CMV after hematopoietic stem cell transplantation: Difference between revisions

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m (Text replacement - "Clinical Presentation" to "Clinical Manifestations")
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== 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"
{| 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
|-
|-
| DĀ±/R+
|DĀ±/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]]
[[Category:Immunocompromised hosts]]

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
DĀ±/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