CMV after hematopoietic stem cell transplantation: Difference between revisions
From IDWiki
m (Text replacement - "Clinical Presentation" to "Clinical Manifestations") |
No edit summary |
||
(One intermediate revision by the same user not shown) | |||
Line 1: | Line 1: | ||
− | == |
+ | == Background == |
⚫ | |||
⚫ | |||
⚫ | |||
⚫ | |||
+ | * Reactivation of latent recipient [[CMV]] infection is common after [[hematopoietic stem cell transplantation]] |
||
⚫ | |||
+ | |||
⚫ | |||
+ | === Microbiology === |
||
⚫ | |||
+ | |||
− | * Antiviral treatment: |
||
+ | * Refer to [[Cytomegalovirus#Microbiology|Cytomegalovirus]] |
||
− | ** [[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 |
||
+ | |||
⚫ | |||
+ | === 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== |
||
+ | |||
⚫ | |||
⚫ | |||
⚫ | |||
⚫ | |||
+ | *Increased risk of rejection |
||
+ | |||
⚫ | |||
+ | |||
+ | === Prophylaxis === |
||
+ | |||
+ | * Now commonly done with [[letermovir]], started within 28 days of transplantation |
||
+ | |||
⚫ | |||
+ | |||
⚫ | |||
+ | *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 |
||
⚫ | |||
+ | **Maintenance therapy |
||
+ | ***[[Is treated by::Valganciclovir]] 900 mg po daily |
||
⚫ | |||
+ | ***If concerns about resistance or bone marrow suppression, [[Is treated by::foscarnet]] 90 mg/kg IV q24h |
||
⚫ | |||
{| class="wikitable sortable" |
{| class="wikitable sortable" |
||
− | ! |
+ | !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 [[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 |
[[Category:Immunocompromised hosts]] |
[[Category:Immunocompromised hosts]] |
Latest revision as of 17:21, 19 September 2020
Background
- Reactivation of latent recipient CMV infection is common after hematopoietic stem cell transplantation
Microbiology
- Refer to 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
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
- 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
Management
Prophylaxis
- Now commonly done with letermovir, started within 28 days of transplantation
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
- Induction therapy
- 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