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Prophylactic, pre-emptive strategies both effective for CMV prevention after transplant
Both prophylaxis and pre-emptive strategies for preventing cytomegalovirus among patients undergoing solid organ transplantation were effective, according to data published in Clinical Infectious Diseases.
However, although patients who receive prophylaxis are at lower risk for CMV infections, they are at higher risk for late-onset CMV disease and more adverse effects, researchers found.
A pre-emptive approach involves monitoring viremia and administering antiviral therapy only if patients develop cytomegalovirus (CMV) replication. With prophylaxis, patients are given antiviral treatment one to four times daily for 3 to 6 months after transplantation.
“Both preventive strategies have been used to prevent CMV infections after solid organ transplantation, and it is still highly debatable which method should be preferred,” Diana Florescu, MD, an associate professor in the department of medicine at the University of Nebraska Medical Center, told Infectious Disease News. “We found that both are equally effective in preventing CMV syndrome and CMV disease. The choice of a strategy depends on a particular transplant program infrastructure, cost of the preventive strategy, patient compliance and potential adverse effects.”
Diana Florescu
Florescu and colleagues conducted a meta-analysis to compare the two methods directly and indirectly. The direct analysis included 20 studies and 2,744 patients, and the indirect analysis included 20 studies and 2,544 patients.
In the direct comparison, there was no difference in the odds for developing CMV syndrome and invasive CMV disease between the pre-emptive treatment and prophylaxis groups. The odds for late-onset CMV disease were higher in the prophylaxis group (OR=6.21; 95% CI, 2.55-15.2).
For secondary outcomes, the odds for CMV viremia were lower in the prophylaxis group (OR=0.42; 95% CI, 0.24-0.74). The prophylaxis group had more leukopenia (OR=1.97; 95% CI, 1.39-2.79) and more neutropenia (OR=2.07; 95% CI, 1.13-3.78). There were no differences between the two groups in terms of graft loss, graft loss censored for death, acute rejection or mortality. In an indirect comparison, there were no differences found.
“Prophylaxis remains the favored method for high-risk and intermediate-risk patients, such as those with CMV sterostatus D+/R- and R+, and the results suggest a hybrid preventive strategy should be studied in these patients,” Florescu said. “We also need to develop and study newer antiviral drugs that are more affordable, have a better safety profile and an easier dosing schedule.” – by Emily Shafer
Diana Florescu, MD, can be reached at dflorescu@unmc.edu.
Disclosure: Florescu is a consultant for Chimerix and CSL Behring and receives grants from both and ViroPharma.