CYTOMEGALOVIRUS PP65 ANTIGENEMIA MONITORING AS A GUIDE FOR PREEMPTIVE THERAPY: A COST EFFECTIVE STRATEGY FOR PREVENTION OF CYTOMEGALOVIRUS DISEASE IN ADULT LIVER TRANSPLANT RECIPIENTS1

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Abstract
The aim of the study was to assess the incidence of cytomegalovirus (CMV) infection and disease in adult liver transplant recipients, using routine preemptive therapy guided by the pp65 antigenemia test. Antigenemia was monitored weekly after liver transplantation (OLTX) for the first 3 months, and once a month for another 3 months. CMV seronegative recipients were treated preemptively for the first positive antigenemia. Seropositive recipients were treated only when their antigenemia count reached a threshold of ≥100 positive cells per 200,000 leukocytes. A total of 144 patients were included between June 1994 and April 1995, of which 137 (95%) were primary OLTX. The percentage of positive antigenemia and CMV disease was 55 and 8%, respectively. Seventy-eight (54%) patients were protocol-monitored for the entire follow-up (group 1) and received appropriate preemptive therapy, although 66 (46%) patients had protocol violation by having missed blood samples or blood drawn at unscheduled times (group 2). Using Cox's proportional hazards model, patients with a first antigenemia count of >11 leukocytes had a significantly higher rate of CMV disease compared to patients with an antigenemia count ≤11 leukocytes (RR=7.3, 95% confidence interval=2.2 to 24.5). In a multivariate Cox regression analysis, adjustments were made to control for: group 1 versus group 2, use of OKT3, and serology risk categories. This analysis showed that the relative rate of CMV disease was still significantly higher among patients with antigenemia count >11 leukocytes (adjusted RR=4.9, 95% confidence interval=1.3 to 18.1). The estimated cost of preemptive therapy was less than that of prophylaxis with i.v. (14-day course) or oral (90-day course) ganciclovir. Preemptive therapy guided by pp65 antigenemia is a useful and cost effective strategy for prevention of CMV disease.