CMV after hematopoietic stem cell transplantation

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:
  • ganciclovir 5 mg/kg q12h for 7 to 14 days (induction) followed by valganciclovir 900 mg po daily (maintenance) until a few weeks after viremia resolves
  • If concerns about oral antiviral, would continue ganciclovir 5 mg/kg IV daily (maintenance)
  • If ganciclovir resistance or bone marrow suppression, next step is 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

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