A Home Hospital Program Offers Versatility in Treating Cytomegalovirus (CMV) Viremia in a Kidney Transplant Recipient

Introduction: Hospital at home (HaH) health care was initially driven by the COVID-19 pandemic as a way to administer comprehensive care to patients in the comfort of their own homes. NYU Langone's Home Hospital Program screens patients either in the emergency department or after they have already been admitted for inpatient stay. After transport home, they receive care through in-person and virtual visits with their team. Literature pertaining to involvement of kidney transplant (KT) patients in HaH initiative is limited. Publications describe it as a potential first line strategy for KT recipients with COVID-19. But what about application to those transplant recipients with other complications (provided they stable enough to be monitored at home)? Case Description: 73 year old female with past history of Hodgkin's lymphoma (status post chemotherapy + radiation + autologous stem cell transplant) in 1996, end-stage-renal-disease with preemptive deceased donor KT in 2022. She presented to the ER at NYU Hospital Long Island after outpatient testing revealed whole blood CMV DNA PCR of 77426 IU/mL. Infectious disease consultation called for renally dosed standard induction Ganciclovir (2.5 mg every 24 hours for creatinine clearance 40 mL/min). After three days in the hospital, she was transferred to the HaH program. In her home, she received IV Ganciclovir via midline catheter for an additional 8 days. Ultimately, viral load (plasma) improved to 1570 IU/mL from plasma peak of 11900 IU/mL. At that point she was discharged on oral Valgancyclovir. Discussion: The choice of CMV therapy is determined by several factors, one of which is inital viral load. While there is no established cut off for high viral load, usually >10,000 copies/mL is considered high. The duration of therapy may vary but is typically 21 days. Our otherwise asymptomatic patient received IV Ganciclovir while at home for the desired duration, administered by a registered nurse. In addition, immunosuppressants were administered, blood work (including daily Tacrolimus levels and weekly CMV viral loads) completed. Per day, she received at least two nurse visits, a hospitalist and nephrologist visit and vital sign monitoring. This case is one example whereby a HaH program offers a unique opportunity to manage a stable KT patient who requires a potentially long hospitalization.