Abstract: SA-PO1136
Letermovir Therapy for Resistant Cytomegalovirus in a Kidney Transplant Recipient: Case Report
Session Information
- Transplant Trainee Case Reports
November 09, 2019 | Location: Exhibit Hall, Walter E. Washington Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Trainee Case Report
- 1902 Transplantation: Clinical
Authors
- Singh, Devender, Hennepin Health Care, Minneapolis, Minnesota, United States
- Lemke, Adley I., Hennepin Healthcare, Hopkins, Minnesota, United States
- Hart, Allyson, Hennepin Health Care, Minneapolis, Minnesota, United States
Introduction
Cytomegalovirus (CMV) infection is a leading cause of morbidity in kidney transplant recipients. Resistant CMV strains and medication toxicities complicate treatment. We describe a case of multidrug resistant CMV suppressed with letermovir after treatment with second line agents.
Case Description
63 year old female with history of living donor kidney transplant (CMV donor + / recipient -) presented with severe diarrhea and leukopenia a month after stopping valganciclovir prophylaxis. CMV viral load was 544,002 copies/mL and she was given 3 weeks of treatment and 2 months of prophylaxis using valganciclovir. Low level viremia followed discontinuation of prophylaxis. After the viral load exceeded 30,000 copies/mL treatment was resumed without successful viral suppression. Genotyping revealed resistance to valganciclovir, foscarnet, and cidofovir. She was initiated on foscarnet and high dose ganciclovir. Upon therapy discontinuation, viral load increased again and oral letermovir 480 mg daily was started. Since introducing letermovir she maintained CMV suppression for 3 months. For treatment course please see figure 1.
Discussion
Resistance to agents for the treatment of CMV is increasing. Valganciclovir alternatives have significant toxicities and necessitate parenteral administration. Letermovir is a novel agent that inhibits the cleavage of CMV DNA concatemers by targeting the pUL56 subunit of the terminase enzyme complex. Letermovir is not myelosuppressive, it is available in an oral formulation, and does not require dose adjustments for renal function. Recently letermovir was approved for CMV prophylaxis in allogeneic hematopoietic stem cell transplant recipients, but use in solid organ transplant is being investigated. Letermovir for salvage therapy has been reported but widespread use has not been adopted due to the low barrier to resistance. Our unconventional approach using combination foscarnet and ganciclovir treatment then switching to letermovir presents a possible niche for agent’s use to sustain suppression of a multidrug resistant CMV.