Human Herpesvirus 6, 7, And 8 In Solid Organ Transplantation

Publication Date: April 1, 2019
Last Updated: March 14, 2022

RECOMMENDATIONS

HHV-6 AND HHV-7

Diagnosis

Serological studies for HHV‐6 and HHV‐7 are not recommended in the evaluation of solid organ transplant (SOT) candidates or recipients. (Low, Strong)
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Culture, while highly specific for active infection, is not widely available and is not routinely recommended. (Low, Strong)
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For suspected HHV‐6 disease, tissue biopsy may be performed where possible to confirm the diagnosis or rule out other etiologies. (Low, Weak)
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Detection of viral nucleic acid by quantitative polymerase chain reaction (PCR) in blood or CSF is the preferred method for diagnosis of HHV‐6 and HHV‐7 infection and is recommended over antigenemia assays. (Moderate, Strong)
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Viral nucleic acid may also be detected from bronchoalveolar lavage fluid and tissue by PCR and may be informative performed in the appropriate clinical context. (Low, Weak)
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Diagnostic testing for HHV‐6 or HHV‐7 should be limited to scenarios where symptomatic infection is plausible, as detection of viral nucleic acid or antigen may be insufficient evidence of disease in the absence of clinically compatible symptoms. (Moderate, Strong)
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CIHHV6 should be a consideration in individuals with persistent, high‐grade DNAemia and may be diagnosed by serial monitoring of viral load by PCR of whole blood or peripheral blood mononuclear cells (PBMC) or by droplet digital PCR. (Low, Strong)
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Treatment

The majority of HHV‐6 and HHV‐7 infections are asymptomatic, transient, and do not require antiviral treatment. (Moderate, Strong)
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Antiviral treatment with foscarnet, ganciclovir, or cidofovir should be initiated in the setting of HHV‐6 encephalitis. (Moderate, Strong)
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Treatment should be considered for other syndromes attributable to HHV‐6 or HHV‐7. (Low, Weak)
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Especially in cases of moderate or severe disease, antiviral treatment may be complemented by reduction of immunosuppression. (Low, Strong)
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Prevention

Antiviral prophylaxis and preemptive antiviral therapy for HHV‐6 or HHV‐7 infections are not recommended after transplant. (Low, Strong)
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Routine monitoring for HHV‐6 and HHV‐7 infections after SOT is not recommended. (Low, Strong)
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HUMAN HERPESVIRUS 8

Diagnosis

Serology is of limited utility in the diagnosis of acute HHV‐8 related disease post‐transplant. (Low, Strong)
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In endemic regions, pretransplant donor and recipient HHV‐8 serologic screening may be helpful to stratify disease risk after transplant. (Low, Weak)
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Targeted pretransplant HHV‐8 serologic screening of at‐risk donors and recipients or those from endemic regions may be considered in low seroprevalence regions. (Very Low, Weak)
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Direct detection of HHV‐8 from involved sites using immunohistochemical testing, in situ hybridization, or viral PCR is useful for diagnosis of HHV‐8‐related disease. (Moderate, Strong)
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Quantitative PCR from clinical samples can detect active HHV‐8 replication and may be useful for the diagnosis of HHV‐8‐related disease. (Low, Strong)
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Quantitative PCR can be used to monitor treatment response in post‐transplant patients with HHV‐8 related diseases (KS, MCD, PEL). (Very Low, Weak)

KS, Kaposi's sarcoma; PEL, primary effusion lymphoma; MCD, multicentric Castleman disease

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Post‐transplant KS disease staging including imaging and invasive investigative procedures (eg, bronchoscopy, esophagogastroduodenoscopy, colonoscopy) should be considered. (Low, Weak)
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Treatment

Judicious reduction or cessation of immunosuppressive therapy should be first‐line therapy for patients with HHV‐8‐related disease. (Low, Strong)
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Calcineurin inhibitor containing immunosuppressive regimens should be converted to mTOR inhibitors (mainly sirolimus). (Low, Strong)
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Antivirals should not be routinely used to treat HHV‐8 related disease. (Low, Weak)
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Post‐transplant KS unresponsive to reduction of immunosuppression or CNI to sirolimus conversion and severe or visceral disease may benefit from chemotherapy. (Low, Strong)
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Prevention

In HHV‐8 seropositive recipients or those who receive an organ from a seropositive donor, viral load monitoring may be useful to predict clinical HHV‐8 disease. (Low, Weak)
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Reduction of immunosuppression in the setting of viral reactivations or primary infection and avoiding over immunosuppression in at‐risk recipients may be beneficial. (Low, Weak)
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Recommendation Grading

Overview

Title

Human Herpesvirus 6, 7, And 8 In Solid Organ Transplantation

Authoring Organization

American Society of Transplantation

Publication Month/Year

April 1, 2019

Last Updated Month/Year

December 2, 2022

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

These updated guidelines from the Infectious Diseases Community of Practice of the American Society of Transplantation review the diagnosis, prevention, and management of HHV‐6A, HHV‐6B, HHV‐7, and HHV‐8 in the pre‐ and post‐transplant period. 

Target Patient Population

Transplant recipients

Inclusion Criteria

Female, Male, Adolescent, Adult, Older adult

Health Care Settings

Ambulatory, Hospital, Operating and recovery room, Outpatient

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Diagnosis, Prevention, Management

Diseases/Conditions (MeSH)

D014180 - Transplantation, D019737 - Transplants, D000998 - Antiviral Agents, D016377 - Organ Transplantation, D015654 - Herpesvirus 6, Human, D016199 - Herpesvirus 7, Human, D019288 - Herpesvirus 8, Human

Keywords

antiviral, antiretroviral therapy (ART), transplant, solid organ transplant

Source Citation

Pellett Madan, R, Hand, J; on behalf of the AST Infectious Diseases Community of Practice. Human herpesvirus 6, 7, and 8 in solid organ transplantation: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant. 2019; 33:e13518