(Val)Ganciclovir TDM in Transplant Recipients

Study Overview
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Brief Summary
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The aim of this study is to gain more insight into therapeutic drug monitoring and thus the pharmacodynamics and pharmacokinetics of ganciclovir, in the context of prophylaxis and treatment of CMV infections, in order to provide the patient with an adequate dose.

Detailed Description
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Patients undergoing solid organ or stem cell transplantation are at risk of developing cytomegalovirus (CMV) infection or reactivation. The risk of CMV infection / reactivation and its severity depends on the CMV serostatus of donor and recipient. Valganciclovir (oral pro-drug of ganciclovir) prophylaxis is used to postpone CMV infection or reactivation to a later point in the post-transplantation. CMV infection/reactivation does not always lead to clinical disease. Valganciclovir (oral) can be used when CMV DNA is detected in the blood, but patient has no or few complaints. However, in case of severe symptoms such as colitis, nephritis, hepatitis, pneumonitis, uveitis or encephalitis (active CMV disease) then ganciclovir is indicated intravenously. In clinical recovery treatment is often completed with valganciclovir. It is important that the ganciclovir level is adequate, because too high level can lead to side effects such as cytopenia and a too low level can lead to treatment failure and resistance development. There are different dosing schedules mentioned in different sources. These schemes are based on dated literature. The aim of (val)ganciclovir therapeutic drug monitoring (TDM) is to gain more insight into the pharmacodynamics and pharmacokinetics of ganciclovir, in the context of prophylaxis and treatment of CMV infections, in order to provide the patient with an adequate dose.

Official Title
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(Val)Ganciclovir Therapeutic Drug Monitoring in Transplant Recipients

Conditions
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Cytomegalovirus Infections

Intervention / Treatment
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* Drug: Ganciclovir
* Drug: Valganciclovir


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Must receive ganciclovir intravenously or valganciclovir orally as routine care Must have received a solid organ or stem cell transplant Must be be 18 years or older Exclusion Criteria: There are no exclusion criteria.

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Prophylaxis<br>Patients who receive (val)ganciclovir for prophylaxis of cytomegalovirus | Drug: Ganciclovir<br>* Intravenous ganciclovir + TDM<br>* Other names: Cymevene;Drug: Valganciclovir<br>* Oral valganciclovir + TDM<br>* Other names: Valcyte;|
| Treatment<br>Patients who receive (val)ganciclovir for treatment of cytomegalovirus | Drug: Ganciclovir<br>* Intravenous ganciclovir + TDM<br>* Other names: Cymevene;Drug: Valganciclovir<br>* Oral valganciclovir + TDM<br>* Other names: Valcyte;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Failure of CMV treatment (with valganciclovir and ganciclovir) using viral load measurements and determining mutations in CMV kinase gene UL97 and DNA polymerase gene UL54 | How many days to the development of failure of treatment? Failure of treatment is defined by increased viral load (measured in serum, whole blood, plasma in copies per mL and/or viral resistance (change of ganciclovir treatment to foscarnet treatment as a consequence, resistance is determined by resistance testing determining CMV kinase gene UL97 and DNA polymerase gene UL54 for mutations) or death due to CMV. | 12 months after transplantation | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Breakthrough CMV infection during CMV prophylaxis with valganciclovir | Breakthrough CMV infection during prophylaxis with valganciclovir, time (days) to development of breakthrough CMV infection during prophylaxis | 12 months after transplantation | 
| Therapeutic window | How many levels are in and out of the therapeutic window (how many low and high levels)? | 12 months after transplantation | 
| Successful treatment while receiving (val)ganciclovir determined by two consequtive negative viral loads | The proportion of patients from CMV treatment group who have a successful CMV treatment, successful CMV treatment is defined by viral load <100 copies/mL (measured twice in a row). | 12 months after transplantation | 
| (Val)ganciclovir for treatment outcomes (1) | The proportion of patients from CMV treatment group who are under-dosed | 12 months after transplantation | 
| (Val)ganciclovir for treatment outcomes (2) | The proportion of patients from CMV treatment group who develop resistance to ganciclovir | 12 months after transplantation | 
| Factors that can influence trough concentrations of (val)ganciclovir (1) | Does the type of transplanted organ (liver, lungs, kidney, heart, stem cell transplant) cause high or low (val)ganciclovir trough concentrations (mg/L)? Defined therapeutic window for prophylaxis is 1-2 mg/L and for therapy is 2-4 mg/L. Number of levels which are out of the therapeutic window for different transplants. | 12 months after transplantation | 
| Factors that can influence trough concentrations of (val)ganciclovir (2) | Does the underlying disease for transplantation cause high or low (val)ganciclovir trough concentrations (mg/L)? Defined therapeutic window for prophylaxis is 1-2 mg/L and for therapy is 2-4 mg/L. Number of levels which are out of the therapeutic window for different underlying diseases. | 12 months after transplantation | 
| Factors that can influence trough concentrations of (val)ganciclovir (3) | Does dose reduction for renal failure cause increase or decrease in (val)ganciclovir trough concentrations (mg/L)? Number of levels which are out of the therapeutic window after dose reduction. | 12 months after transplantation | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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ganciclovir, valganciclovir, therapeutic drug monitoring, pharmacokinetics