ABSTRACT
Treatment of CMV disease is based on intravenous ganciclovir, which has proven to be effective in the vast majority of cases when given for 21 days. Some centers will add hyperimmune CMV globulin, particularly if organ function is badly compromised or if the disease has relapsed after initial therapy. For severe disease, consideration should be given to reducing maintenance immunosuppression, but this may increase the likelihood of rejection at a later time. Nonetheless, if the recipient appears near death from CMV disease, a drastic reduction in immunosuppression is justifiable. Relapse of disease after initial therapy is certainly not the rule, but it occurs often enough that it must be watched for carefully. Repeat transbronchial biopsy is indicated 1-2 weeks after completion of therapy. This biopsy will also help to clarify whether rejection is present, since the in
flammatory response to CMV may mask acute and chronic rejection. Persistence of inclu sion bodies in the tissue at this time warrants another course of ganciclovir and testing for ganciclovir resistance in the CMV isolate. If resistance is documented or clinically suspected, foscamet should be given in place of ganciclovir. CMV disease may relapse weeks to months after the first episode, particularly if the recipient has received augmented immunosuppression in the form of antilymphocyte globulin. Relapsing disease is associ ated with loss of memory cells specific for CMV antigens in peripheral blood. When memory cells are present in peripheral blood, the risk of relapse is negligible.
