Cytomegalovirus Viraemia after Allogeneic Transplant: A Prospective Study of a Risk-Adapted Strategy in a Single Transplant Unit.

CMV infection causes significant morbidity and mortality following allogeneic transplantation. In 2003, the NSW Bone Marrow Transplant network adopted a uniform CMV prevention policy. This prospective study aimed to evaluate the impact of the policy on the rate, management and outcome of CMV reactivation in allogeneic transplant recipients at St Vincent’s Hospital, Sydney. All patients at high risk for CMV reactivation (recipient and/or donor CMV seropositive pre-transplant) had weekly blood samples screened using nucleic acid tests for CMV RNA and DNA. Patients with a related donor were screened from day +21 to +84 post-transplant and received antiviral treatment for CMV only if reactivation was detected. Patients with an unrelated donor received ganciclovir 5mg/kg 3x/week from day +21 to +84, in addition to screening tests. Between October 2003 and June 2005, 40 patients (median age 44 years, range 20-67) received allogeneic transplants, with 21 (53%) originating from an unrelated donor. Thirty-six (90%) patients were high risk for CMV disease and 13 (33%) developed CMV viraemia at a median of 39 days (range 16–101) post-transplant. Six of the 13 (46%) PCR positive patients had unrelated donors, and three had severe, steroid resistant GVHD requiring monoclonal antibody therapy. The median CMV viral load was 3200 copies/mL (range 870 to >100,000) and three of the 13 patients had CMV disease (all biopsy-proven CMV enteritis). All viraemic patients were treated with ganciclovir 5mg/kg BD for a median of 2 weeks, with clinical improvement and reduction in viral load in 10 patients. Overall survival of the CMV viraemia group was 85% at a median of 303 days follow up, compared with 78% for the whole group (p = NS). The described risk-adapted CMV preventive strategy is associated with acceptable rates of viral reactivation and low morbidity and mortality post-allogeneic transplant.