CMV infection in solid organ transplant recipients: the future of prevention and treatment

Cytomegalovirus (CMV) remains one of the most common infectious complications after solid organ transplantation. The International Consensus Guidelines on CMV Management have updated recommendations for clinical practice. This review summarizes current evidence and guideline-based approaches to CMV prevention and treatment in transplant recipients. The literature search was conducted using Pubmed using the terms “cytomegalovirus,” “organ transplantation,” “prevention,” “refractory/resistant,” “ganciclovir,” “maribavir,” and “letermovir.” CMV prevention relies on either universal prophylaxis or preemptive therapy. Valganciclovir remains the cornerstone of prevention and treatment. In high-risk kidney transplant recipients, letermovir has demonstrated efficacy comparable to valganciclovir for CMV prevention, with fewer adverse hematologic effects. For refractory or resistant CMV infection, maribavir has shown superior efficacy compared with high-dose ganciclovir, foscarnet, or cidofovir. However, relapse after treatment discontinuation remains common. CMV management has improved substantially in recent years, yet important unmet needs remain. Although letermovir is approved for CMV prophylaxis in high-risk kidney transplant recipients, its use is limited, likely due to cost. Broader access could benefit other solid organ transplant populations. Despite advances with maribavir, a significant proportion of patients continue to experience uncontrolled CMV infection. Further studies evaluating antiviral combination therapies, immune-based approaches, and optimized immunosuppressive regimens are needed to improve long-term outcomes.