Ganciclovir for cytomegalovirus: a call for indefinite prophylaxis in lung transplantation.
BACKGROUND
Universal ganciclovir (GCV) prophylaxis is a strategy aimed at reducing cytomegalovirus (CMV) infection and delaying the development of bronchiolitis obliterans syndrome (BOS). However, the optimal duration of GCV prophylaxis remains unclear. We report our experience with GCV prophylaxis administered indefinitely and its effect on CMV pneumonitis, BOS and survival after lung transplantation (LT).


METHODS
One hundred fifty-one patients surviving >100 days after LT were analyzed. GCV was given to 130 CMV donor- or recipient-seropositive patients. Data from 90 patients who received indefinite GCV prophylaxis (IND) and 40 patients who discontinued their GCV prophylaxis (STOP) were compared.


RESULTS
CMV pneumonitis occurred in 16%, 8%, 17% and 19% of patients in the D+R+, D-R+, D+R- and D-R- groups, respectively. In the STOP cohort, 15 of 40 patients developed CMV pneumonitis (median time 79 days) after GCV was stopped. Ten of these 15 patients developed BOS (median time 116 days) after discontinuing GCV. The risk of CMV pneumonitis in the STOP cohort was significantly higher when GCV prophylaxis was discontinued within the first year. Cumulative incidence of CMV pneumonitis in the IND and STOP groups at 5 years was 2% and 57%, respectively (p < 0.001). BOS-free survival and survival were similar across both groups.


CONCLUSIONS
Indefinite GCV prophylaxis prevents CMV pneumonitis in 98% of LT recipients. Thirty-eight percent of patients discontinuing prophylaxis developed CMV pneumonitis, 50% of whom progressed to BOS within 1 year. Continuing ganciclovir prophylaxis indefinitely after lung transplantation should be considered.
Valentine
Vincent G
VG
Texas Transplant Center, Department of Internal Medicine, University of Texas Medical Branch, Galveston, Texas 77555-0772, USA. vgvalent@utmb.edu
Weill
David
D
Gupta
Meera R
MR
Raper
Brad
B
Laplace
Stephanie G
SG
Lombard
Gisele A
GA
Bonvillain
Ryan W
RW
Taylor
David E
DE
Dhillon
Gundeep S
GS
D000293:Adolescent; D000328:Adult; D000368:Aged; D000998:Antiviral Agents / Q000627:therapeutic use*; D001989:Bronchiolitis Obliterans / Q000517:prevention & control; D015331:Cohort Studies; D003586:Cytomegalovirus Infections / Q000517:prevention & control*; D004305:Dose-Response Relationship, Drug; D005260:Female; D015774:Ganciclovir / Q000627:therapeutic use*; D006801:Humans; D007165:Immunosuppression Therapy / Q000379:methods; D016040:Lung Transplantation; D008297:Male; D008875:Middle Aged; D009894:Opportunistic Infections / Q000517:prevention & control*; D011014:Pneumonia / Q000517:prevention & control; D012189:Retrospective Studies; D016896:Treatment Outcome
D000998:Antiviral Agents; D015774:Ganciclovir