Cytomegalovirus in solid organ transplant recipients—Guidelines of the American Society of Transplantation Infectious Diseases Community of Practice

Abstract

Cytomegalovirus (CMV) is one of the most common opportunistic infections that affect the outcome of solid organ transplantation. This updated guideline from the American Society of Transplantation Infectious Diseases Community of Practice provides evidence‐based and expert recommendations for screening, diagnosis, prevention, and treatment of CMV in solid organ transplant recipients. CMV serology to detect immunoglobulin G remains as the standard method for pretransplant screening of donors and transplant candidates. Antiviral prophylaxis and preemptive therapy are the mainstays of CMV prevention. The lack of a widely applicable viral load threshold for diagnosis and preemptive therapy is highlighted, as a result of variability of CMV nucleic acid testing, even in the contemporary era when calibrators are standardized. Valganciclovir and intravenous ganciclovir remain as drugs of choice for CMV management. Strategies for managing drug‐resistant CMV infection are presented. There is an increasing use of CMV‐specific cell‐mediated immune assays to stratify the risk of CMV infection after solid organ transplantation, but their role in optimizing CMV prevention and treatment efforts has yet to be demonstrated. Specific issues related to pediatric transplant recipients are discussed.

The use of CMVIg rescue therapy in cardiothoracic transplantation: A single‐center experience over 6 years (2011‐2017)

“…This, in our view, clearly suggests a clinical benefit of adding CMVIg in combination with antiviral agents in rescue therapy protocols (Table 4). CMV syndrome defined as at least 2 of the symptom's presence of fever, malaise lymphopenia, thrombocytopenia 8,19 3. Box: first-third quartile range (with median indicated); whiskers: minimum and maximum values.…”

“…American guidelines 19 state that the addition of CMVIg to antiviral treatment can be considered for patients with life-threatening disease, including CMV pneumonitis and other severe forms of disease, drug resistant virus and those with hypogammaglobulinaemia.…”

“…CMV viral load ≥log 10 5-5.5 and rising 18 2. CMV syndrome defined as at least 2 of the symptom's presence of fever, malaise lymphopenia, thrombocytopenia 8,19 3. CMV disease with evidence of end-organ involvement (pneumonitis, retinitis, gastritis, colitis etc) 12,20 4.…”

“…Some recommend CMVIg therapy when viral loads are high, 13 or when CMV syndrome 9,14 or CMV disease with evidence of end-organ involvement is present. [17][18][19][20][21][22] Schulz et al 15 suggested that prophylactic use of CMVIg in combination with antiviral therapy is beneficial in D+R− heart transplant recipients and D+ lung transplant recipients. [17][18][19][20][21][22] Schulz et al 15 suggested that prophylactic use of CMVIg in combination with antiviral therapy is beneficial in D+R− heart transplant recipients and D+ lung transplant recipients.…”

“…15,16 Others advocate use when there is difficulty associated with standard antiviral drugs (eg, ganciclovir-induced pancytopenia), or when acute rejection, renal impairment, or hypogammaglobulinaemia is present, or when patients are refractory or resistant to standard antiviral therapies. [17][18][19][20][21][22] Schulz et al 15 suggested that prophylactic use of CMVIg in combination with antiviral therapy is beneficial in D+R− heart transplant recipients and D+ lung transplant recipients. A metaanalysis of 11 randomized trials, mostly in kidney transplant patients, suggested CMVIg prophylaxis reduced CMV disease and CMV-associated death, and improved overall survival.…”