CMV after hematopoietic stem cell transplantation
From IDWiki
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:
- ganciclovir 5 mg/kg q12h for 7 to 14 days (induction) followed by valganciclovir 900 mg po daily (maintenance) until a few weeks after viremia resolves
- If concerns about oral antiviral, would continue ganciclovir 5 mg/kg IV daily (maintenance)
- If ganciclovir resistance or bone marrow suppression, next step is 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
| 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
