Cytomegalovirus prophylaxis with IV ganciclovir in lung transplant recipients: the long and the short of it!

Critical care perspective on immunotherapy in lung transplantation

Lung transplantation is now a viable therapeutic option in the care of patients with advanced pulmonary parenchymal or pulmonary vascular disease. Lung transplantation, however, with chronic posttransplant immunosuppression, creates a uniquely vulnerable population of patients likely to experience significant life-threatening complications requiring intensive care. The introduction of several novel immunosuppressive agents, such as sirolimus and mycophenolate mofetil, in conjunction with more established agents such as cyclosporine and tacrolimus, has greatly increased treatment options for lung transplant recipients and likely contributed to improved short-term transplant outcomes. Modern transplant immunosuppression, however, is associated with a host of complications such as opportunistic infections, renal failure, and thrombotic thrombocytopenic purpura. The main focus of this review is to provide a comprehensive summary of modern immunotherapy in lung transplantation and to increase awareness of the serious and potentially life-threatening complications of these medications.

Cytomegalovirus prophylaxis with valganciclovir in kidney, pancreas-kidney, and pancreas transplantation

Cytomegalovirus, seen in more than 50% of solid organ transplant recipients, is responsible for numerous direct and indirect consequences, including infection with opportunistic pathogens and allograft rejection. Prophylaxis with intravenous ganciclovir has been the gold standard for prevention; however, intravenous treatment is expensive and carries risks of its own. Oral ganciclovir, to be effective, must be given in large, divided doses. Valganciclovir, the valine ester of ganciclovir, at 900 mg/day, provides oral bioavailability equivalent to that of intravenous ganciclovir and superior to that of oral ganciclovir. This retrospective study assessed the efficacy of 3 months prophylaxis with valganciclovir in kidney, simultaneous pancreas-kidney, and pancreas transplantation. Of 161 patients, all of whom received potent immunosuppressive regimens and were followed for a mean of 440 days, only one developed cytomegalovirus infection, at 120 days post-transplantation. Two patients died, and two others lost their grafts. There were seven incidents of acute rejection. Only seven patients discontinued treatment early, five because of leukopenia. These results suggest that prophylaxis with 900 mg/day of valganciclovir for at least 3 months safely and effectively prevents cytomegalovirus infection in kidney, simultaneous pancreas-kidney and pancreas transplant recipients on highly potent immunosuppression.