Cytomegalovirus (CMV)
- All transplant recipients except CMV IgG negative recipients of CMV IgG negative donors (D-/R-) receive CMV prophylaxis with valganciclovir for 6 months.
- If T-Cell depleting induction [ATG/Alemtuzumab (Campath)] is used, CMV D-/R- cases will also receive 6 months valganciclovir.
The initial valganciclovir dose is dependent on renal function as shown in the table below:
Creatinine clearance (ml/min) |
Prophylactic dose of valganciclovir |
>40 |
450mg od |
25 to 39 |
450mg every 2 days |
10 to 24 |
450mg twice weekly |
- Note that our maximum dose of valganciclovir is 450mg od (even if creatinine clearance >60 ml/min).
- Valganciclovir is available as 450mg tablets. The tablets should be taken with food and not broken or crushed.
- FBC and LFTs must be monitored during therapy.
Investigation of any episode of illness that might be CMV related, at any stage following a transplant operation.
- An EDTA (4.5ml) sample for CMV should be sent to Virology whenever is clinically relevant; on request form, include details of illness (e.g. pyrexia or hepatitis etc.).
- Request CMV PCR.
- Please try to ensure samples reach General Laboratory Reception (FAO Virology), Level 2, RIE, by 9am weekdays; the assay is carried out at least twice weekly (Tuesdays, Fridays).
- It will often be appropriate to send respiratory and/or other samples (e.g. broncho-alveolar lavage, induced sputum or fresh colon biopsies) for CMV PCR testing.
Treatment of CMV disease
- Patients in whom the diagnosis of CMV disease has been made with positive CMV PCR should be treated with IV ganciclovir followed by oral valganciclovir; whilst the approach should be decided on a case-by-case basis as per severity of disease and/or viral load, a general initial approach should aim for 2 weeks IV ganciclovir followed by oral valganciclovir.
- Ideally, this should be continued until two consecutive (within the same week) negative CMV PCR results have been obtained.
- Dose of IV gancyclovir will depend on creatinine clearance:
Creatinine clearance (ml/min) |
Treatment dose of ganciclovir IV |
>70 |
5mg/kg every 12 hours |
50 to 69 |
2.5mg/kg every 12 hours |
25 to 49 |
2.5mg/kg/day |
10 to 24 |
1.25mg/kg/day |
<10 |
1.25mg/kg/day after haemodialysis |
- Ganciclovir is made in the aseptic department in pharmacy, contact the renal transplant pharmacist to organize a supply.
In some cases (asymptomatic or mild disease, low viral loads) treatment with oral valganciclovir can be used instead of IV ganciclovir. The doses are:
Creatinine clearance (ml/min) |
Treatment dose of Valganciclovir tablets |
>60 |
900mg (2 tablets) twice daily |
40 to 59 |
450mg (1 tablet) twice daily |
25 to 39 |
450mg daily |
10 to 24 |
450mg every 2 days |
<10 |
Not recommended |