Donor CMV
status / Recipient CMV Status / Risk / Monitoring / Therapy / Notes
Positive / Negative / HIGH / CMV antigenemia every month after stopping Valcyte therapy / §  Acyclovir 400mg twice daily (PO or PT) until POD 7-10
§  Valcyte 900mg** daily upon discharge or at POD#14 (see note)– continue for 3-6 months
§  Resume acyclovir 400mg BID and adjust for renal function
§  Stop therapy at 1 yr post-tx / If pt in HIGH risk category with a significant rejection and high dose steroid or antibody therapy --- continue Valcyte for 6 months post tx and resume acyclovir 800mg TID thereafter
Positive
Negative / Positive
Positive / Moderate / CMV antigenemia every month after stopping Valcyte therapy / §  Acyclovir 400mg twice daily PO or PT) until POD 7-10
§  Valcyte 900mg** daily upon discharge or at POD#14 for 3 months
§  Consider resuming acyclovir 400 mg twice daily and adjust for renal function
§  Stop therapy at 6 months post-tx / If the patient stays in the hospital longer than 14 days post operatively, start Valcyte at POD#14
Negative / Negative / Low / CMV antigenemia q 2 weeks x 3 months, then check IgG IgM for seroconversion / §  Acyclovir 400 twice daily for 6 months post-tx

CMV Prophylaxis in Heart Transplant Recipients

Renal Dosing of Valcyte (Valganciclovir) / Induction/ Treatment dose / Prophylaxis/ Maintenance Dose
CrCl ≥ 60ml/min / 900 mg twice daily / 900 mg daily (or 450 twice daily)
CrCl 69-40 ml/min / 900 mg once daily (or 450 twice daily) / 450 mg daily
CrCl 39-25 ml/min / 450 mg daily / 450 mg every other day
CrCl 25-10 ml/min / 450 mg every other day / 450 mg twice weekly

References:

Akalin JS, Bronberg V, Shegal S, et al. Six months valganciclovir prophylaxis significantly decreased cytomegalovirus infection incidence in thymoglobulin treated patients. Am J Transplant 2004(4):495.

Valcyte [package insert]. Philadelphia, PA: Wyeth; September 2007.

Kalil AC, Levitsky J, Lyden E, et al. Meta Analysis: the efficacy of strategies to prevent organ disease by cytomegalovirus in solid organ transplant recipients. Ann Intern Med 2005; 143: 870-80.

Cvetkovic RS, Wellington K. Valganciclovir: A review of its use in the management of CMV infection and disease in immunocompromised patients. Drugs 2005; 65(6):859-78.

Kusne S, Shapiro R, Fung J, et al. Prevention and treatment of cytomegalovirus infection in organ transplant recipients. Transpl Infect Dis. 1999;1:187-203.

Singh N. Preemptive therapy versus universal prophylaxis with Ganciclovir for CMV in solid organ transplant recipients. Clin Infect Dis. 2001; 32: 742-51.

Khoury JA, Storch GA, Bohl DL, et al. Prophylactic versus preemptive oral valganciclovir for the management of CMV infection in adult renal transplant recipients. Am J Transplantation. 2006; 6:2134-2143.

Singh N. Cytomegalovirus infection in solid organ transplant recipients: new challenges and their implications for preventive strategies. J Clin Virol. 2006; 35 (4):474-44.

Revised 9/2007