Management of cytomegalovirus infection after liver transplantation

Table 1 Recommended approaches for cytomegalovirus prevention in liver transplantation[17]

CMV serostatus	Comments
D/R; low risk	Antiviral prophylaxis: CMV D-/R- LT recipients do not require anti-CMV prophylaxis; but if they are HSV1-or HSV2-seropositive, they should receive anti-HSV prophylaxis during the early period after LT (strong, high)
	Alternative: (1) Pre-emptive therapy (if higher risk, i.e., significant transfusions): If blood transfusion is required, CMV D/R patients should receive; and (2) CMV-seronegative or leuko-reduced blood products (strong, high)
D+/R+; D/R+; intermediate risk	Antiviral prophylaxis: (1) Drugs: valganciclovir1 900 mg po every 24 h; (2) ganciclovir 5 mg / kg (iv) 1×/d; and (3) duration: 3 months (strong, high)
	Alternative: (1) Pre-emptive therapy (if logistic support is available) (strong, high); (2) weekly CMV QNAT (or pp65 antigenemia) for 12 wk after LT; and (3) if a positive CMV threshold is reached, treat with valganciclovir 900 mg (po) BID (preferred), or ganciclovir 5 mg/kg (iv) every 12 h until negative test
D+/R; high risk	Antiviral prophylaxis: (1) Drugs: valganciclovir 900 mg (po) every 24 h; (2) ganciclovir 5 mg/kg (iv) 1×/d; and (3) duration: 3 mo (strong, high), 6 mo (strong, moderate)
	Alternative: (1) Pre-emptive therapy (if logistic support is available) (strong, high); (2) weekly CMV QNAT (or pp65 antigenemia) for 12 wk after LT; and (3) if a positive CMV threshold is reached, treat with valganciclovir 900 mg (po) BID (preferred), or ganciclovir 5 mg/kg (iv) every 12 h until negative test

¹Valgansiklovir use in LT recipients is not US FDA approved because of high rate of tissue-invasive disease, however experts still recommend its use for CMV prophylaxis in liver recipients (strong, moderate). Ease of administration. Leukopenia is major toxicity.

CMV: Cytomegalovirus; HSV: Herpes simplex virus; QNAT: Quantitative nucleic acid amplification test.