Cytomegalovirus infection in liver-transplanted children

Table 4 Summary of pre-emptive, prophylaxis and treatment of cytomegalovirus disease in post-liver transplant patients

Condition	Pre-emptive		Prophylaxis	Treatment
Monitoring and endpoint	Monitoring: Weekly or every 2 wk CBC, BUN, Cr, AST, and ALT for first month and then monthly; Monthly CMV QNAT for 12 mo. Endpoint: CMV QNAT for VL negative for two samples 2 wk apart		Monitoring: Weekly CMV QNAT. Endpoint: CMV QNAT for VL negative for two samples 2 wk apart	Monitoring: Weekly CBC, BUN, Cr; Weekly CMV QNAT. Endpoint: CMV syndrome: Clinical resolution; VL less than 200 IU/mL on 1-2 consecutive weeks; Tissue-invasive CMV disease: Clinical resolution; Histologic evidence
Cut-off for start medication	Reference	Verma et al[8,14]; Saitoh et al[13]; Martín-Gandul et al[77]; Atabani et al[58]; Griffiths et al[78]	-	Kotton et al[55]
	Values	Non-specific: VL 500 copies/mL; VL 650 copies/mL; pp65 Ag 5 per 50000 leucocytes. D+/R-: Plasma VL 1500 IU/mL. D+/R- and R+: Plasma VL 2275 IU/mL or 2500 copies/mL; Whole blood VL 2520 or 3000 copies/mL. R+: VL 3983 IU/mL	None (risk donor/recipient pair-based)	VL > 200 IU/mL for 2 consecutive weeks
Duration	Reference	Razonable et al[32,38;71]; Razonable[39]; Razonable and Humar[51]; Razonable and Hayden[56]; Razonable[79]; Pappo et al[72]; Ueno et al[73]; Kotton et al[55]	Kotton et al[55]	Kotton et al[55]
	Values	Non-specific: 14 d to 3 mo; Extended to 6 mo; Extended to 12 mo. High risk: 6 mo. Intermediate risk: 3 mo. Low risk (D-/R-): Clinical follow-up	D+/R-: 3-6 mo. Others: 3-4 mo or 2-4 wk with CMV surveillance	At least 2 wk
Drug/dose/route	First-line: Ganciclovir (5 mg/kg IV q 24 h); Valganciclovir (< 15 kg: 15 mg/kg/dose po once daily; > 15 kg: 500 mg/m2/dose po once daily); Maximum dose: 900 mg/dose once daily; Combined ganciclovir then valganciclovir		First-line: Ganciclovir (same dose as pre-emptive); Valganciclovir (same dose as pre-emptive)	First-line: Ganciclovir [5 mg/kg IV q 12 h (+/- with dose adjustment for renal function)]. Second-line (ganciclovir-induced leucopenia): Foscarnet [60 mg/kg IV q 8 h or 90 mg/kg IV q 12 h (+/- with dose adjustment for renal function)]; Cidofovir [5 mg/kg once weekly × 2 doses then every 2 wk (+/- with dose adjustment for renal function)]. For ganciclovir-resistant [Ganciclovir: 7.5-10 mg/kg IV q 12 h (+/- with dose adjustment for renal function). Add or switch to Foscarnet. Switch to Cidofovir

ALT: Alanine aminotransferase; AST: Aspartate aminotransferase; BUN: Blood urea nitrogen; CBC: Complete blood count; CMV: Cytomegalovirus; Cr: Creatinine; Ig: Immunoglobulin; QNAT: Quantitative nucleic acid testing; VL: Viral load; D: Donor; R: Recipient.