Varga Marina, Remport Adám, Czebe Krisztina, Péter Antal, Toronyi Eva, Sárváry Eniko, Fehérvári Imre, Sulyok Beáta, Járay Jeno
Semmelweis Egyetem, Altalános Orvostudományi Kar Transzplantációs és Sebészeti Klinika Budapest Baross u. 23-25. 1082.
Orv Hetil. 2008 Mar 23;149(12):551-8. doi: 10.1556/OH.2008.28324.
The human cytomegalovirus is widely prevalent among human population and it is the most common viral pathogen that affects both the graft's and solid-organ transplant recipient's survival. The risk is highest in donor-seropositive, recipient-seronegative pairing transplantation. These recipients carry increased risk of developing symptomatic primary CMV infection; however, other risk factors may have an impact on cytomegalovirus activation as well: intensity of immunosuppression, type of organ transplanted, rejection and/or treatment for rejection, HLA-mismatch between recipient and donor, certain HLA-types of the recipient, female sex etc. Cytomegalovirus infection in transplant patients has been associated with both direct (symptoms) and indirect effects which are derived from the immunomodulating impact of the virus such as cellular effects and cytokine expression or systemic immune suppression leading to other opportunistic infections. Prevention of the direct and indirect effects of cytomegalovirus infection is the therapeutic goal in transplanted patients. Most transplant centers use either universal prophylaxis or preemptive therapy to prevent the infection. The advantages and disadvantages of these two preventive strategies and current evidence-based recommendations for preventing cytomegalovirus disease in solid-organ transplant recipients are discussed according to others' and the authors' own observations. According to recommendations of the American and Canadian Societies of Transplantation, most of the centers--after analyzing of the CMV-infection risk factors of the recipients--divide them into three groups: high-, moderate- and low-risk groups. The preventive strategy is attached to the risk-group type. In the high-risk group (R-/D+ and lung transplant patients) the use of the universal prophylaxis is necessary. The patients administered anti-lymphocyte antibodies (ATG, ALG or OKT3) need selective (subtype of universal) prophylaxis. Among the moderate-risk patients (R+/D+ or R+/D-) the doctors may choose either universal prophylaxis or preemptive therapy. Selection of a strategy requires consideration of patient-specific factors as well as practical considerations such as available resources. For avoidance of the indirect effects of CMV infection universal prophylaxis is preferred. The use of preventive proceedings in low-risk patients is the matter of the center's decision.
人类巨细胞病毒在人群中广泛流行，是影响移植物和实体器官移植受者存活的最常见病毒病原体。在供体血清学阳性、受体血清学阴性的配对移植中，风险最高。这些受者发生有症状的原发性巨细胞病毒感染的风险增加；然而，其他风险因素也可能对巨细胞病毒激活产生影响：免疫抑制强度、移植器官类型、排斥反应和/或排斥反应治疗、受体与供体之间的HLA不匹配、受体的某些HLA类型、女性等。移植患者的巨细胞病毒感染与直接（症状）和间接效应相关，这些效应源于病毒的免疫调节作用，如细胞效应、细胞因子表达或导致其他机会性感染的全身免疫抑制。预防巨细胞病毒感染的直接和间接效应是移植患者的治疗目标。大多数移植中心使用普遍预防或抢先治疗来预防感染。根据他人和作者自己的观察，讨论了这两种预防策略的优缺点以及目前关于预防实体器官移植受者巨细胞病毒疾病的循证建议。根据美国和加拿大移植学会的建议，大多数中心在分析受者的巨细胞病毒感染风险因素后，将他们分为三组：高风险组、中风险组和低风险组。预防策略取决于风险组类型。在高风险组（R-/D+和肺移植患者）中，必须使用普遍预防。接受抗淋巴细胞抗体（ATG、ALG或OKT3）治疗的患者需要选择性（普遍预防的亚型）预防。在中风险患者（R+/D+或R+/D-）中，医生可以选择普遍预防或抢先治疗。选择策略需要考虑患者的具体因素以及实际因素，如可用资源。为避免巨细胞病毒感染的间接效应，首选普遍预防。在低风险患者中使用预防措施由中心决定。
