Abstract: TH-PO0926
Role of Cytomegalovirus (CMV) Immunoglobulin in Managing Multidrug-Resistant CMV Infection in a Kidney Transplant Recipient
Session Information
- Transplantation: Clinical - Glomerular Diseases, Infections, and Rejection
November 06, 2025 | Location: Exhibit Hall, Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Transplantation
- 2102 Transplantation: Clinical
Authors
- Laroia, Aprajita, Jefferson Einstein Philadelphia Hospital, Philadelphia, Pennsylvania, United States
- Vangapalli, Ananthalaxmi, Jefferson Einstein Philadelphia Hospital, Philadelphia, Pennsylvania, United States
- Chewaproug, Daranee, Jefferson Einstein Philadelphia Hospital, Philadelphia, Pennsylvania, United States
- Bradauskaite, Gitana, Jefferson Einstein Philadelphia Hospital, Philadelphia, Pennsylvania, United States
- Knorr, John P., Jefferson Einstein Philadelphia Hospital, Philadelphia, Pennsylvania, United States
- Pydimarri, Sudhindra, Mercy Health, Cincinnati, Ohio, United States
Introduction
Resistant CMV infection remains a significant cause of morbidity and mortality among transplant recipients. Management is often complicated by limited antiviral options, drug toxicities, and the development of resistance. CMV immunoglobulin (CMV-Ig) has been used as adjunctive therapy, though its role in multidrug-resistant (MDR) CMV remains uncertain.
Case Description
A 60-year-old CMV-negative male with diabetes, hypertension, liver fibrosis, gout, and ESRD underwent a kidney transplant from a CMV-positive donor (KDPI 55%). Post-transplant course was complicated by delayed graft function and leukopenia. He received induction with thymoglobulin and maintenance immunosuppression with tacrolimus, MMF, and prednisone. Prophylaxis included valganciclovir (VGCV) and TMP-SMX.
At two months, CMV viremia of 9,130 IU/mL was detected. Despite VGCV therapy and MMF reduction, viral load rebounded to 94,600 IU/mL with resistance to VGCV and cidofovir. Maribavir (MBV) was initiated, resulting in temporary improvement, but viremia rebounded to 404,000 IU/mL. At five months, MBV resistance emerged. Foscarnet (FOS) was started but failed to reduce viremia. CMV-Ig was added (100 mg/kg every other day x7), and MMF was stopped, leading to partial control (197–364 IU/mL).
At seven months, he was discharged on letermovir (LTV), but viremia rose to 40,200 IU/mL by ten months. He was readmitted after nonadherence; LTV resistance was detected. FOS resumed, reducing CMV DNA to 285 IU/mL. Due to outpatient FOS inaccessibility and unavailable T-cell therapy, weekly CMV-Ig was started (200 mg/kg x2, then 150 mg/kg weekly). Over the next three months, the patient remained asymptomatic, with viremia stabilizing between 611–885 IU/mL.
Discussion
This case highlights the challenges in managing MDR-CMV in a high-risk transplant recipient. Antiviral resistance and toxicity limits options. CMV-Ig, used both with FOS and later as monotherapy, was associated with clinical stability and partial virologic control. While not curative, CMV-Ig appeared to modulate disease activity, especially when standard options were exhausted or unavailable. This case underscores the importance of adherence, timely resistance testing, and the potential role of immunotherapeutics like CMV-Ig in refractory CMV management.