Valganciclovir Dosing Strategies for Cytomegalovirus Prophylaxis in Pediatric Solid Organ Transplant Recipients: A Comparative Single-Center Study

Optimal valganciclovir dosing for cytomegalovirus (CMV) prophylaxis in pediatric solid organ transplant recipients remains difficult due to variable pharmacokinetics. This study compared the efficacy and safety of three dosing strategies: body surface area (BSA)-based, weight-based, and Pescovitz algorithm-based dosing. This retrospective cohort study included pediatric patients aged ≤14 years who underwent kidney or liver transplantation between 2010 and 2018 and received valganciclovir for CMV prophylaxis. The primary outcome was the comparative effectiveness of the three dosing approaches in preventing CMV infection and disease. The study included 150 patients, with 50 in each group. CMV infection occurred more frequently in the BSA-based group than in the Pescovitz algorithm-based or weight-based groups. Among patients who developed CMV DNAemia, CMV disease occurred in 54%, 28%, and 50% of patients in the BSA-based, Pescovitz algorithm-based, and weight-based groups, respectively. No tissue-invasive CMV disease was observed within 12 months after transplantation. All groups showed acceptable safety profiles, and no patients discontinued therapy due to hematologic adverse events. Weight-based dosing was associated with lower CMV infection and disease rates than BSA-based dosing and Pescovitz algorithm-based dosing, with similar safety. In pediatric solid organ transplant recipients, valganciclovir dosing strategy was not independently associated with CMV infection after adjustment. Age emerged as the sole independent predictor of CMV risk, underscoring the predominance of patient-related factors in CMV prophylaxis.