Are You Ready to Tackle the Troll? New Guidelines for the Management of Post-transplant Cytomegalovirus InfectionPretest Self Assessment Survey

1.A liver transplant recipient being treated for CMV infection asks whether it can affect his transplant beyond making him feel unwell. In addition to tissue-invasive disease, CMV infection after transplant is associated with which of the following?(Required.)

A. Chronic allograft injury and increased risk of other opportunistic infections

B. Graft injury driven by sustained CMV DNAemia above the treatment threshold

C. Faster tacrolimus metabolism that leads to subtherapeutic immunosuppressant levels

D. Cross-reactive T-cell immunity that lowers the risk of Epstein-Barr virus–associated posttransplant lymphoproliferative disorder

2.Which of the following scenarios should raise the greatest concern for progression toward refractory/resistant CMV?(Required.)

A. A CMV D+/R− lung transplant recipient who recently received augmented immunosuppression for rejection and now has high-level CMV DNAemia at first presentation

B. A CMV-seropositive allogeneic HCT recipient after haploidentical transplant with GVHD requiring corticosteroids, whose CMV DNAemia remains persistently elevated after 4 weeks of appropriately dosed antiviral therapy

C. A CMV D+/R− kidney transplant recipient 3 weeks after completing prophylaxis who has new low-level CMV DNAemia and mild fatigue, with no prior treatment for CMV infection

D. A CMV-seropositive allogeneic HCT recipient after umbilical cord blood transplant who remains on extended prophylaxis after day 100 and has an isolated low-level CMV DNAemia result that clears on repeat testing

3.A clinician is reviewing treatment options for refractory/resistant CMV after renal transplant. Which statement best reflects current evidence and practical treatment differentiation?(Required.)

A. High-dose ganciclovir is preferred for refractory/resistant CMV with UL54 mutations because the higher dose overcomes polymerase-mediated resistance.

B. Ganciclovir and maribavir are commonly combined for refractory/resistant CMV because dual targeting of UL54 and UL97 improves viral clearance.

C. Letermovir is generally preferred as definitive treatment for established refractory/resistant CMV disease because of its favorable tolerability profile.

D. Maribavir offers effective oral therapy with less nephrotoxicity than foscarnet and less neutropenia than valganciclovir.

4.A heart transplant recipient with CMV DNAemia has completed 5 weeks of appropriately dosed IV ganciclovir. Her viral load initially declined, then plateaued, and this week has risen by 0.7 log10 IU/mL. She remains on full-dose therapy with adequate drug exposure. According to current consensus guidelines, what is the best next step?(Required.)

A. Add maribavir to the current ganciclovir regimen

B. Continue the current regimen and repeat CMV-QNAT in 4 weeks

C. Send genotypic resistance testing

D. Switch to letermovir monotherapy

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