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Hardinger KL, Brennan DC. Cytomegalovirus Treatment in Solid Organ Transplantation: An Update on Current Approaches. Ann Pharmacother 2024:10600280241237534. [PMID: 38501850 DOI: 10.1177/10600280241237534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/20/2024] Open
Abstract
OBJECTIVE The article reviews the safety and efficacy of treatments for cytomegalovirus (CMV) in solid organ transplantation. DATA SOURCES A literature review was conducted in PubMed, MEDLINE, and Clinicaltrials.gov from database inception through January 2024, using terms CMV, therapy, and solid organ transplantation. STUDY SELECTION AND DATA EXTRACTION Clinical trials, meta-analyses, cohort studies, case reports, and guidelines were included. Letters to the editor, reviews, and commentaries were excluded. DATA SYNTHESIS After abstract screening and full-text review of 728 citations for eligibility, 53 were included. Valganciclovir and intravenous ganciclovir are drugs of choice for CMV management and, until recently, the availability of alternative options has been restricted due to toxicity. For instance, foscarnet and cidofovir serve as second-line agents due to potential bone marrow and renal toxicity. In patients with refractory or resistant CMV, maribavir, a novel oral agent, has proven efficacy and a lower adverse effect profile. However, in refractory or resistant CMV, foscarnet and cidofovir are preferred in invasive disease (CMV gastritis, CMV retinitis, and CMV encephalitis), high viral loads, and inability to tolerate oral preparations. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE Consensus guidelines have not been revised since approval of novel antivirals in solid organ transplantation. Valganciclovir and ganciclovir remain drugs of choice for initial CMV therapy. Foscarnet, cidofovir, and maribavir are treatments for refractory or resistant-CMV. CONCLUSIONS Selection of CMV antiviral treatment should be determined by patient-specific factors, including severity of illness, resistant or refractory disease, dose-limiting adverse effects, and the preferred route of administration.
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Affiliation(s)
- Karen L Hardinger
- Division of Pharmacy Practice and Administration, School of Pharmacy, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Daniel C Brennan
- Johns Hopkins Comprehensive Transplant Center, Baltimore, MD, USA
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Kotton CN, Torre-Cisneros J, Yakoub-Agha I. Slaying the "Troll of Transplantation"-new frontiers in cytomegalovirus management: A report from the CMV International Symposium 2023. Transpl Infect Dis 2024; 26:e14183. [PMID: 37942955 DOI: 10.1111/tid.14183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 10/15/2023] [Indexed: 11/10/2023]
Abstract
The 2023 International CMV Symposium took place in Barcelona in May 2023. During the 2-day meeting, delegates and faculty discussed the ongoing challenge of managing the risk of cytomegalovirus infection (the Troll of Transplantation) after solid organ or hematopoietic cell transplantation. Opportunities to improve outcomes of transplant recipients by applying advances in antiviral prophylaxis or pre-emptive therapy, immunotherapy, and monitoring of cell-mediated immunity to routine clinical practice were debated and relevant educational clinical cases presented. This review summarizes the presentations, cases, and discussions from the meeting and describes how further advances are needed before the Troll of Transplantation is slain.
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Affiliation(s)
- Camille N Kotton
- Transplant and Immunocompromised Host Infectious Diseases, Infectious Diseases Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Julian Torre-Cisneros
- Maimónides Institute for Biomedical Research of Cordoba (IMIBIC)/Reina Sofía University Hospital/University of Cordoba (UCO), Cordoba, Spain
- CIBERINFEC, ISCIII - CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
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Gourin C, Alain S, Hantz S. Anti-CMV therapy, what next? A systematic review. Front Microbiol 2023; 14:1321116. [PMID: 38053548 PMCID: PMC10694278 DOI: 10.3389/fmicb.2023.1321116] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 11/06/2023] [Indexed: 12/07/2023] Open
Abstract
Human cytomegalovirus (HCMV) is one of the main causes of serious complications in immunocompromised patients and after congenital infection. There are currently drugs available to treat HCMV infection, targeting viral polymerase, whose use is complicated by toxicity and the emergence of resistance. Maribavir and letermovir are the latest antivirals to have been developed with other targets. The approval of letermovir represents an important innovation for CMV prevention in hematopoietic stem cell transplant recipients, whereas maribavir allowed improving the management of refractory or resistant infections in transplant recipients. However, in case of multidrug resistance or for the prevention and treatment of congenital CMV infection, finding new antivirals or molecules able to inhibit CMV replication with the lowest toxicity remains a critical need. This review presents a range of molecules known to be effective against HCMV. Molecules with a direct action against HCMV include brincidofovir, cyclopropavir and anti-terminase benzimidazole analogs. Artemisinin derivatives, quercetin and baicalein, and anti-cyclooxygenase-2 are derived from natural molecules and are generally used for different indications. Although they have demonstrated indirect anti-CMV activity, few clinical studies were performed with these compounds. Immunomodulating molecules such as leflunomide and everolimus have also demonstrated indirect antiviral activity against HCMV and could be an interesting complement to antiviral therapy. The efficacy of anti-CMV immunoglobulins are discussed in CMV congenital infection and in association with direct antiviral therapy in heart transplanted patients. All molecules are described, with their mode of action against HCMV, preclinical tests, clinical studies and possible resistance. All these molecules have shown anti-HCMV potential as monotherapy or in combination with others. These new approaches could be interesting to validate in clinical trials.
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Affiliation(s)
- Claire Gourin
- INSERM, CHU Limoges, University of Limoges, RESINFIT, Limoges, France
| | - Sophie Alain
- INSERM, CHU Limoges, University of Limoges, RESINFIT, Limoges, France
- CHU Limoges, Laboratoire de Bactériologie-Virologie-Hygiène, National Reference Center for Herpesviruses, Limoges, France
| | - Sébastien Hantz
- INSERM, CHU Limoges, University of Limoges, RESINFIT, Limoges, France
- CHU Limoges, Laboratoire de Bactériologie-Virologie-Hygiène, National Reference Center for Herpesviruses, Limoges, France
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Panda K, Parashar D, Viswanathan R. An Update on Current Antiviral Strategies to Combat Human Cytomegalovirus Infection. Viruses 2023; 15:1358. [PMID: 37376657 DOI: 10.3390/v15061358] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 05/29/2023] [Accepted: 06/06/2023] [Indexed: 06/29/2023] Open
Abstract
Human cytomegalovirus (HCMV) remains an essential global concern due to its distinct life cycle, mutations and latency. As HCMV is a herpesvirus, it establishes a lifelong persistence in the host through a chronic state of infection. Immunocompromised individuals are at risk of significant morbidity and mortality from the virus. Until now, no effective vaccine has been developed to combat HCMV infection. Only a few antivirals targeting the different stages of the virus lifecycle and viral enzymes are licensed to manage the infection. Therefore, there is an urgent need to find alternate strategies to combat the infection and manage drug resistance. This review will provide an insight into the clinical and preclinical antiviral approaches, including HCMV antiviral drugs and nucleic acid-based therapeutics.
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Affiliation(s)
- Kingshuk Panda
- Dengue-Chikungunya Group, Indian Council of Medical Research-National Institute of Virology, Pune 411001, India
| | - Deepti Parashar
- Dengue-Chikungunya Group, Indian Council of Medical Research-National Institute of Virology, Pune 411001, India
| | - Rajlakshmi Viswanathan
- Bacteriology Group, Indian Council of Medical Research-National Institute of Virology, Pune 411001, India
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Van Aelst LNL, Droogné W, Vörös G, Van Cleemput J. Combination prophylaxis in CMV high risk heart transplant recipients: A single center experience. Clin Transplant 2023; 37:e14848. [PMID: 36374223 DOI: 10.1111/ctr.14848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 06/24/2022] [Accepted: 11/01/2022] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Cytomegalovirus (CMV) is the most clinically relevant infectious agent following heart transplantation (HTX). Data on the beneficial effects of prophylactic use of CMV immunoglobulins (CMVIG) are scarce. METHODS In this single-center, retrospective study, we reported patient outcomes following cardiac transplantation using prophylactic CMV treatment, including CMVIG. Distinct clinically relevant outcomes were compared across different CMV risk groups (CMV D-/R-, CMV D-/R+, CMV D+/R+, and CMV D+/R- or CMV high risk group). RESULTS We included 272 heart transplant procedures, performed between 1/1/2009 and 1/11/2020. Sixty-one (22%) procedures belonged to the CMV high risk group, while 96 (35%), 50 (18%), and 65 (24%) were CMV D-/R-, CMV D-/R+, and CMV D+/R+, respectively. Baseline donor and recipient characteristics (sex, age, body mass index, cause of death, indication for HTX), ischemia times and baseline immunosuppressive regimens were similar across the different CMV risk groups, yet fewer patients were bridged with a mechanical circulatory support in the CMV D+/R- group. CMV disease following cardiac transplantation was more common in the CMV D+/R- risk group (n = 40 or 66.7%; p < .001), yet mortality and re-transplantation rates, cardiac allograft vasculopathy (CAV) severity, rejection episodes, and development of donor-specific antibodies (DSA), post-transplant lymphoproliferative diseases (PTLD), and EBV infections were similar across all four CMV risk groups. CONCLUSION High risk CMV D+/R- patients had a similar survival compared to low and intermediate CMV risk groups using a prophylactic strategy combining CMVIG and viral DNA polymerase inhibitors. This may be related to a number of factors unrelated to prophylaxis strategy as two out of three CMV D+/R- recipients developed CMV primary infection after prophylaxis was discontinued.
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Affiliation(s)
- Lucas N L Van Aelst
- Department of Cardiovascular Sciences, Katholieke Universiteit Leuven, Leuven, Belgium.,Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Walter Droogné
- Department of Cardiovascular Sciences, Katholieke Universiteit Leuven, Leuven, Belgium.,Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Gabor Vörös
- Department of Cardiovascular Sciences, Katholieke Universiteit Leuven, Leuven, Belgium.,Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Johan Van Cleemput
- Department of Cardiovascular Sciences, Katholieke Universiteit Leuven, Leuven, Belgium.,Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
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Balani SS, Sadiq S, Jensen CJ, Kizilbash SJ. Prevention and management of CMV infection in pediatric solid organ transplant recipients. Front Pediatr 2023; 11:1098434. [PMID: 36891229 PMCID: PMC9986459 DOI: 10.3389/fped.2023.1098434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 01/31/2023] [Indexed: 02/22/2023] Open
Abstract
Human cytomegalovirus (CMV) remains one of the most common opportunistic infections following solid organ transplantation in children. CMV causes morbidity and mortality through direct tissue-invasive disease and indirect immunomodulatory effects. In recent years, several new agents have emerged for the prevention and treatment of CMV disease in solid organ transplant recipients. However, pediatric data remain scarce, and many of the treatments are extrapolated from the adult literature. Controversies exist about the type and duration of prophylactic therapies and the optimal dosing of antiviral agents. This review provides an up-to-date overview of treatment modalities used to prevent and treat CMV disease in solid organ transplant (SOT) recipients.
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Affiliation(s)
- Shanthi S Balani
- Division of Nephrology, Department of Pediatrics, University of Minnesota, Minneapolis, MN, United States
| | - Sanober Sadiq
- Division of Nephrology, Department of Pediatrics, University of California, San Francisco, CA, United States
| | - Chelsey J Jensen
- Department of Solid Organ Transplant, University of Minnesota, Minneapolis, MN, United States
| | - Sarah J Kizilbash
- Division of Nephrology, Department of Pediatrics, University of Minnesota, Minneapolis, MN, United States
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Santhanakrishnan K, Yonan N, Iyer K, Callan P, Al-Aloul M, Venkateswaran R. Management of ganciclovir resistance cytomegalovirus infection with CMV hyperimmune globulin and leflunomide in seven cardiothoracic transplant recipients and literature review. Transpl Infect Dis 2021; 24:e13733. [PMID: 34534396 DOI: 10.1111/tid.13733] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 07/31/2021] [Accepted: 08/19/2021] [Indexed: 12/20/2022]
Abstract
Cytomegalovirus (CMV) disease caused by genetically resistant CMV poses a major challenge in solid organ transplant recipients, and the development of resistance is associated with increased morbidity and mortality. Antiviral resistance affects 5%-12% of patients following ganciclovir (GCV) therapy, but is more common in individuals with specific underlying risk factors. These include the CMV D+R- serostatus, type of transplanted organ, dose and duration of (Val)GCV ([V]GCV) prophylaxis, peak viral loads, and the intensity of immunosuppressive therapy. Guideline recommendations for the management of GCV resistance (GanR) in solid organ transplant recipients are based on expert opinion as there is a lack of data from controlled trials. Second-line options to treat GanR include foscarnet (FOS) and cidofovir (CDV), but these drugs are often poorly tolerated due to high rates of toxicity, such as renal dysfunction and neutropenia. Here, we report seven cardiothoracic transplant recipients with GCV resistance CMV infection from our centre treated with CMV immunoglobulin (CMVIG) +/- leflunomide (LEF) and reviewed the literature on the use of these agents in this therapeutic setting.
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Affiliation(s)
- Karthik Santhanakrishnan
- Transplant Department, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Nizar Yonan
- Transplant Department, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Kapil Iyer
- Transplant Department, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Paul Callan
- Transplant Department, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Mohamed Al-Aloul
- Transplant Department, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Rajamiyer Venkateswaran
- Transplant Department, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
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Brahier M, Neuda R, Davis W, Poon R. 'Lipo-tourism' gone wrong: blood transfusion-transmitted cytomegalovirus disease. BMJ Case Rep 2021; 14:14/3/e236892. [PMID: 33664022 PMCID: PMC7934768 DOI: 10.1136/bcr-2020-236892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Medical tourism is the pursuit of more affordable surgeries; however, this comes at the risk of suboptimal standards and potential for life-threatening complications. In this case, we describe the diagnostic challenge of cytomegalovirus (CMV) pneumonia in a 40-year-old woman who experienced wound dehiscence and subsequent blood transfusion-transmitted CMV as complications of liposuction in the Dominican Republic. We explore the role of histopathology in the diagnosis of disseminated CMV, discuss the underlying aetiology of CMV pneumonia in this patient and weigh the risks and benefits of initiating antiviral therapy in an immunocompetent patient with CMV disease.
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Affiliation(s)
- Mark Brahier
- Georgetown University School of Medicine, Washington, DC, USA
| | - Rhanika Neuda
- Department of Internal Medicine, Georgetown University Medical Center, Washington, DC, USA
| | - William Davis
- Department of Infectious Disease, Georgetown University Medical Center, Washington, DC, USA
| | - Rita Poon
- Department of Internal Medicine, Georgetown University Medical Center, Washington, DC, USA
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