CMV after hematopoietic stem cell transplantation: Difference between revisions

Revision as of 01:06, 12 September 2020

Clinical Manifestations

With monitoring and preemptive therapy, CMV pneumonitis has decreased to 5% of seropositive allogeneic recipients
Pneumonitis (63%)
Enteritis (26%)
Retinitis (5%)

Management

Preemptive Therapy

Most frequently managed with weekly viral loads and preemptive treatment (PET) at a lab-specific threshold
Antiviral treatment follows a model of induction therapy for 14 days; if it has declined by at least 1 log, then step down to lower-dose maintenance therapy until viremia resolves fully; otherwise, continue induction dosing
- Induction therapy
  - Ganciclovir 5 mg/kg q12h
  - If concerns about resistance or bone marrow suppression, foscarnet 90 mg/kg IV q12h
- Maintenance therapy
  - Valganciclovir 900 mg po daily
  - If concerns about oral absorption, continue ganciclovir 5 mg/kg IV q24h
  - If concerns about resistance or bone marrow suppression, foscarnet 90 mg/kg IV q24h
Use CMV safe (leukoreduced or filtered) blood products if the recipient is CMV seronegative

Serostatus	Blood products	Duration of PET
D-/R-	CMV safe	weeks 2 to 12
D+/R-	CMV safe	weeks 2 to 12
autologous R-	CMV safe	weeks 2 to 5
D±/R+	CMV untested	weeks 2 to 12, then q2-4wk until week 26
autologous R+	CMV untested	weeks 2 to 5

CMV Disease

Treatment is with ganciclovir induction for 14 to 21 days with IVIG 500 mg/kg every other day, followed by maintenance ganciclovir for at least 3 to 4 weeks
May need to continue maintenance for longer if patient has GVHD, enteritis with deep ulcerations, or retinitis

@@ Line 1: / Line 1: @@
-== Clinical Manifestations ==
+==Clinical Manifestations==
-* With monitoring and preemptive therapy, CMV pneumonitis has decreased to 5% of seropositive allogeneic recipients
-* [[Pneumonitis]] (63%)
-* [[Enteritis]] (26%)
-* [[Retinitis]] (5%)
+*With monitoring and preemptive therapy, CMV pneumonitis has decreased to 5% of seropositive allogeneic recipients
-== Management ==
+*[[Pneumonitis]] (63%)
-=== Preemptive therapy ===
+*[[Enteritis]] (26%)
-* Most frequently managed with weekly viral loads and preemptive treatment (PET) at a lab-specific threshold
+*[[Retinitis]] (5%)
-* Antiviral treatment:
-** [[Is treated by::ganciclovir]] 5 mg/kg q12h for 7 to 14 days (induction) followed by [[Is treated by::valganciclovir]] 900 mg po daily (maintenance) until a few weeks after viremia resolves
+==Management==
-** If concerns about oral antiviral, would continue [[Is treated by::ganciclovir]] 5 mg/kg IV daily (maintenance)
+===Preemptive Therapy===
-** If ganciclovir resistance or bone marrow suppression, next step is [[Is treated by::foscarnet]] 90 mg/kg IV q12h (induction) followed by q24h (maintenance)
-* Use CMV safe (leukoreduced or filtered) blood products if the recipient is CMV seronegative
+*Most frequently managed with weekly viral loads and preemptive treatment (PET) at a lab-specific threshold
+*Antiviral treatment follows a model of induction therapy for 14 days; if it has declined by at least 1 log, then step down to lower-dose maintenance therapy until viremia resolves fully; otherwise, continue induction dosing
+**Induction therapy
+***[[Is treated by::Ganciclovir]] 5 mg/kg q12h
+***If concerns about resistance or bone marrow suppression, [[Is treated by::foscarnet]] 90 mg/kg IV q12h
+**Maintenance therapy
+***[[Is treated by::Valganciclovir]] 900 mg po daily
+***If concerns about oral absorption, continue [[Is treated by::ganciclovir]] 5 mg/kg IV q24h
+***If concerns about resistance or bone marrow suppression, [[Is treated by::foscarnet]] 90 mg/kg IV q24h
+*Use CMV safe (leukoreduced or filtered) blood products if the recipient is CMV seronegative
 {| class="wikitable sortable"
-! Serostatus
+!Serostatus
-! Blood products
+!Blood products
-! Duration of PET
+!Duration of PET
 |-
-| D-/R-
+|D-/R-
-| CMV safe
+|CMV safe
-| weeks 2 to 12
+|weeks 2 to 12
 |-
-| D+/R-
+|D+/R-
-| CMV safe
+|CMV safe
-| weeks 2 to 12
+|weeks 2 to 12
 |-
-| autologous R-
+|autologous R-
-| CMV safe
+|CMV safe
-| weeks 2 to 5
+|weeks 2 to 5
 |-
-| D±/R+
+|D±/R+
-| CMV untested
+|CMV untested
-| weeks 2 to 12, then q2-4wk until week 26
+|weeks 2 to 12, then q2-4wk until week 26
 |-
-| autologous R+
+|autologous R+
-| CMV untested
+|CMV untested
-| weeks 2 to 5
+|weeks 2 to 5
 |}
-=== CMV disease ===
+===CMV Disease===
-* Treatment is with [[Is treated by::ganciclovir]] induction for 14 to 21 days with IVIG 500 mg/kg every other day, followed by maintenance [[ganciclovir]] for at least 3 to 4 weeks
+*Treatment is with [[Is treated by::ganciclovir]] induction for 14 to 21 days with IVIG 500 mg/kg every other day, followed by maintenance [[ganciclovir]] for at least 3 to 4 weeks
-* May need to continue maintenance for longer if patient has [[GVHD]], enteritis with deep ulcerations, or retinitis
+*May need to continue maintenance for longer if patient has [[GVHD]], enteritis with deep ulcerations, or retinitis
 [[Category:Immunocompromised hosts]]