Effect of delaying prophylaxis against CMV in D+/R− solid organ transplant recipients in the development of CMV-specific cellular immunity and occurrence of late CMV disease

Easier Control of Late-Onset Cytomegalovirus Disease Following Universal Prophylaxis Through an Early Antiviral Immune Response in Donor-Positive, Recipient-Negative Kidney Transplants

“…Conversely, we found that the time to Vd2 neg cd T cell expansion was shorter in patients with LOD, most of whom were treated with universal prophylaxis. Other studies found that universal prophylaxis did not suppress CMV-specific antibodies and T cell response (40,41). We hypothesized that the delay from transplantation obtained with prophylaxis could allow (i) local priming of Vd2 neg cd T cells in tissues in the absence of systemic dissemination of the virus and (ii) a decrease of the immunosuppressive burden.…”

Delayed vs initial cytomegalovirus prophylaxis after kidney transplantation

“…The follow‐up study reported a 40% incidence of CMV infection at 1 year in both groups and no difference in time to onset of infection 8 . There was less use of lymphocyte‐depleting induction therapy (26.3%) as compared to our study (78.6%), and maintenance immunosuppression was not described past the initial post‐transplant regimen 8 . The authors of these studies theorized that delaying the start of CMV prophylaxis may promote the development of immune responses in CMV IgG seronegative recipients that could confer protection from late onset CMV infection.…”

“…In a single center, retrospective pilot study, San Juan et al found that delaying CMV prophylaxis until postoperative day 14 in CMV D+/R− heart, liver, or kidney transplant recipients did not affect rates of CMV infection up to 1 year post‐transplant (35% early group vs 44% delayed group, P > .1), and the time to infection was significantly later in the early group as compared to delayed group (147 vs 84 days, P = .04) in their cohort 7 . A prospective, multicenter follow‐up study was performed by the same investigators evaluating the same protocol of initiating prophylaxis on postoperative day 14 in CMV D+/R− transplant recipients 8 . The follow‐up study reported a 40% incidence of CMV infection at 1 year in both groups and no difference in time to onset of infection 8 .…”

“…A prospective, multicenter follow‐up study was performed by the same investigators evaluating the same protocol of initiating prophylaxis on postoperative day 14 in CMV D+/R− transplant recipients 8 . The follow‐up study reported a 40% incidence of CMV infection at 1 year in both groups and no difference in time to onset of infection 8 . There was less use of lymphocyte‐depleting induction therapy (26.3%) as compared to our study (78.6%), and maintenance immunosuppression was not described past the initial post‐transplant regimen 8 .…”

“…Guidelines state that prophylaxis should be initiated within the first 10 days of transplantation, but many centers start therapy on postoperative day zero or one 4,5 . There is limited data evaluating the effects of delayed vs initial prophylaxis against CMV, but two studies reported no difference in the rates of CMV infection at 1 year in CMV D+/R− transplant patients when delaying prophylaxis until postoperative day 14; however, these studies did not include CMV R + subjects and a minority of patients received lymphocyte‐depleting induction 7,8 . As part of a cost containment measure, the Duke Kidney Transplant team instituted a protocol in 2015 to delay the initiation of valganciclovir until postoperative day 7 or upon discharge, as it was hypothesized that the delay would not impact rates of CMV infection or disease but could decrease medication costs.…”