Buscar en
Enfermedades Infecciosas y Microbiología Clínica
Toda la web
Inicio Enfermedades Infecciosas y Microbiología Clínica Profilaxis de la infección por citomegalovirus en el trasplante hepático
Información de la revista
Vol. 29. Núm. S6.
La infección por citomegalovirus en el trasplante de órgano sólido: nuevas evidencias de un patógeno clásico
Páginas 42-45 (Diciembre 2011)
Compartir
Compartir
Descargar PDF
Más opciones de artículo
Vol. 29. Núm. S6.
La infección por citomegalovirus en el trasplante de órgano sólido: nuevas evidencias de un patógeno clásico
Páginas 42-45 (Diciembre 2011)
Acceso a texto completo
Profilaxis de la infección por citomegalovirus en el trasplante hepático
Prophylaxis of cytomegalovirus infection in liver transplantation
Visitas
5378
José Miguel Cisnerosa,
Autor para correspondencia
jmcisnerosh@gmail.com

Autor para correspondencia.
, Evaristo Varob
a Unidad Clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospital Virgen del Rocío/IBIS, Sevilla, España
b Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, España
Este artículo ha recibido
Información del artículo
Resumen

En los receptores de trasplante hepático, las estrategias de prevención de la enfermedad por citomegalovirus (CMV) deben estratificarse según el status serológico. En los receptores D–/R– no se recomienda profilaxis ni tratamiento anticipado. En el resto, la profilaxis universal y el tratamiento anticipado son las estrategias más utilizadas. Frente a placebo ambas son eficaces, pero no se han comparado entre sí mediante ensayos clínicos bien diseñados. El tratamiento anticipado es la estrategia preferida en los pacientes de bajo riesgo, mientras que la profilaxis es la más utilizada en los pacientes de alto riesgo.

La enfermedad tardía por CMV es una consecuencia adversa de la profilaxis universal; su prolongación de 100 a 200 días no reduce la incidencia de enfermedad por CMV. La inmunidad celular específica frente a CMV, facilitada por el tratamiento anticipado y demorada por la profilaxis, tiene un efecto terapéutico reduciendo la replicación por CMV. Valganciclovir es el fármaco de elección en sendas estrategias, pero las dosis y la duración son distintas en cada una de ellas. Si se elige el tratamiento anticipado es necesario monitorizar la viremia durante los 4 primeros meses. Para ello, la PCR cuantitativa es la técnica diagnóstica de elección. A falta de datos concluyentes, la elección de una u otra estrategia en estos pacientes debe individualizarse en cada centro y en cada paciente, en función de los recursos disponibles y de la facilidad para el seguimiento.

Palabras clave:
Citomegalovirus
Trasplante hepático
Profilaxis
Tratamiento anticipado
Abstract

CMV prevention strategies in liver transplant recipients should be stratified according to serological status. In donor (D)-/recipient (R)- combinations, no prophylaxis or preemptive therapy is recommended. In the remaining combinations, the most widely used strategies are universal prophylaxis and preemptive therapy. Both strategies are effective compared with placebo but have not been compared with each other in welldesigned clinical trials. Preemptive therapy is the preferred strategy in low-risk patients while prophylaxis is the most widely used option in those at high-risk. Delayed CMV disease is an adverse consequence of universal prophylaxis. Prolongation of prophylaxis from 100 to 200 days does not reduce the incidence of CMV disease. CMV-specific cell mediated immunity, facilitated by preemptive therapy and delayed by prophylaxis, has a therapeutic effect by reducing CMV replication. The drug of choice in both strategies is valganciclovir but the duration and dose differ. When preemptive therapy is used, viremia monitoring is required for the first 4 months. The technique of choice is quantitative polymerase chain reaction. Given the lack of conclusive data, the choice of one or other strategy in these patients should be individualized in each patient and center according to the available resources and possibilities of follow-up.

Keywords:
Cytomegalovirus
Liver transplant
Prophylaxis
Preemptive therapy
El Texto completo está disponible en PDF
Bibliografía
[1.]
J. Levitsky, N. Singh, M.M. Wagener, V. Stosor, M. Abecassis, M.G. Ison.
A survey of CMV prevention strategies after liver transplantation.
Am J Transplant, 8 (2008), pp. 158-161
[2.]
A.C. Kalil, J. Levitsky, E. Lyden, J. Stoner, A.G. Freifeld.
Metaanalysis: The efficacy of strategies to prevent organ disease by cytomegalovirus in solid organ transplant recipients.
Ann Intern Med, 143 (2005), pp. 870-880
[3.]
L.N. Small, J. Lau, D.R. Snydman.
Preventing post-organ transplantation cytomegalovirus disease with ganciclovir: a meta-analysis comparing prophylactic and preemptive therapies.
Clin Infect Dis, 43 (2006), pp. 869-880
[4.]
E.M. Hodson, J.C. Craig, G.F.M. Strippoli, A.C. Webster.
Antiviral medications for preventing cytomegalovirus disease in solid organ transplant recipients.
Cochrane Database Syst Rev, (2008), pp. CD003774
[5.]
L. Barkholt, I. Lewensohn-Fuchs, B.G. Ericzon, G. Tydén, J. Andersson.
High-dose acyclovir prophylaxis reduces cytomegalovirus disease in liver transplant patients.
Transpl Infect Dis, 1 (1999), pp. 89-97
[6.]
E. Gane, F. Saliba, G.J. Valdecasas, J. O’Grady, M.D. Pescovitz, S. Lyman, et al.
Randomised trial of efficacy and safety of oral ganciclovir in the prevention of cytomegalovirus disease in liver-transplant recipients.
Lancet, 350 (1997), pp. 1729-1733
[7.]
D.J. Winston, R.W. Busutil.
Ranzomized controlled trial of sequential intravenous and oral ganciclovir versus prolonged intravenous ganciclovir for long-term prophylaxis of cytomegalovirus disease in high-risk cytomegalovirus-seronegative liver transplant recipients with cytomegalovirus-seropositive donors.
Trasplantation, 77 (2004), pp. 305-308
[8.]
D.J. Winston, R.W. Busutil.
Ranzomized controlled trial of oral ganciclovir versus oral acyclovir after induction with intravenous ganciclovir for long-term profphylaxis of cytomagelovirus disease in cytomgalovirus-seropositive liver transplant recipients.
Trasplantation, 75 (2003), pp. 229-233
[9.]
M. Montejo, E. Montejo, M. Gastaca, A. Valdivieso, J.R. Fernández, M. Testillano, et al.
Prophylactic therapy with valgancyclovir in high-risk (cytomegalovirus D+/R–) liver transplant recipients: a single-center experience.
Transplant Proc, 41 (2009), pp. 2189-2191
[10.]
C. Paya, A. Humar, E. Domínguez, K. Washburn, E. Blumberg, B. Alexander, et al.
Efficacy and safety of valganciclovir vs. oral ganciclovir for prevention of cytomegalovirus disease in solid organ transplant recipients.
Am J Transplant, 4 (2004), pp. 611-620
[11.]
K.T. Shiley, L.B. Gasink, T.D. Barton, P. Pfeiffenberger, K.M. Olthoff, E.A. Blumberg.
Increased incidence of cytomegalovirus infection in high-risk liver transplant recipients receiving valganciclovir prophylaxis versus ganciclovir prophylaxis.
Liver Transpl, 15 (2009), pp. 963-967
[12.]
A.C. Kalil, A.G. Freifeld, E.R. Lyden, J.A. Stoner.
Valganciclovir for cytomegalovirus prevention in solid organ transplant patients: an evidence-based reassessment of safety and efficacy.
[14.]
R.R. Razonable, A. Rivero, A. Rodríguez, J. Wilson, J. Daniels, G. Jenkins, et al.
Allograft rejection predicts the occurrence of late-onset cytomegalovirus (CMV) disease among CMV-mismatched solid organ transplant patients receiving prophylaxis with oral ganciclovir.
J Infect Dis, 184 (2001), pp. 1461-1464
[15.]
A.P. Limaye, R. Bakthavatsalam, H.W. Kim, S.E. Randolph, J.B. Halldorson, P.J. Healey, et al.
Impact of cytomegalovirus in organ transplant recipients in the era of antiviral prophylaxis.
Transplantation, 81 (2006), pp. 1645-1652
[16.]
S.M. Palmer, A.P. Limaye, M. Banks, D. Gallup, J. Chapman, E.C. Lawrence, et al.
Extended valganciclovir prophylaxis to prevent cytomegalovirus after lung transplantation: a randomized, controlled trial.
[17.]
A. Humar, Y. Lebranchu, F. Vincenti, E.A. Blumberg, J.D. Punch, A.P. Limaye, et al.
The efficacy and safety of 200 days valganciclovir cytomegalovirus prophylaxis in high-risk kidney transplant recipients.
Am J Transplant, 10 (2010), pp. 1228-1237
[18.]
A. Humar, A.P. Limaye, E.A. Blumberg, I.A. Hauser, F. Vincenti, A.G. Jardine, et al.
Extended valganciclovir prophylaxis in D+/R- kidney transplant recipients is associated with long-term reduction in cytomegalovirus disease: two-year results of the IMPACT study.
Transplantation, 90 (2010), pp. 1427-1431
[19.]
G. Gerna, D. Lilleri, A. Callegaro, A. Goglio, S. Cortese, P. Stroppa, et al.
Prophylaxis followed by preemptive therapy versus preemptive therapy for prevention of human cytomegalovirus disease in pediatric patients undergoing liver transplantation.
Transplantation, 86 (2008), pp. 163-166
[20.]
A.C. Kalil, C. Mindru, D.F. Florescu.
Effectiveness of valganciclovir 900 mg versus 450 mg for cytomegalovirus prophylaxis in transplantation: direct and indirect treatment comparison meta-analysis.
Clin Infect Dis, 52 (2011), pp. 313-321
[21.]
G.F. Strippoli, E.M. Hodson, C. Jones, J.C. Craig.
Preemptive treatment for cytomegalovirus viremia to prevent cytomegalovirus disease in solid organ transplant recipients.
Transplantation, 81 (2006), pp. 139-145
[22.]
C.V. Paya, J.A. Wilson, M.J. Espy, I.G. Sia, M.J. DeBernardi, T.F. Smith, et al.
Preemptive use of oral ganciclovir to prevent cytomegalovirus infection in liver transplant patients: a randomized, placebo-controlled trial.
J Infect Dis, 185 (2002), pp. 854-860
[23.]
N. Singh, D.L. Paterson, T. Gayowski, M.M. Wagener, I.R. Marino.
Cytomegalovirus antigenemia directed pre-emptive prophylaxis with oral versus I.V. ganciclovir for the prevention of cytomegalovirus disease in liver transplant recipients: a randomized, controlled trial.
Transplantation, 70 (2000), pp. 717-722
[24.]
N. Singh, C. Wannstedt, L. Keyes, D. Mayher, L. Tickerhoof, M. Akoad, et al.
Valganciclovir as preemptive therapy for cytomegalovirus in cytomegalovirus-seronegative liver transplant recipients of cytomegalovirus-seropositive donor allografts.
Liver Transpl, 14 (2008), pp. 240-244
[25.]
N. Singh, C. Wannstedt, L. Keyes, M.M. Wagener, T. Gayowski, T.V. Cacciarelli.
Indirect outcomes associated with cytomegalovirus (opportunistic infections, hepatitis C virus sequelae, and mortality) in liver-transplant recipients with the use of preemptive therapy for 13 years.
Transplantation, 79 (2005), pp. 1428-1434
[26.]
O.J. Benmarzouk-Hidalgo, J.M. Cisneros, E. Cordero, A. Martín-Peña, B. Sánchez, C. Martín-Gandul, et al.
Therapeutic effect of the acquisition of cytomegalovirusspecific immune response during preemptive treatment.
Transplantation, 91 (2011), pp. 927-933
[27.]
M.T. Van der Beek, S.P. Berger, A.C. Vossen, C.S. Van der Blij-de Brouwer, R.R. Press, J.W. De Fijter, et al.
Preemptive versus sequential prophylactic-preemptive treatment regimens for cytomegalovirus in renal transplantation: comparison of treatment failure and antiviral resistance.
Transplantation, 89 (2010), pp. 320-326
[28.]
C. Díaz-Pedroche, C. Lumbreras, R. San Juan, D. Folgueira, A. Andrés, J. Delgado, et al.
Valganciclovir preemptive therapy for the prevention of cytomegalovirus disease in high-risk seropositive solid-organ transplant recipients.
Transplantation, 82 (2006), pp. 30-35
[29.]
D. Dahiya, C.F. Lee, K.M. Chan, T.J. Wu, H.S. Chou, S.S. Cheng, et al.
A short-term preemptive treatment for cytomegalovirus infection in seropositive patients after liver transplantation.
J Hepatobiliary Pancreat Sci, 18 (2011), pp. 32-38
[30.]
O.J. Benmarzouk-Hidalgo, E. Cordero, A. Martín-Peña, E. García-Prado, M.A. Gentil, M.A. Gómez-Bravo, et al.
Prevention of cytomegalovirus disease using pre-emptive treatment after solid organ transplant in patients at high risk for cytomegalovirus infection.
Antivir Ther, 14 (2009), pp. 641-647
[31.]
J.A. Khoury, G.A. Storch, D.L. Bohl, R.M. Schuessler, S.M. Torrence, M. Lockwood, et al.
Prophylactic versus preemptive oral valganciclovir for the management of cytomegalovirus infection in adult renal transplant recipients.
Am J Transplant, 6 (2006), pp. 2134-2143
Copyright © 2011. Elsevier España S.L.. Todos los derechos reservados
Opciones de artículo
Herramientas
es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos