Current management strategies for the treatment and prevention of cytomegalovirus infection in solid organ transplant recipients

Cytomegalovirus (CMV) infection in solid organ transplantation is associated with significant morbidity and mortality. Primary infection, secondary infection or superinfection may occur in this setting. Progression to disease may ensue with development of symptoms, with or without organ involvement. The mainstay of treatment of CMV disease is intravenous ganciclovir. Aside from protective organ matching and use of CMV-seronegative blood products, methods of preventing CMV infection and disease include passive immunisation with immunoglobulins, vaccination, and prophylaxis with antiviral agents such as aciclovir, oral or intravenous ganciclovir, and oral valaciclovir. A promising subunit vaccine is currently being investigated. Pre-emptive therapy is a form of prevention that is based either on the early detection of CMV or targeting of transplant recipients with risk factors for CMV. New sensitive laboratory assays, including the pp65 antigenaemia assay, qualitative, quantitative and reverse-transcription polymerase chain reaction assays, hybridisation assays, and nucleic acid sequence-based essays, have the ability to detect early CMV replication before disease becomes evident. These assays are being used as prospective surveillance tests, with pre-emptive therapy initiated when they become positive or demonstrate an increasing titre.