The Troll Is Weakened but Not yet Defeated: An Update on Cytomegalovirus Management in Transplantation From the International CMV Symposium 2025.

The 2025 International CMV Symposium convened in Königstein, Germany, bringing together transplant clinicians and researchers to address cytomegalovirus management following the publication of three major guidelines in 2025. The Transplantation Society, European Conference on Infections in Leukaemia, and American Society for Transplantation and Cellular Therapy each released updated recommendations reflecting significant advances, including letermovir prophylaxis for hematopoietic stem cell and high-risk renal transplantation, maribavir for resistant or refractory disease, and cell-mediated immunity testing to guide personalized prevention strategies. This review synthesizes symposium discussions, emphasizing translation of evidence-based recommendations into clinical practice across diverse healthcare settings. Key topics included risk-stratified prevention approaches balancing efficacy with practical implementation, precision medicine through immune biomarkers, adoptive cellular therapies advancing from experimental to clinical platforms, and vaccine development showing renewed promise after decades of setbacks. Symposium faculty highlighted persistent challenges despite recent progress, such as late-onset disease after extended prophylaxis, economic barriers limiting access to novel therapies and diagnostics, resistance patterns evolving with increasing antiviral use, and infrastructure requirements for preemptive strategies that may be prohibitive in many settings. Case presentations illustrated real-world practical challenges to effective guideline implementation. The integration of solid organ and hematopoietic stem cell transplant expertise enabled cross-disciplinary learning while respecting population-specific differences. As the transplant community advances toward defeating the "troll of transplantation," continued therapeutic innovation must be coupled with implementation science, economic analyses, and global cooperation to ensure all transplant recipients benefit from these advances.