BK virus: II. Serologic studies in children with congenital disease and patients with malignant tumors and immunodeficiencies

Optimizing the approach to monitoring allograft inflammation using serial urinary CXCL10/creatinine testing in pediatric kidney transplant recipients

BACKGROUND

Urinary CXCL10/creatinine (uCXCL10/Cr) is proposed as an effective biomarker of subclinical rejection in pediatric kidney transplant recipients. This study objective was to model implementation in the clinical setting.

METHODS

Banked urine samples at a single center were tested for uCXCL10/Cr to validate published thresholds for rejection diagnosis (>80% specificity). The positive predictive value (PPV) for rejection diagnosis for uCXCL10/Cr-indicated biopsy was modeled with first-positive versus two-test-positive approaches, with accounting for changes associated with urinary tract infection (UTI), BK and CMV viremia, and subsequent recovery.

RESULTS

Seventy patients aged 10.5 ± 5.6 years at transplant (60% male) had n = 726 urine samples with n = 236 associated biopsies (no rejection = 167, borderline = 51, and Banff 1A = 18). A threshold of 12 ng/mmol was validated for Banff 1A versus no-rejection diagnosis (AUC = 0.74, 95% CI = 0.57-0.92). The first-positive test approach (n = 69) did not resolve a clinical diagnosis in 38 cases (55%), whereas the two-test approach resolved a clinical diagnosis in the majority as BK (n = 17/60, 28%), CMV (n = 4/60, 7%), UTI (n = 8/60, 13%), clinical rejection (n = 5/60, 8%), and transient elevation (n = 18, 30%). In those without a resolved clinical diagnosis, PPV from biopsy for subclinical rejection is 24% and 71% (p = .017), for first-test versus two-test models, respectively. After rejection treatment, uCXCL10/Cr level changes were all concordant with change in it-score. Sustained uCXCL10/Cr after CMV and BK viremia resolution was associated with later acute rejection.

CONCLUSIONS

Urinary CXCL10/Cr reliably identifies kidney allograft inflammation. These data support a two-test approach to reliably exclude other clinically identifiable sources of inflammation, for kidney biopsy indication to rule out subclinical rejection.

Discovery and epidemiology of the human polyomaviruses BK virus (BKV) and JC virus (JCV)

Although discovered over thirty years ago, many aspects of the epidemiology of BKV and JCV in the general population, such as the source of infectious virus and the mode of transmission, are still unknown. Primary infection with both BKV and JCV is usually asymptomatic, and so age seroprevalence studies have been used to indicate infection. BKV commonly infects young children in all parts of the world, with the exception of a few very isolated communities, adult seroprevalence rates of 65-90% being reached by the age of ten years. In contrast, the pattern of JCV infection appears to vary between populations; in some anti-JCV antibody is acquired early as for BKV, but in others anti-JCV antibody prevalence continues to rise throughout life. This indicates that the two viruses are probably transmitted independently and by different routes. Whilst BKV DNA is found infrequently in the urine of healthy adults, JCV viruria occurs universally, increasing with age, with adult prevalence rates often between 20% and 60%. Four antigenic subtypes have been described for BKV and eight genotypes are currently recognized for JCV. The latter have been used to trace population movements and to reconstruct the population history in various communities.

Bk virus: a clinical review

We present a review of the clinically oriented literature about BK virus, a relative of JC virus, which is the etiologic agent of progressive multifocal leukoencephalopathy (PML). The kidney, lung, eye, liver, and brain have been proposed as sites of BK virus-associated disease, both primary and reactivated. BK virus has also been detected in tissue specimens from a variety of neoplasms. We believe that BK virus is most often permissively present in sites of disease in immunosuppressed patients, rather than being an etiologic agent that causes symptoms or pathologic findings. There is, however, strong evidence for BK virus-associated hemorrhagic cystitis and nephritis, especially in recipients of solid organ or bone marrow transplants. Now that BK virus can be identified by use of specific and sensitive techniques, careful evaluation of the clinical and pathologic presentations of patients with BK virus will allow us to form a clearer picture of viral-associated pathophysiology in many organ systems.

Transplacental transmission of human polyomavirus BK

The presence of BK virus (BKV) and JC virus (JCV) in autopsy materials (placenta, brain, and kidney) of aborted fetuses was investigated by PCR using two sets of primers, specific for the regulatory region (RR) and for the capsid protein VP1, respectively. The RR of BKV was detected in 12 samples of placenta and brain and in nine samples of kidney obtained from 15 fetuses. Out of the 12 positive cases, four placentas, one brain, and three kidney samples also showed the presence of BKV DNA in the VP1 region. Of 12 placentas from a control group with a normal pregnancy outcome, the RR of BKV was detected in six samples, four of which were also positive for the VP1 region. None of the samples from either group was positive for the RR of JCV. In two cases, the nucleotide sequence of the BK RR demonstrated that the viruses isolated from maternal and fetal tissues showed a high homology with one another and had a characteristic deletion of the R63 box compared to the archetype strain. The results indicate that BKV may be transmitted vertically.

Characteristics of different solid-phase immunoassay formats for the measurement of BK virus immunoglobulin M in sera of patients on renal dialysis or with kidney allografts

Solid-phase immunoglobulin M (IgM) antigen capture enzyme immunoassay (AgCEIA) and antibody capture enzyme immunoassay (AbCEIA) were developed for the diagnosis of BK virus (BKV) infections. Of 37 serum samples from renal allograft recipients, 15 were positive for BKV IgM antibody by either AgCEIA, AbCEIA, or antigen capture radioimmunoassay. False-positive IgM results were observed in the AgCEIA in the presence of high levels of BKV IgG antibody (titers greater than or equal to 1:51,200), when rheumatoid factor (RF) titers were greater than or equal to 1:20, or in the presence of high levels of RF (titers greater than or equal to 1:10,240) when BKV hemagglutination inhibition titers exceeded 1:40. False-positives due to RF could be eliminated by treatment of sera with anti-human IgG antisera or IgG-coated latex particles. The presence of RF did not, however, produce false-positive results in the AbCEIA. Both AgCEIA and AbCEIA were specific for BKV IgM antibody, as 14 serum samples containing either JC papovavirus, cytomegalovirus, rubella virus, hepatitis A virus, or hepatitis B virus core IgM antibody were negative in both EIAs. Comparison of results obtained for 37 serum samples revealed 14 positive by radioimmunoassay and 11 positive by both AgCEIA and AbCEIA. Both EIAs detected BKV IgM antibody in sera of renal allograft patients and patients on renal dialysis who had reactivated BKV infections persisting for several months after transplantation.

BK virus infection in children with cancer: serological response studied by haemagglutination inhibition, neutralization, and IgG- and IgM-class specific ELISA tests

We recently developed enzyme-linked immunosorbent assays (ELISAs) for the detection of anti-BK virus IgG- and IgM-antibodies, and also a convenient and rapid serum neutralization test. Complemented by a traditional haemagglutination inhibition test (HAI) these methods were used to investigate the longitudinal response to BKV infection in sequentially taken sera from 29 children under treatment for cancer. In separate experiments it was shown that the results were not at any extent influenced by antibodies against other polyomaviruses. At the time of diagnosis the prevalence of specific IgG- and IgM-antibodies and the geometric mean IgG levels were not significantly different for the patients compared with a group of healthy children. The primary infections seemed to occur at the same age for the two groups of children. Seven of the patients had a primary infection with BKV. The results indicate that the host response in moderately immunosuppressed children during primary infection is the same as expected for healthy individuals with the development of specific IgG, HAI, and NT antibodies, and, usually, production of BKV-IgM for several months. The results indicated that whether specific IgM was demonstrated in the first sample or appeared later during a reactivation episode, this parameter was correlated with profound immunosuppression. Significant titre changes, detectable IgM antibodies and/or seroconversions were demonstrated in 69% (20/29) of the cancer patients. Such indications of recent viral activity was recorded in 42% (8/19) of children with meningococcal infections. The observation periods for the two groups of patients are, however, not directly comparable.

Age-dependent prevalence of BK virus IgG and IgM antibodies measured by enzyme-linked immunosorbent assays (ELISA)

Enzyme immunoassays (ELISA) have been developed for the detection of BK virus IgG- and IgM-antibodies. Specific IgG is detected by an antigen-coated solid phase test; IgM by an antibody capture method. These methods have been used to study the age-distribution of BK virus antibodies in Tromsø county in Northern Norway. The serum panels tested were: 60 sera from paediatric patients aged 0-1 year; 220 sera from healthy persons aged 1-82 years; 74 sera from healthy blood donors; 107 sera from healthy pregnant women. The age-distribution of BKV-IgG antibodies showed that primary infections took place predominantly between the ages of 1 and 6 years, and that there were no sex differences, either in the age-specific prevalence or in the level of BKV-IgG. We found no significant differences in the prevalence of BKV-IgM antibodies in healthy children and adults and pregnant women. BKV-IgM was detected in 26 of the 461 sera tested (5.6%).

Detection of BK virus IgM antibodies by two enzyme-linked immunosorbent assays (ELISA) and a hemagglutination inhibition method

We have used an antigen solid-phase enzyme-linked immunosorbent assay (SP-ELISA) and an IgM antibody capture ELISA (MACELISA) for detecting IgM antibodies to human polyomavirus BK (BKV). These tests were compared with the standard hemagglutination inhibition test (HAI) of IgM serum fractions following sucrose density gradient fractionation. The SP- and MACELISA were not influenced by concomitant BKV-IgG, but high levels of both BKV-IgG and rheumatoid factor could cause false positive results by SPELISA, but not by MACELISA. The MACELISA gave much higher positive to negative ratios than the SPELISA. The sensitivity and specificity of the two tests were high compared to the IgM-HAI method. The sera could be tested in a single dilution (1:160), and thus the ELISA-tests are useful for testing large numbers of sera.

BK virus specific IgM responses in cord sera, young children and healthy adults detected by RIA

An IgM capture solid-phase radioimmunoassay (MACRIA) for BK virus (BKV) specific IgM is described. This test was found to be more sensitive in detecting BKV specific IgM than both haemagglutination inhibition and immune electron microscopy with serum fractions from sucrose density gradients. The use of this specific assay allowed large numbers of sera to be examined with ease so that the distribution of BKV specific IgM in different populations could be studied more fully. BKV specific IgM was detected in 11/300 sera from London blood donors, in 24/114 sera from children aged between 2 and 11 years admitted to a paediatric unit and 14/79 sera taken from children aged between 2 and 5 years for the investigation of anti-streptolysin 0 titres. BKV specific IgM was not detected in 404 cord sera examined to investigate the transplacental transmission of BK virus.

Measurement of BK papovavirus IgG and IgM by radioimmunoassay (RIA)

Current techniques for the measurement of BK papovavirus (BKV) specific IgM include sucrose density gradient centrifugation followed by hemagglutination inhibition (HAI) or indirect immunofluorescent (IF) staining of BKV infected cells using a fluorescein conjugated anti-human IgM antibody. These techniques are cumbersome and labor intensive and do not lend themselves to testing large numbers of sera. A solid phase radioimmunoassay (RIA) was developed to facilitate the measurement of BKV IgG and IgM in large numbers of sera. Solid phase antigen was prepared by adsorbing CsCl purified BKV antigen to polyvinyl chloride microtiter plates. Following reaction with serum, bound immunoglobulin was detected with iodinated goat anti-human IgG or IgM. RIA for the measurement of BKV IgG was sensitive with titers approaching 10(-6). Determination of IgG titers by RIA and HAI showed good agreement (P less than 0.01, correlation coefficient = 0.74). Measurement of BKV IgM was not affected by the presence of BKV IgG as evidenced by sucrose density gradient fractionation of IgM positive sera, removal of IgG by treatment with S. aureus protein A, and addition of BKV IgG to BKV IgM. Rheumatoid factor (RF) gave false positive IgM titers in the presence of BKV IgG when RF titers were greater than or equal to 1:640 by latex agglutination testing and BKV IgG levels exceed 1:256 by HAI. False positives due to RF could be eliminated by treatment of sera with sheep anti-human IgG antisera. RIA for BKV IgM was specific as sera containing JCV-, cytomegalovirus (CMV)-, rubella-, or hepatitis B core antibody (anti HBc)-IgM were negative by RIA. RIA detected BKV IgM in several sera from renal dialysis or allograft patients with titers ranging from 1:400 to 1:128,000 and demonstrated that BKV IgM persisted in sera of renal allograft patients for as long as 343 days post transplantation.

Progressive multifocal leucoencephalopathy: detection of papovavirus JC in kidney tissue

Cellular DNA of the kidney from a patient with PML was analyzed by reassociation kinetics for the presence of JC virus DNA. Various amounts of viral DNA sequences were detected in different areas of the kidney. The highest concentration (175 genome equivalents/cell) was found in the renal medulla and there were almost none in the renal cortex. Differentiation from the closely related BK virus was carried out by reassociation kinetics and restriction enzyme cleavage with subsequent Southern blot analysis. The enzyme Hind II, which does not cleave within the BK virus genome, generated four restriction enzyme fragments in the cellular DNA from the kidney, thus documenting the presence of JC virus DNA. By examination of the renal DNA with the "no-cut" restriction enzyme XHO I and the "one-cut" enzymes Eco RI and BAM HI it was possible to show that free and not integrated viral DNA was present in these cells. Nonhomogeneous defective DNA bands were not detectable. By in situ hybridization the epithelial cells lining the collecting tubules were found as predominant site of the viral infection in the kidney.

Prevalence rate and age of acquisition of antibodies against JC virus and BK virus in human sera

A total of 480 serum samples from donors including 384 children up to 10 years of age were examined by the hemagglutination-inhibition (HI) test for the rates of prevalence and age of acquisition of HI antibodies against JC virus and BK virus. Among 136 serum samples from various age groups, there were five (4%) with no detectable antibodies against BK or JC virus, 75 (55%) with antibodies against both viruses, 41 (30.1%) with antibodies against only BK virus and 26 (19%) with antibodies against only JC virus. The prevalence of antibodies against JC and BK viruses was 70.5% and 80.8%, respectively, and the mean HI titers (4 x 2n,n greater than or equal to 1) were 4.90 and 4.30. About 50% of the children had acquired antibodies against BK virus by 3 years of age and against JC virus by 6 years of age. These results indicate that dual latent infections with both viruses are common, although independent infections with either virus are predominant in the human population.

Occurrence of IgM antibodies against BK and JC polyomaviruses during pregnancy

In a serological survey of 430 pregnant women 45 had high or rising titres of BK-virus haemagglutination-inhibiting antibodies. The presence of BK-virus-specific IgM was confirmed in 10 of these women. No BK-virus-specific IgM was detected in the samples of cord blood from the babies born to these women. The sera from 40 women known to be excreting inclusion-bearing cells during pregnancy were tested for the presence of BK-virus and JC-virus-specific IgM and IgG. The presence of BK-virus-specific IgM was confirmed in three cases and JC-virus-specific IgM in seven cases. Specific IgM persisted for several months in some pregnant women. No Bk-virus-specific IgM was detected in any of the samples of cord blood from the babies born to these women with evidence of polyomavirus infection. No JC-virus-specific IgM was detected in 36 out of 37 of the cord bloods; however, in one it is possible that minute amounts of JC-virus-specific IgM were present.

The persistence of papovavirus BK DNA sequences in normal human renal tissue

Evidence has accumulated indicating that BK virus, following an inapparent primary infection, persists in the renal organs of normal healthy individuals and reactivates upon immunosuppression. Data to support this hypothesis are presented and suggest that BK virus DNA sequences are present at very low levels in the kidneys of more than 50% of the population and that this persistence is localized in several foci within these organs.