CMV Infection after Lung Transplant: incidence, risk factors and management in a multi-center cohort

Cytomegalovirus (CMV) infection after lung transplant is associated with chronic rejection, but risk factors besides serology are not well-defined. Utilizing a multicenter, prospective cohort, CMV infection risk factors during and after prophylaxis were analyzed with an extended Cox model occurring either after completion of primary prophylaxis or for a breakthrough CMV episode, while on prophylaxis. The overall cohort included 785 lung transplant recipients, of which 221 developed at least one CMV episode. Of the 362 recipients eligible for the off-prophylaxis analysis, 124 had a CMV episode a median of 57 days post prophylaxis. In adjusted models off-prophylaxis, an increased risk of CMV was noted for CMV D+/R- serostatus, shorter duration of previous CMV prophylaxis, and augmented immunosuppression with either high dose steroids or T cell targeted therapy. In the 586 recipients eligible for the breakthrough CMV analysis, 71 had a CMV episode and in adjusted models while on primary prophylaxis, CMV D+/R- serostatus was the only significant risk factor. While CMV D+/R- serostatus remains an important risk factor for CMV, additional risk factors include prophylaxis duration and augmented immunosuppression, which should be considered in CMV prevention after lung transplant.