Late-onset cytomegalovirus disease in patients with solid organ transplant

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Abstract
To review existing data regarding late cytomegalovirus disease occurring after antiviral prophylaxis. There is a continued debate as to the respective merits of the preemptive and the prophylactic approach to prevent cytomegalovirus disease after transplantation. Arguably, by allowing some infection, the preemptive approach helps build immunity in contrast to prophylaxis, explaining the occurrence of late cytomegalovirus disease in the latter approach. No study comparing directly both approaches is large enough to definitely determine whether the preemptive approach leads to a faster development of immune response protective from late disease nor whether late disease is clinically different after prophylaxis compared to early cytomegalovirus diseases. While risk factors for late cytomegalovirus disease all point to a delay in mounting immune responses, there are no identified markers that would help predict the risk for late disease at the time of prophylaxis discontinuation. Various approaches to prevent late cytomegalovirus disease have been developed: prolonged prophylaxis, microbiological surveillance and preemptive treatment after prophylaxis discontinuation. Considering the identifying risk factors for late disease, it would also make sense to envision vaccinating cytomegalovirus-seronegative recipients. The best approach to prevent or manage late cytomegalovirus disease associated with cytomegalovirus prophylaxis remains to be defined.