Pre-emptive therapy against cytomegalovirus (CMV) disease guided by CMV antigenemia assay after allogeneic hematopoietic stem cell transplantation: asingle-center experience in Japan

From April 1998 to March 2000, a cytomegalovirus (CMV) antigenemia-guided p re-emptive approach for CMV disease was evaluated in 77 adult patients who received allogeneic hematopoietic stem cell transplantation at the National Cancer Center Hospital. A CMV antigenemia assay was performed at least onc e a week after engraftment. High-level antigenemia was defined as a positiv e result with 10 or more positive cells per 50 000 cells and low-level anti genemia was defined as less than 10 positive cells. Among the 74 patients w ith initial engraftment, 51 developed positive antigenemia, Transplantation from alternative donors and the development of grade II-IV GVHD were indep endent risk factors for positive antigenemia, Ganciclovir was administered as pre-emptive therapy in 39 patients in a risk-adapted manner. None of the nine low-risk patients with few-level antigenemia as their initial positiv e result developed high-level antigenemia even though ganciclovir was withh eld. Only one patient developed early CMV disease (hepatitis) during the st udy period, CMV antigenemia resolved in all but two cases, in whom ganciclo vir was replaced with foscarnet, In eight patients, however, the neutrophil count decreased to 0.5 x 10(9)/l or less after starting ganciclovir, inclu ding three with documented infections and two with subsequent secondary gra ft failure. The total amount of ganciclovir and possibly the duration of hi gh-dose ganciclovir might affect the incidence of neutropenia. We concluded that antigenemia-guided pre-emptive therapy with a decreased dose of ganci clovir and response-oriented dose adjustment might be appropriate to decrea se the toxicity of ganciclovir without increasing the risk of CMV disease.