TAILIEUCHUNG - Chapter 126. Infections in Transplant Recipients (Part 5)

Like prophylaxis, preemptive treatment, which targets patients with polymerase chain reaction (PCR) evidence of CMV entails the unnecessary treatment of many individuals (on the basis of a laboratory test that is not highly predictive of disease) with drugs that have adverse effects. Currently, because of the neutropenia associated with ganciclovir in HSCT recipients, a preemptive approach—that is, treatment of those patients in whose blood CMV is detected by an antigen or nucleic acid amplification test—is used at most centers. This approach is almost as effective as prophylaxis and causes less toxicity. Quantitative viral load assays, which are not dependent. | Chapter 126. Infections in Transplant Recipients Part 5 Like prophylaxis preemptive treatment which targets patients with polymerase chain reaction PCR evidence of CMV entails the unnecessary treatment of many individuals on the basis of a laboratory test that is not highly predictive of disease with drugs that have adverse effects. Currently because of the neutropenia associated with ganciclovir in HSCT recipients a preemptive approach that is treatment of those patients in whose blood CMV is detected by an antigen or nucleic acid amplification test is used at most centers. This approach is almost as effective as prophylaxis and causes less toxicity. Quantitative viral load assays which are not dependent on circulating polymorphonuclear leukocytes have supplanted antigen-based assays and are used by most centers. A positive test or increasing viral load prompts the initiation of preemptive therapy. When prophylaxis or preemptive therapy is stopped late disease may occur although by then the patient is often equipped with improved graft function and is better able to combat disease. Treatment of CMV pneumonia in HSCT recipients unlike that in other clinical settings involves both IV immune globulin IVIg and ganciclovir. In patients who cannot tolerate ganciclovir foscarnet is a useful alternative although it may produce nephrotoxicity and electrolyte imbalance. When neither ganciclovir nor foscarnet is clinically tolerated cidofovir can be used however its efficacy is less well established and its side effects include nephrotoxicity. Case reports have suggested that the immunosuppressive agent leflunomide may be active in this setting but controlled studies are lacking. Maribavir is under investigation for treatment as well as prophylaxis. Transfusion of CMV-specific T cells from the donor decreased viral load in a small series of patients this result suggests that immunotherapy may play a role in the treatment of this disease in the future. For further discussion

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