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Purpose: Rabbit antithymocyte globulin (r-ATG) induction is associated with an increased risk for CMV after transplant. Limited data exists for optimal antiviral prophylaxis strategies in low CMV risk (D-/R-) renal transplant recipients (RTRs) receiving r-ATG. Our objective was to compare risk of CMV disease associated with r-ATG versus IL2 antagonist (IL2) induction and the impact of CMV-directed prophylaxis on the incidence of CMV disease in D-/R- RTRs who received r-ATG induction.
Methods: A multicenter, retrospective analysis evaluated adult D-/R- RTRs between 01/01/04 to 09/30/A multicenter, retrospective analysis evaluated adult D-/R- RTRs between 01/01/04 to 09/30/2010. All patients received induction therapy with either r-ATG or IL2 plus maintenance immunosuppression with tacrolimus, mycophenolic acid, with or without steroids. Group A (n=118) received r-ATG induction without CMV-directed antiviral prophylaxis. Group B (n=41) received r-ATG induction with CMV-directed prophylaxis using valganciclovir. Group C (n=73) received IL2 induction without CMV-directed antiviral prophylaxis. The primary endpoint was CMV disease incidence and secondary endpoints included CMV viremia, acute rejection (AR), antibody mediated rejection (AMR), and other opportunistic infections (OIs) at 1 year post-transplant.
Results: Differences in baseline characteristics included proportion of living donor transplants (24.4%, 60.2% vs 75.3%), rate of early steroid withdrawal (2.4%, 48.8% vs 19.2%), and mean duration of antiviral prophylaxis (5.1, 3.0 vs 3.5 months) in group A, B and C, respectively (p<0.05). There was no difference in rate of CMV disease (0.0%, 0.8% vs 1.4%) or rate of AR (14.6%, 14.4%, vs 19.2%) in groups A, B and C, respectively (p>0.05). Similarly, there were no significant differences in rate of AMR, BK or HSV infection.
Conclusion: Our study demonstrates that the incidence of CMV disease in D-/R- RTRs is rare, regardless of induction or antiviral prophylaxis strategy utilized. Non-CMV-directed prophylaxis may provide sufficient efficacy and potentially offer significant cost avoidance in this population.