Pharmacokinetics of ganciclovir for prevention of cytomegalovirus infection in a lung transplant recipient on veno-arterial extracorporeal membrane oxygenation: A case report and literature review

Abstract

Ganciclovir (GCV) plays an important role in preventing cytomegalovirus (CMV) infection after lung transplantation. Because of the large inter-individual and intra-individual variabilities in GCV pharmacokinetics, it has been suggested that individualized dosages based on blood levels are required. However, GCV pharmacokinetics during veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is unknown. Here, we describe a case in which blood levels of GCV were measured during ECMO after lung transplantation. Additionally, we compared the blood levels of GCV in this case with those of 11 lung transplant recipients who were not on ECMO. A woman in her 40s who underwent deceased-donor bilateral lung transplantation was treated with prolonged VA-ECMO postoperatively. Prophylactic administration of GCV (2.5 mg/kg/12 h) was initiated on postoperative day (POD) 7. The GCV trough concentration during ECMO (PODs 8–28) was 940 ± 854 ng/mL. Thrombocytopenia and renal dysfunction were observed on POD 23. Conversely, 11 adult patients who underwent lung transplantation in the same year as the present patient, but without ECMO, had a GCV trough concentration of 445 ± 263 ng/mL on PODs 8–28. This is the first report of GCV trough concentrations in a patient receiving VA-ECMO after lung transplantation. Compared with lung transplant patients not receiving ECMO, this patient undergoing ECMO exhibited elevated GCV blood trough concentrations, along with acute kidney injury and thrombocytopenia. When GCV is administered during VA-ECMO, therapeutic drug monitoring may be necessary to prevent adverse reactions and account for intra-individual variability.