Cytomegalovirus Prevention in Liver Transplant Recipients: A Comparative Study of Universal and Preemptive Strategies with Valganciclovir

Abstract

Background and Objectives: Universal prophylaxis and preemptive therapy are established strategies to prevent cytomegalovirus (CMV) after liver transplantation, yet their real-world comparative performance varies by center and risk mix. Methods: We conducted a single-center retrospective cohort of consecutive adult recipients transplanted from 2013 - 2021 in Mashhad, Iran. Exposure was the CMV-prevention strategy received (universal valganciclovir prophylaxis vs preemptive PCR-based monitoring). Primary outcomes were CMV viremia (PCR-confirmed) and CMV disease (clinical/histologic). Secondary outcomes were late-onset CMV (> 100 days post-transplant), acute rejection, and mortality. Multivariable logistic regression (and Cox proportional hazards where event dates were available) adjusted for calendar era, donor/recipient serostatus (D/R), immunosuppression regimen, monitoring protocol, age, and sex. Results: Among 475 recipients (universal valganciclovir: 170; preemptive monitoring: 305), CMV viremia occurred in 10/170 (5.9%) vs 18/305 (5.9%) (P = 0.993). Among the 28 infected patients, 23 (82.1%) were male. Onset timing was < 1 month in 6 (21.4%), 1 - 3 months in 9 (32.1%), and > 6 months in 13 (46.4%), indicating late-onset (> 3 months) in 22/28 (78.6%) overall. Conclusions: In this cohort, universal prophylaxis and preemptive monitoring showed no significant adjusted differences in CMV infection or disease. Given era effects and center-specific practices, policy selection should consider D/R risk, monitoring logistics, and late-onset CMV risk. Multicenter studies are warranted.