Incidence and Risk of Cytomegalovirus Infection After Intestine Transplantation

BACKGROUND: Cytomegalovirus (CMV) is a major infectious complication after intestine transplantation, but data in this population remain limited. We evaluated the incidence, risk factors, and outcomes of clinically significant CMV infection (csCMVi) in intestine transplant recipients. METHODS: We performed a retrospective cohort study of adult and pediatric patients who underwent intestine transplantation between 2008 and 2022. csCMVi was defined as CMV disease or asymptomatic CMV DNAemia requiring treatment. Multivariable Cox regression identified predictors of csCMVi and its association with death or allograft failure. RESULTS: Among 133 patients undergoing 143 intestine transplant procedures, csCMVi occurred in 44 patients (30.8%) at a median of 174 days posttransplant. Symptomatic disease occurred in 36.4% of cases, most commonly CMV enteritis. Breakthrough infection during prophylaxis occurred in 27.3% of csCMVi episodes, most frequently in patients receiving underdosed valganciclovir. Antiviral resistance mutations were identified in six patients. Donor-positive/recipient-negative (D+/R-) serostatus was strongly associated with csCMVi (HR 3.82, 95% CI 1.86-7.82), while donor-negative/recipient-negative serostatus was protective (HR 0.08, 95% CI 0.02-0.33). Lower absolute lymphocyte count independently increased risk (HR 1.23 per 50% decrease, 95% CI 1.10-1.37). Recurrent CMV infection occurred in 26 patients after treatment. Overall, csCMVi was independently associated with a higher risk of death or allograft failure (HR 2.28, 95% CI 1.28-4.07). CONCLUSIONS: csCMVi is a common and serious complication after intestine transplantation. Optimizing CMV prophylaxis dosing and monitoring immune status may help reduce risk, though further studies are needed to improve prevention and individualized management strategies.