Is preemptive therapy for CMV infection following liver transplantation superior to symptom-triggered treatment?

Prospective evaluation of the clinical utility of different methods for the detection of human cytomegalovirus disease after liver transplantation

Standardized human cytomegalovirus (HCMV) assays were prospectively evaluated to predict HCMV disease. In 135 consecutive adult liver transplantations, pp65-antigenemia, quantitative HCMV-DNA and qualitative pp67-messenger-RNA were determined weekly. No ganciclovir prophylaxis or preemptive treatment was used. One hundred and ten (81.5%) patients showed no HCMV-infection, 25 patients were positive in at least one of the HCMV-tests (18.5%). Four suffered from HCMV viral syndrome (3.0%) and another four from tissue invasive disease. In total, pp65-antigenemia was detected in 18, HCMV-DNA in 22 and pp67-mRNA in 18 patients. The sensitivity and negative predictive value (NPV) for HCMV-disease was 100% for all tests. The PPV for symptomatic HCMV-infection was 47% for pp67 mRNA. In contrast, the PPV of pp65-antigenemia (using a threshold of > 2/200 000 cells) and quantitative PCR (using a cutoff of > 5000 copies/mL) were 80% and 89%, respectively. A cost analysis revealed symptom-triggered or preemptive treatment was less expensive than general ganciclovir prophylaxis, if the incidence of CMV disease was low (<30%). Quantitative human cytomegalovirus (HCMV)-DNA and pp65-antigen assays have a comparable sensitivity and can therefore predict the onset of HCMV symptoms at an early stage. Compared with general prophylaxis, symptom-triggered or preemptive treatment based on one of these assays might reduce the costs and also the danger of ganciclovir resistance.

Gastrointestinal Infections Caused by Cytomegalovirus

Cytomegalovirus (CMV) is an important human pathogen, causing a variety of syndromes ranging from asymptomatic infections to life-threatening end-organ disease. Infections of the gastrointestinal tract are an especially common form of disease caused by CMV and are usually manifest as luminal infections, such as esophagitis or colitis. Solid organ disease caused by CMV is also known to occur, with hepatitis being the most common syndrome. The large majority of cases of tissue-invasive disease caused by CMV have been reported to occur in immunocompromised hosts. Patients at highest risk for serious CMV-mediated disease are commonly HIV infected, recipients of transplants, or are receiving potent immunosuppressive medications. Intriguingly, several recent reports have discussed the previously underappreciated role of serious forms of CMV-mediated disease occurring in immunocompetent patients. This paper reviews several recent reports addressing important aspects related to the diagnosis, treatment, and management of CMV infections of the gastrointestinal tract.