CMV after solid organ transplantation - Revision history

Aidan: /* Prevention */

2020-09-12T00:42:04Z

Prevention

← Older revision		Revision as of 00:42, 12 September 2020
Line 46:		Line 46:

	{\| class="wikitable"		{\| class="wikitable"
			! colspan="2" \|Serostatus
	!Serostatus!!Risk profile!!Approach!!Prophylaxis regimen
			! rowspan="2" \|Risk profile
			! rowspan="2" \|Approach
			! rowspan="2" \|Prophylaxis regimen
	\|-		\|-
			!D
	\|D+/R-
			!R
			\|-
			\| +
			\|–
	\|High		\|High
	\|Either prophylaxis or PET; prophylaxis preferred for lung, heart, and pancreas		\|Either prophylaxis or PET; prophylaxis preferred for lung, heart, and pancreas
	\|3-6 months for most organs; 6 months for kidney; 6-12 months for lung		\|3-6 months for most organs; 6 months for kidney; 6-12 months for lung
	\|-		\|-
	\|~~D+/R~~+		\| +
			\| +
	\| rowspan="2" \|Intermediate		\| rowspan="2" \|Intermediate
	\| rowspan="2" \|Either prophylaxis or PET; prophylaxis preferred for lung, heart, and pancreas		\| rowspan="2" \|Either prophylaxis or PET; prophylaxis preferred for lung, heart, and pancreas
	\| rowspan="2" \|3 months for most organs; 6 months for lung		\| rowspan="2" \|3 months for most organs; 6 months for lung
	\|-		\|-
			\|–
	\|D-/R+
			\| +
	\|-		\|-
			\|–
	\|D-/R-
			\|–
	\|Low		\|Low
	\|Clinical monitoring; consider PET if other risk factors for CMV		\|Clinical monitoring; consider PET if other risk factors for CMV

Aidan: /* Prevention */

2020-09-12T00:40:48Z

Prevention

← Older revision		Revision as of 00:40, 12 September 2020
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	\|3-6 months for most organs; 6 months for kidney; 6-12 months for lung		\|3-6 months for most organs; 6 months for kidney; 6-12 months for lung
	\|-		\|-
	\|R+		\|D+/R+
	\|Intermediate		\| rowspan="2" \|Intermediate
	\|Either prophylaxis or PET; prophylaxis preferred for lung, heart, and pancreas		\| rowspan="2" \|Either prophylaxis or PET; prophylaxis preferred for lung, heart, and pancreas
	\|3 months for most organs; 6 months for lung		\| rowspan="2" \|3 months for most organs; 6 months for lung
			\|-
			\|D-/R+
	\|-		\|-
	\|D-/R-		\|D-/R-

Aidan: /* Clinical Manifestations */

2020-09-05T13:01:00Z

Clinical Manifestations

← Older revision		Revision as of 13:01, 5 September 2020
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	==Clinical Manifestations==		==Clinical Manifestations==

	*Tends to reactivate in the transplanted organ		*Tends to reactivate in the transplanted organ, but can have colitis

	===CMV Syndrome===		===CMV Syndrome===

Aidan: /* Further Reading */

2020-09-05T12:59:10Z

Further Reading

Aidan: Text replacement - "([Ss])olid-organ" to "$1olid organ"

2020-08-07T14:21:16Z

Text replacement - "([Ss])olid-organ" to "$1olid organ"

← Older revision		Revision as of 14:21, 7 August 2020
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	==Further Reading==		==Further Reading==

	*The Third International Consensus Guidelines on the Management of Cytomegalovirus in Solid-organ Transplantation. ''Transplantation''. 2018;102:900–931. DOI: [https://doi.org/10.1097/TP.0000000000002191 10.1097/TP.0000000000002191]		*The Third International Consensus Guidelines on the Management of Cytomegalovirus in Solid organ Transplantation. ''Transplantation''. 2018;102:900–931. DOI: [https://doi.org/10.1097/TP.0000000000002191 10.1097/TP.0000000000002191]

	[[Category:Immunocompromised hosts]]		[[Category:Immunocompromised hosts]]

Aidan: Split Management and Prevention

2020-08-06T23:59:29Z

Split Management and Prevention

← Older revision		Revision as of 23:59, 6 August 2020
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	== Clinical Manifestations ==		==Clinical Manifestations==

	* Tends to reactivate in the transplanted organ		*Tends to reactivate in the transplanted organ

	=== CMV Syndrome ===		===CMV Syndrome===

	* Detectable CMV viremia, plus at least two of:		*Detectable CMV viremia, plus at least two of:
	** Fever ≥38ºC for 2+ days		**Fever ≥38ºC for 2+ days
	** New or increased malaise or fatigue		**New or increased malaise or fatigue
	** Leukopenia or neutropenia on 2 separate measurements		**Leukopenia or neutropenia on 2 separate measurements
	** 5% atypical lymphocytes		**5% atypical lymphocytes
	** Thrombocytopenia		**Thrombocytopenia
	** Hepatic aminotransferases ≥2 times the upper limit of normal (except non-liver transplant recipients)		**Hepatic aminotransferases ≥2 times the upper limit of normal (except non-liver transplant recipients)

	==Management==		== Management ==

			* Treated with [[Is treated by::ganciclovir]] 5 mg/kg IV q12h or [[Is treated by::valganciclovir]] 900 mg PO bid, depending on severity of illness
			* Second-line treatment includes [[Is treated by::foscarnet]] and [[Is treated by::cidofovir]]
			* Expect a 1-log decrease in viral level after 2 weeks
			* Duration is for a minimum of 2 weeks, until resolution of symptoms, and until viral load falls below the negative cutoff
			* While being treated, check CBC and creatinine weekly to monitor for toxicity

			=== Refractory Disease ===

			* Refractory CMV infection: viral load increases >1 log after 2 weeks of appropriate therapy
			* Probable refractory CMV infection: viral load persists or increases <1 log after 2 weeks of appropriate therapy
			* Lack of clinical improvement after 2 weeks is also concerning
			* The causes of refractory disease include:
			** Over-immunosuppression resulting in a severe deficiency of CMV-specific T cells
			** Subtherapeutic antiviral drug levels
			** Antiviral resistance
			*** Ganciclovir resistance occurs in 0-3% of patients, and foscarnet resistance in less
			*** Risk factors include prolonged subtherapeutic levels, D+/R– serostatus, heavy immunosuppression, and lung transplantation
			*** If suspected, send testing for UL97 kinase (ganciclovir) ± UL54 DNA polymerase (ganciclovir & foscarnet)

			==Prevention==

	*Two approaches are used, either ongoing antimicrobial '''prophylaxis''' following transplantation, or close monitoring of viral load with '''preemptive treatment''' (PET) of subclinical viremia		*Two approaches are used, either ongoing antimicrobial '''prophylaxis''' following transplantation, or close monitoring of viral load with '''preemptive treatment''' (PET) of subclinical viremia

Aidan: added Clinical Manifestations

2020-08-06T21:45:54Z

added Clinical Manifestations

← Older revision		Revision as of 21:45, 6 August 2020
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	== ~~Management~~ ==		== Clinical Manifestations ==

⚫	* Two approaches are used, either ongoing antimicrobial '''prophylaxis''' following transplantation, or close monitoring of viral load with '''preemptive treatment''' (PET) of subclinical viremia
			* Tends to reactivate in the transplanted organ
⚫	* Approach and duration depends on risk profile and organ transplanted

⚫	** Intermediate and high risk patients should get either prophylaxis or PET
			=== CMV Syndrome ===
⚫	*** Prophylaxis (rather than PET) is preferred in lung, heart, and pancreas transplantations

⚫	** Low risk should either be monitored for symptoms or be followed with PET (if there is other concern for CMV disease, such as frequent transfusions)
			* Detectable CMV viremia, plus at least two of:
⚫	* Antimicrobial of choice is [[Is treated by::valganciclovir]] 900 mg po daily, starting within 10 days of transplantation
			** Fever ≥38ºC for 2+ days
			** New or increased malaise or fatigue
			** Leukopenia or neutropenia on 2 separate measurements
			** 5% atypical lymphocytes
			** Thrombocytopenia
			** Hepatic aminotransferases ≥2 times the upper limit of normal (except non-liver transplant recipients)

			==Management==

		⚫	*Two approaches are used, either ongoing antimicrobial '''prophylaxis''' following transplantation, or close monitoring of viral load with '''preemptive treatment''' (PET) of subclinical viremia
			**Prophylaxis: easier to coordinate, higher drug costs, greater drug toxicity (myelosuppression)
			**Preemptive therapy: harder to coordinate, viral load thresholds not well-defined, higher laboratory costs, lower drug toxicity
		⚫	*Approach and duration depends on risk profile and organ transplanted
		⚫	**Intermediate and high risk patients should get either prophylaxis or PET
		⚫	***Prophylaxis (rather than PET) is preferred in lung, heart, and pancreas transplantations
		⚫	**Low risk should either be monitored for symptoms or be followed with PET (if there is other concern for CMV disease, such as frequent transfusions)
		⚫	*Antimicrobial of choice is [[Is treated by::valganciclovir]] 900 mg po daily, starting within 10 days of transplantation

	{\| class="wikitable"		{\| class="wikitable"
	! Serostatus !! Risk profile !! Approach !! Prophylaxis regimen		!Serostatus!!Risk profile!!Approach!!Prophylaxis regimen
	\|-		\|-
	\| D+/R-		\|D+/R-
	\| High		\|High
	\| Either prophylaxis or PET; prophylaxis preferred for lung, heart, and pancreas		\|Either prophylaxis or PET; prophylaxis preferred for lung, heart, and pancreas
	\| 3-6 months for most organs; 6 months for kidney; 6-12 months for lung		\|3-6 months for most organs; 6 months for kidney; 6-12 months for lung
	\|-		\|-
	\| R+		\|R+
	\| Intermediate		\|Intermediate
	\| Either prophylaxis or PET; prophylaxis preferred for lung, heart, and pancreas		\|Either prophylaxis or PET; prophylaxis preferred for lung, heart, and pancreas
	\| 3 months for most organs; 6 months for lung		\|3 months for most organs; 6 months for lung
	\|-		\|-
	\| D-/R-		\|D-/R-
	\| Low		\|Low
	\| Clinical monitoring; consider PET if other risk factors for CMV		\|Clinical monitoring; consider PET if other risk factors for CMV
	\|		\|
	\|}		\|}

	== Further Reading ==		==Further Reading==

	* The Third International Consensus Guidelines on the Management of Cytomegalovirus in Solid-organ Transplantation. ''Transplantation''. 2018;102:900–931. DOI: [https://doi.org/10.1097/TP.0000000000002191 10.1097/TP.0000000000002191]		*The Third International Consensus Guidelines on the Management of Cytomegalovirus in Solid-organ Transplantation. ''Transplantation''. 2018;102:900–931. DOI: [https://doi.org/10.1097/TP.0000000000002191 10.1097/TP.0000000000002191]

	[[Category:Immunocompromised hosts]]		[[Category:Immunocompromised hosts]]

Aidan: /* Management */ added low risk to table

2020-03-06T16:30:00Z

Management: added low risk to table

← Older revision		Revision as of 16:30, 6 March 2020
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	\| Either prophylaxis or PET; prophylaxis preferred for lung, heart, and pancreas		\| Either prophylaxis or PET; prophylaxis preferred for lung, heart, and pancreas
	\| 3 months for most organs; 6 months for lung		\| 3 months for most organs; 6 months for lung
			\|-
			\| D-/R-
			\| Low
			\| Clinical monitoring; consider PET if other risk factors for CMV
			\|
	\|}		\|}

Aidan: /* Management */ bolded

2020-03-06T16:29:07Z

Management: bolded

← Older revision		Revision as of 16:29, 6 March 2020
Line 1:		Line 1:
	== Management ==		== Management ==
	* Two approaches are used, either ongoing antimicrobial prophylaxis following transplantation, or close monitoring of viral load with preemptive treatment (PET) of subclinical viremia		* Two approaches are used, either ongoing antimicrobial '''prophylaxis''' following transplantation, or close monitoring of viral load with '''preemptive treatment''' (PET) of subclinical viremia
	* Approach and duration depends on risk profile and organ transplanted		* Approach and duration depends on risk profile and organ transplanted
	** Intermediate and high risk patients should get either prophylaxis or PET		** Intermediate and high risk patients should get either prophylaxis or PET

Aidan: Created page with "== Management == * Two approaches are used, either ongoing antimicrobial prophylaxis following transplantation, or close monitoring of viral load with preemptive treatment (PE..."

2020-03-06T16:28:32Z

Created page with "== Management == * Two approaches are used, either ongoing antimicrobial prophylaxis following transplantation, or close monitoring of viral load with preemptive treatment (PE..."

New page

== Management ==
* Two approaches are used, either ongoing antimicrobial prophylaxis following transplantation, or close monitoring of viral load with preemptive treatment (PET) of subclinical viremia
* Approach and duration depends on risk profile and organ transplanted
** Intermediate and high risk patients should get either prophylaxis or PET
*** Prophylaxis (rather than PET) is preferred in lung, heart, and pancreas transplantations
** Low risk should either be monitored for symptoms or be followed with PET (if there is other concern for CMV disease, such as frequent transfusions)
* Antimicrobial of choice is [[Is treated by::valganciclovir]] 900 mg po daily, starting within 10 days of transplantation

{| class="wikitable"
! Serostatus !! Risk profile !! Approach !! Prophylaxis regimen
|-
| D+/R-
| High
| Either prophylaxis or PET; prophylaxis preferred for lung, heart, and pancreas
| 3-6 months for most organs; 6 months for kidney; 6-12 months for lung
|-
| R+
| Intermediate
| Either prophylaxis or PET; prophylaxis preferred for lung, heart, and pancreas
| 3 months for most organs; 6 months for lung
|}

== Further Reading ==
* The Third International Consensus Guidelines on the Management of Cytomegalovirus in Solid-organ Transplantation. ''Transplantation''. 2018;102:900–931. DOI: [https://doi.org/10.1097/TP.0000000000002191 10.1097/TP.0000000000002191]

[[Category:Immunocompromised hosts]]

← Older revision		Revision as of 12:59, 5 September 2020
Line 13:		Line 13:
	**Hepatic aminotransferases ≥2 times the upper limit of normal (except non-liver transplant recipients)		**Hepatic aminotransferases ≥2 times the upper limit of normal (except non-liver transplant recipients)

	== Management ==		==Management==

	* Treated with [[Is treated by::ganciclovir]] 5 mg/kg IV q12h or [[Is treated by::valganciclovir]] 900 mg PO bid, depending on severity of illness		*Treated with [[Is treated by::ganciclovir]] 5 mg/kg IV q12h or [[Is treated by::valganciclovir]] 900 mg PO bid, depending on severity of illness
	* Second-line treatment includes [[Is treated by::foscarnet]] and [[Is treated by::cidofovir]]		*Second-line treatment includes [[Is treated by::foscarnet]] and [[Is treated by::cidofovir]]
	* Expect a 1-log decrease in viral level after 2 weeks		*Expect a 1-log decrease in viral level after 2 weeks
	* Duration is for a minimum of 2 weeks, until resolution of symptoms, and until viral load falls below the negative cutoff		*Duration is for a minimum of 2 weeks, until resolution of symptoms, and until viral load falls below the negative cutoff
	* While being treated, check CBC and creatinine weekly to monitor for toxicity		*While being treated, check CBC and creatinine weekly to monitor for toxicity

	=== Refractory Disease ===		===Refractory Disease===

	* Refractory CMV infection: viral load increases >1 log after 2 weeks of appropriate therapy		*Refractory CMV infection: viral load increases >1 log after 2 weeks of appropriate therapy
	* Probable refractory CMV infection: viral load persists or increases <1 log after 2 weeks of appropriate therapy		*Probable refractory CMV infection: viral load persists or increases <1 log after 2 weeks of appropriate therapy
	* Lack of clinical improvement after 2 weeks is also concerning		*Lack of clinical improvement after 2 weeks is also concerning
	* The causes of refractory disease include:		*The causes of refractory disease include:
	** Over-immunosuppression resulting in a severe deficiency of CMV-specific T cells		**Over-immunosuppression resulting in a severe deficiency of CMV-specific T cells
	** Subtherapeutic antiviral drug levels		**Subtherapeutic antiviral drug levels
	** Antiviral resistance		**Antiviral resistance
	*** Ganciclovir resistance occurs in 0-3% of patients, and foscarnet resistance in less		***Ganciclovir resistance occurs in 0-3% of patients, and foscarnet resistance in less
	*** Risk factors include prolonged subtherapeutic levels, D+/R– serostatus, heavy immunosuppression, and lung transplantation		***Risk factors include prolonged subtherapeutic levels, D+/R– serostatus, heavy immunosuppression, and lung transplantation
	*** If suspected, send testing for UL97 kinase (ganciclovir) ± UL54 DNA polymerase (ganciclovir & foscarnet)		***If suspected, send testing for UL97 kinase (ganciclovir) ± UL54 DNA polymerase (ganciclovir & foscarnet)

	==Prevention==		==Prevention==
Line 66:		Line 66:
	==Further Reading==		==Further Reading==

			*Cytomegalovirus in solid organ transplant recipients— Guidelines of the American Society of Transplantation Infectious Diseases Community of Practice. ''Clin Transplant''. 2019;33:e13512. doi: [https://doi.org/10.1111/ctr.13512 10.1111/ctr.13512]
	*The Third International Consensus Guidelines on the Management of Cytomegalovirus in Solid organ Transplantation. ''Transplantation''. 2018;102:900–931. DOI: [https://doi.org/10.1097/TP.0000000000002191 10.1097/TP.0000000000002191]		*The Third International Consensus Guidelines on the Management of Cytomegalovirus in Solid organ Transplantation. ''Transplantation''. 2018;102:900–931. DOI: [https://doi.org/10.1097/TP.0000000000002191 10.1097/TP.0000000000002191]