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Optimal Strategy for CMV Prevention in HCT

CE / CME

Reducing the Burden of Cytomegalovirus in HCT: Optimal Strategy for Prevention

Physician Assistants/Physician Associates: 1.00 AAPA Category 1 CME credit

Nurse Practitioners: 1.00 Nursing contact hours, includes 1.00 hour of pharmacotherapy credit

Released: July 21, 2023

Expiration: July 20, 2024

Roy F. Chemaly
Roy F. Chemaly, MD, MPH
CME/CE Information

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Timing and CMV Risk

The factors that affect risk for CMV are dynamic, in the sense that different factors are associated with increased risk at different time points after transplantation. Risk for CMV can be thought of in 3 phases: Days 0 to 30 post-HCT, Days 30 to 99, and Day 100+. In the 30 days right after transplantation, key risk factors are the type of conditioning chemotherapy used prior to transplant (myeloablative regimens having highest risk), as well as older age and recipient seropositivity (Figur e 1).1 Use of post-transplant cyclophosphamide or high-dose anti-thymocyte for T-cell depletion, which effectively reduces risk for acute GVHD also increases risk for CMV infection.2 Use of matched unrelated donors or haploidentical donors is associated with higher risk for CMV reactivation compared with matched related donors. Cord-blood transplant also increases risk, as the naive T-cells in cord blood take longer to restore antigen-specific immunity.2

Figure 1. CMV risk factors and presentation over time from allo-HCT.1

In the intermediate period, risk factors include GVHD development and steroid use as treatment. Risk factors in the late time period include chronic steroid use, chronic GVHD, and delayed T-cell recovery. It is also during the intermediate and late phases that CMV end-organ disease tends to manifest.1 

Donor positivity can affect risk for CMV infection but it is not currently a factor in treatment decisions in guidelines. One European study suggests increased mortality with transplant from an unrelated donor whose CMV status is opposite the recipient’s, but this is controversial. In contrast, transplants between CMV-seropositive recipients and seropositive unmatched donors improved overall survival (OS) vs seronegative donors in that study.12 

Expert Insights From Dr Chemaly: How CMV Risk Changes Over Time and the Impact on Late-onset Disease Risks.

Which of these is the first-line recommended agent in PET for CMV?

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