Risk-Adapted Preemptive Therapy for Cytomegalovirus Disease after Allogeneic Stem Cell Transplantation: A Single-Center Experience in Korea

Abstract

Cytomegalovirus (CMV) remains a major cause of infection in recipients of hematopoietic stem cell transplants (HSCT) and results in significant mortality and morbidity. We present the results of CMV pp65 antigenemia-guided, risk-adapted preemptive therapy aimed at preventing CMV disease in allogeneic HSCT. Preemptive ganciclovir treatment was started when more than 5 CMV antigen-positive cells were detected in the low-risk group (with grade 0-I acute GVHD and matched related HSCT) and when any antigen-positive cells were seen in the high-risk group (with grade II-IV acute GVHD or matched unrelated HSCT). At least 1 episode of antigenemia was observed in 53 (59.6%) of 89 patients before day 100, and preemptive therapy was performed in 33 patients. CMV disease occurred in 6 patients (5 in the high-risk group and 1 in the low-risk group), and late CMV disease developed in 4 patients. Only 1 patient died of CMV pneumonitis before day 100. Neutropenia was observed in 51.5% of ganciclovir-treated patients, and coinfection/superinfection was observed in 42.4%. A strategy of ganciclovir treatment focusing on patients at higher risk could reduce the toxicity from the antiviral drug and be cost-effective. Extended surveillance for CMV disease using more sensitive diagnostic methods is necessary in high-risk patients.

Cytomegalovirus infection/disease after hematopoietic stem cell transplantation

“…Thus, a lower threshold should be used for highrisk patients, and a higher threshold should be used for lowrisk patients. Such a risk-adapted approach could refine the uniform preemptive therapy by reducing the patients who receive toxic antiviral agents without increasing the incidence of breakthrough CMV disease [31][32][33][34].…”

“…Ganciclovir has been used and has played an important role in preemptive therapy [26][27][28][30][31][32][33][34]. An alternative to ganciclovir is foscarnet, which is as effective as ganciclovir.…”

Clinical impact of thrombotic microangiopathy on the outcome of patients with acute graft-versus-host disease after allogeneic hematopoietic stem cell transplantation

“…All patients were monitored for cytomegalovirus (CMV) at least twice weekly during admission, and when they visited the outpatient clinic. 17 Various clinical and laboratory data of the patients were retrieved from the database and the medical records of the hospital.…”

Vascular endothelial growth factor (VEGF) is associated with reduced severity of acute graft-versus-host disease and nonrelapse mortality after allogeneic stem cell transplantation

“…20 Blood sample collection and cytokine level determination Blood samples were collected on day 0 (before the stem cell infusion) as well as on days þ 7 and þ 14 after the transplant. The blood was centrifuged for 10 min at 2500 r.p.m., aliquots of the serum were stored at À201C until needed.…”