Enter Note
A220 - Letermovir CMV Prophylaxis Associated with Resolution of Valganciclovir-Related Neutropenia in Liver Transplant Recipients
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Author Block: W. Shivega, M. Hack, P. Neppala, A. Olyaei, A. Bolognese, C. Enestvedt, E. Maynard, D. Scott, O. Shaked, D. Woodland, C. Connelly, Surgery, Oregon Health & Science University, Portland, OR
*Purpose: Cytomegalovirus (CMV) infection and valganciclovir (VGC)-related myelosuppression remain significant challenges following liver transplantation (LT), with about 50% of high-risk LT recipients developing CMV infection. Although letermovir (LTV) has shown efficacy and lower myelotoxicity in other solid organ transplants, data in LT is limited. The purpose of this study was to evaluate the utility and side effects of LTV in CMV prophylaxis of LT recipients.
*Methods: This was a single-center, retrospective study of adult LT recipients between 04/2022 and 03/2025. Maintenance immunosuppression was tacrolimus, mycophenolate or azathioprine, and prednisone. CMV prophylaxis consisted of either LTV with acyclovir (LTV) for the entire course, or VGC and LTV sequentially (VGC+LTV). Outcomes included CMV infection, antiviral-associated neutropenia (AAN), and use of granulocyte colony-stimulating factor (G-CSF) for AAN.
*Results: During the study period, 24 LT recipients received LTV for CMV prophylaxis, 17 were high CMV-risk (D+/R−) and 7 were intermediate-risk (D−/R+ or D+/R+). Four patients received LTV for the entire CMV prophylaxis duration. One patient began with LTV and transitioned to VGC while 19 started VGC and transitioned to LTV; 10 due to delayed LTV insurance approval and 9 due to AAN. Patients receiving VGC+LTV, spent more days on VGC than LTV (78 vs 66 days, p < 0.001). CMV infection occurred in 6 high-risk patients, 2 (50%) in the LTV group, and 4 (20%) in the VGC+LTV group. CMV infection occurred 93 days (IQR: 60, 144) after prophylaxis completion. Only 1 patient in the LTV group developed AAN requiring G-CSF. All 9 patients who transitioned from VGC to LTV due to AAN, resolved their AAN while actively on LTV. Two of the 9 patients had received G-CSF prior to transitioning to LTV, but none of the remaining 7 required G-CSF after transitioning to LTV given resolution of AAN.
*Conclusions: In this study, LTV CMV prophylaxis was associated with resolution of VGC-related neutropenia in LT recipients without need for G-CSF support and comparable CMV infection risk. These data support LTV as an alternative to VGC for CMV prophylaxis in LT recipients at risk for myelosuppression.
| N (%) or Median (IQR) | Total | LTV | VGC+LTV | |
| N = 24 | N = 4 | N = 20 | ||
| CMV Risk | High | 17 (71%) | 3 (75%) | 14 (70%) |
| Intermediate | 7 (29%) | 1 (25%) | 6 (30%) | |
| Antimetabolite | Mycophenolate | 23 (96%) | 4 (100%) | 19 (20%) |
| Azathioprine | 1 (4%) | 0 | 1 (5%) | |
| Days on antiviral | LTV | 89 (35, 149) | 180 (113, 180) | 66 (22, 120) |
| VGC | 76 (30, 107) | - | 78 (56, 116) | |
| Reason for VGC to LTV change | Neutropenia | 9 (38%) | - | 9 (47%) |
| Insurance approval | 10 (42%) | - | 10 (53%) | |
| Outcomes | CMV infection | 6 (25%) | 2 (50%) | 4 (20%) |
| CMV disease | 5 (17%) | 1 (25%) | 3 (15%) | |
| Neutropenia | 10 (42%) | 1 (25%) | 9 (45%) | |
| G-CSF use | 3 (13%) | 1 (25%) | 2 (10%) |