What is the recommended treatment for Cytomegalovirus (CMV) infection after lung transplant?

Management of CMV Infection Post Lung Transplant

For post-lung transplant CMV infection, first-line treatment should be oral valganciclovir or intravenous ganciclovir for at least 2 weeks and until CMV is no longer detectable by PCR. 1

First-Line Treatment Options

• Oral valganciclovir at 900 mg twice daily for 21 days (induction phase), followed by 900 mg once daily as maintenance until CMV is no longer detectable 2, 3
• Intravenous ganciclovir at 5 mg/kg twice daily for at least 2 weeks and until CMV is no longer detectable 1, 4
• Typically, therapy is initiated with oral valganciclovir unless there are absorption or toxicity issues 1
• The choice between oral valganciclovir and IV ganciclovir depends on:
  • Severity of infection
  • Gastrointestinal absorption capacity
  • Renal function 2

Monitoring During Treatment

• Weekly quantitative CMV viral load monitoring by PCR 1
• Complete blood counts to monitor for myelosuppression (particularly with ganciclovir/valganciclovir) 4, 3
• Renal function monitoring, especially with foscarnet 1
• Continue treatment until CMV is no longer detectable by PCR 1, 2

Second-Line Treatment Options

• For ganciclovir-resistant CMV or when ganciclovir is not tolerated (e.g., ganciclovir-induced myelosuppression):
  • Intravenous foscarnet 1, 2
  • Intravenous cidofovir (with caution due to nephrotoxicity) 1
• For CMV infection refractory to ganciclovir/valganciclovir, foscarnet, or cidofovir:
  • Oral maribavir (shown to achieve CMV viremia clearance in 56% of patients vs. 24% with other agents) 1
• Infectious disease consultation is highly recommended for resistant or refractory cases 1

Important Considerations and Potential Complications

• Dose adjustments are necessary for patients with renal impairment 4, 3
• Common adverse effects to monitor:
  • Ganciclovir/valganciclovir: neutropenia, thrombocytopenia, anemia 1, 5
  • Foscarnet: nephrotoxicity and electrolyte abnormalities 1
  • Cidofovir: substantial nephrotoxicity and possible ocular toxicity 1
• Risk factors for CMV disease in lung transplant recipients include:
  • Advanced age 5
  • Reduced-dose valganciclovir (less than 900 mg/day) 5
  • Less than 6 months of prophylaxis 5
  • Single-lung transplant 5

Special Considerations for Lung Transplant Recipients

• Lung transplant recipients are at particularly high risk for CMV disease, with incidence rates of 27% reported even with prophylaxis 5
• Breakthrough CMV disease can occur during prophylaxis (9% of cases) 5
• Ganciclovir-resistant CMV has been associated with high mortality (100% in one study) 5
• For patients with significant gastrointestinal GVHD, IV ganciclovir may be preferred over oral valganciclovir 1

Duration of Treatment

• Treatment should continue for at least 2 weeks 1
• Therapy should be maintained until CMV is no longer detectable by PCR 1, 2
• For patients with high-risk factors, longer treatment courses may be necessary 1

Remember that acyclovir and valacyclovir have excellent safety profiles but are only weakly active against CMV and are not recommended for treatment of CMV infection 1.