prophylaxis in the pediatric population. K E Y W O R D Scytomegalovirus, pediatric, prevention, solid organ transplantation

Incidence of cytomegalovirus DNAemia in pediatric kidney, liver, and heart transplant recipients: Efficacy and risk factors associated with failure of weight‐based dosed valganciclovir prophylaxis

“…17 Pangonis et al reported that more CMV events occurred while patients were on prophylaxis predominantly for heart and liver transplant among 380 pediatric transplant recipients. 18 The majority of CMV DNAemia cases occurred in the first 180 days (median 126 days) post-transplant, which is comparable to other reports. However, our data are not suitable for evaluating the pre-emptive approach in our cohort.…”

“…Similarly, a recent study identified that 47% of the CMV DNAemia cases occurred on appropriate VGC prophylaxis among 93 pediatric kidney transplant patients 17 . Pangonis et al reported that more CMV events occurred while patients were on prophylaxis predominantly for heart and liver transplant among 380 pediatric transplant recipients 18 …”

CMV infection and management among pediatric solid organ transplant recipients

“…The utility of monitoring for CMV DNAemia while on antiviral prophylaxis is unclear. Pangonis et al evaluated a practice change at their institution that included increased surveillance among high‐ and medium‐risk pediatric heart, liver, and kidney transplant recipients receiving antiviral prophylaxis 16 . Increased surveillance resulted in a significant increase in the detection of CMV by PCR ( p = .04).…”

“…Increased surveillance resulted in a significant increase in the detection of CMV by PCR ( p = .04). However, most CMV events were asymptomatic DNAemia; only 3 episodes of CMV syndrome and zero cases of end‐organ disease occurred among children receiving antiviral prophylaxis 16 …”

“…However, most CMV events were asymptomatic DNAemia; only 3 episodes of CMV syndrome and zero cases of end-organ disease occurred among children receiving antiviral prophylaxis. 16 Many clinicians will initiate treatment dosing when CMV DNAemia is detected in a child already on antiviral prophylaxis, but the clinical significance and natural history of DNAemia in such patients is unknown. It is possible that many of these events are transient and do not require treatment dosing to resolve.…”