CMV after hematopoietic stem cell transplantation: Difference between revisions

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== Management ==
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== Background ==
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⚫
* Most frequently managed with weekly viral loads and preemptive treatment (PET) at a lab-specific threshold
  
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* Reactivation of latent recipient [[CMV]] infection is common after [[hematopoietic stem cell transplantation]]
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* Antiviral treatment:
  
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** [[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
  
  +
=== Microbiology ===
⚫
** If concerns about oral antiviral, would continue [[Is treated by::ganciclovir]] 5 mg/kg IV daily (maintenance)
  
  +
⚫
** If ganciclovir resistance, next step is [[Is treated by::foscarnet]] 90 mg/kg IV q12h (induction) followed by q24h (maintenance)
  
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* Refer to [[Cytomegalovirus#Microbiology|Cytomegalovirus]]
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** Major adverse effect of ganciclovir is bone marrow suppression
  
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⚫
* Use CMV safe (leukoreduced or filtered) blood products if the recipient is CMV seronegative
  
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=== Epidemiology ===
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* Reactivates in 60 to 70% of CMV-seropositive patients and primary infection affects 20 to 30% of seronegative recipients who have seropositive donors
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  +
{| class="wikitable"
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!Donor
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!Recipient
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!Risk
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|-
  +
|±
  +
| +
  +
|60-70%
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|-
  +
| +
  +
|–
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|20-30%
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|-
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|–
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|–
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|5%
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|}
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  +
* Risk is proportional to the amount of T cell dysfunction, so risk is higher earlier in disease and after [[fludarabine]], [[alemtuzumab]], or [[2-chlorodeoxyadenose]]
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* GVHD is another important risk factor
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  +
==Clinical Manifestations==
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  +
*With monitoring and preemptive therapy, CMV pneumonitis has decreased to 5% of seropositive allogeneic recipients
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*[[Pneumonitis]] (63%)
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*[[Enteritis]] (26%)
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*[[Retinitis]] (5%)
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*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"
  
{| class="wikitable sortable"
−
! Serostatus
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!Serostatus
−
! Blood products
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!Blood products
−
! Duration of PET
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!Duration of PET
 
|-
  
|-
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| D-/R-
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|D-/R-
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| CMV safe
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|CMV safe
−
| weeks 2 to 12
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|weeks 2 to 12
 
|-
  
|-
−
| D+/R-
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|D+/R-
−
| CMV safe
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|CMV safe
−
| weeks 2 to 12
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|weeks 2 to 12
 
|-
  
|-
−
| autologous R-
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|autologous R-
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| CMV safe
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|CMV safe
−
| weeks 2 to 5
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|weeks 2 to 5
 
|-
  
|-
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| D±/R+
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|D±/R+
−
| CMV untested
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|CMV untested
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| weeks 2 to 12, then q2-4wk until week 26
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|weeks 2 to 12, then q2-4wk until week 26
 
|-
  
|-
−
| autologous R+
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|autologous R+
−
| CMV untested
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|CMV untested
−
| weeks 2 to 5
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|weeks 2 to 5
 
|}
  
|}
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  +
===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]]
  
[[Category:Immunocompromised hosts]]

Latest revision as of 17:21, 19 September 2020

Background

Microbiology

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%

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
  • 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
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