title: Cytomegalovirus in transplantation - challenging the status quo.
abstract: BACKGROUND
  Cytomegalovirus (CMV) infection of solid organ transplant (SOT) recipients causes both ''direct'' and ''indirect'' effects including allograft rejection, decreased graft and patient survival, and predisposition to opportunistic infections and malignancies. Options for CMV prevention include pre-emptive therapy, whereby anti-CMV agents are administered based on sensitive viral assays, or universal prophylaxis of all at-risk patients. Each approach has advantages and disadvantages in terms of efficacy, costs, and side effects. Standards of care for prophylaxis have not been established.
  
  
  METHODS
  A committee of international experts was convened to review the available data regarding CMV prophylaxis and to compare preventative strategies for CMV after transplantation from seropositive donors or in seropositive recipients.
  
  
  RESULTS
  Pre-emptive therapy requires frequent monitoring with subsequent treatment of disease and associated costs, while universal prophylaxis results in greater exposure to potential toxicities and costs of drugs. The advantages of prophylaxis include suppressing asymptomatic viremia and prevention of both direct and indirect effects of CMV infection. Meta analyses reveal decreased in mortality for patients receiving CMV prophylaxis. Costs associated with prophylaxis are less than for routine monitoring and pre-emptive therapy. The optimal duration of antiviral prophylaxis remains undefined. Extended prophylaxis may improve clinical outcomes in the highest-risk patient populations including donor-seropositive/recipient-seronegative renal transplants and in CMV-infected lung and heart transplantation.
  
  
  CONCLUSIONS
  Prophylaxis is beneficial in preventing direct and indirect effects of CMV infection in transplant recipients, affecting both allograft and patient survival. More studies are necessary to define optimal prophylaxis regimens.
authors.affiliation: Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
authors.forename: Jay A
authors.initials: JA
authors.lastname: Fishman
authors.forename: Vincent
authors.initials: V
authors.lastname: Emery
authors.forename: Richard
authors.initials: R
authors.lastname: Freeman
authors.forename: Manuel
authors.initials: M
authors.lastname: Pascual
authors.forename: Lionel
authors.initials: L
authors.lastname: Rostaing
authors.forename: Hans J
authors.initials: HJ
authors.lastname: Schlitt
authors.forename: Dino
authors.initials: D
authors.lastname: Sgarabotto
authors.forename: Julian
authors.initials: J
authors.lastname: Torre-Cisneros
authors.forename: Marc E
authors.initials: ME
authors.lastname: Uknis
mesh_terms: D000998:Antiviral Agents / Q000627:therapeutic use; D015897:Comorbidity; D003586:Cytomegalovirus Infections / Q000188:drug therapy / Q000209:etiology* / Q000517:prevention & control; D015774:Ganciclovir / Q000031:analogs & derivatives / Q000627:therapeutic use; D006084:Graft Rejection; D006801:Humans; D016031:Liver Transplantation; D009503:Neutropenia / Q000453:epidemiology / Q000209:etiology; D016377:Organ Transplantation; D011183:Postoperative Complications / Q000821:virology*; D000077562:Valganciclovir; D014779:Virus Replication
chemical_list: D000998:Antiviral Agents; D000077562:Valganciclovir; D015774:Ganciclovir