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Logical versus absolute lymphocyte count-guided preemptive therapy for cytomegalovirus prevention in kidney
Piyangkul Lorcharassriwong1, Sarinya Boongird2, Surasak Kantachuvesiri2
1Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.
Objectives:
A preemptive approach using plasma cytomegalovirus (CMV) DNA load monitoring is recommended for CMV-seropositive solid organ transplant recipients. However, limited access to CMV quantitative nucleic acid amplification testing poses challenges in resource-constrained settings. We hypothesized that absolute lymphocyte count (ALC)-guided monitoring could provide an effective alternative strategy.
Methods:
We conducted an open-label, randomized controlled trial at a single transplant center in Thailand (February-November 2023). Adult CMV-seropositive kidney transplant (KT) recipients who did not receive anti-thymocyte globulin induction were randomized in a 1:1 ratio to either the logical (LOG) group, defined as routine plasma CMV quantitative nucleic acid amplification testing performed every 4 weeks for 12 weeks, or the ALC group, which underwent testing only when the ALC was <1000 cells/mm³. Participants were followed for 6 months after transplantation to compare CMV infection rates and testing costs.
Results:
A total of 98 KT recipients were enrolled (49 per group; mean ± SD age, 46 ± 11 years; 66.3% male). Baseline demographic characteristics were comparable between groups. Overall, 25 participants (25.5%) developed CMV infection within 6 months after KT. CMV infection occurred in 13 participants (26.5%) in the LOG group and 12 participants (24.5%) in the ALC group (P = 0.817). No significant differences were observed between groups in the rates of CMV DNAemia, CMV disease, anti-CMV therapy, or mortality (all P >0.05). The total cost of plasma CMV DNA load testing was significantly lower in the ALC group than in the LOG group ($2320 vs $10,014; P = 0.002).
Conclusions:
ALC-guided monitoring could demonstrate effectiveness comparable to that of routine CMV DNA surveillance for CMV infection prevention in KT recipients. Given its simplicity and availability, ALC may serve as a feasible and cost-efficient adjunct for guiding preemptive therapy in low- to moderate-risk solid organ transplant recipients.
Insights
Absolute lymphocyte count (ALC) monitoring offers a cost-effective alternative to plasma cytomegalovirus (CMV) DNA load testing for preventing CMV infection in kidney transplant recipients. This simpler approach shows comparable effectiveness in resource-limited settings.
Area of Science:
- Transplant Immunology
- Infectious Diseases
- Clinical Virology
Background:
- Plasma cytomegalovirus (CMV) DNA load monitoring is recommended for CMV-seropositive solid organ transplant recipients (SOTr).
- Limited access to quantitative nucleic acid amplification testing (QNAT) challenges CMV monitoring in resource-constrained settings.
- Absolute lymphocyte count (ALC)-guided monitoring is proposed as an alternative strategy.
Purpose of the Study:
- To evaluate the effectiveness and cost-efficiency of ALC-guided monitoring versus routine plasma CMV DNA load monitoring in kidney transplant (KT) recipients.
- To compare CMV infection rates and associated testing costs between the two monitoring strategies.
Main Methods:
- An open-label randomized controlled trial was conducted with adult CMV R+ KT recipients.
- Participants were randomized to either routine plasma CMV QNAT (LOG group) or ALC-based testing (ALC group).
- The ALC group underwent testing only when ALC was <1,000 cells/mm³; follow-up was for 6 months.
Main Results:
- A total of 98 KT recipients were enrolled, with comparable baseline characteristics.
- Overall CMV infection occurred in 25.5% of participants, with no significant difference between the LOG (26.5%) and ALC (24.5%) groups (p=0.817).
- The ALC group had significantly lower total CMV DNA load testing costs ($2,320 vs. $10,014, p=0.002).
Conclusions:
- ALC-guided monitoring demonstrates comparable effectiveness to routine CMV DNA surveillance for CMV infection prevention in KT recipients.
- ALC monitoring is a feasible, simple, and cost-efficient adjunct for guiding preemptive therapy in low- to moderate-risk SOTr.
- This strategy addresses challenges in resource-limited settings for CMV surveillance.
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