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 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