Prevention and treatment of cytomegalovirus infection in solid organ transplant recipients

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Abstract
Cytomegalovirus remains the single most important pathogen affecting solid organ transplant recipients. Its importance lies both in its effects and as a model for deciphering the clinical impact and management of other agents such as hepatitis C virus and other herpes viruses such as human herpes virus-6 and 7. The effects of cytomegalovirus infection in these patients can be divided into two categories: the direct causation of a wide variety of infectious disease syndromes; and the indirect effects, which include contributing to the net state of immunosuppression, allograft injury, and potentiating posttransplant lymphoproliferative disease. The advent of valganciclovir, with its excellent oral bioavailability, combined with intravenous ganciclovir have provided powerful tools for controlling the direct effects of cytomegalovirus, particularly with the recognition that the intensity of the antiviral therapy has to be linked to the intensity of the immunosuppression required. Unfortunately, far less is known about the efficacy of antiviral therapy in managing the indirect effects of cytomegalovirus. Preliminary data suggest antiviral prophylaxis protects against acute allograft injury, as well as decreasing the incidence of some opportunistic infection. A great deal of progress has been made in the prevention and treatment of the infectious disease syndromes caused by cytomegalovirus, with the development of the concept of the therapeutic prescription. This has two components: an immunosuppressive component to prevent and treat rejection and an antimicrobial component to make it safe. Much more information, however, is required.