51
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Raupp FVV, Meinerz G, da Silva CK, Bianco PCD, Goldani JC, Pegas KL, Stolfo JB, Garcia VD, Keitel E. BK Polyomavirus-associated nephropathy managed by screening policy in a real-life setting. Transpl Infect Dis 2019; 22:e13213. [PMID: 31724282 DOI: 10.1111/tid.13213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 10/13/2019] [Accepted: 11/04/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND BK polyomavirus-associated nephropathy (PyVAN) is an important complication after kidney transplantation. Prevalence ranges from 1% to 10%, and graft loss occurs in approximately 50% of the cases. There is no effective treatment, so early viral detection with immunosuppression tapering is the current strategy to prevent PyVAN. AIMS To verify the frequency of PyVAN in a single center and evaluate the response to immunosuppressive adjustments through graft survival analysis. METHODS Retrospective evaluation of a cohort of kidney transplant recipients with biopsy-proven PyVAN, compared with no-PyVAN patients regarding clinical aspects, immunosuppression, and graft survival over at least 2 years. RESULTS There were 1404 kidney transplants analyzed in the study period, 58 with biopsy-proven PyVAN. Cumulative incidence was 4.1%. Median time from transplantation to PyVAN diagnosis was 6 (1-41) months. PyVAN was associated with recipient male gender (P = .041) and deceased donation (P = .005). Graft survival was inferior for PyVAN compared to no-PyVAN patients, 81.8% vs 75.2%, P = .019. Thirteen (22.4%) PyVAN patients lost their grafts, nine (15.5%) losses attributed to BKPyV infection. Three patients with BKPyV-associated graft losses were submitted to a successful second kidney transplant, with no evidence of viral replication during follow-up. CONCLUSION PyVAN still is an important cause of kidney graft failure. Even though implementing active vigilance and immunosuppressive adjustment, this real-life single-center study demonstrated inferior graft survival in PyVAN patients compared to non-PyVAN.
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Affiliation(s)
| | - Gisele Meinerz
- Post Graduation Program in Pathology, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Brazil.,Department of Nephrology and Kidney Transplantation, Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, Brazil
| | - Cynthia Keitel da Silva
- Post Graduation Program in Pathology, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Brazil.,Department of Nephrology and Kidney Transplantation, Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, Brazil
| | | | - João Carlos Goldani
- Department of Nephrology and Kidney Transplantation, Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, Brazil
| | - Karla Lais Pegas
- Post Graduation Program in Pathology, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Brazil.,Department of Pathology, Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, Brazil
| | - Josiane Borges Stolfo
- Department of Pathology, Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, Brazil
| | - Valter Duro Garcia
- Department of Nephrology and Kidney Transplantation, Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, Brazil
| | - Elizete Keitel
- Post Graduation Program in Pathology, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Brazil.,Department of Nephrology and Kidney Transplantation, Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, Brazil
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52
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Thongprayoon C, Khoury NJ, Bathini T, Aeddula NR, Boonpheng B, Leeaphorn N, Ungprasert P, Bruminhent J, Lertjitbanjong P, Watthanasuntorn K, Chesdachai S, Mao MA, Cheungpasitporn W. BK polyomavirus genotypes in renal transplant recipients in the United States: A meta-analysis. J Evid Based Med 2019; 12:291-299. [PMID: 31769221 DOI: 10.1111/jebm.12366] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 09/13/2019] [Accepted: 11/03/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND In the United States, increasing ethnic diversity has been apparent. However, the epidemiology and trends of BKV genotypes remain unclear. This meta-analysis was conducted with the aim to assess the prevalence of BKV genotypes among kidney transplant (KTx) recipients in the United States. METHODS A comprehensive literature review was conducted through October 2018 utilizing MEDLINE, Embase, and Cochrane Database to identify studies that reported the prevalence of BKV subtypes and/or subgroups in KTx recipients in the United States. Pooled prevalence rates were combined using random effects, generic inverse variance method. The protocol for this study is registered with PROSPERO (no. CRD42019134582). RESULTS A total of eight observational studies with a total of 193 samples (urine, blood, and kidney tissues) from 188 BKV-infected KTX recipients were enrolled. Overall, the pooled estimated prevalence rates of BKV subtypes were 72.2% (95% confidence of interval [CI]: 62.7-80.0%) for subtype I, 6.8% (95% CI: 2.5-16.9%) for subtype II, 8.3% (95% CI: 4.4-15.1%) for subtype III, and 16.1% (95% CI: 10.4-24.2%) for subtype IV, respectively. While metaregression analysis demonstrated a significant positive correlation between year of study and the prevalence of BKV subtype I (slopes = +0.1023, P = .01), there were no significant correlations between year of study and percentages of BKV subtype II-IV (P > .05). Among KTx recipients with BKV subtype I, the pooled estimated percentages of BKV subgroups were 22.4% (95% CI: 13.7-34.5%) for subgroup Ia, 30.6% (95% CI: 17.7-47.5%) for subgroup Ib1, 47.7% (95% CI: 35.8-59.9%) for subgroup Ib2, and 4.1% (95% CI:1.2-13.3%) for subgroup Ic, respectively. CONCLUSION BKV subtype I is the most prevalent subtype among KTx recipients in the United States and its prevalence seems to increasing overtime. Subgroup Ib2 is the most common subgroup among BKV subtype I.
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Affiliation(s)
| | - Nadeen J Khoury
- Division of Nephrology and Hypertension, Henry Ford Health System, Detroit, Michigan
| | - Tarun Bathini
- Department of Internal Medicine, University of Arizona, Tucson, Arizona
| | - Narothama Reddy Aeddula
- Department of Medicine, Indiana University School of Medicine and, Deaconess Health System, Evansville, Indiana
| | - Boonphiphop Boonpheng
- Department of Internal Medicine, East Tennessee State University, Johnson City, Tennessee
| | - Napat Leeaphorn
- Renal Transplant Program, University of Missouri-Kansas City School of Medicine/Saint Luke's Health System, Kansas City, Missouri
| | - Patompong Ungprasert
- Clinical Epidemiology Unit, Department of Research and Development, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Jackrapong Bruminhent
- Division of Infectious Diseases, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | | | | | | | - Michael A Mao
- Division of Nephrology and Hypertension, Mayo Clinic, Jacksonville, Florida
| | - Wisit Cheungpasitporn
- Division of Nephrology, Department of Medicine, University of Mississippi Medical Center, Mississippi
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53
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Reischig T, Kacer M, Hes O, Machova J, Nemcova J, Lysak D, Jindra P, Pivovarcikova K, Kormunda S, Bouda M. Cytomegalovirus prevention strategies and the risk of BK polyomavirus viremia and nephropathy. Am J Transplant 2019; 19:2457-2467. [PMID: 31220412 DOI: 10.1111/ajt.15507] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Revised: 06/11/2019] [Accepted: 06/13/2019] [Indexed: 01/25/2023]
Abstract
Polyomavirus BK (BKV) is the cause of polyomavirus-associated nephropathy resulting in premature graft loss. There are limited data regarding the role of cytomegalovirus (CMV) infection and its prevention in developing BKV viremia and PVAN. In a prospective study, we analyzed 207 consecutive renal transplant recipients previously enrolled in 2 randomized trials evaluating different CMV prevention regimens with routine screening for BKV and CMV. Of these, 59 received valganciclovir and 100 valacyclovir prophylaxis; 48 patients were managed by preemptive therapy. At 3 years, the incidence of BKV viremia and PVAN was 28% and 5%, respectively. CMV DNAemia developed in 55% and CMV disease in 6%. Both BKV viremia (42% vs 23% vs 21%, P = .006) and PVAN (12% vs 2% vs 2%, P = .011) were increased in patients treated with valganciclovir prophylaxis compared to valacyclovir and preemptive therapy. Using multivariate Cox proportional hazard regression, valganciclovir prophylaxis was independent predictor of BKV viremia (hazard ratio [HR] = 2.38, P = .002) and PVAN (HR = 4.73, P = .026). In contrast, the risk of subsequent BKV viremia was lower in patients with antecedent CMV DNAemia (HR = 0.50, P = .018). These data suggest valganciclovir prophylaxis may be associated with increased risk of BKV viremia and PVAN. CMV DNAemia did not represent a risk for BKV.
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Affiliation(s)
- Tomas Reischig
- Department of Internal Medicine I, Faculty of Medicine in Pilsen, Charles University, and Teaching Hospital, Pilsen, Czech Republic.,Biomedical Centre, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
| | - Martin Kacer
- Department of Internal Medicine I, Faculty of Medicine in Pilsen, Charles University, and Teaching Hospital, Pilsen, Czech Republic.,Biomedical Centre, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
| | - Ondrej Hes
- Biomedical Centre, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic.,Department of Pathology, Faculty of Medicine in Pilsen, Charles University, and Teaching Hospital, Pilsen, Czech Republic
| | - Jana Machova
- Department of Internal Medicine I, Faculty of Medicine in Pilsen, Charles University, and Teaching Hospital, Pilsen, Czech Republic.,Biomedical Centre, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
| | - Jana Nemcova
- Biomedical Centre, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
| | - Daniel Lysak
- Biomedical Centre, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic.,Department of Haematology and Oncology, Faculty of Medicine in Pilsen, Charles University, and Teaching Hospital, Pilsen, Czech Republic
| | - Pavel Jindra
- Biomedical Centre, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic.,Department of Haematology and Oncology, Faculty of Medicine in Pilsen, Charles University, and Teaching Hospital, Pilsen, Czech Republic
| | - Kristyna Pivovarcikova
- Department of Pathology, Faculty of Medicine in Pilsen, Charles University, and Teaching Hospital, Pilsen, Czech Republic
| | - Stanislav Kormunda
- Biomedical Centre, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic.,Division of Information Technologies and Statistics, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
| | - Mirko Bouda
- Department of Internal Medicine I, Faculty of Medicine in Pilsen, Charles University, and Teaching Hospital, Pilsen, Czech Republic.,Biomedical Centre, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
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54
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Christiadi D, Karpe KM, Walters GD. Interventions for BK virus infection in kidney transplant recipients. Hippokratia 2019. [DOI: 10.1002/14651858.cd013344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Daniel Christiadi
- The Canberra Hospital; Department of Renal Medicine; Yamba Drive Canberra ACT Australia 2605
| | - Krishna M Karpe
- The Canberra Hospital; Department of Renal Medicine; Yamba Drive Canberra ACT Australia 2605
| | - Giles D Walters
- The Canberra Hospital; Department of Renal Medicine; Yamba Drive Canberra ACT Australia 2605
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55
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Shah A, Kumar V, Palmer MB, Trofe-Clark J, Laskin B, Sawinski D, Hogan JJ. Native kidney BK virus nephropathy, a systematic review. Transpl Infect Dis 2019; 21:e13083. [PMID: 30907978 DOI: 10.1111/tid.13083] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 02/10/2019] [Accepted: 02/15/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND There is a growing base of literature describing BK nephropathy (BKVN) in patients outside of the setting of kidney transplant. Previous systematic reviews of the literature have been limited by methodology or by the scope of patients included. STUDY DESIGN AND METHODS Systematic Review (Prospero # CRD42018088524). SETTING & POPULATION Patients without kidney transplant who had biopsy-proven BKVN. SELECTION CRITERIA FOR STUDIES Full-text articles that describe native BKVN patient cases. ANALYTICAL APPROACH Descriptive synthesis. RESULTS The search identified 630 unique articles of which 51 were included in the final review. Sixty-five cases (including two new cases presented in this review) were identified, all but one occurred in the setting of known immunosuppression. LIMITATIONS The primary limitation was the exclusion of studies that did not fulfill the stringent review criteria. We excluded reports with only a clinical diagnosis of BKVN, such as those with viruria and/or viremia without biopsy. CONCLUSIONS As of May 2018, there are 65 reported cases of BKVN in native kidneys. This represents the most comprehensive description of biopsy-proven BKVN in native kidneys to date. Evaluation for BK nephropathy should be considered in immunocompromised patients who exhibit unexplained renal failure.
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Affiliation(s)
- Ankur Shah
- Division of Nephrology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Vinayak Kumar
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Matthew B Palmer
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Pathology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jennifer Trofe-Clark
- Division of Nephrology, University of Pennsylvania, Philadelphia, Pennsylvania.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Pharmacy Services, Hospital of the University of Pennsylvania, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Benjamin Laskin
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Division of Nephrology, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Deirdre Sawinski
- Division of Nephrology, University of Pennsylvania, Philadelphia, Pennsylvania.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jonathan J Hogan
- Division of Nephrology, University of Pennsylvania, Philadelphia, Pennsylvania.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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56
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Dalianis T, Eriksson BM, Felldin M, Friman V, Hammarin AL, Herthelius M, Ljungman P, Mölne J, Wennberg L, Swartling L. Management of BK-virus infection - Swedish recommendations. Infect Dis (Lond) 2019; 51:479-484. [PMID: 31012777 DOI: 10.1080/23744235.2019.1595130] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
BK-virus (BKV) associated nephropathy (BKVAN) and BKV associated haemorrhagic cystitis (HC) are complications of BKV infection/reactivation in renal and allogeneic haematopoietic stem cell transplantation (HSCT) patients, respectively. The task of how to manage these diseases was given to the chair by the Swedish Reference Group for Antiviral Therapy (RAV). After individual contributions by members of the working group, consensus discussions were held in a meeting on 23 January 2018 arranged by RAV. Thereafter, the recommendations were published in Swedish on November 2018. The current translation to English has been approved by all co-authors. High BKV serum levels suggest an increased risk for BKVAN and potential graft failure. For detection of BKVAN, careful monitoring of BKV DNA levels in serum or plasma is recommended the first year after renal transplantation and when increased creatinine serum levels of unknown cause are observed. Notably, a renal biopsy is mandatory for diagnosis. To reduce the risk for progression of BKVAN, there is no specific treatment, and tailored individual decrease of immunosuppression is recommended. For BKV-HC, BKV monitoring is not recommended, since BK-viruria frequently occurs in HSCT patients and the predictive value of BKV in plasma/serum has not been determined. However, the risk for BKV-HC is higher for patients undergoing myeloablative conditioning, having an unrelated, HLA-mismatched, or a cord blood donor, and awareness of the increased risk and early intervention may benefit the patients. Also for BKV-HC, no specific therapy is available. Symptomatic treatment, e.g. forced diuresis and analgesics could be of use.
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Affiliation(s)
- Tina Dalianis
- a Department of Oncology-Pathology , Karolinska Institutet , Stockholm , Sweden
| | - Britt-Marie Eriksson
- b Department of Medical Science, Section of Infectious Diseases , Uppsala University , Uppsala , Sweden
| | - Marie Felldin
- c Transplant Institute, Sahlgrenska University Hospital , Gothenburg , Sweden
| | - Vanda Friman
- d Department of Infectious Diseases , Sahlgrenska University Hospital , Gothenburg , Sweden
| | - Anna-Lena Hammarin
- e Unit for Laboratory Development and Technology Transfer , The Public Health Agency of Sweden , Stockholm , Sweden
| | - Maria Herthelius
- f Paediatric Nephrology , The Children's and Women's Health Theme, Karolinska University Hospital , Stockholm , Sweden
| | - Per Ljungman
- g Department of Cellular Therapy and Allogeneic Stem Cell Transplantation , Karolinska University Hospital , Stockholm , Sweden
| | - Johan Mölne
- h Department of Pathology and Genetics , Sahlgrenska Academy, University of Gothenburg , Gothenburg , Sweden
| | - Lars Wennberg
- i Department of Clinical Science, Intervention and Technology , Karolinska Institutet , Stockholm , Sweden.,j Department of Transplantation Surgery , Karolinska University Hospital , Stockholm , Sweden
| | - Lisa Swartling
- k Department of Infectious Diseases , Karolinska University Hospital , Stockholm , Sweden
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57
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Hirsch HH, Randhawa PS. BK polyomavirus in solid organ transplantation-Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant 2019; 33:e13528. [PMID: 30859620 DOI: 10.1111/ctr.13528] [Citation(s) in RCA: 222] [Impact Index Per Article: 44.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 02/26/2019] [Indexed: 02/07/2023]
Abstract
The present AST-IDCOP guidelines update information on BK polyomavirus (BKPyV) infection, replication, and disease, which impact kidney transplantation (KT), but rarely non-kidney solid organ transplantation (SOT). As pretransplant risk factors in KT donors and recipients presently do not translate into clinically validated measures regarding organ allocation, antiviral prophylaxis, or screening, all KT recipients should be screened for BKPyV-DNAemia monthly until month 9, and then every 3 months until 2 years posttransplant. Extended screening after 2 years may be considered in pediatric KT. Stepwise immunosuppression reduction is recommended for KT patients with plasma BKPyV-DNAemia of >1000 copies/mL sustained for 3 weeks or increasing to >10 000 copies/mL reflecting probable and presumptive BKPyV-associated nephropathy, respectively. Reducing immunosuppression is also the primary intervention for biopsy-proven BKPyV-associated nephropathy. Hence, allograft biopsy is not required for treating BKPyV-DNAemic patients with baseline renal function. Despite virological rationales, proper randomized clinical trials are lacking to generally recommend treatment by switching from tacrolimus to cyclosporine-A, from mycophenolate to mTOR inhibitors or leflunomide or by the adjunct use of intravenous immunoglobulins, leflunomide, or cidofovir. Fluoroquinolones are not recommended for prophylaxis or therapy. Retransplantation after allograft loss due to BKPyV nephropathy can be successful if BKPyV-DNAemia is definitively cleared, independent of failed allograft nephrectomy.
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Affiliation(s)
- Hans H Hirsch
- Transplantation & Clinical Virology, Department of Biomedicine, University of Basel, Basel, Switzerland.,Infectious Diseases & Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - Parmjeet S Randhawa
- Division of Transplantation Pathology, Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania.,Thomas E Starzl Transplantation Institute, Pittsburgh, Pennsylvania
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58
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Chong S, Antoni M, Macdonald A, Reeves M, Harber M, Magee CN. BK virus: Current understanding of pathogenicity and clinical disease in transplantation. Rev Med Virol 2019; 29:e2044. [PMID: 30958614 DOI: 10.1002/rmv.2044] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 02/28/2019] [Accepted: 03/01/2019] [Indexed: 12/19/2022]
Abstract
BK polyomavirus (BKV) is an important cause of graft loss in renal transplant recipients that continues to pose a significant challenge to clinicians due to its frequently unpredictable onset, persistence, and the lack of effective antiviral agents or prevention strategies. This review covers our current understanding of epidemiology, viral transmission and disease progression, and treatment and prevention strategies that have been used to manage this disease.
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Affiliation(s)
- Stephanie Chong
- Department of Renal Medicine, Royal Free Hospital, University College London, London, UK
| | - Michelle Antoni
- School of Molecular and Cellular Biology, Faculty of Biological Sciences, University of Leeds, London, UK
| | - Andrew Macdonald
- School of Molecular and Cellular Biology, Faculty of Biological Sciences, University of Leeds, London, UK
| | - Matthew Reeves
- Institute of Immunity and Transplantation, Royal Free Hospital, University College London, London, UK
| | - Mark Harber
- Department of Renal Medicine, Royal Free Hospital, University College London, London, UK
| | - Ciara N Magee
- Department of Renal Medicine, Royal Free Hospital, University College London, London, UK
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59
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Keller N, Duquennoy S, Conrad A, Fafi-Kremer S, Morelon E, Bouvier N, Moulin B, Hurault De Ligny B, Caillard S. Clinical utility of leflunomide for BK polyomavirus associated nephropathy in kidney transplant recipients: A multicenter retrospective study. Transpl Infect Dis 2019; 21:e13058. [PMID: 30730102 DOI: 10.1111/tid.13058] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Revised: 01/25/2019] [Accepted: 01/27/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND BK polyomavirus associated nephropathy (BKPyVAN) is a significant clinical issue in kidney transplant (KT) recipients. No specific therapy is currently available, although treatment with leflunomide may be part of the therapeutic strategy. Here, we sought to examine the impact of leflunomide on the evolution of BKPyVAN. METHODS This was an observational retrospective study conducted in 3 French transplant centers. KT recipients who developed BKPyVAN and received leflunomide after failure of other treatment approaches were deemed eligible. Graft function, viral clearance, patient survival, rejection rates, treatment tolerability, and immunosuppression levels served as the main outcome measures. RESULTS A total of 55 patients were included. Treatment with leflunomide was started after a mean of 1.4 ± 4.1months after BKPyVAN diagnosis. Between the introduction of leflunomide and the end of follow-up, creatinine levels increased by 31 ± 118% (P = 0.04), whereas viremia decreased by 79 ± 37% (P < 0.001). Blood viral clearance was observed in 76% of the study patients. Rejection episodes occurred in 33% of the participants. Eleven patients lost their graft (9 of which because of BKPyVAN). Ten patients developed adverse effects and 3 discontinued leflunomide. CONCLUSION We cannot conclude about the exact place of leflunomide in the therapeutic strategy of BKPyVAN. It may be a part of the therapy to promote BK polyomavirus clearance in cases of BKPyVAN who fail to improve after immunosuppression lowering alone. Unfortunately, a significant decline in renal function and high rejection rates remain major clinical challenges.
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Affiliation(s)
- Nicolas Keller
- Nephrology and Transplantation Department, Universitary Hospital, Strasbourg, France
| | - Simon Duquennoy
- Nephrology-Dialysis-Transplantation Department, Universitary Hospital, Caen, France
| | - Anne Conrad
- Nephrology-Transplantation and Immunology Department, Hôpital Edouard-Herriot, Universitary Hospital, Lyon, France
| | - Samira Fafi-Kremer
- Virology Laboratory, Strasbourg University Hospital, Strasbourg, France.,INSERM UMR_S 1109, ImmunoRhumatologie Moléculaire, Fédération Hospitalo-Universitaire OMICARE, Fédération de Médecine Translationnelle de Strasbourg, Institut d'Immunologie et d'Hématologie, Strasbourg Cedex, France
| | - Emmanuel Morelon
- Nephrology-Transplantation and Immunology Department, Hôpital Edouard-Herriot, Universitary Hospital, Lyon, France
| | - Nicolas Bouvier
- Nephrology-Dialysis-Transplantation Department, Universitary Hospital, Caen, France
| | - Bruno Moulin
- Nephrology and Transplantation Department, Universitary Hospital, Strasbourg, France.,INSERM UMR_S 1109, ImmunoRhumatologie Moléculaire, Fédération Hospitalo-Universitaire OMICARE, Fédération de Médecine Translationnelle de Strasbourg, Institut d'Immunologie et d'Hématologie, Strasbourg Cedex, France
| | | | - Sophie Caillard
- Nephrology and Transplantation Department, Universitary Hospital, Strasbourg, France.,INSERM UMR_S 1109, ImmunoRhumatologie Moléculaire, Fédération Hospitalo-Universitaire OMICARE, Fédération de Médecine Translationnelle de Strasbourg, Institut d'Immunologie et d'Hématologie, Strasbourg Cedex, France
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60
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Chen XT, Li J, Deng RH, Yang SC, Chen YY, Chen PS, Wang ZY, Huang Y, Wang CX, Huang G. The therapeutic effect of switching from tacrolimus to low-dose cyclosporine A in renal transplant recipients with BK virus nephropathy. Biosci Rep 2019; 39:BSR20182058. [PMID: 30737303 PMCID: PMC6386765 DOI: 10.1042/bsr20182058] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 01/30/2019] [Accepted: 02/07/2019] [Indexed: 01/08/2023] Open
Abstract
Background: There is no effective therapy for BK virus (BKV) nephropathy (BKVN). Cyclosporine A (CsA) has a lower immunosuppressive effect than tacrolimus. In vitro studies have shown that CsA inhibits BKV replication. The present study aimed to evaluate the effectiveness of switching from tacrolimus to low-dose CsA in renal transplant recipients with BKVN. Methods: Twenty-four patients diagnosed with BKVN between January 2015 and December 2016 were included. Tacrolimus was switched to low-dose CsA, and patients were followed for 24 months. Primary end points were BKV clearance in blood and graft. Secondary end points were urine specific gravity, serum creatinine, and graft loss. Results: The viremia in all patients cleared at a mean of 2.7 ± 2.0 months after switching to CsA. Urine specific gravity at 3 months after switching to CsA increased significantly compared with that at diagnosis (P=0.002). The timing and trend of urine specific gravity increase was consistent with the timing and trend of blood and urine viral load decrease. Repeated biopsies at a median of 11.2 months (range: 9.1-12.5 months) after switching to CsA showed that 8 patients (42.1%) were negative for BKV, and 11 patients (58.9%) had a decrease in BKV load (P<0.001). There was no statistical difference in the serum creatinine level between the time of diagnosis and 24 months of CsA therapy (P=0.963). The graft survival rate was 100%. Only two patients (8.3%) suffered from acute rejection. Conclusion: Switching from tacrolimus to low-dose CsA may be an effective therapy for BKVN.
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Affiliation(s)
- Xu-Tao Chen
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan Road 2, Guangzhou 510080, Guangdong Province, China
| | - Jun Li
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan Road 2, Guangzhou 510080, Guangdong Province, China
| | - Rong-Hai Deng
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan Road 2, Guangzhou 510080, Guangdong Province, China
| | - Shi-Cong Yang
- Department of Pathology, The First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan Road 2, Guangzhou 510080, Guangdong Province, China
| | - Yan-Yang Chen
- Department of Pathology, The First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan Road 2, Guangzhou 510080, Guangdong Province, China
| | - Pei-Song Chen
- Department of Clinical Laboratory, The First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan Road 2, Guangzhou 510080, Guangdong Province, China
| | - Ze-Yuan Wang
- Zhongshan School of Medicine, Sun Yat-Sen University, 74 Zhongshan Road 2, Guangzhou 510080, Guangdong Province, China
| | - Yang Huang
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan Road 2, Guangzhou 510080, Guangdong Province, China
| | - Chang-Xi Wang
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan Road 2, Guangzhou 510080, Guangdong Province, China
| | - Gang Huang
- Organ Transplant Center, The First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan Road 2, Guangzhou 510080, Guangdong Province, China
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Abstract
Kidney transplantation (KT) is the most effective way to decrease the high morbidity and mortality of patients with end-stage renal disease. However, KT does not completely reverse the damage done by years of decreased kidney function and dialysis. Furthermore, new offending agents (in particular, immunosuppression) added in the post-transplant period increase the risk of complications. Cardiovascular (CV) disease, the leading cause of death in KT recipients, warrants pre-transplant screening based on risk factors. Nevertheless, the screening methods currently used have many shortcomings and a perfect screening modality does not exist. Risk factor modification in the pre- and post-transplant periods is of paramount importance to decrease the rate of CV complications post-transplant, either by lifestyle modification (for example, diet, exercise, and smoking cessation) or by pharmacological means (for example, statins, anti-hyperglycemics, and so on). Post-transplantation diabetes mellitus (PTDM) is a major contributor to mortality in this patient population. Although tacrolimus is a major contributor to PTDM development, changes in immunosuppression are limited by the higher risk of rejection with other agents. Immunosuppression has also been implicated in higher risk of malignancy; therefore, proper cancer screening is needed. Cancer immunotherapy is drastically changing the way certain types of cancer are treated in the general population; however, its use post-transplant is limited by the risk of allograft rejection. As expected, higher risk of infections is also encountered in transplant recipients. When caring for KT recipients, special attention is needed in screening methods, preventive measures, and treatment of infection with BK virus and cytomegalovirus. Hepatitis C virus infection is common in transplant candidates and in the deceased donor pool; however, newly developed direct-acting antivirals have been proven safe and effective in the pre- and post-transplant periods. The most important and recent developments on complications following KT are reviewed in this article.
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Affiliation(s)
- Abraham Cohen-Bucay
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, 14080, Mexico.,Nephrology Department, American British Cowdray Medical Center, Mexico City, 05300, Mexico
| | - Craig E Gordon
- Division of Nephrology, Tufts Medical Center, Boston, MA, 02111, USA
| | - Jean M Francis
- Renal Section, Boston University Medical Center, Boston, MA, 02118, USA
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Favi E, Puliatti C, Sivaprakasam R, Ferraresso M, Ambrogi F, Delbue S, Gervasi F, Salzillo I, Raison N, Cacciola R. Incidence, risk factors, and outcome of BK polyomavirus infection after kidney transplantation. World J Clin Cases 2019; 7:270-290. [PMID: 30746369 PMCID: PMC6369392 DOI: 10.12998/wjcc.v7.i3.270] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Revised: 12/08/2018] [Accepted: 12/12/2018] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Polyomavirus-associated nephropathy is a leading cause of kidney allograft failure. Therapeutic options are limited and prompt reduction of the net state of immunosuppression represents the mainstay of treatment. More recent application of aggressive screening and management protocols for BK-virus infection after renal transplantation has shown encouraging results. Nevertheless, long-term outcome for patients with BK-viremia and nephropathy remains obscure. Risk factors for BK-virus infection are also unclear.
AIM To investigate incidence, risk factors, and outcome of BK-virus infection after kidney transplantation.
METHODS This single-centre observational study with a median follow up of 57 (31-80) mo comprises 629 consecutive adult patients who underwent kidney transplantation between 2007 and 2013. Data were prospectively recorded and annually reviewed until 2016. Recipients were periodically screened for BK-virus by plasma quantitative polymerized chain reaction. Patients with BK viral load ≥ 1000 copies/mL were diagnosed BK-viremia and underwent histological assessment to rule out nephropathy. In case of BK-viremia, immunosuppression was minimized according to a prespecified protocol. The following outcomes were evaluated: patient survival, overall graft survival, graft failure considering death as a competing risk, 30-d-event-censored graft failure, response to treatment, rejection, renal function, urologic complications, opportunistic infections, new-onset diabetes after transplantation, and malignancies. We used a multivariable model to analyse risk factors for BK-viremia and nephropathy.
RESULTS BK-viremia was detected in 9.5% recipients. Initial viral load was high (≥ 10000 copies/mL) in 66.7% and low (< 10000 copies/mL) in 33.3% of these patients. Polyomavirus-associated nephropathy was diagnosed in 6.5% of the study population. Patients with high initial viral load were more likely to experience sustained viremia (95% vs 25%, P < 0.00001), nephropathy (92.5% vs 15%, P < 0.00001), and polyomavirus-related graft loss (27.5% vs 0%, P = 0.0108) than recipients with low initial viral load. Comparison between recipients with or without BK-viremia showed that the proportion of patients with Afro-Caribbean ethnicity (33.3% vs 16.5%, P = 0.0024), panel-reactive antibody ≥ 50% (30% vs 14.6%, P = 0.0047), human leukocyte antigen (HLA) mismatching > 4 (26.7% vs 13.4%, P = 0.0110), and rejection within thirty days of transplant (21.7% vs 9.5%; P = 0.0073) was higher in the viremic group. Five-year patient and overall graft survival rates for patients with or without BK-viremia were similar. However, viremic recipients showed higher 5-year crude cumulative (22.5% vs 12.2%, P = 0.0270) and 30-d-event-censored (22.5% vs 7.1%, P = 0.001) incidences of graft failure than control. In the viremic group we also observed higher proportions of recipients with 5-year estimated glomerular filtration rate < 30 mL/min than the group without viremia: 45% vs 27% (P = 0.0064). Urologic complications were comparable between the two groups. Response to treatment was complete in 55%, partial in 26.7%, and absent in 18.3% patients. The nephropathy group showed higher 5-year crude cumulative and 30-d-event-censored incidences of graft failure than control: 29.1% vs 12.1% (P = 0.008) and 29.1% vs 7.2% (P < 0.001), respectively. Our multivariable model demonstrated that Afro-Caribbean ethnicity, panel-reactive antibody > 50%, HLA mismatching > 4, and rejection were independent risk factors for BK-virus viremia whereas cytomegalovirus prophylaxis was protective.
CONCLUSION Current treatment of BK-virus infection offers sub-optimal results. Initial viremia is a valuable parameter to detect patients at increased risk of nephropathy. Panel-reactive antibody > 50% and Afro-Caribbean ethnicity are independent predictors of BK-virus infection whereas cytomegalovirus prophylaxis has a protective effect.
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Affiliation(s)
- Evaldo Favi
- Renal Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan 20122, Italy
| | - Carmelo Puliatti
- Renal Transplantation, Barts Health NHS Trust, Royal London Hospital, London E1 1BB, United Kingdom
| | - Rajesh Sivaprakasam
- Renal Transplantation, Barts Health NHS Trust, Royal London Hospital, London E1 1BB, United Kingdom
| | - Mariano Ferraresso
- Renal Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan 20122, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan 20122, Italy
| | - Federico Ambrogi
- Department of Clinical Sciences and Community Health, University of Milan, Milan 20122, Italy
| | - Serena Delbue
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan 20100, Italy
| | - Federico Gervasi
- Department of Clinical Sciences and Community Health, University of Milan, Milan 20122, Italy
| | - Ilaria Salzillo
- Renal Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan 20122, Italy
| | - Nicholas Raison
- MRC Centre for Transplantation, King’s College London, London WC2R 2LS, United Kingdom
| | - Roberto Cacciola
- Renal Transplantation, Barts Health NHS Trust, Royal London Hospital, London E1 1BB, United Kingdom
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63
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Other Forms of Immunosuppression. KIDNEY TRANSPLANTATION - PRINCIPLES AND PRACTICE 2019. [PMCID: PMC7152196 DOI: 10.1016/b978-0-323-53186-3.00020-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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64
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Vanichanan J, Udomkarnjananun S, Avihingsanon Y, Jutivorakool K. Common viral infections in kidney transplant recipients. Kidney Res Clin Pract 2018; 37:323-337. [PMID: 30619688 PMCID: PMC6312768 DOI: 10.23876/j.krcp.18.0063] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 09/22/2018] [Accepted: 10/07/2018] [Indexed: 12/15/2022] Open
Abstract
Infectious complications have been considered as a major cause of morbidity and mortality after kidney transplantation, especially in the Asian population. Therefore, prevention, early detection, and prompt treatment of such infections are crucial in kidney transplant recipients. Among all infectious complications, viruses are considered to be the most common agents because of their abundance, infectivity, and latency ability. Herpes simplex virus, varicella zoster virus, Epstein-Barr virus, cytomegalovirus, hepatitis B virus, BK polyomavirus, and adenovirus are well-known etiologic agents of viral infections in kidney transplant patients worldwide because of their wide range of distribution. As DNA viruses, they are able to reactivate after affected patients receive immunosuppressive agents. These DNA viruses can cause systemic diseases or allograft dysfunction, especially in the first six months after transplantation. Pretransplant evaluation and immunization as well as appropriate prophylaxis and preemptive approaches after transplant have been established in the guidelines and are used effectively to reduce the incidence of these viral infections. This review will describe the etiology, diagnosis, prevention, and treatment of viral infections that commonly affect kidney transplant recipients.
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Affiliation(s)
- Jakapat Vanichanan
- Division of Infectious Diseases, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Suwasin Udomkarnjananun
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand.,Renal Immunology and Therapeutic Apheresis Research Unit, Chulalongkorn University, Bangkok, Thailand
| | - Yingyos Avihingsanon
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand.,Renal Immunology and Therapeutic Apheresis Research Unit, Chulalongkorn University, Bangkok, Thailand.,Excellence Center of Immunology and Immune-mediated Diseases, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Kamonwan Jutivorakool
- Division of Infectious Diseases, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
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65
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Masutani K. Viral infections directly involved in kidney allograft function. Nephrology (Carlton) 2018; 23 Suppl 2:31-37. [PMID: 29968408 DOI: 10.1111/nep.13285] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2018] [Indexed: 12/22/2022]
Abstract
Modern immunosuppressive therapy has dramatically reduced the incidence of acute rejection and improved graft survival in kidney transplant patients. However, infectious complications remain an important issue. Amongst the various pathogens, viruses such as adenovirus and polyomavirus BK can directly cause acute or chronic graft dysfunction. Adenovirus mainly causes haemorrhagic cystitis and tubulointerstitial nephritis in kidney transplant patients. While patients show apparent clinical symptoms such as fever, dysuria, gross haematuria, frequency and urgency of urination, and most patients show acute graft dysfunction, these symptoms and graft dysfunction are reversible. Polyomavirus BK infection, however, is asymptomatic but graft outcome is poor if the patient develops tissue-invasive nephropathy confirmed by graft biopsy. Recently, an attempt to create a pathological classification for predicting the clinical course has been made by the Banff Working Group on Polyomavirus Nephropathy. With regards to treatment, the basic strategy is a reduction of calcineurin inhibitor and/or antimetabolites, and the effectiveness of several adjunct treatments has been investigated in several clinical trials. There are other unresolved issues, such as the diagnosis of subsequent acute rejection, the definition of remission, methods of resuming immunosuppression and long-term follow-up. Most of all, development of effective vaccines and novel drug discovery are necessary to prevent the development and progression of BKV-associated nephropathy.
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Affiliation(s)
- Kosuke Masutani
- Division of Nephrology and Rheumatology, Fukuoka University, Fukuoka, Japan
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66
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Baek CH, Kim H, Yu H, Yang WS, Han DJ, Park SK. Risk Factors of Acute Rejection in Patients with BK Nephropathy After Reduction of Immunosuppression. Ann Transplant 2018; 23:704-712. [PMID: 30297686 PMCID: PMC6248279 DOI: 10.12659/aot.910483] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Background BK nephropathy (BKN) affects graft function and increases the risk of graft failure. The reduction of immunosuppression is the main treatment for BKN. However, acute rejection may develop following immunosuppression reduction, and data regarding the risk factors of acute rejection during the post-reduction period are insufficient. Material/Methods Of 758 patients who received a kidney transplantation (KT) between 2008 and 2011, 79 who underwent immunosuppression reduction as BKN treatment were enrolled. The risk factors of acute rejection after immunosuppression reduction were identified using multivariate logistic regression analysis. Results During the median follow-up period (75 months), acute rejection developed in 21.5% of study group patients and in 22.5% of KT recipients without BKN. The rejection group showed a trend of higher body mass index (24.13±3.92 vs. 22.40±3.31 kg/m2, P=0.070) and lower tacrolimus levels than the no rejection group, although mycophenolate mofetil (MMF) doses were not lower in the rejection group. The rejection group showed worse graft survival than the no rejection group (P=0.001 by the log rank test). A greater number of patients in the rejection group exhibited reduced calcineurin inhibitor (CNI) level by >20% at 1 month after initial BKV detection (34.2% vs. 7.9%, P=0.008). Multivariate analysis indicated that the peak BKV PCR level (odds ratio [OR], 0.136; 95% confidence interval [CI], 0.025–0.732; P=0.020), MMF discontinuation (vs. MMF reduction; OR, 0.112; 95% CI, 0.020–0.618; P=0.012) and CNI level reduction >20% (OR, 33.752; 95% CI, 4.263–267.251; P=0.001) were significantly associated with acute rejection. Conclusions Acute rejection after immunosuppression reduction for BKN showed worse allograft survival than the patients without acute rejection. In addition, a CNI dose reduction >20% at 1 month after the initial BKV detection can increase the risk of acute rejection.
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Affiliation(s)
- Chung Hee Baek
- Division of Nephrology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Hyosang Kim
- Division of Nephrology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Hoon Yu
- Division of Nephrology, Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Seoul, South Korea
| | - Won Seok Yang
- Division of Nephrology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Duck Jong Han
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Su-Kil Park
- Division of Nephrology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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Gabardi S, Pavlakis M, Tan C, Francis J, Cardarelli F, Asch W, Bodziak K, Chobanian M, Gilligan H, Gohh R, Kung SC, Inker L, Martin S, Rodig N, Rossi A, Chandraker A. New England BK consortium: Regional survey of BK screening and management protocols in comparison to published consensus guidelines. Transpl Infect Dis 2018; 20:e12985. [PMID: 30175491 DOI: 10.1111/tid.12985] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 08/17/2018] [Accepted: 08/21/2018] [Indexed: 12/18/2022]
Abstract
INTRODUCTION BK polyomavirus (BKPyV) continues to impact renal transplant recipients (RTR). The New England BK Consortium aims to jointly optimize screening and management of BKPyV. METHODS Our first project was to survey centers' BKPyV screening protocols and compare them to consensus guidelines. RESULTS Thirteen of 15 centers (86.7%) returned the survey. Only two center reported using monitoring parameters that were in line with consensus guidelines for BKPyV screening, while the majority of centers reported less intensive methods and shorter duration. One center reported performing renal biopsies in all patients with plasma viral loads >10 000 copies/mL, while all other centers only perform for-cause biopsies. For presumptive nephropathy, 11 centers recommend a biopsy for confirmation. For management of documented BKPyV-associated nephropathy, 12 centers propose further immunosuppression reduction. Nine centers report CNI dose reduction as their primary treatment. More than half of centers surveyed reported use of leflunomide, cidofovir or intravenous immunoglobulin. CONCLUSIONS There was a large variance in BKPyV screening and management strategies among centers. Due to these results, all participating centers agreed to implement uniform screening and aim to optimize management protocols.
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Affiliation(s)
- Steven Gabardi
- Departments of Transplant Surgery, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Martha Pavlakis
- Transplant Institute, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Chen Tan
- Department of Medicine, Harvard Medical School, Boston, Massachusetts.,Division of Infectious Diseases, Center for Virology and Vaccine Research, Transplant Institute, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Jean Francis
- Boston Medical Center, Boston, Massachusetts.,Boston University School of Medicine, Boston, Massachusetts
| | - Francesca Cardarelli
- Transplant Institute, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - William Asch
- Yale New Haven Transplantation Center and the Section of Nephrology, Yale New Haven Hospital, New Haven, Connecticut.,Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Kenneth Bodziak
- Department of Nephrology, UMass Memorial Medical Center, Worcester, Massachusetts.,Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Michael Chobanian
- Department of Nephrology and Hypertension, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.,Department of Medicine, Geisel School of Medicine of Dartmouth College, Hanover, New Hampshire
| | - Hannah Gilligan
- Department of Medicine, Harvard Medical School, Boston, Massachusetts.,Department of Nephrology, Massachusetts General Hospital, Boston, Massachusetts
| | - Reginald Gohh
- Division of Organ Transplantation, Rhode Island Hospital, Providence, Rhode Island.,Warren Alpert School of Medicine of Brown University, Providence, Rhode Island
| | - Shiang-Cheng Kung
- Department of Nephrology, Lahey Hospital and Medical Center, Burlington, Massachusetts.,Department of Medicine, Tufts University School of Medicine, Boston, Massachusetts
| | - Lesley Inker
- Department of Medicine, Tufts University School of Medicine, Boston, Massachusetts.,Kidney and Blood Pressure Center and Kidney Function and Evaluation Center, Tufts Medical Center, Boston, Massachusetts
| | - Spencer Martin
- Department of Pharmacy Service, Hartford Hospital, Hartford, Connecticut
| | - Nancy Rodig
- Division of Nephrology, Boston Children's Hospital, Boston, Massachusetts
| | - Ana Rossi
- Division of Nephrology, Maine Medical Center, Portland, Maine
| | - Anil Chandraker
- Department of Medicine, Harvard Medical School, Boston, Massachusetts.,Renal Division, Brigham and Women's Hospital, Boston, Massachusetts
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Bicalho CS, Oliveira RDR, David DR, Fink MCDS, Agena F, Castro MC, Panutti C, David-Neto E, Pierrotti LC. Determination of viremia cut-off for risk to develop BKPyV-associated nephropathy among kidney transplant recipients. Transpl Infect Dis 2018; 20:e12969. [PMID: 30074295 DOI: 10.1111/tid.12969] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Revised: 06/18/2018] [Accepted: 07/08/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND BK polyomavirus (BKPyV)-associated nephropathy (BKPyVAN) is a consequence of BKPyV replication in the urinary tract in kidney transplant recipients (KTR). OBJECTIVES The objectives were to determine the prevalence of BKPyV replication and BKPyVAN, risk factors associated to sustained viremia and BKPyVAN, and viremia cut-off that best predict the occurrence of sustained viremia and nephropathy in KTR of a single University Hospital Kidney Transplant Center. PATIENTS AND METHODS All KTR undergoing transplantation from August 2010 to December 2011 were enrolled and monitored up to 2 years posttransplantation for BKPyV viruria by decoy cells shedding or polymerase chain reaction (PCR) and viremia by PCR. Kidney biopsy was indicated if sustained viremia (two or more viremia above 10 000 copies/mL) to confirm BKPyVAN diagnosis. RESULTS In this study, 326 transplants were performed and 246 patients were included. Prevalence of viruria was 36.9%, viremia 22.3% and nephropathy 3.2%. Male gender was the only risk factor associated to sustained viremia or nephropathy. Cut-off value of viremia that best discriminates the progression to sustained viremia and to BKPyVAN was 37 488 and 44 956 copies/mL, respectively. CONCLUSIONS Prevalence of viruria, viremia, and nephropathy were similar to those reported in literature but the cut-off value of viremia that best discriminates the risk of progression to nephropathy was greater than the value usually reported, which is 10 000 copies/mL.
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Affiliation(s)
- Camila Silva Bicalho
- Department of Infectious Diseases, Hospital das Clínicas da Faculdade de Medicina da, Universidade de São Paulo, São Paulo, Brazil
| | | | - Daísa Ribeiro David
- Department of Pathology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | | | - Fabiana Agena
- Renal Transplantation Service, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Maria Cristina Castro
- Renal Transplantation Service, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Cláudio Panutti
- São Paulo Institute of Tropical Medicine, Universidade de São Paulo, São Paulo, Brazil
| | - Elias David-Neto
- Renal Transplantation Service, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Ligia Camera Pierrotti
- Department of Infectious Diseases, Hospital das Clínicas da Faculdade de Medicina da, Universidade de São Paulo, São Paulo, Brazil
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69
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Ng JCY, Leung M, Wright AJ, Ensom MHH. Clinical Pharmacokinetic Monitoring of Leflunomide in Renal Transplant Recipients with BK Virus Reactivation: A Review of the Literature. Clin Pharmacokinet 2018; 56:1015-1031. [PMID: 28247238 DOI: 10.1007/s40262-017-0521-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Leflunomide is an immunosuppressive drug with in vitro and initial observational evidence of antiviral activity against BK virus (BKV), a pathogen that causes opportunistic infection upon reactivation in renal transplant recipients. Leflunomide is considered an ancillary option to immunosuppression reduction in the management of BKV reactivation. Plasma or blood concentrations of teriflunomide, the active metabolite of leflunomide, are commonly monitored because of high leflunomide doses being used, known inter-individual variability in pharmacokinetics, and hepatotoxicity risk. However, the utility of clinical pharmacokinetic monitoring for leflunomide is as yet unclear. A literature search of MEDLINE (1946-December 2016), EMBASE (1974-December 2016), the CENTRAL database, and Google Scholar was performed to identify relevant English-language articles. Further articles were identified from references in relevant literature. A previously published 9-step decision-making algorithm was used to assess the available literature and determine the utility of clinical pharmacokinetic monitoring for leflunomide. Teriflunomide is readily measurable in the plasma or blood, but a clear relationship between concentration and efficacy or toxicity is lacking, and its therapeutic range is not well-established. Efficacy and toxicity endpoints such as renal function and BKV clearance can be readily assessed without measuring teriflunomide concentrations. Pharmacokinetic parameters are affected by genetic polymorphisms in cytochrome P450 CYP2C19 and ABCG2 genes. Therefore, routine clinical pharmacokinetic monitoring of leflunomide cannot be recommended based on current available evidence. However, it may provide clinical benefit in difficult situations when patients demonstrate a lack of therapeutic response or exhibit signs of drug toxicity.
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Affiliation(s)
- Joan C Y Ng
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada.,Providence Health Care, Vancouver, BC, Canada
| | - Marianna Leung
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada.,Providence Health Care, Vancouver, BC, Canada
| | - Alissa J Wright
- Transplant Infectious Disease, Division of Infectious Diseases, University of British Columbia, Vancouver, BC, Canada
| | - Mary H H Ensom
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada. .,Department of Pharmacy, Children's and Women's Health Centre of British Columbia, Vancouver, BC, Canada.
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70
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Park WY, Kang SS, Jin K, Park SB, Choe M, Han S. Long-term prognosis of BK virus-associated nephropathy in kidney transplant recipients. Kidney Res Clin Pract 2018; 37:167-173. [PMID: 29971212 PMCID: PMC6027809 DOI: 10.23876/j.krcp.2018.37.2.167] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Revised: 03/20/2018] [Accepted: 04/23/2018] [Indexed: 12/29/2022] Open
Abstract
Background The long-term prognosis of BK virus-associated nephropathy (BKVAN) in kidney transplant recipients (KTRs) is uncertain. We evaluated the long-term prognosis in KTRs with BKVAN and the clinical significance of BKVAN on post-transplant clinical outcome. Methods We retrospectively analyzed the medical records of 582 patients who underwent kidney transplant (KT) between 2001 and 2014. We divided the patients into a BKVAN group (15 patients) diagnosed by allograft biopsy and a control group (356 patients). Results The incidence of BKVAN was 4.0%, and the mean follow-up duration was 93.1 ± 52.3 months. Median time from KT to BKVAN diagnosis was 5.9 months (interquartile range [IQR], 4.4–8.7). In the BKVAN group, 9 (60.0%) KTRs with combined acute rejection progressed to graft failure, and the median time from BKVAN diagnosis to graft failure was 36.2 months (IQR, 9.7–65.5). Death-censored graft survival rate and patient survival rate in the BKVAN group were significantly lower than those in the control group. BKVAN and rejection were independent risk factors for graft failure. In the subgroup analysis, death-censored graft survival rate of KTRs with BKVAN with acute rejection was significantly worst in comparison with similar patients without BKVAN regardless of acute rejection (P < 0.001). Conclusion The long-term prognosis of BKVAN with acute rejection was very poor because of graft failure caused by inadequate treatment for acute rejection considering BKVAN. Therefore, we should carefully monitor the allograft status of KTRs through regular surveillance tests after treatment for BKVAN with acute rejection.
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Affiliation(s)
- Woo Yeong Park
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea.,Keimyung University Kidney Institute, Daegu, Korea
| | - Seong Sik Kang
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea.,Keimyung University Kidney Institute, Daegu, Korea
| | - Kyubok Jin
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea.,Keimyung University Kidney Institute, Daegu, Korea
| | - Sung Bae Park
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea.,Keimyung University Kidney Institute, Daegu, Korea
| | - Misun Choe
- Department of Pathology, Keimyung University School of Medicine, Daegu, Korea.,Keimyung University Kidney Institute, Daegu, Korea
| | - Seungyeup Han
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea.,Keimyung University Kidney Institute, Daegu, Korea
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71
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Alkadi MM, Kim J, Aull MJ, Schwartz JE, Lee JR, Watkins A, Lee JB, Dadhania DM, Seshan SV, Serur D, Kapur S, Suthanthiran M, Hartono C, Muthukumar T. Kidney allograft failure in the steroid-free immunosuppression era: A matched case-control study. Clin Transplant 2018; 31. [PMID: 28921709 DOI: 10.1111/ctr.13117] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/13/2017] [Indexed: 02/06/2023]
Abstract
We studied the causes and predictors of death-censored kidney allograft failure among 1670 kidney recipients transplanted at our center in the corticosteroid-free maintenance immunosuppression era. As of January 1, 2012, we identified 137 recipients with allograft failure; 130 of them (cases) were matched 1-1 for recipient age, calendar year of transplant, and donor type with 130 recipients with functioning grafts (controls). Median time to allograft failure was 29 months (interquartile range: 18-51). Physician-validated and biopsy-confirmed categories of allograft failure were as follows: acute rejection (21%), glomerular disease (19%), transplant glomerulopathy (13%), interstitial fibrosis tubular atrophy (10%), and polyomavirus-associated nephropathy (7%). Graft failures were attributed to medical conditions in 21% and remained unresolved in 9%. Donor race, donor age, human leukocyte antigen mismatches, serum creatinine, urinary protein, acute cellular rejection, acute antibody-mediated rejection, BK viremia, and CMV viremia were associated with allograft failure. Independent predictors of allograft failure were acute cellular rejection (odds ratio: 18.31, 95% confidence interval: 5.28-63.45) and urine protein ≥1 g/d within the first year post-transplantation (5.85, 2.37-14.45). Serum creatinine ≤1.5 mg/dL within the first year post-transplantation reduced the odds (0.29, 0.13-0.64) of allograft failure. Our study has identified modifiable risk factors to reduce the burden of allograft failure.
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Affiliation(s)
- Mohamad M Alkadi
- Division of Nephrology and Hypertension, Department of Medicine, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, NY, USA.,Department of Transplantation Medicine, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, NY, USA.,Division of Nephrology, Department of Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Jim Kim
- Division of Transplantation Surgery, Department of Surgery, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, NY, USA
| | - Meredith J Aull
- Division of Transplantation Surgery, Department of Surgery, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, NY, USA
| | - Joseph E Schwartz
- Division of Nephrology and Hypertension, Department of Medicine, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, NY, USA.,Department of Psychiatry, Stony Brook University, Stony Brook, NY, USA
| | - John R Lee
- Division of Nephrology and Hypertension, Department of Medicine, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, NY, USA.,Department of Transplantation Medicine, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, NY, USA
| | - Anthony Watkins
- Division of Transplantation Surgery, Department of Surgery, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, NY, USA
| | - Jun B Lee
- Division of Nephrology and Hypertension, Department of Medicine, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, NY, USA.,Department of Transplantation Medicine, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, NY, USA.,The Rogosin Institute, New York, NY, USA
| | - Darshana M Dadhania
- Division of Nephrology and Hypertension, Department of Medicine, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, NY, USA.,Department of Transplantation Medicine, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, NY, USA
| | - Surya V Seshan
- Department of Pathology, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, NY, USA
| | - David Serur
- Division of Nephrology and Hypertension, Department of Medicine, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, NY, USA.,Department of Transplantation Medicine, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, NY, USA.,The Rogosin Institute, New York, NY, USA
| | - Sandip Kapur
- Division of Transplantation Surgery, Department of Surgery, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, NY, USA
| | - Manikkam Suthanthiran
- Division of Nephrology and Hypertension, Department of Medicine, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, NY, USA.,Department of Transplantation Medicine, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, NY, USA
| | - Choli Hartono
- Division of Nephrology and Hypertension, Department of Medicine, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, NY, USA.,Department of Transplantation Medicine, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, NY, USA.,The Rogosin Institute, New York, NY, USA
| | - Thangamani Muthukumar
- Division of Nephrology and Hypertension, Department of Medicine, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, NY, USA.,Department of Transplantation Medicine, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, NY, USA
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72
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High-Dose Intravenous Immunoglobulin Treatment of Polyomavirus Nephropathy Developing After T Cell-Mediated Rejection Treatment: A Case Report. Transplant Proc 2018; 50:2575-2578. [PMID: 29871774 DOI: 10.1016/j.transproceed.2018.01.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Revised: 12/28/2017] [Accepted: 01/23/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND Reactivation of BK polyomavirus causes destructive virus allograft nephropathy; however, treatment options are limited. Herein, we report a case in which a patient with T cell-mediated rejection was treated with steroid therapy. The patient subsequently developed BK viremia and was successfully treated by using intravenous immunoglobulin (IVIG) after failing to respond to conventional treatment. CASE PRESENTATION A 54-year-old man had been undergoing peritoneal dialysis for 3 years before kidney transplantation. He had an elevated serum creatinine level (2.26 mg/dL; normal range, 1.2-1.4 mg/dL) and reduced urine output 2 months after transplantation. Suspecting T cell-mediated rejection, steroid pulse therapy (methylprednisolone 250 mg twice daily) was performed for 3 days. Despite treatment, there was a recurrence of increased serum creatinine, and real-time quantitative polymerase chain reaction (serum samples) indicated BK viremia (>5.5 × 105 copies/mL). Results of a kidney biopsy revealed polyomavirus nephropathy (BK virus positive and C4d negative). Thus, the patient's tacrolimus dosage was reduced (from 2.75 mg twice daily to 2 mg once daily), he discontinued mycophenolate mofetil, and he was administered ciprofloxacin and leflunomide. However, the BK viremia showed no improvement, even after 3 months of treatment. Thus, he was administered high-dose IVIG (1 g/kg, 5 times over 5 weeks). The viremia load (blood specimen) decreased to 5197 copies/mL, and the patient's graft function stabilized. His serum creatinine decreased to 2.68 mg/dL. The patient is currently being followed up. CONCLUSIONS Optimal BK treatment methods have not been established, and IVIG treatment remains controversial. However, the present case provides an example of successful treatment using high-dose IVIG.
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73
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Blazquez-Navarro A, Schachtner T, Stervbo U, Sefrin A, Stein M, Westhoff TH, Reinke P, Klipp E, Babel N, Neumann AU, Or-Guil M. Differential T cell response against BK virus regulatory and structural antigens: A viral dynamics modelling approach. PLoS Comput Biol 2018; 14:e1005998. [PMID: 29746472 PMCID: PMC5944912 DOI: 10.1371/journal.pcbi.1005998] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 01/24/2018] [Indexed: 12/26/2022] Open
Abstract
BK virus (BKV) associated nephropathy affects 1-10% of kidney transplant recipients, leading to graft failure in about 50% of cases. Immune responses against different BKV antigens have been shown to have a prognostic value for disease development. Data currently suggest that the structural antigens and regulatory antigens of BKV might each trigger a different mode of action of the immune response. To study the influence of different modes of action of the cellular immune response on BKV clearance dynamics, we have analysed the kinetics of BKV plasma load and anti-BKV T cell response (Elispot) in six patients with BKV associated nephropathy using ODE modelling. The results show that only a small number of hypotheses on the mode of action are compatible with the empirical data. The hypothesis with the highest empirical support is that structural antigens trigger blocking of virus production from infected cells, whereas regulatory antigens trigger an acceleration of death of infected cells. These differential modes of action could be important for our understanding of BKV resolution, as according to the hypothesis, only regulatory antigens would trigger a fast and continuous clearance of the viral load. Other hypotheses showed a lower degree of empirical support, but could potentially explain the clearing mechanisms of individual patients. Our results highlight the heterogeneity of the dynamics, including the delay between immune response against structural versus regulatory antigens, and its relevance for BKV clearance. Our modelling approach is the first that studies the process of BKV clearance by bringing together viral and immune kinetics and can provide a framework for personalised hypotheses generation on the interrelations between cellular immunity and viral dynamics.
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Affiliation(s)
- Arturo Blazquez-Navarro
- Berlin-Brandenburg Center for Regenerative Therapies (BCRT), Charité-Universitätsmedizin, Berlin, Germany
- Systems Immunology Lab, Department of Biology, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Thomas Schachtner
- Berlin-Brandenburg Center for Regenerative Therapies (BCRT), Charité-Universitätsmedizin, Berlin, Germany
- Department of Nephrology and Internal Intensive Care, Charité-Universitätsmedizin, Berlin, Germany
| | - Ulrik Stervbo
- Berlin-Brandenburg Center for Regenerative Therapies (BCRT), Charité-Universitätsmedizin, Berlin, Germany
- Medical Clinic I, Marien Hospital Herne, Ruhr University Bochum, Herne, Germany
| | - Anett Sefrin
- Department of Nephrology and Internal Intensive Care, Charité-Universitätsmedizin, Berlin, Germany
| | - Maik Stein
- Berlin-Brandenburg Center for Regenerative Therapies (BCRT), Charité-Universitätsmedizin, Berlin, Germany
| | - Timm H Westhoff
- Medical Clinic I, Marien Hospital Herne, Ruhr University Bochum, Herne, Germany
| | - Petra Reinke
- Berlin-Brandenburg Center for Regenerative Therapies (BCRT), Charité-Universitätsmedizin, Berlin, Germany
- Department of Nephrology and Internal Intensive Care, Charité-Universitätsmedizin, Berlin, Germany
| | - Edda Klipp
- Theoretical Biophysics Group, Department of Biology, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Nina Babel
- Berlin-Brandenburg Center for Regenerative Therapies (BCRT), Charité-Universitätsmedizin, Berlin, Germany
- Medical Clinic I, Marien Hospital Herne, Ruhr University Bochum, Herne, Germany
| | - Avidan U Neumann
- Berlin-Brandenburg Center for Regenerative Therapies (BCRT), Charité-Universitätsmedizin, Berlin, Germany
- Institute of Environmental Medicine, UNIKA-T, Helmholtz Zentrum München, Augsburg, Germany
- Institute of Computational Biology, Helmholtz Zentrum München, Munich, Germany
| | - Michal Or-Guil
- Systems Immunology Lab, Department of Biology, Humboldt-Universität zu Berlin, Berlin, Germany
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74
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Scadden JRW, Sharif A, Skordilis K, Borrows R. Polyoma virus nephropathy in kidney transplantation. World J Transplant 2017; 7:329-338. [PMID: 29312862 PMCID: PMC5743870 DOI: 10.5500/wjt.v7.i6.329] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 11/17/2017] [Accepted: 12/01/2017] [Indexed: 02/05/2023] Open
Abstract
BK virus (BKV) is a polyomavirus that is able to cause renal dysfunction in transplanted grafts via BK virus-associated nephritis (BKVAN). This condition was mis-diagnosed in the past due to clinical and histopthological similarities with acute rejection. Due to the prevalence of the virus in the population, it is an important pathogen in this context, and so it is important to understand how this virus functions and its' relationship with the pathogenesis of BKVN. Screening for BKV often reveals viruria and/or viremia, which then manifests as BKVN, which can be asymptomatic or result in clinical features namely renal dysfunction. The pathogenesis of BKV infection is still unclear and needs to be further investigated; nevertheless there are a variety of hypotheses that indicate that there are a host of factors that play important roles. Treatments for BKVAN include a reduction in immunosuppression, the use of antiviral therapy or the combination of both treatment options.
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Affiliation(s)
- Jacob RW Scadden
- University of Birmingham, Edgbaston, Birmingham B15 2TH, United Kingdom
| | - Adnan Sharif
- Department of Kidney Transplantation, Queen Elizabeth Hospital Birmingham, Birmingham B15 2TH, United Kingdom
| | - Kassi Skordilis
- Department of Renal Histopathology, Queen Elizabeth Hospital Birmingham, Birmingham B15 2TH, United Kingdom
| | - Richard Borrows
- Department of Kidney Transplantation, Queen Elizabeth Hospital Birmingham, Birmingham B15 2TH, United Kingdom
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75
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Santeusanio AD, Lukens BE, Eun J. Antiviral treatment of BK virus viremia after kidney transplantation. Am J Health Syst Pharm 2017; 74:2037-2045. [DOI: 10.2146/ajhp160585] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Affiliation(s)
| | - Benjamin E. Lukens
- Touro College of Pharmacy, New York, NY, and Mount Sinai Hospital, New York, NY
| | - Judy Eun
- Mount Sinai Hospital, New York, NY
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76
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Smith SDB, Erdag G, Cuda JD, Rangwala S, Girardi N, Bibee K, Orens JB, Prono MD, Toptan T, Loss MJ. Treatment of human polyomavirus-7-associated rash and pruritus with topical cidofovir in a lung transplant patient: Case report and literature review. Transpl Infect Dis 2017; 20. [PMID: 29064138 DOI: 10.1111/tid.12793] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Revised: 06/21/2017] [Accepted: 06/25/2017] [Indexed: 12/21/2022]
Abstract
Human polyomavirus-7-associated rash and pruritus (PVARP) is a chronic superficial viral skin infection, which primarily impacts immunocompromised individuals. We report on a case of PVARP in a lung transplant recipient. Our patient developed symptoms 13 years after being on his immunosuppressive regimen, with an insidious course of progressive gray lichenification with marked islands of sparing and quality of life-altering pruritus. Treatment for PVARP is not established; however, topical cidofovir combined with immunomodulation may offer sustained therapeutic benefit.
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Affiliation(s)
- Shane D B Smith
- Department of Dermatology, Johns Hopkins University, Baltimore, MD, USA
| | - Gulsun Erdag
- Department of Dermatology, Johns Hopkins University, Baltimore, MD, USA.,Department of Pathology, Johns Hopkins University, Baltimore, MD, USA
| | - Jonathan D Cuda
- Department of Dermatology, Johns Hopkins University, Baltimore, MD, USA.,Department of Pathology, Johns Hopkins University, Baltimore, MD, USA
| | - Sophie Rangwala
- Department of Pathology, Johns Hopkins University, Baltimore, MD, USA
| | - Nicholas Girardi
- Department of Dermatology, Johns Hopkins University, Baltimore, MD, USA
| | - Kristin Bibee
- Department of Dermatology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jonathan B Orens
- Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | | | - Tuna Toptan
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Manisha J Loss
- Department of Dermatology, Johns Hopkins University, Baltimore, MD, USA
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77
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Inhibition of Retrograde Transport Limits Polyomavirus Infection In Vivo. mSphere 2017; 2:mSphere00494-17. [PMID: 29152583 PMCID: PMC5687923 DOI: 10.1128/mspheredirect.00494-17] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 10/30/2017] [Indexed: 02/08/2023] Open
Abstract
PyVs can cause significant morbidity and mortality in immunocompromised individuals. No clinically efficacious anti-PyV therapeutic agents are available. A recently identified inhibitor of retrograde transport, Retro-2cycl, blocks movement of PyV virion-containing vesicles from early endosomes to the endoplasmic reticulum, an early step in the PyV life cycle. Retro-2cycl and its derivatives have been shown to inhibit infection by human PyVs in tissue culture. Here, we demonstrate that a derivative of Retro-2cycl, Retro-2.1, reduces infection by MuPyV in the kidneys of acutely infected mice. Mimicking the common clinical scenario of PyV resurgence, we further show that MuPyV levels increase in the kidneys of immunocompromised, persistently infected mice and that this increase is inhibited by Retro-2.1. These data provide the first evidence for control of a natural PyV infection in vivo by administration of an inhibitor of retrograde transport. Polyomaviruses (PyVs) silently infect most humans, but they can cause life-threatening diseases in immunocompromised individuals. The JC polyomavirus (JCPyV) induces progressive multifocal leukoencephalopathy, a severe demyelinating disease in multiple sclerosis patients receiving immunomodulatory therapy, and BK polyomavirus (BKPyV)-associated nephropathy is a major cause of kidney allograft failure. No effective anti-PyV agents are available. Several compounds have been reported to possess anti-PyV activity in vitro, but none have shown efficacy in clinical trials. Productive PyV infection involves usurping the cellular retrograde vesicular transport pathway to enable endocytosed virions to navigate to the endoplasmic reticulum where virion uncoating begins. Compounds inhibiting this pathway have been shown to reduce infection by simian virus 40 (SV40), JCPyV, and BKPyV in tissue culture. In this study, we investigated the potential of Retro-2.1, a retrograde transport inhibitor, to limit infection by mouse polyomavirus (MuPyV) in vivo. We found that Retro-2.1 significantly reduced MuPyV levels in the kidney during acute infection without affecting renal function or the MuPyV-specific CD8 T cell response. To approximate the clinical setting of PyV resurgence in immunocompromised hosts, we showed that antibody-mediated depletion of T cells in persistently infected mice elevated MuPyV levels in the kidney and that Retro-2.1 blunted this increase in virus levels. In summary, these data indicate that inhibition of retrograde vesicular transport in vivo controls infection in a natural PyV mouse model and supports development of these compounds as potential therapeutic agents for individuals at risk for human PyV-associated diseases. IMPORTANCE PyVs can cause significant morbidity and mortality in immunocompromised individuals. No clinically efficacious anti-PyV therapeutic agents are available. A recently identified inhibitor of retrograde transport, Retro-2cycl, blocks movement of PyV virion-containing vesicles from early endosomes to the endoplasmic reticulum, an early step in the PyV life cycle. Retro-2cycl and its derivatives have been shown to inhibit infection by human PyVs in tissue culture. Here, we demonstrate that a derivative of Retro-2cycl, Retro-2.1, reduces infection by MuPyV in the kidneys of acutely infected mice. Mimicking the common clinical scenario of PyV resurgence, we further show that MuPyV levels increase in the kidneys of immunocompromised, persistently infected mice and that this increase is inhibited by Retro-2.1. These data provide the first evidence for control of a natural PyV infection in vivo by administration of an inhibitor of retrograde transport.
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78
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Abstract
BK polyomavirus (BKV) causes frequent infections during childhood and establishes persistent infections within renal tubular cells and the uroepithelium, with minimal clinical implications. However, reactivation of BKV in immunocompromised individuals following renal or hematopoietic stem cell transplantation may cause serious complications, including BKV-associated nephropathy (BKVAN), ureteric stenosis, or hemorrhagic cystitis. Implementation of more potent immunosuppression and increased posttransplant surveillance has resulted in a higher incidence of BKVAN. Antiviral immunity plays a crucial role in controlling BKV replication, and our increasing knowledge about host-virus interactions has led to the development of improved diagnostic tools and clinical management strategies. Currently, there are no effective antiviral agents for BKV infection, and the mainstay of managing reactivation is reduction of immunosuppression. Development of immune-based therapies to combat BKV may provide new and exciting opportunities for the successful treatment of BKV-associated complications.
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79
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邓 伟, 刘 燕, 于 立, 邓 文, 付 绍, 徐 健, 杜 传, 王 亦, 刘 如, 叶 桂, 黄 刚, 苗 芸. [Early intervention of BK virus replication promotes stabilization of renal graft function]. NAN FANG YI KE DA XUE XUE BAO = JOURNAL OF SOUTHERN MEDICAL UNIVERSITY 2017; 37:1110-1115. [PMID: 28801294 PMCID: PMC6765723 DOI: 10.3969/j.issn.1673-4254.2017.08.18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/08/2016] [Indexed: 06/07/2023]
Abstract
OBJECTIVE To investigate the optimal time window for intervention of BK virus (BKV) replication and its effect on the outcomes of kidney transplant recipients (KTRs). METHODS A retrospective analysis of the clinical data and treatment regimens was conducted among KTRs whose urine BKV load was ≥1.0×104 copies/mL following the operation between April, 2000 and April, 2015. KTRs with urine BKV load <1.0×104 copies/mL matched for transplantation time served as the control group. RESULTS A total of 54 recipients positive for urine BKV were included in the analysis. According to urine BKV load, the recipients were divided into 3 groups: group A with urine BKV load of 1.0×104-1.0×107 copies/mL (n=22), group B with urine BKV load >1.0×107 copies/mL (n=24), and group C with plasma BKV load ≥1.0×104 copies/mL (n=8); 47 recipients were included in the control group. During the follow-up for 3.2-34.5 months, the urine and plasma BKV load was obviously lowered after intervention in all the 54 BKV-positive recipients (P<0.05). Eighteen (81.82%) of the recipients in group A and 19 (79.17%) in group B showed stable or improved estimated glomerular filtration rate (eGFR) after the intervention; in group C, 4 recipients (50%) showed stable eGFR after the intervention. In the last follow-up, the recipients in groups A and B showed similar eGFR with the control group (P>0.05), but in group C, eGFR was significantly lower than that of the control group (P=0.001). The recipients in group A and the control group had the best allograft outcome with stable or improved eGFR. CONCLUSION Early intervention of BKV replication (urine BKV load ≥1.0×104 copies/mL) in KTRs with appropriate immunosuppression reduction can be helpful for stabilizing the allograft function and improving the long-term outcomes.
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Affiliation(s)
- 伟明 邓
- 南方医科大学南方医院器官移植科, 广东 广州 510515Department of Organ Transplantation, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - 燕娜 刘
- 南方医科大学南方医院器官移植科, 广东 广州 510515Department of Organ Transplantation, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - 立新 于
- 南方医科大学南方医院器官移植科, 广东 广州 510515Department of Organ Transplantation, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - 文锋 邓
- 南方医科大学南方医院器官移植科, 广东 广州 510515Department of Organ Transplantation, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - 绍杰 付
- 南方医科大学南方医院器官移植科, 广东 广州 510515Department of Organ Transplantation, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - 健 徐
- 南方医科大学南方医院器官移植科, 广东 广州 510515Department of Organ Transplantation, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - 传福 杜
- 南方医科大学南方医院器官移植科, 广东 广州 510515Department of Organ Transplantation, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - 亦斌 王
- 南方医科大学南方医院器官移植科, 广东 广州 510515Department of Organ Transplantation, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - 如敏 刘
- 南方医科大学南方医院器官移植科, 广东 广州 510515Department of Organ Transplantation, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - 桂荣 叶
- 南方医科大学南方医院器官移植科, 广东 广州 510515Department of Organ Transplantation, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - 刚 黄
- 中山大学附属第一医院器官移植科, 广东 广州 510080Department of Organ Transplantation, First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
| | - 芸 苗
- 南方医科大学南方医院器官移植科, 广东 广州 510515Department of Organ Transplantation, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
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80
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Nankivell BJ, Renthawa J, Sharma RN, Kable K, O'Connell PJ, Chapman JR. BK Virus Nephropathy: Histological Evolution by Sequential Pathology. Am J Transplant 2017; 17:2065-2077. [PMID: 28371308 DOI: 10.1111/ajt.14292] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Revised: 03/09/2017] [Accepted: 03/18/2017] [Indexed: 01/25/2023]
Abstract
Reactivation of BK virus in renal allografts causes a destructive chronic infection. This single-center retrospective cohort study describes the evolution of BK virus allograft nephropathy (BKVAN) from 63 kidneys (from 61 patients) using sequential histopathology (454 biopsies, averaging 7.8 ± 2.6 per kidney) followed for 60.1 mo. Uninfected protocol biopsies formulated time-matched control Banff scores (n = 975). Interstitial inflammation occurred in 73% at diagnosis, correlating with viral histopathology (r = 0.413, p = 0.008) and amplifying early injury with accelerated interstitial fibrosis and tubular atrophy (IF/TA, p = 0.017) by 3 mo. Prodromal simian virus 40 large T antigen (SV40T)-negative inflammation with viremia preceded the histological diagnosis in 23.8%. Persistent subacute injury from viral cytopathic effect was associated with acute tubular necrosis and ongoing interstitial inflammation, culminating in IF/TA in 86.9%. Overall, cellular interstitial infiltration mitigated the intensity of subsequent tubular injury, SV40T, and tissue viral load, assessed by sequential paired histology (p < 0.001). Graft loss was predicted by high-level viremia (hazard ratio [HR] 4.996, 95% CI 2.19-11.396, p < 0.001), deceased donor (HR 3.201, 95% CI 1.149-8.915, p = 0.026), and late acute rejection (HR 3.124, 95% CI 1.037-9.413, p = 0.043). Transplant failure occurred in 38.1%, with uncontrolled infection (58.3%) and SV40T-negative chronic rejection (41.7%) causing losses. BKVAN is characterized by subacute virus-induced tubular injury, inflammation, and progressive nephron destruction. Effective antiviral therapy remains an unmet clinical need.
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Affiliation(s)
- B J Nankivell
- Department of Renal Medicine, Westmead Hospital, Westmead, Australia
| | - J Renthawa
- Department of Tissue Pathology and Diagnostic Oncology, ICPMR, Sydney, Australia
| | - R N Sharma
- Department of Tissue Pathology and Diagnostic Oncology, ICPMR, Sydney, Australia
| | - K Kable
- Department of Renal Medicine, Westmead Hospital, Westmead, Australia
| | - P J O'Connell
- Department of Renal Medicine, Westmead Hospital, Westmead, Australia
| | - J R Chapman
- Department of Renal Medicine, Westmead Hospital, Westmead, Australia
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81
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Baker RJ, Mark PB, Patel RK, Stevens KK, Palmer N. Renal association clinical practice guideline in post-operative care in the kidney transplant recipient. BMC Nephrol 2017; 18:174. [PMID: 28571571 PMCID: PMC5455080 DOI: 10.1186/s12882-017-0553-2] [Citation(s) in RCA: 104] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 04/16/2017] [Indexed: 02/08/2023] Open
Abstract
These guidelines cover the care of patients from the period following kidney transplantation until the transplant is no longer working or the patient dies. During the early phase prevention of acute rejection and infection are the priority. After around 3-6 months, the priorities change to preservation of transplant function and avoiding the long-term complications of immunosuppressive medication (the medication used to suppress the immune system to prevent rejection). The topics discussed include organization of outpatient follow up, immunosuppressive medication, treatment of acute and chronic rejection, and prevention of complications. The potential complications discussed include heart disease, infection, cancer, bone disease and blood disorders. There is also a section on contraception and reproductive issues.Immediately after the introduction there is a statement of all the recommendations. These recommendations are written in a language that we think should be understandable by many patients, relatives, carers and other interested people. Consequently we have not reworded or restated them in this lay summary. They are graded 1 or 2 depending on the strength of the recommendation by the authors, and AD depending on the quality of the evidence that the recommendation is based on.
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Affiliation(s)
- Richard J Baker
- Renal Unit, St. James's University Hospital, Leeds, England.
| | - Patrick B Mark
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, Scotland
| | - Rajan K Patel
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, Scotland
| | - Kate K Stevens
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, Scotland
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82
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BK Polyomavirus and the Transplanted Kidney: Immunopathology and Therapeutic Approaches. Transplantation 2017; 100:2276-2287. [PMID: 27391196 PMCID: PMC5084638 DOI: 10.1097/tp.0000000000001333] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BK polyomavirus is ubiquitous, with a seropositivity rate of over 75% in the adult population. Primary infection is thought to occur in the respiratory tract, but asymptomatic BK virus latency is established in the urothelium. In immunocompromised host, the virus can reactivate but rarely compromises kidney function except in renal grafts, where it causes a tubulointerstitial inflammatory response similar to acute rejection. Restoring host immunity against the virus is the cornerstone of treatment. This review covers the virus-intrinsic features, the posttransplant microenvironment as well as the host immune factors that underlie the pathophysiology of polyomavirus-associated nephropathy. Current and promising therapeutic approaches to treat or prevent this complication are discussed in relation to the complex immunopathology of this condition.
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83
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van Doesum WB, Gard L, Bemelman FJ, de Fijter JW, Homan van der Heide JJ, Niesters HG, van Son WJ, Stegeman CA, Groen H, Riezebos-Brilman A, Sanders JSF. Incidence and outcome of BK polyomavirus infection in a multicenter randomized controlled trial with renal transplant patients receiving cyclosporine-, mycophenolate sodium-, or everolimus-based low-dose immunosuppressive therapy. Transpl Infect Dis 2017; 19. [DOI: 10.1111/tid.12687] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Revised: 12/02/2016] [Accepted: 12/04/2016] [Indexed: 02/06/2023]
Affiliation(s)
- Willem B. van Doesum
- Department of Internal Medicine; Division of Nephrology; University Medical Center Groningen; University of Groningen; Groningen The Netherlands
| | - Lilli Gard
- Department of Clinical Virology; University Medical Center Groningen; University of Groningen; Groningen The Netherlands
| | - Frederike J. Bemelman
- Renal Transplant Unit; Academic Medical Center; University of Amsterdam; Amsterdam The Netherlands
| | - Johan W. de Fijter
- Renal Transplant Unit; Department of Nephrology; Leiden University Medical Center; Leiden The Netherlands
| | | | - Hubert G. Niesters
- Department of Clinical Virology; University Medical Center Groningen; University of Groningen; Groningen The Netherlands
| | - Willem J. van Son
- Department of Internal Medicine; Division of Nephrology; University Medical Center Groningen; University of Groningen; Groningen The Netherlands
| | - Coen A. Stegeman
- Department of Internal Medicine; Division of Nephrology; University Medical Center Groningen; University of Groningen; Groningen The Netherlands
| | - Henk Groen
- Department of Epidemiology; University Medical Center Groningen; University of Groningen; Groningen The Netherlands
| | - Annelies Riezebos-Brilman
- Department of Clinical Virology; University Medical Center Groningen; University of Groningen; Groningen The Netherlands
| | - Jan Stephan F. Sanders
- Department of Internal Medicine; Division of Nephrology; University Medical Center Groningen; University of Groningen; Groningen The Netherlands
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84
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Clearance of BK Virus Nephropathy by Combination Antiviral Therapy With Intravenous Immunoglobulin. Transplant Direct 2017; 3:e142. [PMID: 28405598 PMCID: PMC5381735 DOI: 10.1097/txd.0000000000000641] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Accepted: 11/11/2016] [Indexed: 01/09/2023] Open
Abstract
Background Reactivation of BK polyoma virus causes a destructive virus allograft nephropathy (BKVAN) with graft loss in 46%. Treatment options are limited to reduced immunosuppression and largely ineffective antiviral agents. Some studies suggest benefit from intravenous immunoglobulin (IVIG). Methods We evaluated effectiveness of adjuvant IVIG to eliminate virus from blood and tissue, in a retrospective, single-center cohort study, against standard-of-care controls. Both groups underwent reduced immunosuppression; conversion of tacrolimus to cyclosporine; and mycophenolate to leflunomide, oral ciprofloxacin, and intravenous cidofovir. Results Biopsy-proven BKVAN occurred in 50 kidneys at 7 (median interquartile range, 3-12) months after transplantation, predominantly as histological stage B (92%), diagnosed following by dysfunction in 46%, screening viremia in 20%, and protocol biopsy in 34%. After treatment, mean viral loads fell from 1581 ± 4220 × 103 copies at diagnosis to 1434 ± 70 639 midtreatment, and 0.138 ± 0.331 after 3 months (P < 0.001). IVIG at 1.01 ± 0.18 g/kg was given to 22 (44%) patients. The IVIG group more effectively cleared viremia (hazard ratio, 3.68; 95% confidence interval, 1.56-8.68; P = 0.003) and BK immunohistochemistry from repeated tissue sampling (hazard ratio, 2.24; 95% confidence interval, 1.09-4.58; P = 0.028), and resulted in faster (11.3 ± 10.4 months vs 29.1 ± 31.8 months, P = 0.015) and more complete resolution of viremia (33.3% vs 77.3%, P = 0.044). Numerically, fewer graft losses occurred with IVIG (27.3% vs 53.6% for control, P = 0.06), although graft and patient survivals were not statistically different. Acute renal dysfunction requiring pulse corticosteroid was common (59.1% vs 78.6%, P = 0.09), respectively, after immunosuppression reduction. Conclusions Combination treatment incorporating adjuvant IVIG was more effective eliminating virus from BKVAN, compared with conventional therapy. Validation by multicenter randomized trial is needed.
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85
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Yang D, Keys B, J. Conti D, Foulke L, Stellrecht K, Cook L, Lopez-Soler RI. JC polyomavirus nephropathy, a rare cause of transplant dysfunction: Case report and review of literature. Transpl Infect Dis 2017; 19. [DOI: 10.1111/tid.12654] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Revised: 06/27/2016] [Accepted: 09/17/2016] [Indexed: 12/27/2022]
Affiliation(s)
- Doyle Yang
- Department of Surgery; Albany Medical College; Albany NY USA
| | - Brandon Keys
- Department of Surgery; Albany Medical College; Albany NY USA
| | - David J. Conti
- Division of Surgery; Section of Transplantation; Albany Medical Center; Albany NY USA
| | | | - Kathleen Stellrecht
- Center for Immunology and Microbial Diseases; Albany Medical College; Albany NY USA
| | - Linda Cook
- Department of Laboratory Medicine; University of Washington; Seattle WA USA
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86
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Katsuma A, Yamakawa T, Nakada Y, Yamamoto I, Yokoo T. Histopathological findings in transplanted kidneys. RENAL REPLACEMENT THERAPY 2017. [DOI: 10.1186/s41100-016-0089-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
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Hsiao CY, Pilmore HL, Zhou L, de Zoysa JR. Outcomes of renal transplant recipients with BK virus infection and BK virus surveillance in the Auckland region from 2006 to 2012. World J Nephrol 2016; 5:497-506. [PMID: 27872831 PMCID: PMC5099595 DOI: 10.5527/wjn.v5.i6.497] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 08/08/2016] [Accepted: 08/29/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate incidence, risk factors and treatment outcome of BK polyomavirus nephropathy (BKVN) in a cohort of renal transplant recipients in the Auckland region without a formal BK polyomavirus (BKV) surveillance programme.
METHODS A cohort of 226 patients who received their renal transplants from 2006 to 2012 was retrospectively reviewed.
RESULTS Seventy-six recipients (33.6%) had a BK viral load (BKVL) test and 9 patients (3.9%) developed BKVN. Cold ischaemia time (HR = 1.18, 95%CI: 1.04-1.35) was found to be a risk factor for BKVN. Four recipients with BKVN had complete resolution of their BKV infection; 1 recipient had BKVL less than 625 copies/mL; 3 recipients had BKVL more than 1000 copies/mL and 1 had graft failure from BKVN. BKVN has a negative impact on graft function [median estimated glomerular filtration rate (eGFR) 22.5 (IQR 18.5-53.0) mL/min per 1.73 m2, P = 0.015), but no statistically significant difference (P = 0.374) in renal allograft function was found among negative BK viraemia group [median eGFR 60.0 (IQR 48.5-74.2) mL/min per 1.73 m2), positive BK viraemia without BKVN group [median eGFR 55.0 (IQR 47.0-76.0) mL/min per 1.73 m2] and unknown BKV status group [median eGFR 54.0 (IQR 43.8-71.0) mL/min per 1.73 m2]. The incidence and treatment outcomes of BKVN were similar to some centres with BKV surveillance programmes.
CONCLUSION Recipients with BVKN have poorer graft function. Although active surveillance for BKV has been shown to be effective in reducing incidence of BKVN, it should be tailored specifically to that transplant centre based on its epidemiology and outcomes of BKVN, particularly in centres with limited resources.
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88
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Barth H, Solis M, Lepiller Q, Sueur C, Soulier E, Caillard S, Stoll-Keller F, Fafi-Kremer S. 45 years after the discovery of human polyomaviruses BK and JC: Time to speed up the understanding of associated diseases and treatment approaches. Crit Rev Microbiol 2016; 43:178-195. [DOI: 10.1080/1040841x.2016.1189873] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Heidi Barth
- Laboratoire de Virologie, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
- INSERM UMR_S1109, LabEx Transplantex, Fédération de Médecine Translationnelle de Strasbourg (FMTS), Université de Strasbourg, Strasbourg, France
| | - Morgane Solis
- Laboratoire de Virologie, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
- INSERM UMR_S1109, LabEx Transplantex, Fédération de Médecine Translationnelle de Strasbourg (FMTS), Université de Strasbourg, Strasbourg, France
| | - Quentin Lepiller
- Laboratoire de Virologie, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
- INSERM UMR_S1109, LabEx Transplantex, Fédération de Médecine Translationnelle de Strasbourg (FMTS), Université de Strasbourg, Strasbourg, France
| | - Charlotte Sueur
- Laboratoire de Virologie, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
- INSERM UMR_S1109, LabEx Transplantex, Fédération de Médecine Translationnelle de Strasbourg (FMTS), Université de Strasbourg, Strasbourg, France
| | - Eric Soulier
- INSERM UMR_S1109, LabEx Transplantex, Fédération de Médecine Translationnelle de Strasbourg (FMTS), Université de Strasbourg, Strasbourg, France
| | - Sophie Caillard
- INSERM UMR_S1109, LabEx Transplantex, Fédération de Médecine Translationnelle de Strasbourg (FMTS), Université de Strasbourg, Strasbourg, France
- Département de Néphrologie et Transplantation, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Françoise Stoll-Keller
- Laboratoire de Virologie, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
- INSERM UMR_S1109, LabEx Transplantex, Fédération de Médecine Translationnelle de Strasbourg (FMTS), Université de Strasbourg, Strasbourg, France
| | - Samira Fafi-Kremer
- Laboratoire de Virologie, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
- INSERM UMR_S1109, LabEx Transplantex, Fédération de Médecine Translationnelle de Strasbourg (FMTS), Université de Strasbourg, Strasbourg, France
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Vigil D, Konstantinov NK, Barry M, Harford AM, Servilla KS, Kim YH, Sun Y, Ganta K, Tzamaloukas AH. BK nephropathy in the native kidneys of patients with organ transplants: Clinical spectrum of BK infection. World J Transplant 2016; 6:472-504. [PMID: 27683628 PMCID: PMC5036119 DOI: 10.5500/wjt.v6.i3.472] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 08/25/2016] [Accepted: 09/08/2016] [Indexed: 02/05/2023] Open
Abstract
Nephropathy secondary to BK virus, a member of the Papoviridae family of viruses, has been recognized for some time as an important cause of allograft dysfunction in renal transplant recipients. In recent times, BK nephropathy (BKN) of the native kidneys has being increasingly recognized as a cause of chronic kidney disease in patients with solid organ transplants, bone marrow transplants and in patients with other clinical entities associated with immunosuppression. In such patients renal dysfunction is often attributed to other factors including nephrotoxicity of medications used to prevent rejection of the transplanted organs. Renal biopsy is required for the diagnosis of BKN. Quantitation of the BK viral load in blood and urine are surrogate diagnostic methods. The treatment of BKN is based on reduction of the immunosuppressive medications. Several compounds have shown antiviral activity, but have not consistently shown to have beneficial effects in BKN. In addition to BKN, BK viral infection can cause severe urinary bladder cystitis, ureteritis and urinary tract obstruction as well as manifestations in other organ systems including the central nervous system, the respiratory system, the gastrointestinal system and the hematopoietic system. BK viral infection has also been implicated in tumorigenesis. The spectrum of clinical manifestations from BK infection and infection from other members of the Papoviridae family is widening. Prevention and treatment of BK infection and infections from other Papovaviruses are subjects of intense research.
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90
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Moscarelli L, Antognoli G, Buti E, Dervishi E, Fani F, Caroti L, Tsalouchos A, Romoli E, Ghiandai G, Minetti E. 1,25 Dihydroxyvitamin D circulating levels, calcitriol administration, and incidence of acute rejection, CMV infection, and polyoma virus infection in renal transplant recipients. Clin Transplant 2016; 30:1347-1359. [PMID: 27532453 DOI: 10.1111/ctr.12829] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/08/2016] [Indexed: 02/01/2023]
Abstract
Observation that 1,25-Dihydroxyvitamin-D3 has an immunomodulatory effect on innate and adaptive immunity raises the possible effect on clinical graft outcome. Aim of this study was to evaluate the correlation of biopsy-proven acute rejection, CMV infection, BKV infection, with 1,25-Dihydroxyvitamin-D3 deficiency and the benefit of calcitriol supplementation before and during the transplantation. Risk factors and kidney graft function were also evaluated. All RTRs received induction therapy with basiliximab, cyclosporine, mycophenolic acid, and steroids. During the first year, the incidence of BPAR (4% vs 11%, P=.04), CMV infection (3% vs 9%, P=.04), and BKV infection (6% vs 19%, P=.04) was significantly lower in users compared to controls. By multivariate Cox regression analysis, 1,25-Dihydroxyvitamin-D3 deficiency and no calcitriol exposure were independent risk factors for BPAR (HR=4.30, P<.005 and HR=3.25, P<.05), for CMV infection (HR=2.33, P<.05 and HR=2.31, P=.001), and for BKV infection (HR=2.41, P<.05 and HR=2.45, P=.001). After one year, users had a better renal function: eGFR was 62.5±6.7 mL/min vs 51.4±7.6 mL/min (P<.05). Only one user developed polyomavirus-associated nephropathy vs 15 controls. Two users lost their graft vs 11 controls. 1,25(OH)2-D3 deficiency circulating levels increased the risk of BPAR, CMV infection, BKV infection after kidney transplantation. Administration of calcitriol is a way to obtain adequate 1,25(OH)2-D3 circulating levels.
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Affiliation(s)
| | | | - Elisa Buti
- Renal Unit, Careggi University Hospital, Florence, Italy
| | | | - Filippo Fani
- Renal Unit, Careggi University Hospital, Florence, Italy
| | | | | | - Elena Romoli
- Renal Unit, Careggi University Hospital, Florence, Italy
| | | | - Enrico Minetti
- Renal Unit, Careggi University Hospital, Florence, Italy
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Risk Factors for BK Polyoma Virus Treatment and Association of Treatment With Kidney Transplant Failure: Insights From a Paired Kidney Analysis. Transplantation 2016; 100:854-61. [PMID: 27003098 DOI: 10.1097/tp.0000000000000890] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Identification of risk factors for BK polyoma virus (BKPyV) without confounding by donor factors and era effects in paired analysis may inform strategies to prevent BKPyV. METHODS In this analysis of 21,575 mate kidney pairs in the Scientific Registry of Transplant Recipients between 2004 and 2010, the presence of a treatment code for BKPyV virus in follow-up forms was used to identify pairs in which 1 of 2 mate kidneys was treated (discordant treatment) or both mate kidneys were treated (concordant treatment). RESULTS Among 1975 discordant pairs, younger than 18 years or 60 years or older, male sex, HLA mismatch or 4 greater, acute rejection, and depleting antibody induction had a higher odds of treatment, whereas diabetes and sirolimus had a lower odds of treatment, and treatment was associated with a higher risk of allograft failure (hazards ratio, 2.01; 95% confidence interval, 1.63-2.48). The rate of concordant treatment (0.81%) was 2.8 times higher than expected. Concordant treatment was associated with nonwhite donor ethnicity, donation after circulatory death, transplantation after 2008, and transplantation of mate kidneys in the same center. CONCLUSIONS This analysis of kidneys from the same donor in which only 1 transplant was treated for BKPyV identifies specific risk factors (age <18 or ≥ 60 years, male sex, depleting antibody, HLA mismatch ≥ 4) for BKPyV and provides an estimate of the BKPyV-associated risk of allograft failure (hazards ratio = 2.01) without confounding by donor factors or era effects. The higher than expected rate of concordant treatment suggests the importance of donor factors in BKPyV pathogenesis and warrants further study.
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93
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Chon WJ, Aggarwal N, Kocherginsky M, Kane B, Sutor J, Josephson MA. High-level viruria as a screening tool for BK virus nephropathy in renal transplant recipients. Kidney Res Clin Pract 2016; 35:176-81. [PMID: 27668162 PMCID: PMC5025461 DOI: 10.1016/j.krcp.2016.05.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 05/10/2016] [Accepted: 05/25/2016] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Although early monitoring of BK virus infection in renal transplant patients has led to improved outcomes over the past decade, it remains unclear whether monitoring for viremia is the best screening tool for BK virus nephropathy (BKVN). METHODS We conducted a retrospective review of the medical records of 368 renal transplant recipients who had a minimum of 18 months of posttransplantation follow-up. The relationship between the presence of BK viruria and a composite end point of BK viremia/BKVN was established, and the predictive value of high-grade BK viruria for development of viremia/BKVN was determined. RESULTS High grade of BK viruria was present in 110 (30.1%) of the renal transplant recipients. BK viremia/BKVN was present in 64 (17.4%) patients and was 50 times more likely to be present in patients with high-grade BK viruria. The risk of developing BK viremia/BKVN was 3 times higher in high-grade viruria patients, and viruria preceded viremia by nearly 7 weeks. CONCLUSION The presence of high-grade viruria is an early marker for developing BK viremia/BKVN. Detection of high-grade viruria should prompt early allograft biopsy and/or preemptive reduction in immunosuppression.
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Affiliation(s)
- W James Chon
- Division of Nephrology & Hypertension, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Nidhi Aggarwal
- Section of Nephrology, Department of Medicine, University of Chicago, Chicago, IL, USA
| | | | - Brenna Kane
- Section of Transplantation, Department of Surgery, University of Chicago, Chicago, IL, USA
| | - Jozefa Sutor
- Section of Transplantation, Department of Surgery, University of Chicago, Chicago, IL, USA
| | - Michelle A Josephson
- Section of Nephrology, Department of Medicine, University of Chicago, Chicago, IL, USA
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94
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Infections à BK virus en transplantation rénale. Nephrol Ther 2016; 12:76-85. [DOI: 10.1016/j.nephro.2015.11.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Revised: 11/10/2015] [Accepted: 11/12/2015] [Indexed: 01/02/2023]
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95
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Song T, Rao Z, Qiu Y, Liu J, Huang Z, Wang X, Lin T. Fluoroquinolone prophylaxis in preventing BK polyomavirus infection after renal transplant: A systematic review and meta‐analysis. Kaohsiung J Med Sci 2016; 32:152-9. [PMID: 27106006 DOI: 10.1016/j.kjms.2016.01.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Revised: 11/19/2015] [Accepted: 12/07/2015] [Indexed: 02/05/2023] Open
Affiliation(s)
- Tu‐Run Song
- Department of Urology, Urology Institute and Organ Transplantation Center, West China Hospital, Sichuan University, Sichuan, China
| | - Zheng‐Sheng Rao
- Department of Urology, Urology Institute and Organ Transplantation Center, West China Hospital, Sichuan University, Sichuan, China
| | - Yang Qiu
- Department of Urology, Urology Institute and Organ Transplantation Center, West China Hospital, Sichuan University, Sichuan, China
| | - Jin‐Peng Liu
- Department of Urology, Urology Institute and Organ Transplantation Center, West China Hospital, Sichuan University, Sichuan, China
| | - Zhong‐Li Huang
- Department of Urology, Urology Institute and Organ Transplantation Center, West China Hospital, Sichuan University, Sichuan, China
| | - Xian‐Ding Wang
- Department of Urology, Urology Institute and Organ Transplantation Center, West China Hospital, Sichuan University, Sichuan, China
| | - Tao Lin
- Department of Urology, Urology Institute and Organ Transplantation Center, West China Hospital, Sichuan University, Sichuan, China
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Abstract
The kidney is involved in a wide range of bacterial, viral, fungal, and parasitic diseases. In most systemic infections, renal involvement is a minor component of the illness, but in some, renal failure may be the presenting feature and the major problem in management. Although individual infectious processes may have a predilection to involve the renal vasculature, glomeruli, interstitium, or collecting systems, a purely anatomic approach to the classification of infectious diseases affecting the kidney is rarely helpful because most infections may involve several different aspects of renal function. In this chapter, a microbiological classification of the organisms affecting the kidney is adopted. Although they are important causes of renal dysfunction in infectious diseases, urinary tract infections and hemolytic uremic syndrome (HUS) are not discussed in detail because they are considered separately in chapters XX and XX, respectively.
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Affiliation(s)
- Ellis D. Avner
- Department of Pediatrics, Medical College of Wisconsin, Children’s Research Institute, Children’s Hospital, Health System of Wisconsin, Milwaukee, Wisconsin USA
| | - William E. Harmon
- Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts USA
| | - Patrick Niaudet
- Service de Néphrologie Pédiatrique, Hôpital Necker-Enfants Malades, Université Paris-Descartes, Paris, France
| | | | - Francesco Emma
- Division of Nephrology, Bambino Gesù Children’s Hospital – IRCCS, Rome, Italy
| | - Stuart L. Goldstein
- Division of Nephrology and Hypertension, The Heart Institute, Cincinnati Children’s Hospital Medical Center, College of Medicine, Cincinnati, Ohio USA
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Wagner M, Earley AK, Webster AC, Schmid CH, Balk EM, Uhlig K. Mycophenolic acid versus azathioprine as primary immunosuppression for kidney transplant recipients. Cochrane Database Syst Rev 2015; 2015:CD007746. [PMID: 26633102 PMCID: PMC10986644 DOI: 10.1002/14651858.cd007746.pub2] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Modern immunosuppressive regimens after kidney transplantation usually use a combination of two or three agents of different classes to prevent rejection and maintain graft function. Most frequently, calcineurin-inhibitors (CNI) are combined with corticosteroids and a proliferation-inhibitor, either azathioprine (AZA) or mycophenolic acid (MPA). MPA has largely replaced AZA as a first line agent in primary immunosuppression, as MPA is believed to be of stronger immunosuppressive potency than AZA. However, treatment with MPA is more costly, which calls for a comprehensive assessment of the comparative effects of the two drugs. OBJECTIVES This review of randomised controlled trials (RCTs) aimed to look at the benefits and harms of MPA versus AZA in primary immunosuppressive regimens after kidney transplantation. Both agents were compared regarding their efficacy for maintaining graft and patient survival, prevention of acute rejection, maintaining graft function, and their safety, including infections, malignancies and other adverse events. Furthermore, we investigated potential effect modifiers, such as transplantation era and the concomitant immunosuppressive regimen in detail. SEARCH METHODS We searched Cochrane Kidney and Transplant's Specialised Register (to 21 September 2015) through contact with the Trials' Search Co-ordinator using search terms relevant to this review. SELECTION CRITERIA All RCTs about MPA versus AZA in primary immunosuppression after kidney transplantation were included, without restriction on language or publication type. DATA COLLECTION AND ANALYSIS Two authors independently determined study eligibility, assessed risk of bias and extracted data from each study. Statistical analyses were performed using the random-effects model and the results were expressed as risk ratio (RR) for dichotomous outcomes and mean difference (MD) for continuous outcomes with 95% confidence intervals (CI). MAIN RESULTS We included 23 studies (94 reports) that involved 3301 participants. All studies tested mycophenolate mofetil (MMF), an MPA, and 22 studies reported at least one outcome relevant for this review. Assessment of methodological quality indicated that important information on factors used to judge susceptibility for bias was infrequently and inconsistently reported.MMF treatment reduced the risk for graft loss including death (RR 0.82, 95% CI 0.67 to 1.0) and for death-censored graft loss (RR 0.78, 95% CI 0.62 to 0.99, P < 0.05). No statistically significant difference for MMF versus AZA treatment was found for all-cause mortality (16 studies, 2987 participants: RR 0.95, 95% CI 0.70 to 1.29). The risk for any acute rejection (22 studies, 3301 participants: RR 0.65, 95% CI 0.57 to 0.73, P < 0.01), biopsy-proven acute rejection (12 studies, 2696 participants: RR 0.59, 95% CI 0.52 to 0.68) and antibody-treated acute rejection (15 studies, 2914 participants: RR 0.48, 95% CI 0.36 to 0.65, P < 0.01) were reduced in MMF treated patients. Meta-regression analyses suggested that the magnitude of risk reduction of acute rejection may be dependent on the control rate (relative risk reduction (RRR) 0.34, 95% CI 0.10 to 1.09, P = 0.08), AZA dose (RRR 1.01, 95% CI 1.00 to 1.01, P = 0.10) and the use of cyclosporin A micro-emulsion (RRR 1.27, 95% CI 0.98 to 1.65, P = 0.07). Pooled analyses failed to show a significant and meaningful difference between MMF and AZA in kidney function measures.Data on malignancies and infections were sparse, except for cytomegalovirus (CMV) infections. The risk for CMV viraemia/syndrome (13 studies, 2880 participants: RR 1.06, 95% CI 0.85 to 1.32) was not statistically significantly different between MMF and AZA treated patients, whereas the likelihood of tissue-invasive CMV disease was greater with MMF therapy (7 studies, 1510 participants: RR 1.70, 95% CI 1.10 to 2.61). Adverse event profiles varied: gastrointestinal symptoms were more likely in MMF treated patients and thrombocytopenia and elevated liver enzymes were more common in AZA treatment. AUTHORS' CONCLUSIONS MMF was superior to AZA for improvement of graft survival and prevention of acute rejection after kidney transplantation. These benefits must be weighed against potential harms such as tissue-invasive CMV disease. However, assessment of the evidence on safety outcomes was limited due to rare events in the observation periods of the studies (e.g. malignancies) and inconsistent reporting and definitions (e.g. infections, adverse events). Thus, balancing benefits and harms of the two drugs remains a major task of the transplant physician to decide which agent the individual patient should be started on.
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Affiliation(s)
- Martin Wagner
- University Hospital WürzburgDepartment of Medicine I, Division of NephrologyOberdürrbacher Str. 6WürzburgGermany97080
- University of WürzburgInstitute of Clinical Epidemiology and BiometryWürzburgGermany
| | - Amy K Earley
- Tufts Medical CenterInstitute for Clinical Research and Health Policy Studies800 Washington StBostonMAUSA02113
| | - Angela C Webster
- The University of SydneySydney School of Public HealthEdward Ford Building A27SydneyNSWAustralia2006
- The University of Sydney at WestmeadCentre for Transplant and Renal Research, Westmead Millennium InstituteWestmeadNSWAustralia2145
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchWestmeadNSWAustralia2145
| | - Christopher H Schmid
- Brown University School of Public HealthCenter for Evidence‐based MedicineProvidenceRIUSA02912
| | - Ethan M Balk
- Brown University School of Public HealthCenter for Evidence‐based MedicineProvidenceRIUSA02912
| | - Katrin Uhlig
- Tufts University School of MedicineDepartment of Medicine, Division of Nephrology750 Washington StBox 391BostonMAUSA02111
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98
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Abstract
BACKGROUND Reactivation of BK polyoma virus can result in destructive viral allograft nephropathy (BKVAN) with limited treatment options. Screening programs using surrogate markers of viral replication are important preventive strategies, guiding immunosuppression reduction. METHODS We prospectively evaluated the diagnostic test performance of urinary decoy cells and urinary SV40T immunochemistry of exfoliated cells, to screen for BKVAN, (defined by reference histology with SV40 immunohistochemistry, n = 704 samples), compared with quantitative viremia, from 211 kidney and 141 kidney-pancreas transplant recipients. RESULTS The disease prevalence of BKVAN was 2.6%. Decoy cells occurred in 95 of 704 (13.5%) samples, with a sensitivity of 66.7%, specificity of 88.6%, positive predictive value (PPV) of 11.7%, and negative predictive value of 98.5% to predict histologically proven BKVAN. Quantification of decoy cells improved the PPV to 32.1% (10 ≥ cells threshold). Immunohistochemical staining of urinary exfoliated cells for SV40T improved sensitivity to 85.7%, detecting atypical or degenerate infected cells (specificity of 92.3% and PPV of 33.3%), but was hampered by technical failures. Viremia occurred in 90 of 704 (12.8%) with sensitivity of 96.3%, specificity of 90.3%, PPV of 31.5%, and negative predictive value of 99.8%. The receiver-operator curve performance of quantitative viremia surpassed decoy cells (area under the curve of 0.95 and 0.79, respectively, P = 0.0018 for differences). Combining decoy cell and BK viremia in a diagnostic matrix improved prediction of BKVAN and diagnostic risk stratification, especially for high-level positive results. CONCLUSIONS Although quantified decoy cells are acceptable surrogate markers of BK viral replication with unexceptional test performances, quantitative viremia displayed superior test characteristics and is suggested as the screening test of choice.
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99
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Yoon SH, Cho JH, Jung HY, Choi JY, Park SH, Kim YL, Kim HK, Huh S, Kim CD. Clinical impact of BK virus surveillance on outcomes in kidney transplant recipients. Transplant Proc 2015; 47:660-5. [PMID: 25891706 DOI: 10.1016/j.transproceed.2014.11.051] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Accepted: 11/12/2014] [Indexed: 12/16/2022]
Abstract
BACKGROUND The objective of this study was to investigate the clinical impact of BK virus surveillance on graft injury in kidney transplantation. METHODS BK viremia in kidney transplant recipients was evaluated by use of plasma quantitative polymerase chain reaction. The prevalence of BK viremia and BK virus-associated nephropathy (BKVAN) and the clinical impact of BK viremia on graft outcomes were assessed. RESULTS This study took place between January 2008 and June 2013. A total of 213 kidney transplant recipients were included. The prevalence of BK viremia and high BK viremia (≥1 × 10(4) copies/mL) was 66.7% (142/213) and 17.4% (37/213), respectively. A diagnosis of BKVAN was confirmed by means of allograft biopsy in 9 patients (4.2%). The estimated glomerular filtration rate after transplantation was similar in both the low BK viremia (<1 × 10(4) copies/mL) and non-BK viremia groups but was significantly lower in the high BK viremia group after 18 months. In receiver operating characteristic curve analysis, the area under the curve value of plasma polymerase chain reaction was 0.980. We found that a viral load >92,850 copies/mL was able to predict BKVAN with 89% sensitivity and 94.6% specificity. The risk factors for viral loads ≥1 × 10(4) copies/mL were cytomegalovirus infection, steroid pulse therapy, and acute rejection. CONCLUSIONS High BK viremia was associated with poor graft function after kidney transplantation. The serial monitoring of BK viremia in kidney transplant recipients was helpful in predicting BKVAN and might prevent further progression.
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Affiliation(s)
- S-H Yoon
- Department of Internal Medicine, Konyang University Hospital, Daejeon, Korea
| | - J-H Cho
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - H-Y Jung
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - J-Y Choi
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - S-H Park
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Y-L Kim
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - H-K Kim
- Department of Surgery, Kyungpook National University School of Medicine, Daegu, Korea
| | - S Huh
- Department of Surgery, Kyungpook National University School of Medicine, Daegu, Korea
| | - C-D Kim
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea.
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100
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Hirsch HH, Babel N, Comoli P, Friman V, Ginevri F, Jardine A, Lautenschlager I, Legendre C, Midtvedt K, Muñoz P, Randhawa P, Rinaldo CH, Wieszek A. European perspective on human polyomavirus infection, replication and disease in solid organ transplantation. Clin Microbiol Infect 2015; 20 Suppl 7:74-88. [PMID: 24476010 DOI: 10.1111/1469-0691.12538] [Citation(s) in RCA: 101] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Accepted: 12/27/2013] [Indexed: 01/15/2023]
Abstract
Human polyomaviruses (HPyVs) are a growing challenge in immunocompromised patients in view of the increasing number of now 12 HPyV species and their diverse disease potential. Currently, histological evidence of disease is available for BKPyV causing nephropathy and haemorrhagic cystitis, JCPyV causing progressive multifocal leukoencephalopathy and occasionally nephropathy, MCPyV causing Merkel cell carcinoma and TSPyV causing trichodysplasia spinulosa, the last two being proliferative skin diseases. Here, the current role of HPyV in solid organ transplantation (SOT) was reviewed and recommendations regarding screening, monitoring and intervention were made. Pre-transplant screening of SOT donor or recipient for serostatus or active replication is currently not recommended for any HPyV. Post-transplant, however, regular clinical search for skin lesions, including those associated with MCPyV or TSPyV, is recommended in all SOT recipients. Also, regular screening for BKPyV replication (e.g. by plasma viral load) is recommended in kidney transplant recipients. For SOT patients with probable or proven HPyV disease, reducing immunosuppression should be considered to permit regaining of immune control. Antivirals would be desirable for treating proven HPyV disease, but are solely considered as adjunct local treatment of trichodysplasia spinulosa, whereas surgical resection and chemotherapy are key in Merkel cell carcinoma. Overall, the quality of the clinical evidence and the strength of most recommendations are presently limited, but are expected to improve in the coming years.
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Affiliation(s)
- H H Hirsch
- Transplantation and Clinical Virology, Department of Biomedicine (Haus Petersplatz), University of Basel, Basel, Switzerland; Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
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