Prevention and Management of CMV Infections after Liver Transplantation: Current Practice in German Transplant Centers.

Cornelius Engelmann,Thomas Lorf,Dennis Eurich,Felix Braun,Kerstin Herzer,Elmar Jäckel,Hans-Michael Hau,Frank Tacke,Martin-Walter Welker,Karl Heinz Weiss,Petra Knipper,Gerald Denk,Martina Sterneck,Johann Pratschke,Dirk Nierhoff,Tim Zimmermann,Silke Templin,Steffen Zopf,Hans-Jürgen Schlitt ,Tung Yu Tsui ,Johannes Weiß ,Aristotelis Perrakis

doi:10.3390/jcm9082352

Abstract

Human cytomegalovirus (CMV) remains a major cause of mortality and morbidity in human liver transplant recipients. Anti-CMV therapeutics can be used to prevent or treat CMV in liver transplant recipients, but their toxicity needs to be balanced against the benefits. The choice of prevention strategy (prophylaxis or preemptive treatment) depends on the donor/recipient sero-status but may vary between institutions. We conducted a series of consultations and roundtable discussions with German liver transplant center representatives. Based on 20 out of 22 centers, we herein summarize the current approaches to CMV prevention and treatment in the context of liver transplantation in Germany. In 90% of centers, transient prophylaxis with ganciclovir or valganciclovir was standard of care in high-risk (donor CMV positive, recipient CMV naive) settings, while preemptive therapy (based on CMV viremia detected during (bi) weekly PCR testing for circulating CMV-DNA) was preferred in moderate- and low-risk settings. Duration of prophylaxis or intense surveillance was 3–6 months. In the case of CMV infection, immunosuppression was adapted. In most centers, antiviral treatment was initiated based on PCR results (median threshold value of 1000 copies/mL) with or without symptoms. Therefore, German transplant centers report similar approaches to the prevention and management of CMV infection in liver transplantation.

Highlights

Human cytomegalovirus (CMV) is nearly ubiquitous in the general population, reaching 60–70% prevalence or higher in adults depending upon ethnicity and region
Based on a panel discussion and the current scientific literature, the following concise suggestions were generated by the authors to harmonize diagnostic approaches for CMV infections after liver transplantation: (a) A weekly polymerase chain reaction (PCR)-based monitoring is necessary in case a preemptive treatment strategy was chosen
CMV viremia is rare during prophylaxis and current guidelines do not recommend regular testing [14,25]

Summary

Introduction

Human cytomegalovirus (CMV) is nearly ubiquitous in the general population, reaching 60–70% prevalence or higher in adults depending upon ethnicity and region. CMV is the most common opportunistic infectious complication after liver transplantation. Allogeneic liver transplant recipients receive immune suppression to prevent graft rejection. The degree of immune suppression must be balanced against drug toxicity and hosts’ capacity to eliminate pathogens and to control infections. Immunosuppressive therapy after solid organ transplantation increases the risk for CMV de novo infections or reactivations, leading to significant morbidity and mortality, and reduced recipient survival [5]. In addition to its direct effects, active CMV infection may cause indirect complications by increasing the risk of other opportunistic infections, initiating graft inflammation and fibrosis, elevating circulating graft antigen levels, and increasing the likelihood of acute or chronic rejection [5]

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Results

Conclusion