Department of General Surgery, Section of Transplantation, Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina, USA.
Pharmacotherapy. 2010 Feb;30(2):144-57. doi: 10.1592/phco.30.2.144.
Cytomegalovirus continues to be one of the most clinically significant infections after solid organ transplantation. Classic definitions of patients at high risk for infection and tissue-invasive disease are focused on recipient-donor serostatus, type of organ transplanted, and overall level of immunosuppression. However, recent trends in clinical practice call for a reevaluation of cytomegalovirus infection risks after solid organ transplantation. Indeed, whereas early-onset cytomegalovirus infection is usually controlled by antiviral prophylaxis with ganciclovir and derivatives, delayed- and late-onset cytomegalovirus infection can develop after the completion of a course of preventive therapy. In addition, indirect effects of cytomegalovirus infection may occur as a result of persistent low-level viremia. Suboptimal dosing of antiviral drugs due to specific drug toxicities may result in the development of ganciclovir-resistant cytomegalovirus disease. The relationship between organ allograft rejection and cytomegalovirus infection and disease has been recognized for some time. Transplantation of increasing numbers of extended-criteria donor organs increases the risk of delayed graft function and acute rejection, prompting the use of more intensive immunosuppression. In addition, the trend to spare long-term exposure to calcineurin inhibitors has contributed to a resurgence in the use of polyclonal T-cell induction immunosuppressive agents, which may reduce host anticytomegalovirus immunity. We discuss the current trends in solid organ transplantation that provide a foundation for defining risks for cytomegalovirus infection and disease, including identification of patients who would benefit from more aggressive cytomegalovirus monitoring and prevention strategies.
巨细胞病毒仍然是实体器官移植后最具临床意义的感染之一。感染和组织侵袭性疾病高危患者的经典定义集中在受者-供者血清状态、移植器官类型和整体免疫抑制水平上。然而，临床实践中的最新趋势要求重新评估实体器官移植后巨细胞病毒感染的风险。事实上，虽然早期巨细胞病毒感染通常通过更昔洛韦和衍生物的抗病毒预防来控制，但在预防性治疗完成后，可能会发生迟发和晚期巨细胞病毒感染。此外，由于持续低水平病毒血症，巨细胞病毒感染可能会产生间接影响。由于特定药物毒性导致抗病毒药物剂量不足，可能导致更昔洛韦耐药巨细胞病毒病的发展。器官同种异体移植排斥反应与巨细胞病毒感染和疾病之间的关系已经被认识了一段时间。越来越多的扩展标准供体器官的移植增加了延迟移植物功能和急性排斥反应的风险，促使使用更强化的免疫抑制。此外，避免长期接触钙调神经磷酸酶抑制剂的趋势导致多克隆 T 细胞诱导免疫抑制剂的使用再次增加，这可能会降低宿主抗巨细胞病毒的免疫力。我们讨论了实体器官移植中的当前趋势，为定义巨细胞病毒感染和疾病的风险提供了基础，包括确定需要更积极的巨细胞病毒监测和预防策略的患者。
