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Does cytomegalovirus serology impact outcome after pediatric heart transplantation?
William T Mahle1, Margaret T Fourshee, David M Naftel
1Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia 30322-1062, USA. wmahle@emory.edu
Insights
Cytomegalovirus (CMV) serology before pediatric heart transplant did not impact mortality or coronary allograft vasculopathy (CAV). CMV mismatching increased clinical CMV disease risk, while prophylaxis efficacy requires further study.
Area of Science:
- Cardiology
- Infectious Diseases
- Transplantation Immunology
Background:
- Cytomegalovirus (CMV) infection is a known complication in heart transplant recipients.
- Previous studies suggested a link between pre-transplant CMV serology and adverse outcomes like coronary allograft vasculopathy (CAV) and death.
- This study investigates the impact of recipient CMV status and CMV mismatching on pediatric heart transplant outcomes.
Purpose of the Study:
- To determine the impact of recipient cytomegalovirus (CMV) serology on outcomes after pediatric heart transplantation.
- To assess the effect of CMV mismatching between donor and recipient on post-transplant complications.
- To evaluate the use and efficacy of CMV prophylaxis in this patient population.
Main Methods:
- Analysis of pediatric heart transplant recipients (<18 years) from 1993-2007, excluding those <6 months of age.
- Primary outcome: freedom from CAV. Secondary outcomes: freedom from death and clinical CMV infection.
- Risk factors analyzed using parametric hazard regression.
Main Results:
- Pre-transplant CMV serology was not associated with increased mortality or CAV risk.
- CMV mismatch (donor CMV+/recipient CMV-) was linked to a higher risk of clinical CMV disease.
- CMV prophylaxis use showed no significant association with mortality, CAV, or clinical CMV infection development.
Conclusions:
- Pre-transplant CMV serology does not appear to influence death or CAV development in pediatric heart transplant recipients.
- CMV-negative recipients receiving a CMV-positive organ face an elevated risk of clinical CMV disease.
- Optimal CMV prophylaxis strategies require further investigation.
Background:
Cytomegalovirus (CMV) infection has been implicated in a number of complications after heart transplantation. A recent study suggested that children with positive CMV serology (CMV(+)) before transplantation are at increased risk of developing coronary allograft vasculopathy (CAV) and death when compared with CMV(-) recipients. We analyzed data from the Pediatric Heart Transplant Study Group to determine the impact of recipient CMV status and CMV mismatching on outcome. In addition, the use and efficacy of CMV prophylaxis were studied.
Methods:
Subjects <18 years of age who underwent heart transplantation during the period from 1993 to 2007 were analyzed. Those transplants in which either the recipient or donor were <6 months of age were excluded due to the confounding effects of maternal antibody. The primary outcome variable was freedom from CAV (mild or greater). Secondary outcomes included freedom from death and freedom from clinical CMV infection. Risk factors were assessed using parametric hazard regression.
Results:
Of the 1,598 subjects included in the analysis, 637 (40%) were CMV(+) at the time of transplantation. Some form of CMV prophylaxis was administered to 67% of all recipients, most commonly with a CMV mismatch (donor CMV(+)/recipient CMV(-)). Freedom from clinical CMV infection at 5 years was 91%. Pre-transplant CMV serology was not associated with mortality (p = 0.40) or risk of developing CAV (p = 0.10). CMV mismatch was associated with increased risk of clinical CMV disease (p < 0.001). The use of CMV prophylaxis had no association with mortality or development of CAV. There was also no significant association between CMV prophylaxis and the development of clinical CMV infection.
Conclusions:
CMV(+) serology at time of pediatric heart transplantation had no demonstrable association with death or development of CAV. CMV(-) recipients who receive a CMV(+) organ are at increased risk of clinical CMV disease. CMV prophylaxis was commonly used, although further studies are needed to establish an optimal approach for prevention of CMV disease in this population.
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