The current status of CMV prophylaxis and treatment in liver transplant recipients: A single center study

• Nearly 40 % of high CMV-risk liver transplant recipients developed CMV disease despite prophylaxis, emphasizing the need for alternative, extended, or tailored strategies. • Approximately 9 % of patients with CMV disease resolved their disease without antiviral therapy, suggesting the importance of predictive tools such as cell mediated immune- assays to determine the need for CMV treatment. • Antiviral-associated neutropenia (AAN) occurred in 13.3 % of patients overall and up to 48.4 % in high-risk recipients, highlighting the side effects associated with antiviral exposure. • More intermediate CMV-risk patients developed AAN (16.1 %) and required G-CSF (8.7 %) than eventually developed CMV disease (1.2 %), indicating potential antiviral overexposure. • High CMV disease and AAN rates in high-risk groups, alongside low CMV incidence but higher AAN in intermediate-risk groups, support personalized approaches to optimize CMV prophylaxis and minimize antiviral overexposure. Cytomegalovirus (CMV) is a common opportunistic viral infection among liver transplant (LT) recipients. This study evaluated the status of current CMV prophylaxis, treatment and associated antiviral side effects in LT patients. This single-center, retrospective study of 570 adult LT recipients from January 1, 2013, to December 31, 2023 compared CMV infection, disease, antiviral side effects and survival among high- ( D +/R-, n = 157), intermediate- (D-/ R +, D +/ R +, n = 341), and low-CMV risk patients (D-/R-, n = 72). Maintenance immunosuppression was tacrolimus, mycophenolate or azathioprine (Imuran), and prednisone. High-risk patients received valganciclovir 900 mg daily for 6 months, and intermediate-risk patients received valganciclovir 450 mg daily for 3 months. Low-risk recipients received acyclovir 400 mg BID for 3 months. Overall, 92 (16 %) patients developed CMV infection, and 64 (11 %) developed CMV disease. The high-risk group had the highest rates of CMV infection (50.3 % vs. 3.2 % vs. 2.8 %; p < 0.001) and disease (37.6 % vs. 1.2 % vs. 1.4 %; p < 0.001) compared to intermediate- and low-risk groups. Of those with CMV disease, 90.6 % received antiviral treatment, while 9.4 % resolved their disease without treatment. During prophylaxis, the high-risk group experienced higher rates of leukopenia (65.6 % vs. 45.7 % vs. 18.1 %; p < 0.001), antiviral-associated neutropenia (AAN; 48.4 % vs. 16.1 % vs. 8.3 %; p < 0.001), and uptrend in AAN requiring G-CSF (28.0 % vs. 8.7 % vs. 2.8 %; p = 0.802). Notably, more intermediate-risk recipients developed AAN requiring G-CSF during prophylaxis than developed CMV disease (8.7 % vs. 1.2 %). This study demonstrates the need for revised antiviral prophylactic and treatment algorithms that effectively manage CMV disease while minimizing antiviral side effects such as AAN.