CMV prophylaxis and treatment

All transplant recipients who are CMV sero-negative should receive CMV -ve blood products. If supplies are available, this is recommended also for CMV sero-positive recipients. Limits risk of CMV blood product transmission regardless of donor/recipient serological status.

CMV surveillance

• All allograft patients and CMV sero-positive autograft recipients should receive CMV surveillance.

• The minimum surveillance required is the DEAFF (detection of early antigen fluorescent foci) test. Should detect CMV antigen in culture by immunofluorescence within 48 hours and virus culture continues for 1-2 weeks. Urine and throat washings are not sent routinely for CMV detection.

• 5 ml EDTA blood should be sent weekly on the above cohort of transplant patients from admission until day 100. Screening of allograft recipients should continue until 1 year post-transplant although the frequency of testing may be reduced in the absence of appropriate symptoms.

334 • More sensitive tests now available to detect CMV antigen or genome by PCR technology in buffy coat of EDTA peripheral blood will soon replace DEAFF as standard tests.

CMV prophylaxis

Indicated in allograft patients when either donor or recipient are CMV sero-positive. Not recommended when both donor and recipient are sero-negative, nor for autograft recipients, even if sero-positive.

Suggested protocol

1. Acyclovir 800mg tds IV from day -5 to discharge, then 800mg tds PO for 3 months plus

2. IVIg 200mg/kg IV day -1, day +13 and then every 3 weeks until day +100.

Note: The graft suppression of this dose of acyclovir may sometimes be dose limiting.

Treatment of CMV infection

A +ve CMV identification in buffy coat by either surveillance method should be treated even if the patient is asymptomatic:

• Gancyclovir: 5 mg/kg IV bd for 14 days minimum then continue maintenance dose 5mg/kg/day IV daily (6mg/kg/day 5 days weekly as outpatient).

• Stop acyclovir when gancyclovir commenced.

• Side effects: myelosuppressive, may be abrogated by G-CSF, nephrotoxic.

• Renal function must be monitored and dose reductions implemented according to the BNF.

• Abnormal LFTs may occur.

• Fever, rashes and headaches.

• Alternative—foscarnet 90 mg/kg IV bd for 14d minimum.

• Administer through a central line as IVI over 2 hours (may be given as a peripheral IVI but should be given concurrently with a fast running litre of 0.9% saline). Side effects-nephrotoxic and hepatotoxic (follow BNF dosage adjustments).

Treatment plan

On a first episode of CMV antigenaemia, start with gancyclovir. Failure to become CMV antigen -ve by the end of the 2 week course would lead to immediate progression to foscarnet.

CMV-related disease

May cause pneumonitis, oesophagitis, gastritis, hepatitis, retinitis and myelosuppression. Where CMV antigenaemia accompanied by symptoms/signs of CMV disease high titre anti-CMV Ig 200mg/kg/day IV should be administered on days 1, 3, 5 and 7 of antiviral therapy with gancyclovir or foscarnet. Broncho-alveolar lavage (BAL) should be performed to establish the presence of CMV locally in the lung.

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