Prophylaxis Followed by Preemptive Approach Versus Prophylaxis to Prevent CMV infection in CMV-Seropositive Kidney Transplant Recipients Receiving Anti-Thymocyte Globulin Induction Therapy.

Background: CMV infection is a major complication in CMV-seropositive kidney transplant recipients receiving ATG induction. This study compared CMV infection rates between hybrid (prophylaxis plus preemptive) and universal prophylaxis strategies in this high-risk group.

Methods: We retrospectively studied CMV-seropositive KT recipients receiving ATG (2018-2024), comparing a hybrid strategy (IV ganciclovir plus CMV DNA monitoring) with universal prophylaxis (3-month oral valganciclovir). Outcomes included CMV infection, clinically significant CMV infection (CsCMVi), and adverse events. Risk factors for CsCMVi were analyzed using multivariate Cox regression.

Results: A total of 111 CMV-seropositive KT recipients were included (75 hybrid, 36 prophylaxis). CMV infection was significantly more frequent in the hybrid group (70.7% vs. 16.7%, p<0.001), as was CsCMVi (33.3% vs. 5.6%, p=0.001) and allograft dysfunction (45.3% vs. 16.7%, p=0.01). Hematologic toxicities (neutropenia, leukopenia, lymphopenia) were comparable (all p=NS). In multivariate analysis, independent risk factors for CsCMVi included the hybrid strategy (HR 6.06; 95% CI,1.04-35.36; p=0.045), higher panel-reactive antibody (HR 1.02; 95% CI,1.00-1.04; p=0.019), and >40% decline in eGFR at discharge (HR 48.09; 95% CI,4.39-527.20; p=0.002). Hypertension was protective (HR 0.12; 95% CI,0.04-0.80; p=0.024).

Conclusion: In CMV-seropositive recipients receiving lymphocyte-depleting induction, a hybrid strategy of initial prophylaxis followed by preemptive therapy was associated with inferior outcomes compared to universal prophylaxis.