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Purpose: To evaluate the association of conversion from valganciclovir to letermovir on cytomegalovirus‐specific cellular immunity. Methods: Adult patients were included if they received a kidney or liver transplant between 8/1/2018‐12/31/20, developed symptomatic, high‐level CMV viremia and were converted to letermovir 480 mg daily as monotherapy after treatment with ganciclovir‐derivatives for a minimum of 4 weeks and had subsequent CMV cell‐mediated immunity (CMI) testing via ICS assay by flow cytometry (Viracor Eurofins T Cell Immunity Panel). Results: Seven patients met inclusion criteria; 87.5% were male and recipients of a kidney transplant. All patients were CMV high risk (D+/R‐). Mean time from transplant to CMV disease was 200 ± 91 days. Peak viral load (VL) during CMV treatment was 540,341 ± 391,211 IU/mL. Patients received a mean of 30 ± 24 weeks (range: 4‐78 weeks) of therapy with ganciclovir‐derivatives at induction doses prior to letermovir introduction. The median absolute lymphocyte count (ALC) at letermovir initiation was 400/μL (IQR 575) and the median VL was 51.6 (range: ND‐490) IU/mL. Most patients (n = 5/7, 71.4%) experienced an increase in VL 1 and/or 2 weeks after conversion to letermovir. All patients had positive CMI per ICS assay after conversion. Patients received a mean of 10.3 ± 6.9 weeks of letermovir prior to having a positive result. Median ALC at positivity was 900/μL. Immunosuppression was not further reduced from initiation of letermovir to demonstration of CMV CMI. No patient had progressive replication or breakthrough disease while maintained on letermovir and three patients (42.9%) underwent antiviral withdrawal without recurrence at the last follow‐up. Conclusion: In this case series of abdominal transplant recipients with severe or persistent CMV infection, patients developed CMV‐specific CMI after conversion to letermovir monotherapy. These data suggest that using letermovir in place of valganciclovir for secondary prophylaxis may address the lack of efficacy previously seen with this approach, as well as the issues that plague antiviral withdrawal with systematic monitoring. Future prospective studies are needed to evaluate this effect in a more controlled research environment with serial CMI testing to elucidate the optimal duration of letermovir when used in this way [ABSTRACT FROM AUTHOR]

Introduction: BK polyomavirus (BKV) is a common infection among kidney transplant recipients (KTR). Risk factors and outcomes based on donor characteristics remain largely unknown. Methods: In this study, we aimed to analyze the impact of donor factors through a paired kidney analysis. We included 289 pairs of adult deceased donor transplants (578 KTRs total); each pair had received kidneys from the same donor. Recipient pairs were divided into three groups: "no BK group" if neither KTR developed BK viremia (n = 336), "discordant" if the only one did (n = 176), and "concordant" if both did (n = 66). Acute rejection (AR), graft failure, and BK nephropathy (BKN) were outcomes of interest. Results: Donors in the concordant group were younger, had lower kidney donor profile index (KDPI), and were less likely to be donor after circulatory death (DCD). In multivariate analyses, KTRs who had a donor with a higher body mass index (BMI) (hazard ratio (HR): 0.97; 95% confidence interval (CI): 0.95–0.99; p =.009) were less likely to develop BKV. Concordance was not associated with AR (HR: 0.83; 95% CI: 0.51–1.34; p =.45), graft failure (HR: 1.77; 95% CI: 0.42–7.50; p =.43), or BKN (HR: 1.02; 95% CI: 0.51–2.03; p =.96). Discussion: Our study suggests lower donor BMI is associated with BKV infection, and concordance or discordance between paired kidney recipients is not associated with poor outcomes. [ABSTRACT FROM AUTHOR]

Aim: The impact of pre‐transplant (pre‐TXP) bariatric surgery (BS) on outcomes after liver transplant (LTX) has not been completely elucidated. Roux‐en Y gastric bypass (RYGB) is one of the most common BS procedures. The primary objective of this study was to identify the risk of infection in LTX recipients with pre‐TXP RYGB. Methods: Adult patients with LTX between 1/1/2001 and 9/30/2018 at our center were screened for pre‐TXP RYGB; patients with gastrectomy via sleeve or banding were excluded. Patients with no history of BS pre‐ or post‐transplant were placed in a comparator group, matched 2:1 via incidence density sampling on age epoch. Results: There were 16 LTX recipients with pre‐TXP RYGB matched to 32 controls. Median time from RYGB to transplant was 11.7 years. Mean weight loss was 66 ± 19 kg. There were significantly more women with pre‐TXP RYGB than in the matched control (RYGB:68.8% vs control:25%, P =.009). Demographics were otherwise similar between groups. Pre‐TXP RYGB did not significantly increase hospital or ICU length of stay (P =.5, P =.3) but was associated with a significantly increased rate of fungal infection at 1 year (RYGB:33.4% vs control:9.7%, P =.01), and a numerical trend to increased bacterial infection (RYGB:56.2% vs control:32.2%, P =.09). Conclusion: Despite the substantial weight loss attributed to BS, patients with pre‐TXP RYGB demonstrated increased rates of fungal infection after transplant and trended toward increased bacterial infection. While the anatomical complexity associated with LTX surgery after RYGB did not appear to significantly affect ICU or hospital length of stay, it may have contributed to overall infectious risk, and possibly to impaired survival. Additionally, bypass of the host natural barrier defenses of the stomach could also have contributed to infectious risk. Our findings highlight the complexity of this patient population. Future prospective studies are needed to investigate risk of infection after LTX in the setting of pre‐Txp BS. Potential modification in fungal prophylaxis protocols to include pre‐TXP RYGB may be warranted. [ABSTRACT FROM AUTHOR]