Wadhawan et al.1 advocate a wait-and-watch strategy for the management of cytomegalovirus (CMV) infections in liver transplant recipients. Before the proposed strategy can be widely accepted as a new standard for CMV-seropositive recipients, its efficacy with respect to more established prevention strategies needs to be proven. Their data indicate that CMV disease developed in the majority of their patients (6/10) who had asymptomatic CMV viremia with >500 copies/mL. It is likely that the CMV disease in these patients would have been prevented with a prophylaxis or preemptive strategy. Given the substantial morbidities, including prolonged hospitalization and even irreversible organ damage, that can occur with symptomatic CMV disease, we have an obligation to do our utmost to prevent this from happening. Neither prophylaxis nor preemptive therapies for CMV are completely satisfactory, but both strategies are clearly advantageous in comparison with doing nothing.2 More insidious are the indirect effects induced by CMV, which include allograft injury, vascular thrombosis, accelerated hepatitis C virus infection, opportunistic infections, and Epstein-Barr virus–associated posttransplant lymphoproliferative disorder.3, 4 Unfortunately, adequate data regarding rates of such nonlethal complications are not reported in this article.

Until it is proven otherwise, the standard for CMV disease prevention in seropositive recipients should continue to be either prophylaxis or preemptive therapy rather than a wait-and-watch strategy. This may be especially true for patients with CMV viremia that exceeds 500 copies/mL.


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  • 1
    Wadhawan M, Gupta S, Goyal N, Vasudevan KR, Makki K, Dawar R, et al. Cytomegalovirus infection: its incidence and management in cytomegalovirus-seropositive living related liver transplant recipients: a single-center experience. Liver Transpl 2012; 18.
  • 2
    Kalil AC, Levitsky J, Lyden E, Stoner J, Freifeld AG. Meta-analysis: the efficacy of strategies to prevent organ disease by cytomegalovirus in solid organ transplant recipients. Ann Intern Med 2005; 143: 870-880.
  • 3
    Razonable RR, Burak KW, van Cruijsen H, Brown RA, Charlton MR, Smith TF, et al. The pathogenesis of hepatitis C virus is influenced by cytomegalovirus. Clin Infect Dis 2002; 35: 974-981.
  • 4
    George MJ, Snydman DR, Werner BG, Griffith J, Falagas ME, Dougherty NN, Rubin RH. The independent role of cytomegalovirus as a risk factor for invasive fungal disease in orthotopic liver transplant recipients. Boston Center for Liver Transplantation CMVIG-Study Group. Cytogam, MedImmune, Inc. Gaithersburg, Maryland. Am J Med 1997; 103: 106-113.

Shmuel Shoham M.D.*, * Transplant and Oncology Infectious Diseases Program Johns Hopkins University School of Medicine Baltimore, MD.