From the Guidelines
Cytomegalovirus (CMV) infection can cause severe disease in immunocompromised individuals, including transplant recipients, and requires prompt treatment with antiviral medications such as ganciclovir, valganciclovir, or letermovir to prevent morbidity and mortality. The effects of CMV infection can vary depending on the individual's immune status, with healthy adults often experiencing mild or asymptomatic infection, while immunocompromised individuals may develop severe disease affecting multiple organ systems, including pneumonia, retinitis, colitis, hepatitis, encephalitis, and graft rejection 1.
Risk Factors and Prevention
CMV infection can occur through viral reactivation or primary infection, with the risk of reactivation and disease highest among transplant recipients with CMV-seropositive status prior to transplant 1. Prevention strategies include good hygiene practices, screening of blood and organ donors, and prophylactic antiviral therapy for high-risk individuals, such as those undergoing allogeneic hematopoietic cell transplantation (HCT) 1.
Treatment and Management
Treatment of CMV infection typically involves antiviral medications, with the specific regimen depending on the severity of infection and the patient's immune status 1. Letermovir has been shown to be effective in preventing CMV infection in allogeneic HCT recipients, with a lower incidence of prophylaxis failure compared to placebo 1. Valganciclovir and ganciclovir are also commonly used for pre-emptive therapy, with foscarnet used for patients who cannot tolerate ganciclovir or for second-line pre-emptive therapy 1.
Monitoring and Follow-up
Regular monitoring of CMV viral load is essential for early detection and treatment of CMV infection, particularly in high-risk individuals such as transplant recipients 1. Weekly monitoring of CMV by nucleic acid testing (NAT) or pp65 antigenemia is recommended for patients with CMV disease 1. Reducing immunosuppressive medication and closely monitoring graft function are also crucial in managing CMV disease in transplant recipients 1.
From the Research
CMV Infection Effects
- CMV infection is a common viral pathogen in organ transplant recipients, contributing to substantial morbidity and occasional mortality 2.
- It can cause febrile illness, bone marrow suppression, and invasion of tissues, including the transplanted liver allograft 2.
- CMV infection has been significantly associated with an increased predisposition to acute and chronic allograft rejection, accelerated hepatitis C recurrence, and other opportunistic infections, as well as reduced overall patient and allograft survival 2.
- The use of antiviral prophylaxis or preemptive therapy is essential to prevent CMV disease in liver transplant recipients 2, 3.
- Valganciclovir is an effective and well-tolerated antiviral agent for the prevention and treatment of CMV infection and disease in solid organ transplant recipients 4, 5.
Risk Factors
- Seronegative recipients of seropositive donors (D+/R-) are at highest risk of developing CMV disease 2, 3.
- Seropositive recipients who receive antilymphocyte agents, such as OKT3 and antithymocyte globulin (ATG), for induction or rejection are also at high risk 3.
- The use of prolonged valganciclovir prophylaxis in D+/R- patients has been shown to delay the onset of CMV disease, but may not prevent late-onset disease 5.
Diagnosis and Treatment
- Sensitive tests, such as antigenemia and polymerase chain reaction (PCR), are used for early diagnosis and monitoring of CMV infection 3.
- Valganciclovir and intravenous ganciclovir are the drugs of choice for CMV management 4, 6.
- Strategies for managing drug-resistant CMV infection are presented, including the use of CMV-specific cell-mediated immune assays to stratify the risk of CMV infection after solid organ transplantation 6.