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Reasons for Breakthrough CMV Disease in Patients Who Receive Preemptive Therapy

I read with interest the study by Atabani et al. regarding clinical and virologic outcomes of a large cohort of kidney and liver transplant patients who received preemptive therapy (PET) for prevention of cytomegalovirus (CMV) disease (1). As discussed by the authors, the overall rate of symptomatic CMV infection (defined as syndrome or end organ disease [EOD]) in the D+R– group was similar to previously described rates with prophylaxis (Human PV 16000; Ref. 2). It would be helpful if the authors could provide additional information on the timing of CMV disease (syndrome and/or EOD) stratified by serogroup and also a detailed summary of the reasons for failure of PET that led to symptomatic CMV infection in the D+R– cohort. This information could have important implications for refining the strategy of PET to further reduce the rate of symptomatic CMV infection. The authors should specify the proportion of D+R– patients who developed symptomatic CMV (syndrome and/or EOD) due to reasons such as: symptoms concordant with viremia, symptoms developing below the treatment threshold of 3000 genomes/mL, symptoms without viremia, symptoms that developed between monitoring visits, symptoms after discontinuation of monitoring, etc. Such information could inform on specific modifications of PET to further reduce the rates of symptomatic CMV infection.