Adenovirus Disease Following Pediatric Liver Transplantation: 10‐Year Experience From a Large Pediatric Transplant Program

Background Human adenovirus in immunocompromised patients can be life‐threatening. We describe the prevalence, clinical presentation, and treatment of adenovirus after pediatric liver transplantation at a large transplant center. Methods We performed a retrospective cohort study of adenovirus infection in children from 2013 to 2022. We compared incidence, clinical characteristics, and outcomes of post‐transplant children by adenovirus treatment status. Results Adenovirus disease developed in 26% (84/320) children after liver transplant. Median age at liver transplant was 17.5 months, 48% were female; 50% had biliary atresia. Fever (53%), gastrointestinal symptoms (48%), and hepatitis (41%) were the most common clinical presentations at diagnosis. Median time to adenovirus diagnosis was 80 days (IQR 19–260) with 40% ( n = 31/84) identified within 30 days post‐transplant. Disseminated adenovirus (≥ 2 organ involvement) occurred in 24% (20/84). Fourteen patients (17%) received cidofovir, and most (13/14, 93%) had DNAemia, compared to 57% untreated patients with DNAemia ( p = 0.013). Median peak adenovirus load was 491 805 copies/mL (IQR 24 800–1 900 000) in treated vs. 1000 copies/mL (IQR 595–794 794) in untreated patients ( p < 0.001). Overall mortality was 8% (7/84). Conclusion The incidence of symptomatic and disseminated adenovirus disease was high in our pediatric liver transplant patients, particularly within 30 days post‐transplant. Patients who received cidofovir treatment presented with high viral load and had the highest mortality. There is a critical need for evidence‐based guidance for early antiviral management of adenovirus disease after pediatric liver transplant.