Cytomegalovirus in transplantation - challenging the status quo.

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Clin Transplant. 2007 Mar-Apr;21(2):149-58.

Cytomegalovirus in transplantation -

challenging the status quo.

Fishman JA, Emery V, Freeman R, Pascual M, Rostaing L, Schlitt HJ, Sgarabotto D, Torre-Cisneros J, Uknis ME.

Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.

BACKGROUND: Cytomegalovirus (CMV) infection of solid organ transplant (SOT)

recipients causes both ''direct'' and ''indirect'' effects including allograft

rejection, decreased graft and patient survival, and predisposition to

opportunistic infections and malignancies. Options for

CMV prevention include pre-emptive therapy, whereby anti-CMV agents are

administered based on sensitive viral assays, or universal prophylaxis of all

at-risk patients. Each approach has advantages and

disadvantages in terms of efficacy, costs, and side effects. Standards

of care for prophylaxis have not been established. METHODS:

A committee of international experts was convened to review the available data

regarding CMV prophylaxis and to compare preventative strategies for CMV after

transplantation from seropositive donors or in seropositive recipients. RESULTS:

Pre-emptive therapy requires frequent monitoring with subsequent treatment of

disease and associated costs, while universal prophylaxis results in greater

exposure to potential toxicities and costs of drugs. The

advantages of prophylaxis include suppressing asymptomatic viremia

and prevention of both direct and indirect effects of CMV infection. Meta analyses reveal decreased in

mortality for patients receiving CMV prophylaxis. Costs

associated with prophylaxis are less than for routine monitoring and

pre-emptive therapy. The optimal duration of antiviral

prophylaxis remains undefined. Extended prophylaxis

may improve clinical outcomes in the highest-risk patient populations including

donor-seropositive/recipient-seronegative renal

transplants and in CMV-infected lung and heart transplantation. CONCLUSIONS: Prophylaxis is beneficial in preventing

direct and indirect effects of CMV infection in transplant recipients,

affecting both allograft and patient survival. More

studies are necessary to define optimal prophylaxis regimens.

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