Cytomegalovirus (CMV) infection may be more common than initially thought in pediatric patients who underwent liver transplants due to Alagille syndrome (ALGS) or other diseases, suggesting the need for different management of these patients, according to a study recently published in Pediatric Transplantation.

“Preemptive therapy for CMV in pediatric [liver transplant] is safe and effective, yields low CMV infection rates that require treatment, and minimal rates of CMV disease, without increasing CMV-related complications,” the authors wrote.

This retrospective study included 118 patients aged 1 to 17.9 years, with a mean of 6.7 years, who had undergone a liver transplant. ALGS was the third most common diagnosis that motivated a liver transplant, present in 11.8% of the participants.

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The most common diagnosis was biliary atresia, followed by metabolic conditions and fulminant hepatitis. The remaining patients had other miscellaneous diagnoses.

Of all individuals, 67% had an infection with CMV, including the majority (64.28%) of the patients with ALGS. Regardless, of all participants, only 37% required targeted treatment, and 4% developed a symptomatic CMV disease, including 3 viral syndromes and 2 hepatitis cases. Among those with ALGS, 50% received treatment.

Of the children who received antivirals, valganciclovir was the most commonly used, either alone (34%) or in combination with ganciclovir (40.9%), followed by ganciclovir used alone in 22.7% of the cases. Only 1 patient (2.2%) received ganciclovir and CMV-IgG. The most common adverse reactions were thrombocytopenia, anemia, leukopenia, and neutropenia, exhibited in 25%, 13.6%, 11.4%, and 2.2% of the cases, respectively.

“This high incidence of drug-related hematological side effects in the pediatric population supports the idea of a preventive approach that avoids exposing a higher number of children to antivirals, such as preemptive therapy,” the authors explained.

Interestingly, although ALGS was not a risk factor associated with presenting CMV disease, a diagnosis of fulminant hepatitis and high-risk groups (D+/R-) did correlate with this infectious entity.


Arroyo‐Orvañanos J, Hernández‐Plata J, Erro‐Aboytia R, Nieto‐Zermeño J, Reyes‐López A, Varela‐Fascinetto G. Cytomegalovirus infection and disease in pediatric liver transplantation: Burden of disease under a preemptive therapy approach. Pediatr Transplant. Published online July 17, 2022. doi:10.1111/petr.14356