CMV after hematopoietic stem cell transplantation: Difference between revisions

Latest revision as of 21:21, 19 September 2020

Reactivation of latent recipient CMV infection is common after hematopoietic stem cell transplantation

Reactivates in 60 to 70% of CMV-seropositive patients and primary infection affects 20 to 30% of seronegative recipients who have seropositive donors

Risk is proportional to the amount of T cell dysfunction, so risk is higher earlier in disease and after fludarabine, alemtuzumab, or 2-chlorodeoxyadenose
GVHD is another important risk factor

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

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

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: @@
+== Background ==
+* Reactivation of latent recipient [[CMV]] infection is common after [[hematopoietic stem cell transplantation]]
+=== Microbiology ===
+* Refer to [[Cytomegalovirus#Microbiology|Cytomegalovirus]]
+=== Epidemiology ===
+* Reactivates in 60 to 70% of CMV-seropositive patients and primary infection affects 20 to 30% of seronegative recipients who have seropositive donors
+{| class="wikitable"
+!Donor
+!Recipient
+!Risk
+|-
+|±
+| +
+|60-70%
+|-
+| +
+|–
+|20-30%
+|-
+|–
+|–
+|5%
+|}
+* Risk is proportional to the amount of T cell dysfunction, so risk is higher earlier in disease and after [[fludarabine]], [[alemtuzumab]], or [[2-chlorodeoxyadenose]]
+* GVHD is another important risk factor
 ==Clinical Manifestations==
@@ Line 5: / Line 38: @@
 *[[Enteritis]] (26%)
 *[[Retinitis]] (5%)
+*Increased risk of rejection
 ==Management==
+=== Prophylaxis ===
+* Now commonly done with [[letermovir]], started within 28 days of transplantation
 ===Preemptive Therapy===