Maribavir in lung transplant recipients with cytomegalovirus infection: real-life experience

Cytomegalovirus remains a major challenge in LTx recipients. Despite advances in antiviral therapy, refractory and resistant CMV infections persist, and real-world data on maribavir, a recently approved UL97 kinase inhibitor, are limited.

We retrospectively analyzed 49 LTx recipients treated with maribavir for refractory and resistant (R/R) CMV between August 2022 and December 2024.

Overall, 34 patients (69.4%) achieved a sustained virological response, defined as complete CMV DNA clearance, with a > 1 log₁₀ viral load decline after a median of 11.5 days and complete viral clearance after a median of 24.8 [7-54] days. Sixteen patients (32.7%) failed therapy; UL97 resistance mutations were detected during maribavir therapy in 14 patients (28.6%). Non-responders had higher baseline viral loads (> 10,000 IU/ml: 53.3% vs. 20.6%; p = 0.047) and slower viral decline (14 (6-85) vs. 10.5 (2-27) days; p = 0.033). In multivariable analysis, higher baseline CMV viral load was independently associated with maribavir resistance (OR 3.729 per log₁₀ increase, 95% CI 1.360-10.226; p = 0.011).

In conclusion, maribavir represents an important therapeutic option for R/R CMV after lung transplantation. However, treatment failure, relapse, and resistance remained common, highlighting the need for careful monitoring and further optimization of treatment strategies.