Dear Editor,
I am grateful to Dr. Hong and Dr. Chen for their correspondence regarding my editorial titled “Call for preemptive treatment of cytomegalovirus in patients with cirrhosis and acute decompensation” [
1] and for further elaborating on their important findings [
2,
3]. Their study provides valuable insights into the clinical impact of human cytomegalovirus (HCMV) reactivation in acutely decompensated cirrhosis and highlights the potential role of preemptive therapy in improving patient outcomes.
I fully agree with the authors on the importance of defining an optimal viral load threshold for initiating treatment. The data they present suggest that 1,000 copies/mL may represent an actionable threshold, illustrating how careful stratification may help identify those most likely to benefit from antiviral therapy while at the same time reducing the risk of overtreatment in patients with low viral loads and limited risk of progression. Establishing such thresholds is crucial not only for minimizing unnecessary drug exposure and its potential adverse effects but also for optimizing the timing of intervention in those who truly need it.
I also share the authors’ view that treatment optimization must go beyond a single threshold and should consider dynamic viral kinetics, host immune status, and organ-specific vulnerability. The open question of when to safely discontinue antiviral therapy remains particularly challenging, given the risks of both relapse and toxicity. Another important unresolved issue is whether organ-specific biomarkers, such as those reflecting pulmonary involvement, could refine our ability to personalize therapy.
Looking ahead, randomized controlled trials with dynamic viral load surveillance and predefined stopping rules will be essential to confirm the benefits of preemptive treatment, establish optimal cut-off values, and provide evidence-based strategies for treatment duration. Only through such studies can we balance the dual priorities of avoiding unnecessary interventions and ensuring timely and effective therapy for those at greatest risk.
I thank Dr. Hong and Dr. Chen once again for their thoughtful response, which I believe contributes to advancing the discussion on how best to manage HCMV reactivation in decompensated cirrhosis.
FOOTNOTES
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Conflicts of Interest
The author has no conflicts to disclose.
Abbreviations
REFERENCES
- 1. Imai N. Call for preemptive treatment of cytomegalovirus in patients with cirrhosis and acute decompensation: Editorial on “Human cytomegalovirus reactivation in cirrhosis patients with acute decompensation”. Clin Mol Hepatol 2026;32:949-952.
- 2. Hong C, Huang Z, He Y, Wang R, Lin J, Liu Y, et al. Human cytomegalovirus reactivation in cirrhosis patients with acute decompensation. Clin Mol Hepatol 2025;31:1316-1332.
- 3. Hong C, Chen J. Correspondence to editorial on “Human cytomegalovirus reactivation in cirrhosis patients with acute decompensation”. Clin Mol Hepatol 2026;32:e227-e230.
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