Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA.
Duke Clinical Research Institute, Durham, North Carolina, USA.
Clin Transplant. 2023 Oct;37(10):e15065. doi: 10.1111/ctr.15065. Epub 2023 Jul 1.
Heart transplant (HT) recipients with prior exposure to cytomegalovirus (CMV R+) are considered intermediate risk for CMV-related complications. Consensus guidelines allow for either universal prophylaxis (UP) or preemptive therapy (PET) (serial CMV testing) approaches to CMV prevention in such patients. Whether an optimal approach to mitigate CMV related risks exists in this setting remains uncertain. We therefore assessed the utility of PET as compared to UP in CMV R+ HT recipients.
Retrospective analysis of all CMV R+ HT recipients from 6 U.S. centers between 2010 and 2018 was performed. The primary outcome was the development of CMV DNAemia or end-organ disease resulting in the initiation/escalation of anti-CMV therapy. The secondary outcome was CMV-related hospitalization. Additional outcomes included incidence of acute cellular rejection (ACR) ≥ grade 2R, death, cardiac allograft vasculopathy (CAV), and leukopenia.
Of 563 CMV R+ HT recipients, 344 (61.1%) received UP. PET was associated with increased risk for the primary (adjusted HR 3.95, 95% CI: 2.65-5.88, p < .001) and secondary (adjusted HR 3.19, 95% CI: 1.47-6.94, p = .004) outcomes, and with increased ACR ≥ grade 2R (PET 59.4% vs. UP 34.4%, p < .001). Incidence of detectable CAV was similar at 1 year (PET 8.2% vs. UP 9.5%, p = .698). UP was associated with increased incidence of leukopenia within 6 months post-HT (PET 34.7% vs. UP 43.6%, p = .036).
The use of a PET CMV prophylaxis strategy in intermediate risk HT recipients associated with increased risk of CMV infection and CMV-related hospitalization, and may associate with worse post-HT graft outcomes.
有巨细胞病毒（CMV）既往暴露史（CMV R+）的心脏移植（HT）受者被认为有发生 CMV 相关并发症的中等风险。共识指南允许对这些患者采用普遍预防（UP）或抢先治疗（PET）（连续 CMV 检测）方法预防 CMV。在这种情况下，是否存在减轻 CMV 相关风险的最佳方法仍不确定。因此，我们评估了 PET 与 UP 相比在 CMV R+ HT 受者中的应用。
对 2010 年至 2018 年间美国 6 个中心的所有 CMV R+ HT 受者进行回顾性分析。主要结局是发生 CMV DNA 血症或终末器官疾病，导致开始/升级抗 CMV 治疗。次要结局是 CMV 相关住院。其他结局包括急性细胞排斥反应（ACR）≥2R 级、死亡、心脏移植物血管病（CAV）和白细胞减少症的发生率。
在 563 例 CMV R+ HT 受者中，344 例（61.1%）接受 UP。PET 与主要结局（调整后的 HR 3.95，95%CI：2.65-5.88，p<0.001）和次要结局（调整后的 HR 3.19，95%CI：1.47-6.94，p=0.004）风险增加相关，与 ACR≥2R 级（PET 59.4%与 UP 34.4%，p<0.001）的发生率增加相关。在 1 年时，可检测到的 CAV 的发生率相似（PET 8.2%与 UP 9.5%，p=0.698）。在 HT 后 6 个月内，UP 与白细胞减少症的发生率增加相关（PET 34.7%与 UP 43.6%，p=0.036）。
在中等风险的 HT 受者中使用 PET CMV 预防策略与 CMV 感染和 CMV 相关住院的风险增加相关，并且可能与 HT 后移植物结局恶化相关。
