View source for CMV after hematopoietic stem cell transplantation

== Background ==

* Reactivation of latent recipient [[CMV]] infection is common after [[hematopoietic stem cell transplantation]]

=== Microbiology ===

* Refer to [[Cytomegalovirus#Microbiology|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

{| 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==

*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
***[[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"
!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]]