Cytomegalovirus (CMV)

Question: A 66 year old male liver transplant recipient is seen in clinic one month after transplant. He is troubled by the number of medications he’s on and wants to know whether he can discontinue some of them, in particular, Valcyte.  He received a CMV
(-) allograft and he was CMV antibody (+) before transplant.  What should you tell him?

A. continue Valcyte, risk for reactivation is too high

B. change dosing to QOD Valcyte

C. discontinue Valcyte; risk of disease is low and no further monitoring is necessary

D. discontinue Valcyte; check CMV viral load occasionally and restart Valcyte if it begins to rise

Answer:  After liver transplant, CMV recurrence comes in two forms: CMV syndrome and CMV organ-specific disease (ie. CMV hepatitis, or CMV colitis).  The CMV syndrome usually features constitutional symptoms like fever and malaise, and may present with leukopenia.

Each transplant center is different, but prophylaxis should always be used when a donor is CMV (+) and the recipient is CMV (-); this represents the highest risk for infection.  Prophylaxis can be 3 or 6 months.

For any other combination of CMV statuses (ie. -/-, +/+, and -/+) you have the option of 3 months of prophylaxis or no prophylaxis with serial CMV viral load surveillance.  Valcyte would then be started if the viral load rises, or if the patient becomes symptomatic and is found to have the syndrome or disease.

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