Low‐dose valganciclovir for cytomegalovirus prophylaxis in intermediate‐risk liver transplantation recipients

Liver transplantation recipients (LTRs) who are seropositive for cytomegalovirus (CMV) (recipient seropositive [R+]) are at intermediate risk for CMV disease. A preventative strategy following transplant is considered standard of care. Current guidelines recommend high‐dose valganciclovir (VGCV; 900 mg/day adjusted for renal function) for prophylaxis given limited data on the efficacy and safety of low‐dose VGCV (450 mg/day adjusted for renal function). We describe our experience using low‐dose VGCV prophylaxis for R+ LTRs at our institution. A single‐center, retrospective study was conducted using a database of 364 LTRs over a 4‐year period (2011‐2014). Adult first‐time R+ LTRs receiving low‐dose VGCV prophylaxis were included. The primary endpoint was CMV disease at 1 year after transplant. Patients were compared with historical controls receiving high‐dose VGCV prophylaxis. Secondary endpoints were biopsy‐proven rejection and leukopenia on VGCV. With respect to leukopenia, patients receiving low‐dose VGCV were compared with a group of D+R– patients from the database receiving high‐dose VGCV. Univariate analyses were performed using chi‐squared, Fisher's exact, and Wilcoxon rank sum tests. A total of 200 R+ LTRs met inclusion criteria. Median age was 60 years (interquartile range [IQR], 54‐66 years), and 129 (65%) LTRs were male. Median Model for End‐Stage Liver Disease score was 22 (IQR, 14‐31), and 178 (89%) patients received deceased donor transplants. CMV disease occurred in only 9 (5%) patients, similar to rates in previous studies of LTRs receiving high‐dose VGCV. Biopsy‐proven rejection occurred in 18 (9%) patients. Patients received VGCV prophylaxis for a median of 3.4 (IQR, 3.1‐4.3) months; 151 (76%) R+ LTRs receiving low‐dose VGCV developed leukopenia. Premature VGCV discontinuation and granulocyte‐colony stimulating factor use were infrequent and not significantly different between the 2 groups. In conclusion, low‐dose VGCV was safe and effective for prevention of CMV disease in our cohort of 200 R+ LTR and should be considered as an option in future guidelines. Liver Transplantation 24 616–622 2018 AASLD.