Immune Monitoring-Guided Versus Fixed Duration of Antiviral Prophylaxis Against Cytomegalovirus in Solid-Organ Transplant Recipients: A Multicenter, Randomized Clinical Trial
Oriol Manuel, Mirjam Laager, Cédric Hirzel, Dionysios Neofytos, Laura N. Walti, Gideon Höenger, Isabelle Binet, Aurelia Schnyder, Susanne Stampf, Michael Koller, Matteo Mombelli, Min-Jeong Kim, Matthias Hoffmann, Katrin Koenig, Christoph Hess, Anne‐Valérie Burgener, Pietro E. Cippà, Kerstin Hübel, Thomas F Mueller, Daniel Sidler, Suzan Dahdal, Franziska Suter‐Riniker, Jean Villard, Andrea Zbinden, Giuseppe Pantaleo, Nasser Semmo, Karine Hadaya, Natalia Enriquez, Pascal Meylan, Marc Froissart, Déla Golshayan, Thomas Fehr, Uyen Huynh‐Do, Manuel Pascual, Christian van Delden, Hans H. Hirsch, Peter Jüni, Nicolas J. Mueller, Swiss Transplant Cohort Study (STCS), Patrizia Amico, John‐David Aubert, Vanessa Banz, Sonja Beckmann, Guido Beldi, Christoph Berger, Ekaterine Berishvili, Annalisa Berzigotti, Isabelle Binet, Pierre–Yves Bochud, Sanda Branca, Heiner C. Bucher, Emmanuelle Catana, Anne Cairoli, Yves Chalandon, Sabina De Geest, Olivier de Rougemont, Sophie de Seigneux, Michael Dickenmann, Joëlle Lynn Dreifuss, Michel A. Duchosal, Thomas Fehr, Sylvie Ferrari-Lacraz, Christian Garzoni, Déla Golshayan, Nicolas Goossens, Fadi Haidar, Jörg Halter, Dominik Heim, Christoph Hess, Sven Hillinger, Hans H. Hirsch, Patricia Hirt, Linard Hoessly, Günther F.L. Hofbauer, Uyen Huynh‐Do, Franz Immer, Michael Koller, Bettina Laesser, Frédéric Lamoth, Roger Lehmann, Alexander Leichtle, Oriol Manuel, Hans‐Peter Marti, Michele Martinelli, Valérie A. McLin, Katell Mellac, Aurélia Merçay, Karin Mettler, Nicolas J. Mueller, Ulrike Müller-Arndt, Beat Müllhaupt, Mirjam Nägeli, Graziano Oldani, Manuel Pascual, Jakob Passweg, Rosemarie Pazeller, Klara M. Posfay‐Barbe, Juliane Rick, Anne Rosselet, Simona Rossi
Abstract
BACKGROUND: The use of assays detecting cytomegalovirus (CMV)-specific T cell-mediated immunity may individualize the duration of antiviral prophylaxis after transplantation. METHODS: In this randomized trial, kidney and liver transplant recipients from 6 centers in Switzerland were enrolled if they were CMV-seronegative with seropositive donors or CMV-seropositive receiving antithymocyte globulins. Patients were randomized to a duration of antiviral prophylaxis based on immune monitoring (intervention) or a fixed duration (control). Patients in the control group were planned to receive 180 days (CMV-seronegative) or 90 days (CMV-seropositive) of valganciclovir. Patients were assessed monthly with a CMV ELISpot assay (T-Track CMV); prophylaxis in the intervention group was stopped if the assay was positive. The co-primary outcomes were the proportion of patients with clinically significant CMV infection and reduction in days of prophylaxis. Between-group differences were adjusted for CMV serostatus. RESULTS: Overall, 193 patients were randomized (92 in the immune-monitoring group and 101 in the control group), of whom 185 had evaluation of the primary outcome (87 and 98 patients). CMV infection occurred in 26 of 87 (adjusted percentage, 30.9%) in the immune-monitoring group and in 32 of 98 (adjusted percentage, 31.1%) in the control group (adjusted risk difference, -0.1; 95% confidence interval [CI], -13.0% to 12.7%; P = .064). The duration of prophylaxis was shorter in the immune-monitoring group (adjusted difference, -26.0 days; 95%, CI, -41.1 to -10.8 days; P < .001). CONCLUSIONS: Immune monitoring resulted in a significant reduction of antiviral prophylaxis, but we were unable to establish noninferiority of this approach on the co-primary outcome of CMV infection. CLINICAL TRIALS REGISTRATION: NCT02538172.