Prevention and Treatment of Cytomegalovirus Infection in Liver and Intestinal Transplantation

Clark A. Bonham, MD

Disclosures

September 05, 2000

In This Article

Introduction

Cytomegalovirus (CMV) infection is one of the most common opportunistic infections following organ transplantation, occurring in up to 30% of liver transplant recipients. It is associated with significant morbidity and increased mortality. The effects of CMV infection are related to direct cytopathic properties of the virus, as well as indirect effects mediated by modulation of the immune system in response to the virus. CMV infection may be asymptomatic, or it may cause a spectrum of illnesses including fever, mononucleosis-type syndrome, pneumonia, hepatitis, gastritis, enteritis, colitis, leukopenia and thrombocytopenia, and chorioretinitis. The transplanted organ is more susceptible to infection than the native organ. Thus, CMV hepatitis is a significant problem only in liver transplant recipients.

The indirect effects of CMV infection probably contribute more to graft loss than the direct effects. CMV infection provides an additional contribution to the level of immunosuppression of the patient, increasing the risk for other opportunistic infections, especially from fungal organisms. CMV infection also increases the risk of Epstein-Barr virus (EBV)-associated posttransplant lymphoproliferative disease (PTLD). Additionally, viral infection results in the upregulation of major histocompatibility complex (MHC) molecules by allograft cells, contributing to acute and chronic injury (ie, rejection) of the transplanted organ.

The risk of developing CMV infection following transplantation is dependent on the serologic status of both the donor and the recipient. Transplantation of an organ from a D+/R- matched patient carries the highest risk of infection. The incidence of symptomatic infection in D+/R- matched patients ranges from 50% to 90%.[1,2,3] In seropositive recipients, symptomatic infection usually results from activation of the virus strain carried over from the donor.[4]

The substantial morbidity and increased graft loss associated with CMV infection have prompted investigation of a number of prophylactic strategies designed to prevent CMV infection. These have included the antiviral agents acyclovir (Zovirax) and ganciclovir (Cytovene), high-titer CMV immunoglobulin (CMVIG, CytoGam), and combinations of an antiviral agent and CMVIG.

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