Tailored cytomegalovirus management in lung transplant recipient: a single-center experience

Among solid organ recipients lung transplant recipients are at highest risk to be affected by cytomegalovirus infection (CMV) or to die from CMV disease. Two strategies are usually adopted in the clinical management of transplant recipients: antiviral prophylaxis and pre-emptive therapy.

In our center we adopted from 2007 a combined prophylaxis with anti-CMV immunoglobulins in the first post-transplant year and antiviral therapy (gancyclovir or valgancyclovir) from post-transplant day 15 for 3 weeks and in case of CMV bronchoalveolar lavage specimen positivity (polymerase chain reaction or shell vial). Moreover, we studied specific cellular immune response by an Elispot assay to define responder patients by the number of spot forming units (<5 nonresponders, 5-20 weeks, 20-100 good, >100 very good responders).

We reduced acute rejections (from 17% to 6%, odds ratio 3.25), lymphocytic bronchitis bronchiolitis (from 11% to 2%), and first-year CMV pneumonia after the first post-transplant month (from 6.4% to 1%). We showed in nonresponders an earlier onset (68 vs 204 post-transplant days) and a longer duration (>14 days vs <14 days) of infection (P < .05 for all referred data).

The morbility reduction has been obtained by antiviral therapy, increasing costs and risk of side effects. Our more recent studies show a population with a good immune response that probably doesn't need a pharmacological intervention but just a strict follow-up.

Our proposed strategy is now tailoring the therapy on immune response clinical application, limiting to the specimen positivity in nonresponders.