CMV after hematopoietic stem cell transplantation
From IDWiki
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
