Cytomegalovirus Management in Solid Organ Transplant Recipients: A Pre-COVID-19 Survey From the Working Group of the European Society for Organ Transplantation

Abstract

Infections are leading causes of morbidity/mortality following solid organ transplantation (SOT) and cytomegalovirus (CMV) is among the most frequent pathogens, causing a considerable threat to SOT recipients. A survey was conducted 19 July–31 October 2019 to capture clinical practices about CMV in SOT recipients (e.g., how practices aligned with guidelines, how adequately treatments met patients’ needs, and respondents’ expectations for future developments). Transplant professionals completed a ∼30-minute online questionnaire: 224 responses were included, representing 160 hospitals and 197 SOT programs (41 countries; 167[83%] European programs). Findings revealed a heterogenous approach to CMV diagnosis and management and, sometimes, significant divergence from international guidelines. Valganciclovir prophylaxis (of variable duration) was administered by 201/224 (90%) respondents in D+/R− SOT and by 40% in R+ cases, with pre-emptive strategies generally reserved for R+ cases: DNA thresholds to initiate treatment ranged across 10–10,000 copies/ml. Ganciclovir-resistant CMV strains were still perceived as major challenges, and tailored treatment was one of the most important unmet needs for CMV management. These findings may help to design studies to evaluate safety and efficacy of new strategies to prevent CMV disease in SOT recipients, and target specific educational activities to harmonize CMV management in this challenging population.

National survey of prevention and management of CMV infection in pediatric kidney transplantation in comparison to clinical practice guidelines

“…It is difficult to determine the reasons for these discrepancies. A large survey from the Working Group of the European Society for Organ Transplantation (adults) noted similar discrepancies in the management of CMV and suggested that may be related to budgetary or reimbursement policies in specific countries (8). However, our survey showed very similar results and a nonuniform approach despite France having the same reimbursement policy for all children and limited budgetary limitations, especially for medications recommended by international guidelines.…”

New Insights on CMV Management in Solid Organ Transplant Patients: Prevention, Treatment, and Management of Resistant/Refractory Disease

“…However, the effect of preemptive therapy on CMV indirect effects is uncertain, including on preventing opportunistic infections [ 7 ]. In a recent survey that assessed prevention strategies from 224 transplant centers, it was shown that universal prophylaxis is used in 90% of centers in D+/R− SOT patients [ 8 ]. Kidney and heart-transplant patients are mostly treated for 6 months and lung-transplant patients are given 12 months prophylaxis, while 50% of liver-transplant patients were treated for 3 months and 50% for 6 months.…”

“…Kidney and heart-transplant patients are mostly treated for 6 months and lung-transplant patients are given 12 months prophylaxis, while 50% of liver-transplant patients were treated for 3 months and 50% for 6 months. Among CMV-seropositive patients, 50% of centers use a prophylaxis strategy while the others prefer a preemptive strategy [ 8 ]. In liver-transplant patients, preemptive therapy is preferred in seropositive patients.…”

“…VGCV is the most anti-CMV drug used to prevent CMV after SOT. The main side effect reported by different centers is VGCV-induced myelotoxicity, which can lead to its discontinuation in at least 10% of patients [ 8 ].…”

“…The minimum duration of therapy is 2 weeks [ 7 ]. In the real-life setting, this recommendation seems to be followed by the large majority of centers [ 8 ]. However, nearly 14% of centers add anti-CMV immunoglobulins to antiviral therapy in the following indications: primary CMV infection in D+/R− patients, in case of hypogammaglobulinemia (< 500 mg/dL), and in case of severe clinical manifestations such as pneumonia, enteritis, or severe leukopenia [ 8 ].…”