BK virus nephropathy in an immunodeficient patient with chronic lymphocytic leukemia

Native kidney BK virus nephropathy, a systematic review

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.

BK nephropathy in the native kidneys of patients with organ transplants: Clinical spectrum of BK infection

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.

Review article: BK virus in systemic lupus erythematosus

BK virus (BKV) is a human polyomavirus with a seroprevalence of 60-80 % in the general population. In renal transplant patients, it is known to cause renal failure, ureteric stenosis and hemorrhagic cystitis. In bone marrow transplant patients, it is evident that BKV can also cause hemorrhagic cystitis along with BK virus nephropathy (BKVN) in the native kidneys, with subsequent renal failure. However, little is known about BVKN in non-transplanted immune-compromised patients, such as systemic lupus erythematosus (SLE) who may have underlying nephritis and have a compromised immune system due to therapy and/or systemic illness. Thus, this article will focus on the clinical aspects of BKV and its association in patients with SLE.

Native kidney BK virus nephropathy associated with acute lymphocytic leukemia

BACKGROUND

Polyoma BK virus nephropathy is a common complication after renal transplantation and is rarely seen in non-renal transplant recipients. There are only a couple of case reports of BK virus nephropathy in native kidneys in non-transplant patients, including a recent report of a 73-year-old patient with chronic lymphatic leukemia. A variety of treatment options, including leflunomide and cidofovir, were reported in these patients.

CASE DIAGNOSIS/TREATMENT

Here we report the case of a 10-year-old boy with acute lymphatic leukemia who presented with non-oliguric hypertensive acute kidney injury at the 12th maintenance cycle of his chemotherapy. The workup supported the clear diagnosis of BK virus nephropathy with tubulointerstitial changes, and the patient responded favorably to intravenous immunoglobulin therapy.

CONCLUSIONS

Pediatric nephrologists need to consider BK virus nephropathy as a differential diagnosis of acute kidney injury in immunocompromised non-transplant patients.

BK polyoma virus nephropathy in the native kidney

BACKGROUND

While BK polyoma virus nephropathy (PVN) is a well-recognized cause of renal allograft dysfunction, PVN of native kidneys is likely under-recognized.

METHODS

We present the pathologic features, risk factors and outcomes of eight cases of PVN in native kidneys.

RESULTS

The cohort included eight males aged 16-73 years (mean 47.4) with an immunocompromised state (mean duration 3.15 years) attributable to: hematologic malignancies (n = 6), for which three had undergone bone marrow transplant; lung transplant (n = 1) and combined tuberculosis and diabetes (n = 1). Seven patients were receiving specific immunosuppressive therapies. Patients were biopsied for acute kidney injury (AKI) with rise in mean creatinine levels from baseline 1.6 to 2.8 mg/dL. Pathology showed BK PVN with characteristic intranuclear inclusions staining positive for SV40 T antigen and negative for JC virus (JCV), with positive serum and/or urine PCR for BK virus. One patient had focal medullary JCV co-infection. Two patients also had renal infiltration by chronic lymphocytic leukemia (CLL). Six patients received specific therapy directed to PVN (cidofovir or leflunomide). Follow-up ranged from 2 to 20 (mean 10) months. Despite marked decrease in serum BK viral copy numbers, creatinine continued to rise in six cases (mean 3.7 mg/dL in four, requiring dialysis in two) and three patients died of malignancy, opportunistic infection or renal failure. Advanced histologic stage of PVN, ineffective antiviral therapy, co-morbidities and persistent immunocompromised state likely contributed to the poor outcomes.

CONCLUSION

A high level of suspicion in immunocompromised patients is needed to diagnose PVN in an early stage that may respond more favorably to antiviral therapy.

Native kidney BK virus nephropathy associated with chronic lymphocytic leukaemia

BK virus nephropathy (BKVN) is a well-recognized complication of renal transplantation. Several cases of native kidney BKVN following other solid organ or bone marrow transplants have been reported. We describe a patient with chronic lymphocytic leukaemia who presented with deteriorating renal function with no history of solid organ or bone marrow transplantation. Renal biopsy demonstrated tubular injury characteristic of viral infection, confirmed as BK virus by immunohistochemistry and elevated serum BK viral titres. Treatment with leflunomide reduced serum viral titres and stabilized renal function. This is the first biopsy-proven case of native kidney BKVN in a patient with no previous transplantation history.

Acute renal failure associated with systemic polyoma BK virus activation in a patient with peripheral T-cell lymphoma

Renal dysfunction associated with polyoma BK virus (BKV) reactivation usually occurs in the setting of profound immunosuppression related to renal transplantation and hematopoietic stem cell transplantation. However, it has been rarely described as a complication during the course of conventional chemotherapy. Here, we report a case of BKV-associated acute renal failure developed in a patient suffering from refractory peripheral T-cell lymphoma, not otherwise specified. After repetitive cycles of salvage chemotherapy, the patient developed fever and urinary frequency, rapidly followed by anuria that necessitated the emergent institution of hemodialysis. Cytologic examination of the urine revealed the presence of decoy cells and positive immunostaining for polyomavirus simian virus 40 antigen. High levels of BKV were detected in urine and plasma with quantitative real-time polymerase chain reaction, strongly suggesting that his renal failure was due to polyoma virus-associated nephropathy. This rare complication should be kept in mind in case of unexplained renal failure developed in immunodeficient patients undergoing cytotoxic chemotherapy.