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Cytomegalovirus Infection in Pediatric Solid Organ Transplant Recipients: a Focus on Prevention

  • Transplant and Oncology (M Ison, N Theodoropoulos and S Pegram, Section Editors)
  • Published:
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Abstract

Solid organ transplantation is a life-saving procedure that has changed the prognosis for infants and children with end-stage organ disease. Cytomegalovirus (CMV) is one of the most common infections that occur after organ transplantation in pediatric patients, yet the standard of care for CMV prevention remains unclear. We review the literature regarding CMV disease effects, risk factors, diagnostics, prevention strategies, and antiviral treatment in pediatric solid organ transplantation. This discussion focuses on the current prevention strategies: prophylaxis, preemptive, and hybrid therapy, as well as novel strategies that may help better prevent the CMV disease in the pediatric solid organ transplant population.

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References

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  1. Green M, Michaels MG. Infections in pediatric solid organ transplant recipients. J Pediatr Infect Dis Soc. 2012;1(2):144–51.

    Article  Google Scholar 

  2. Beam E, Razonable RR. Cytomegalovirus in solid organ transplantation: epidemiology, prevention, and treatment. Curr Infect Dis Rep. 2012;14(6):633–41.

    Article  PubMed  Google Scholar 

  3. Bate SL, Dollard SC, Cannon MJ. Cytomegalovirus seroprevalence in the United States: the national health and nutrition examination surveys, 1988–2004. Clin Infect Dis. 2010;50(11):1439–47.

    Article  PubMed  Google Scholar 

  4. Cannon MJ, Schmid DS, Hyde TB. Review of cytomegalovirus seroprevalence and demographic characteristics associated with infection. Rev Med Virol. 2010;20(4):202–13.

    Article  PubMed  Google Scholar 

  5. Romero FA, Razonable RR. Infections in liver transplant recipients. World J Hepatol. 2011;3(4):83–92.

    Article  PubMed Central  PubMed  Google Scholar 

  6. Marcelin JR, Beam E, Razonable RR. Cytomegalovirus infection in liver transplant recipients: updates on clinical management. World J Gastroenterol. 2014;20(31):10658–67.

    Article  PubMed Central  PubMed  Google Scholar 

  7. Razonable RR, Humar A. the ASTIDCoP. Cytomegalovirus in solid organ transplantation. Am J Transplant. 2013;13(s4):93–106.

    Article  CAS  PubMed  Google Scholar 

  8. Kotton CN, Kumar D, Caliendo AM, et al. Updated international consensus guidelines on the management of cytomegalovirus in solid-organ transplantation. Transplantation. 2013;96(4):333–60. This comprehensive guideline addresses both management and prevention of CMV infection in solid organ transplant recipients. Special attention is given to pertinent issues relating to treatment and prevention strategies in pediatric patients.

    Article  CAS  PubMed  Google Scholar 

  9. Bowman JS, Green M, Scantlebury VP, et al. OKT3 and viral disease in pediatric liver transplant recipients. Clin Transplant. 1991;5(4):294–300.

    PubMed Central  PubMed  Google Scholar 

  10. Höcker B, Zencke S, Krupka K, et al. Cytomegalovirus Infection in Pediatric Renal Transplantation and the Impact of Chemoprophylaxis With (Val-)Ganciclovir. Transplantation. 2015;Online First.

  11. Linares L, Sanclemente G, Cervera C, et al. Influence of cytomegalovirus disease in outcome of solid organ transplant patients. Transplant Proc. 2011;43(6):2145–8.

    Article  CAS  PubMed  Google Scholar 

  12. Madan RP, Campbell AL, Shust GF, et al. A hybrid strategy for the prevention of cytomegalovirus-related complications in pediatric liver transplantation recipients. Transplantation. 2009;87(9):1318–24.

    Article  PubMed  Google Scholar 

  13. Danziger-Isakov L, Worley S, Michaels M, et al. The risk, prevention & outcome of cytomegalovirus after pediatric lung transplantation. Transplantation. 2009;87(10):1541–8.

    Article  PubMed Central  PubMed  Google Scholar 

  14. Gupta P, Hart J, Cronin D, Kelly S, Millis JM, Brady L. Risk factors for chronic rejection after pediatric liver transplantation. Transplantation. 2001;72(6):1098–102.

    Article  CAS  PubMed  Google Scholar 

  15. Paya CV, Wiesner RH, Hermans PE, et al. Risk factors for cytomegalovirus and severe bacterial infections following liver transplantation: a prospective multivariate time-dependent analysis. J Hepatol. 1993;18(2):185–95.

    Article  CAS  PubMed  Google Scholar 

  16. Falagas ME, Snydman DR, Griffith J, Werner BG. Exposure to cytomegalovirus from the donated organ is a risk factor for bacteremia in orthotopic liver transplant recipients. Boston Center for Liver Transplantation CMVIG Study Group. Clin Infect Dis. 1996;23(3):468–74.

    Article  CAS  PubMed  Google Scholar 

  17. George MJ, Snydman DR, Werner BG, et al. The independent role of cytomegalovirus as a risk factor for invasive fungal disease in orthotopic liver transplant recipients. Boston Center for Liver Transplantation CMVIG-Study Group. Cytogam, MedImmune, Inc. Gaithersburg, Maryland. Am J Med. 1997;103(2):106–13.

    Article  CAS  PubMed  Google Scholar 

  18. Munoz P, Rodriguez C, Bouza E, et al. Risk factors of invasive aspergillosis after heart transplantation: protective role of oral itraconazole prophylaxis. Am J Transplant. 2004;4(4):636–43.

    Article  CAS  PubMed  Google Scholar 

  19. Danziger-Isakov L, Worley S, Arrigain S, et al. Increased mortality after pulmonary fungal infection within the first year after pediatric lung transplantation. J Heart Lung Transplant. 2008;27(6):655–61.

    Article  PubMed Central  PubMed  Google Scholar 

  20. Liu M, Worley S, Arrigain S, et al. Respiratory viral infections within one year after pediatric lung transplant. Transpl Infect Dis. 2009;11(4):304–12.

    Article  CAS  PubMed  Google Scholar 

  21. de Otero J, Gavalda J, Murio E, et al. Cytomegalovirus disease as a risk factor for graft loss and death after orthotopic liver transplantation. Clin Infect Dis. 1998;26(4):865–70.

    Article  PubMed  Google Scholar 

  22. Limaye AP, Bakthavatsalam R, Kim HW, et al. Impact of cytomegalovirus in organ transplant recipients in the era of antiviral prophylaxis. Transplantation. 2006;81(12):1645–52.

    Article  PubMed  Google Scholar 

  23. Bosch W, Heckman MG, Diehl NN, Shalev JA, Pungpapong S, Hellinger WC. Association of cytomegalovirus infection and disease with death and graft loss after liver transplant in high-risk recipients. Am J Transplant. 2011;11(10):2181–9.

    Article  CAS  PubMed  Google Scholar 

  24. Razonable RR. Management strategies for cytomegalovirus infection and disease in solid organ transplant recipients. Infect Dis Clin N Am. 2013;27(2):317–42.

    Article  Google Scholar 

  25. Bruminhent J, Razonable RR. Management of cytomegalovirus infection and disease in liver transplant recipients. World J Hepatol. 2014;6(6):370–83.

    Article  PubMed Central  PubMed  Google Scholar 

  26. Sarmiento JM, Dockrell DH, Schwab TR, Munn SR, Paya CV. Mycophenolate mofetil increases cytomegalovirus invasive organ disease in renal transplant patients. Clin Transplant. 2000;14(2):136–8.

    Article  CAS  PubMed  Google Scholar 

  27. Lebranchu Y, Bridoux F, Buchler M, et al. Immunoprophylaxis with basiliximab compared with antithymocyte globulin in renal transplant patients receiving MMF-containing triple therapy. Am J Transplant. 2002;2(1):48–56.

    Article  CAS  PubMed  Google Scholar 

  28. Brennan DC, Daller JA, Lake KD, Cibrik D, Del Castillo D. Rabbit antithymocyte globulin versus basiliximab in renal transplantation. N Engl J Med. 2006;355(19):1967–77.

    Article  CAS  PubMed  Google Scholar 

  29. Demopoulos L, Polinsky M, Steele G, et al. Reduced risk of cytomegalovirus infection in solid organ transplant recipients treated with sirolimus: a pooled analysis of clinical trials. Transplant Proc. 2008;40(5):1407–10.

    Article  CAS  PubMed  Google Scholar 

  30. Mutimer DJ, Shaw J, O'Donnell K, Elias E. Enhanced (cytomegalovirus) viral replication after transplantation for fulminant hepatic failure. Liver Transplant Surg. 1997;3(5):506–12.

    Article  CAS  Google Scholar 

  31. Saitoh A, Sakamoto S, Fukuda A, et al. A universal preemptive therapy for cytomegalovirus infections in children after live-donor liver transplantation. Transplantation. 2011;92(8):930–5.

    Article  PubMed  Google Scholar 

  32. Rayes N, Seehofer D, Schmidt CA, et al. Prospective randomized trial to assess the value of preemptive oral therapy for CMV infection following liver transplantation. Transplantation. 2001;72(5):881–5.

    Article  CAS  PubMed  Google Scholar 

  33. Razonable RR, Paya CV, Smith TF. Role of the laboratory in diagnosis and management of cytomegalovirus infection in hematopoietic stem cell and solid-organ transplant recipients. J Clin Microbiol. 2002;40(3):746–52.

    Article  PubMed Central  PubMed  Google Scholar 

  34. Kotton CN, Kumar D, Caliendo AM, et al. International consensus guidelines on the management of cytomegalovirus in solid organ transplantation. Transplantation. 2010;89(7):779–95.

    Article  PubMed  Google Scholar 

  35. Gerna G, Baldanti F, Torsellini M, et al. Evaluation of cytomegalovirus DNAaemia versus pp 65-antigenaemia cutoff for guiding preemptive therapy in transplant recipients: a randomized study. Antivir Ther. 2007;12(1):63–72.

    CAS  PubMed  Google Scholar 

  36. Fryer J, Heath AB, Anderson R, Minor PD, Collaborative Study Group. Collaborative Study to Evaluate the Proposed 1st WHO International Standard for Human Cytomegalovirus (HCMV) for Nucleic Acid Amplification (NAT)-Based Assays. Geneva: World Health Organization. 2010: 40.

  37. Razonable RR, Brown RA, Wilson J, et al. The clinical use of various blood compartments for cytomegalovirus (CMV) DNA quantitation in transplant recipients with CMV disease. Transplantation. 2002;73(6):968–73.

    Article  PubMed  Google Scholar 

  38. Bodro M, Sabe N, Llado L, et al. Prophylaxis versus preemptive therapy for cytomegalovirus disease in high-risk liver transplant recipients. Liver Transpl. 2012;18(9):1093–9.

    Article  PubMed  Google Scholar 

  39. Fishman JA. Infection in solid-organ transplant recipients. N Engl J Med. 2007;357(25):2601–14.

    Article  CAS  PubMed  Google Scholar 

  40. Kalil AC, Levitsky J, Lyden E, Stoner J, Freifeld AG. Meta-analysis: the efficacy of strategies to prevent organ disease by cytomegalovirus in solid organ transplant recipients. Ann Intern Med. 2005;143(12):870–80.

    Article  PubMed  Google Scholar 

  41. Arthurs SK, Eid AJ, Pedersen RA, et al. Delayed-onset primary cytomegalovirus disease after liver transplantation. Liver Transpl. 2007;13(12):1703–9.

    Article  PubMed  Google Scholar 

  42. Limaye AP, Bakthavatsalam R, Kim HW, et al. Late-onset cytomegalovirus disease in liver transplant recipients despite antiviral prophylaxis. Transplantation. 2004;78(9):1390–6.

    Article  PubMed  Google Scholar 

  43. Husain S, Pietrangeli CE, Zeevi A. Delayed onset CMV disease in solid organ transplant recipients. Transpl Immunol. 2009;21(1):1–9.

    Article  CAS  PubMed  Google Scholar 

  44. Kim JM, Kim SJ, Joh JW, et al. Early and delayed onset cytomegalovirus infection of liver transplant recipients in endemic areas. Transplant Proc. 2010;42(3):884–9.

    Article  CAS  PubMed  Google Scholar 

  45. Sun HY, Wagener MM, Singh N. Prevention of posttransplant cytomegalovirus disease and related outcomes with valganciclovir: a systematic review. Am J Transplant: Off J Am Soc Transplant Am Soc Transplant Surg. 2008;8(10):2111–8.

    Article  Google Scholar 

  46. Gerna G, Lilleri D, Callegaro A, et al. Prophylaxis followed by preemptive therapy versus preemptive therapy for prevention of human cytomegalovirus disease in pediatric patients undergoing liver transplantation. Transplantation. 2008;86(1):163–6.

    Article  PubMed  Google Scholar 

  47. Small LN, Lau J, Snydman DR. Preventing post-organ transplantation cytomegalovirus disease with ganciclovir: a meta-analysis comparing prophylactic and preemptive therapies. Clin Infect Dis. 2006;43(7):869–80.

    Article  CAS  PubMed  Google Scholar 

  48. Singh N, Wannstedt C, Keyes L, Wagener MM, Gayowski T, Cacciarelli TV. Indirect outcomes associated with cytomegalovirus (opportunistic infections, hepatitis C virus sequelae, and mortality) in liver-transplant recipients with the use of preemptive therapy for 13 years. Transplantation. 2005;79(10):1428–34.

    Article  PubMed  Google Scholar 

  49. Owers DS, Webster AC, Strippoli GF, Kable K, Hodson EM. Pre-emptive treatment for cytomegalovirus viraemia to prevent cytomegalovirus disease in solid organ transplant recipients. Cochrane Database Syst Rev. Feb 28 2013. This systematic review evaluates the data available assessing efficacy of a preemptive monitoring strategy for CMV in organ transplant recipients focusing on randomized controlled trials.

  50. Couzi L, Helou S, Bachelet T, et al. High incidence of anticytomegalovirus drug resistance among D + R- kidney transplant recipients receiving preemptive therapy. Am J Transplant. 2012;12(1):202–9.

    Article  CAS  PubMed  Google Scholar 

  51. Boillat Blanco N, Pascual M, Venetz JP, Nseir G, Meylan PR, Manuel O. Impact of a preemptive strategy after 3 months of valganciclovir cytomegalovirus prophylaxis in kidney transplant recipients. Transplantation. 2011;91(2):251–5.

    Article  PubMed  Google Scholar 

  52. Lisboa LF, Preiksaitis JK, Humar A, Kumar D. Clinical utility of molecular surveillance for cytomegalovirus after antiviral prophylaxis in high-risk solid organ transplant recipients. Transplantation. 2011;92(9):1063–8.

    CAS  PubMed  Google Scholar 

  53. Lin A, Worley S, Brubaker J, et al. Assessment of cytomegalovirus hybrid preventative strategy in pediatric heart transplant patients. J Pediatr Infect Dis Soc. 2012;1(4):278–83.

    Article  Google Scholar 

  54. Kelly DA, Bucuvalas JC, Alonso EM, et al. Long-term medical management of the pediatric patient after liver transplantation: 2013 practice guideline by the American Association for the Study of Liver Diseases and the American Society of Transplantation. Liver Transplant: Off Publ Am Assoc Study Liver Dis Int Liver Transplant Soc. 2013;19(8):798–825. This expert guidance document addresses several critical aspects of care pertinent to pediatric liver transplant recipients. The prevention of viral infections, including CMV, is addressed in a larger context of overall post-transplant care.

    Article  Google Scholar 

  55. Camacho-Gonzalez AF, Gutman J, Hymes LC, Leong T, Hilinski JA. 24 weeks of valganciclovir prophylaxis in children after renal transplantation: a 4-year experience. Transplantation. 2011;91(2):245–50.

    Article  PubMed Central  PubMed  Google Scholar 

  56. Jongsma H, Bouts AH, Cornelissen EA, et al. Cytomegalovirus prophylaxis in pediatric kidney transplantation: the Dutch experience. Pediatr Transplant. 2013;17(6):510–7.

  57. Fijo-Lopez-Viota J, Espinosa-Roman L, Herrero-Hernando C, Sanahuja-Ibanez MJ, Vila-Santandreu A, Praena-Fernandez JM. Cytomegalovirus and paediatric renal transplants: is this a current issue? Nefrol. 2013;33(1):7–13.

    Google Scholar 

  58. Mahle WT, Fourshee MT, Naftel DM, et al. Does cytomegalovirus serology impact outcome after pediatric heart transplantation? J Heart Lung Transplant. 2009;28(12):1299–305.

    Article  PubMed  Google Scholar 

  59. Kasiske BL, Zeier MG, Chapman JR, et al. KDIGO clinical practice guideline for the care of kidney transplant recipients: a summary. Kidney Int. 2010;77(4):299–311.

    Article  PubMed  Google Scholar 

  60. Wiltshire H, Hirankarn S, Farrell C, et al. Pharmacokinetic profile of ganciclovir after its oral administration and from its prodrug, valganciclovir, in solid organ transplant recipients. Clin Pharmacokinet. 2005;44(5):495–507.

    Article  CAS  PubMed  Google Scholar 

  61. Åsberg A, Humar A, Rollag H, et al. Oral valganciclovir is noninferior to intravenous ganciclovir for the treatment of cytomegalovirus disease in solid organ transplant recipients. Am J Transplant. 2007;7(9):2106–13.

    Article  PubMed  Google Scholar 

  62. Asberg A, Humar A, Jardine AG, et al. Long-term outcomes of CMV disease treatment with valganciclovir versus IV ganciclovir in solid organ transplant recipients. Am J Transplant. 2009;9(5):1205–13.

    Article  CAS  PubMed  Google Scholar 

  63. U.S. Food and Drug Administration. Valcyte Label Approval. 2013; http://www.accessdata.fda.gov/scripts/cder/drugsatfda/index.cfm?fuseaction=Search.DrugDetails. Accessed January 19, 2015.

  64. Vaudry W, Ettenger R, Jara P, et al. Valganciclovir dosing according to body surface area and renal function in pediatric solid organ transplant recipients. Am J Transplant. 2009;9(3):636–43.

    Article  CAS  PubMed  Google Scholar 

  65. Pescovitz MD, Jain A, Robson R, Mulgaonkar S, Freeman R, Bouw MR. Establishing pharmacokinetic bioequivalence of valganciclovir oral solution versus the tablet formulation. Transplant Proc. 2007;39(10):3111–6.

    Article  CAS  PubMed  Google Scholar 

  66. Pescovitz MD, Ettenger RB, Strife CF, et al. Pharmacokinetics of oral valganciclovir solution and intravenous ganciclovir in pediatric renal and liver transplant recipients. Transpl Infect Dis. 2010;12(3):195–203.

    Article  CAS  PubMed  Google Scholar 

  67. Villeneuve D, Brothers A, Harvey E, et al. Valganciclovir dosing using area under the curve calculations in pediatric solid organ transplant recipients. Pediatr Transplant. 2013;17(1):80–5.

    Article  PubMed  Google Scholar 

  68. Asberg A, Bjerre A, Neely M. New algorithm for valganciclovir dosing in pediatric solid organ transplant recipients. Pediatr Transplant. 2014;18(1):103–11. This article addresses a significant change in the dosing of valganciclovir in pediatric patients.

    Article  PubMed Central  PubMed  Google Scholar 

  69. Winston DJ, Saliba F, Blumberg E, et al. Efficacy and safety of maribavir dosed at 100 mg orally twice daily for the prevention of cytomegalovirus disease in liver transplant recipients: a randomized, double-blind, multicenter controlled trial. Am J Transplant. 2012;12(11):3021–30.

    Article  CAS  PubMed  Google Scholar 

  70. Marty FM, Winston DJ, Rowley SD, et al. CMX001 to prevent cytomegalovirus disease in hematopoietic-cell transplantation. N Engl J Med. 2013;369(13):1227–36.

    Article  CAS  PubMed  Google Scholar 

  71. Chemaly RF, Ullmann AJ, Stoelben S, et al. Letermovir for cytomegalovirus prophylaxis in hematopoietic-cell transplantation. N Engl J Med. 2014;370(19):1781–9.

    Article  CAS  PubMed  Google Scholar 

  72. Stoelben S, Arns W, Renders L, et al. Preemptive treatment of cytomegalovirus infection in kidney transplant recipients with letermovir: results of a Phase 2a study. Transpl Int. 2014;27(1):77–86.

    Article  CAS  PubMed  Google Scholar 

  73. Egli A, Humar A, Kumar D. State-of-the-art monitoring of cytomegalovirus-specific cell-mediated immunity after organ transplant: a primer for the clinician. Clin Infect Dis. 2012;55(12):1678–89.

    Article  PubMed  Google Scholar 

  74. Manuel O, Husain S, Kumar D, et al. Assessment of cytomegalovirus-specific cell-mediated immunity for the prediction of cytomegalovirus disease in high-risk solid-organ transplant recipients: a multicenter cohort study. Clin Infect Dis. 2013;56(6):817–24.

    Article  CAS  PubMed  Google Scholar 

  75. Lilja AE, Mason PW. The next generation recombinant human cytomegalovirus vaccine candidates-beyond gB. Vaccine. 2012;30(49):6980–90.

    Article  CAS  PubMed  Google Scholar 

  76. Kharfan-Dabaja MA, Boeckh M, Wilck MB, et al. A novel therapeutic cytomegalovirus DNA vaccine in allogeneic haemopoietic stem-cell transplantation: a randomised, double-blind, placebo-controlled, phase 2 trial. Lancet Infect Dis. 2012;12(4):290–9.

    Article  CAS  PubMed  Google Scholar 

  77. Brestrich G, Zwinger S, Roemhild A, et al. Generation of HCMV-specific T-cell lines from seropositive solid-organ-transplant recipients for adoptive T-cell therapy. J Immunother. 2009;32(9):932–40.

    Article  PubMed  Google Scholar 

  78. Spada M, Riva S, Maggiore G, Cintorino D, Gridelli B. Pediatric liver transplantation. World J Gastroenterol. 2009;15(6):648–74.

    Article  PubMed Central  PubMed  Google Scholar 

  79. Martin SR, Atkison P, Anand R, Lindblad AS. Studies of pediatric liver transplantation 2002: patient and graft survival and rejection in pediatric recipients of a first liver transplant in the United States and Canada. Pediatr Transplant. 2004;8(3):273–83.

    Article  CAS  PubMed  Google Scholar 

  80. Soltys KA, Mazariegos GV, Squires RH, Sindhi RK, Anand R. Late graft loss or death in pediatric liver transplantation: an analysis of the SPLIT database. Am J Transplant. 2007;7(9):2165–71.

    Article  CAS  PubMed  Google Scholar 

  81. Duffy JP, Kao K, Ko CY, et al. Long-term patient outcome and quality of life after liver transplantation: analysis of 20-year survivors. Ann Surg. 2010;252(4):652–61.

    PubMed  Google Scholar 

  82. Danziger-Isakov L, Bucavalas J. Current prevention strategies against cytomegalovirus in the studies in pediatric liver transplantation (SPLIT) centers. Am J Transplant. 2014;14(8):1908–11.

    Article  CAS  PubMed  Google Scholar 

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Correspondence to David B. Banach.

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Karen C. Tsai and David B. Banach have no conflicts of interest to disclose. Lara A. Danziger-Isakov is a clinical investigator in a study of brincidofovir for the treatment of adenovirus infection.

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This article is part of the Topical Collection on Transplant and Oncology

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Tsai, K., Danziger-Isakov, L.A. & Banach, D.B. Cytomegalovirus Infection in Pediatric Solid Organ Transplant Recipients: a Focus on Prevention. Curr Infect Dis Rep 18, 5 (2016). https://doi.org/10.1007/s11908-015-0511-8

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