CMV infections are fairly common in solid organ transplantations. A nice review in Nature Review Nephrology this month highlights prophylaxis treatment, active treatment and serology testing. What I found very useful wa a table on dosage recommendations for ganciclovir and valganciclovir in varied renal function states.
A nice section on anti viral resistance also reveals some important data on use of foscarnet and when there is UL97 mutations. These strains usually have ganciclovir resistance. The UL54 strain mutation can have resistance to even foscarnet and cidofivir. The advent of commercially available genotyping allows for rapid results of UL97 or 54 and allow for personalized treatment of CMV viremia or disease.
Resistant CMV guidelines
1. Increase dose of ganciclovir
2. Change to foscarnet with or without continued ganciclovir
3. Change to Cidofovir only if pol mutations are not present otherwise it cross reacts with ganciclovir resistance.
4. leflunomide has been tried in few cases.
5. CMV immunoglobulin (IVIG) as a last resort and if there is organ damage happening.
Check it out