Prophylaxis and treatment of cytomegalovirus disease in recipients of solid organ transplants: current approach and future challenges

Abstract

Cytomegalovirus infection is a major cause of morbidity and mortality in solid-organ transplant recipients, in terms of cytomegalovirus disease itself and the associated outcomes of organ rejection and death. This review focuses on recent literature concerning prevention and treatment of cytomegalovirus disease in this population. Two major strategies for the prevention of cytomegalovirus infection in solid-organ transplant recipients - preemptive and prophylactic treatment - are reviewed. Both strategies result in a lower incidence of cytomegalovirus disease when compared to a 'wait and treat' approach, and are generally considered cost-effective. Neither prophylaxis nor preemption has yet been shown to be superior. Newer trials are also reviewed, which are beginning to evaluate protocols of preemption or prophylaxis representative of current practice, as well as to explore alternative dosing strategies, the benefits of cytomegalovirus immune globulin, and the potential benefit of a longer course of prophylaxis. Concerns for the selection of ganciclovir-resistant strains of cytomegalovirus are also addressed. The consensus is that there is benefit for the treatment of solid-organ transplant patients with an antiviral agent before clinical evidence of cytomegalovirus disease. So far, there has been no demonstration of the superiority of prophylactic or preemptive regimens, nor has the exact nature and dosing of the oral antiviral agent of choice been established.