1
|
Kotton CN, Kamar N, Wojciechowski D, Eder M, Hopfer H, Randhawa P, Sester M, Comoli P, Tedesco Silva H, Knoll G, Brennan DC, Trofe-Clark J, Pape L, Axelrod D, Kiberd B, Wong G, Hirsch HH. The Second International Consensus Guidelines on the Management of BK Polyomavirus in Kidney Transplantation. Transplantation 2024; 108:1834-1866. [PMID: 38605438 PMCID: PMC11335089 DOI: 10.1097/tp.0000000000004976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 01/10/2024] [Accepted: 01/18/2024] [Indexed: 04/13/2024]
Abstract
BK polyomavirus (BKPyV) remains a significant challenge after kidney transplantation. International experts reviewed current evidence and updated recommendations according to Grading of Recommendations, Assessment, Development, and Evaluations (GRADE). Risk factors for BKPyV-DNAemia and biopsy-proven BKPyV-nephropathy include recipient older age, male sex, donor BKPyV-viruria, BKPyV-seropositive donor/-seronegative recipient, tacrolimus, acute rejection, and higher steroid exposure. To facilitate early intervention with limited allograft damage, all kidney transplant recipients should be screened monthly for plasma BKPyV-DNAemia loads until month 9, then every 3 mo until 2 y posttransplant (3 y for children). In resource-limited settings, urine cytology screening at similar time points can exclude BKPyV-nephropathy, and testing for plasma BKPyV-DNAemia when decoy cells are detectable. For patients with BKPyV-DNAemia loads persisting >1000 copies/mL, or exceeding 10 000 copies/mL (or equivalent), or with biopsy-proven BKPyV-nephropathy, immunosuppression should be reduced according to predefined steps targeting antiproliferative drugs, calcineurin inhibitors, or both. In adults without graft dysfunction, kidney allograft biopsy is not required unless the immunological risk is high. For children with persisting BKPyV-DNAemia, allograft biopsy may be considered even without graft dysfunction. Allograft biopsies should be interpreted in the context of all clinical and laboratory findings, including plasma BKPyV-DNAemia. Immunohistochemistry is preferred for diagnosing biopsy-proven BKPyV-nephropathy. Routine screening using the proposed strategies is cost-effective, improves clinical outcomes and quality of life. Kidney retransplantation subsequent to BKPyV-nephropathy is feasible in otherwise eligible recipients if BKPyV-DNAemia is undetectable; routine graft nephrectomy is not recommended. Current studies do not support the usage of leflunomide, cidofovir, quinolones, or IVIGs. Patients considered for experimental treatments (antivirals, vaccines, neutralizing antibodies, and adoptive T cells) should be enrolled in clinical trials.
Collapse
Affiliation(s)
- Camille N. Kotton
- Transplant and Immunocompromised Host Infectious Diseases Unit, Infectious Diseases Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Nassim Kamar
- Department of Nephrology and Organ Transplantation, Toulouse Rangueil University Hospital, INSERM UMR 1291, Toulouse Institute for Infectious and Inflammatory Diseases (Infinity), University Paul Sabatier, Toulouse, France
| | - David Wojciechowski
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Michael Eder
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Helmut Hopfer
- Division of Medical Genetics and Pathology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Parmjeet Randhawa
- Division of Transplantation Pathology, The Thomas E. Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA
| | - Martina Sester
- Department of Transplant and Infection Immunology, Saarland University, Homburg, Germany
| | - Patrizia Comoli
- Cell Factory and Pediatric Hematology/Oncology Unit, Department of Mother and Child Health, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Helio Tedesco Silva
- Division of Nephrology, Hospital do Rim, Fundação Oswaldo Ramos, Paulista School of Medicine, Federal University of São Paulo, Brazil
| | - Greg Knoll
- Department of Medicine (Nephrology), University of Ottawa and The Ottawa Hospital, Ottawa, ON, Canada
| | | | - Jennifer Trofe-Clark
- Renal-Electrolyte Hypertension Division, Associated Faculty of the Perelman School of Medicine, University of Pennsylvania, Pennsylvania, PA
- Transplantation Division, Associated Faculty of the Perelman School of Medicine, University of Pennsylvania, Pennsylvania, PA
| | - Lars Pape
- Pediatrics II, University Hospital of Essen, University of Duisburg-Essen, Essen, Germany
| | - David Axelrod
- Kidney, Pancreas, and Living Donor Transplant Programs at University of Iowa, Iowa City, IA
| | - Bryce Kiberd
- Division of Nephrology, Dalhousie University, Halifax, NS, Canada
| | - Germaine Wong
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia
- Centre for Kidney Research, The Children’s Hospital at Westmead, Sydney, NSW, Australia
- Centre for Transplant and Renal Research, Westmead Hospital, Sydney, NSW, Australia
| | - Hans H. Hirsch
- Division of Transplantation and Clinical Virology, Department of Biomedicine, Faculty of Medicine, University of Basel, Basel, Switzerland
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| |
Collapse
|
2
|
Nast CC. Polyomavirus nephropathy: diagnosis, histologic features, and differentiation from acute rejection. CLINICAL TRANSPLANTATION AND RESEARCH 2024; 38:71-89. [PMID: 38725187 PMCID: PMC11228385 DOI: 10.4285/ctr.24.0006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 02/28/2024] [Accepted: 03/20/2024] [Indexed: 06/29/2024]
Abstract
Polyomaviruses, particularly BK virus, are ubiquitous latent infections that may reactivate with immunosuppression during kidney transplantation, resulting in polyomavirus nephropathy (PVN). The levels of viruria and viremia serve as tools for screening and making a presumptive diagnosis of PVN, respectively, while a definitive diagnosis requires a kidney biopsy. There are histologic classifications of PVN based on the extent of tubular cell viral infection, interstitial fibrosis, and interstitial inflammation. These classifications correlate to some degree with graft function and loss, aiding in determining treatment efficacy and prognostication. PVN has histologic overlap with acute cell-mediated rejection, making the differential diagnosis challenging, although there are suggestive features for these different causes of graft dysfunction. This article reviews the diagnosis, histologic findings, and classifications of PVN, and discusses how to differentiate viral nephropathy from acute rejection.
Collapse
Affiliation(s)
- Cynthia C Nast
- Department of Pathology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| |
Collapse
|
3
|
Scott N, Ben-David A, Davidov Y, Cohen-Hagai K, Yemini R, Ghinea R, Mor E, Hod T. The Clinical Manifestation of Immunosuppressive Therapy as a Tool to Improve Immune Monitoring in Renal Transplant Recipients. Kidney Blood Press Res 2023; 48:445-459. [PMID: 37231964 PMCID: PMC10357385 DOI: 10.1159/000530855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 04/24/2023] [Indexed: 05/27/2023] Open
Abstract
INTRODUCTION Metrics for posttransplant immune monitoring to prevent over or under immunosuppression in renal transplant recipients (RTRs) are lacking. METHODS We surveyed 132 RTRs, 38 in the first year posttransplant and 94 >1-year posttransplant, to study the clinical expression of immunosuppressive therapy. A questionnaire administered to these RTRs was divided into physical (Q physical) and mental (Q mental) symptoms. RESULTS In multivariable models for the association between the calculated Q physical and Q mental scores and different clinical and biochemical variables in the 38 RTRs who filled out the questionnaire 130 times during the first year posttransplant, it was found that mycophenolic acid (MPA) and prednisone use increased the mean Q physical score by 0.59 (95% CI: 0.21-0.98, p = 0.002) and 0.53 (95% CI: 0.26-0.81, p = 0.00), respectively, while MPA use increased the mean Q mental score by 0.72 (95% CI: 0.31-1.12, p = 0.001). Among the 94 RTRs who each completed the questionnaire only once, the odds for the mean Q mental score to be above the median value were more than 3 times higher for RTRs treated versus non-treated with MPA (OR 3.38, 95% CI: 1.1-10.3, p = 0.03). MPA-treated RTRs had higher mean scores for questions related to sleep disorders (1.83 ± 1.06 vs. 1.32 ± 0.67 for not treated, p = 0.037), to difficulty falling asleep (1.72 ± 1.11 vs. 1.16 ± 0.5, p = 0.02), and to depression and anxiety. CONCLUSION We concluded that prednisone and MPA use are associated with an increased Q physical and Q mental scores in RTRs. Routine monitoring of physical and mental status of RTRs should be implemented to improve the diagnosis of overimmunosuppression. Dose reduction or discontinuation of MPA should be considered in RTRs who report sleep disorders, depression, and anxiety.
Collapse
Affiliation(s)
- Noa Scott
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Aharon Ben-David
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
- Renal Transplant Center, Sheba Medical Center, Tel Hashomer, Israel
- Nephrology Department, Sheba Medical Center, Tel Hashomer, Israel
| | - Yana Davidov
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
- Liver Disease Center, Sheba Medical Center, Tel Hashomer, Israel
| | - Keren Cohen-Hagai
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
- Department of Nephrology and Hypertension, Meir Medical Center, Kfar Saba, Israel
| | - Renana Yemini
- Division of Transplant Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, VA, USA
| | - Ronen Ghinea
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
- Renal Transplant Center, Sheba Medical Center, Tel Hashomer, Israel
| | - Eytan Mor
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
- Renal Transplant Center, Sheba Medical Center, Tel Hashomer, Israel
| | - Tammy Hod
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
- Renal Transplant Center, Sheba Medical Center, Tel Hashomer, Israel
- Nephrology Department, Sheba Medical Center, Tel Hashomer, Israel
| |
Collapse
|
4
|
Characteristics, risk factors and outcome of BKV nephropathy in kidney transplant recipients: a case-control study. BMC Infect Dis 2023; 23:74. [PMID: 36747162 PMCID: PMC9903532 DOI: 10.1186/s12879-023-08043-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 01/30/2023] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Following kidney transplantation, BK virus associated nephropathy (BKVN) occurs in 1 to 10% of kidney transplant recipients (KTR) and represents a major cause of graft loss. We aim at identifying factors associated with biopsy proven BKVN among KTR. METHODS We conducted a retrospective case-control study including all KTR with a biopsy-proven diagnosis of BKVN between 2005 and 2019. Clinical characteristics and outcome were described. For each case, one control KTR without BKV infection was identified and matched by age, transplant date, and donor status. Factors associated with BKVN diagnosis were identified using exact conditional logistic regression. Comparative survival was described using Kaplan-Meier estimator. RESULTS Sixty-four cases of BKVN were identified among 1737 new kidney transplantation (3.7% prevalence). Clinical characteristics did not differ between groups, except for a higher c-PRA among cases. BKVN occurred in a median time of 11 (5-14.5) months after KT, and was associated with a significantly impaired graft function at diagnosis. Following BKVN, 61 (95%) of the patients had immunosuppression reduction, which led to BKV DNAemia resolution in 49% of cases. In multivariate analysis, factors associated with BKVN diagnosis were lymphopenia < 500/mm3 and a prednisone dose > 7.5 mg/day. Median duration of follow-up was 40 months for both groups. BKVN was associated with a significantly increased risk of graft rejection (P = 0.02) and return to dialysis (P = 0.01). CONCLUSIONS BKVN remains a severe complication in KTR and is associated with an increased risk for acute rejection and return to dialysis. Lymphopenia below 500/mm3 and corticosteroid maintenance therapy are significantly associated with biopsy-proven BKVN diagnosis.
Collapse
|
5
|
Preemptive Second Kidney Transplant Outcomes by Induction Type in the United States. Transplant Proc 2022; 54:2125-2132. [PMID: 36210195 DOI: 10.1016/j.transproceed.2022.08.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 08/29/2022] [Indexed: 11/06/2022]
|
6
|
Omić H, Kläger JP, Herkner H, Aberle SW, Regele H, Weseslindtner L, Schrag TA, Bond G, Hohenstein K, Watschinger B, Werzowa J, Strassl R, Eder M, Kikić Ž. Clinical Relevance of Absolute BK Polyoma Viral Load Kinetics in Patients With Biopsy Proven BK Polyomavirus Associated Nephropathy. Front Med (Lausanne) 2022; 8:791087. [PMID: 35071271 PMCID: PMC8770438 DOI: 10.3389/fmed.2021.791087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 12/06/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: The absolute BK viral load is an important diagnostic surrogate for BK polyomavirus associated nephropathy (PyVAN) after renal transplant (KTX) and serial assessment of BK viremia is recommended. However, there is no data indicating which particular viral load change, i.e., absolute vs. relative viral load changes (copies/ml; percentage of the preceding viremia) is associated with worse renal graft outcomes. Materials and Methods: In this retrospective study of 91 biopsy proven PyVAN, we analyzed the interplay of exposure time, absolute and relative viral load kinetics, baseline risk, and treatment strategies as risk factors for graft loss after 2 years using a multivariable Poisson-model. Results: We compared two major treatment strategies: standardized immunosuppression (IS) reduction (n = 53) and leflunomide (n = 30). The median viral load at the index biopsy was 2.15E+04 copies/ml (interquartile range [IQR] 1.70E+03–1.77E+05) and median peak viremia was 3.6E+04 copies/ml (IQR 2.7E+03–3.3E+05). Treatment strategies and IS-levels were not related to graft loss. After correction for baseline viral load and estimated glomerular filtration rate (eGFR), absolute viral load decrease/unit remained an independent risk factor for graft loss [incidence rate ratios [IRR] = 0.77, (95% CI 0.61–0.96), p = 0.02]. Conclusion: This study provides evidence for the prognostic importance of absolute BK viremia kinetics as a dynamic parameter indicating short-term graft survival independently of other established risk factors.
Collapse
Affiliation(s)
- Haris Omić
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | | | - Harald Herkner
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Stephan W Aberle
- Center for Virology, Medical University of Vienna, Vienna, Austria
| | - Heinz Regele
- Department of Pathology, Medical University of Vienna, Vienna, Austria
| | | | - Tarek Arno Schrag
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Gregor Bond
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Katharina Hohenstein
- Department of Orthopedics and Trauma Surgery at the Medical University of Vienna in the General Hospital, Vienna, Austria
| | - Bruno Watschinger
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Johannes Werzowa
- Ludwig Boltzmann Institute of Osteology at the Hanusch Hospital of WGKK and AUVA Trauma Centre Meidling, 1st Medical Department, Hanusch Hospital, Vienna, Austria
| | - Robert Strassl
- Division of Clinical Virology, Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Michael Eder
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Željko Kikić
- Department of Urology, Medical University of Vienna, Vienna, Austria
| |
Collapse
|
7
|
Myint TM, Chong CHY, Wyld M, Nankivell B, Kable K, Wong G. Polyoma BK Virus in Kidney Transplant Recipients: Screening, Monitoring, and Management. Transplantation 2022; 106:e76-e89. [PMID: 33908382 DOI: 10.1097/tp.0000000000003801] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Polyomavirus BK virus (BKPyV) infection is an important complication of kidney transplantation and allograft failure. The prevalence of viremia is 10%-15%, compared with BK-associated nephropathy (BKPyVAN) at 3%-5%. Given that there are no effective antiviral prophylaxis or treatment strategies for BKPyVAN, active screening to detect BKPyV viremia is recommended, particularly during the early posttransplant period. Immunosuppression reduction to allow viral clearance may avoid progression to severe and irreversible allograft damage. The frequency and duration of screening are highly variable between transplant centers because the evidence is reliant largely on observational data. While the primary treatment goals center on achieving viral clearance through immunosuppression reduction, prevention of subsequent acute rejection, premature graft loss, and return to dialysis remain as major challenges. Treatment strategies for BKPyV infection should be individualized to the recipient's underlying immunological risk and severity of the allograft infection. Efficacy data for adjuvant therapies including intravenous immunoglobulin and cidofovir are sparse. Future well-powered and high-quality randomized controlled trials are needed to inform evidence-based clinical practice for the management of BKPy infection.
Collapse
Affiliation(s)
- Thida Maung Myint
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia
- Newcastle Transplant Unit, John Hunter Hospital, Newcastle, NSW, Australia
| | - Chanel H Y Chong
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia
| | - Melanie Wyld
- Department of Renal Medicine, Centre for Transplant and Renal Research, Westmead Hospital, Westmead, NSW, Australia
| | - Brian Nankivell
- Department of Renal Medicine, Centre for Transplant and Renal Research, Westmead Hospital, Westmead, NSW, Australia
| | - Kathy Kable
- Department of Renal Medicine, Centre for Transplant and Renal Research, Westmead Hospital, Westmead, NSW, Australia
| | - Germaine Wong
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia
- Department of Renal Medicine, Centre for Transplant and Renal Research, Westmead Hospital, Westmead, NSW, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, NSW, Australia
| |
Collapse
|
8
|
Breyer I, Dodin B, Djamali A, Jorgenson MR, Garg N, Aziz F, Mohamed MA, Mandelbrot DA, Parajuli S. Risk factors and outcomes of BK viremia among deceased donor kidney transplant recipients based on donor characteristics. Transpl Infect Dis 2021; 24:e13768. [PMID: 34825437 DOI: 10.1111/tid.13768] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 10/22/2021] [Accepted: 11/17/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION BK polyomavirus (BKV) is a common infection among kidney transplant recipients (KTR). Risk factors and outcomes based on donor characteristics remain largely unknown. METHODS In this study, we aimed to analyze the impact of donor factors through a paired kidney analysis. We included 289 pairs of adult deceased donor transplants (578 KTRs total); each pair had received kidneys from the same donor. Recipient pairs were divided into three groups: "no BK group" if neither KTR developed BK viremia (n = 336), "discordant" if the only one did (n = 176), and "concordant" if both did (n = 66). Acute rejection (AR), graft failure, and BK nephropathy (BKN) were outcomes of interest. RESULTS Donors in the concordant group were younger, had lower kidney donor profile index (KDPI), and were less likely to be donor after circulatory death (DCD). In multivariate analyses, KTRs who had a donor with a higher body mass index (BMI) (hazard ratio (HR): 0.97; 95% confidence interval (CI): 0.95-0.99; p = .009) were less likely to develop BKV. Concordance was not associated with AR (HR: 0.83; 95% CI: 0.51-1.34; p = .45), graft failure (HR: 1.77; 95% CI: 0.42-7.50; p = .43), or BKN (HR: 1.02; 95% CI: 0.51-2.03; p = .96). DISCUSSION Our study suggests lower donor BMI is associated with BKV infection, and concordance or discordance between paired kidney recipients is not associated with poor outcomes.
Collapse
Affiliation(s)
- Isabel Breyer
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Ban Dodin
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Arjang Djamali
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Margaret R Jorgenson
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Neetika Garg
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Fahad Aziz
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Maha A Mohamed
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Didier A Mandelbrot
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Sandesh Parajuli
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| |
Collapse
|
9
|
BK Polyomavirus Nephropathy in Kidney Transplantation: Balancing Rejection and Infection. Viruses 2021; 13:v13030487. [PMID: 33809472 PMCID: PMC7998398 DOI: 10.3390/v13030487] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 03/12/2021] [Accepted: 03/14/2021] [Indexed: 12/16/2022] Open
Abstract
BK polyomavirus nephropathy (BKVN) and allograft rejection are two closely-associated diseases on opposite ends of the immune scale in kidney transplant recipients. The principle of balancing the immune system remains the mainstay of therapeutic strategy. While patient outcomes can be improved through screening, risk factors identification, and rapid reduction of immunosuppressants, a lack of standard curative therapy is the primary concern during clinical practice. Additionally, difficulty in pathological differential diagnosis and clinicopathology’s dissociation pose problems for a definite diagnosis. This article discusses the delicate evaluation needed to optimize immunosuppression and reviews recent advances in molecular diagnosis and immunological therapy for BKVN patients. New biomarkers for BKVN diagnosis are under development. For example, measurement of virus-specific T cell level may play a role in steering immunosuppressants. The development of cellular therapy may provide prevention, even a cure, for BKVN, a complex post-transplant complication.
Collapse
|
10
|
Zanotto E, Allesina A, Barreca A, Sidoti F, Gallo E, Bottino P, Iannaccone M, Bianco G, Biancone L, Cavallo R, Costa C. Renal Allograft Biopsies with Polyomavirus BK Nephropathy: Turin Transplant Center, 2015-19. Viruses 2020; 12:v12091047. [PMID: 32962215 PMCID: PMC7550990 DOI: 10.3390/v12091047] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 09/16/2020] [Accepted: 09/18/2020] [Indexed: 12/22/2022] Open
Abstract
Background: In kidney transplant patients, polyomavirus-associated nephropathy (PVAN) represents a serious complication; the key factor for the development of PVAN is immunosuppression level and modulation of anti-rejection treatment represents the first line of intervention. Allograft biopsy and histology remain the criterion standard for diagnosing PVAN. Methods: All consecutive renal biopsies with the diagnosis of PVAN carried out at the University Hospital City of Health and Science of Turin over a five-years period were studied. Renal allograft biopsy was performed due to renal function alterations associated to medium-high polyomavirus BK (BKV)-DNA levels on plasma specimen. Results: A total of 21 patients underwent a first biopsy to diagnose a possible BKV nephropathy, in 18, a second biopsy was made, in eight, a third biopsy, and finally, three underwent the fourth renal biopsy; following the results of each biopsies, immunosuppressant agents dosages were modified in order to reduce the effect of PVAN. Conclusions: In this study, the clinical and histological features of 21 kidney transplant recipients with BKV reactivation and development of PVAN are described. To date, the only treatment for PVAN consists in the reduction of immunosuppressive agents, constantly monitoring viral load.
Collapse
Affiliation(s)
- Elisa Zanotto
- Microbiology and Virology Unit, University Hospital City of Health and Science of Turin, Corso Bramante 88, 10126 Turin, Italy; (F.S.); (P.B.); (M.I.); (G.B.); (R.C.); (C.C.)
- Correspondence:
| | - Anna Allesina
- Nephrology Unit, University Hospital City of Health and Science of Turin, Corso Bramante 88, 10126 Turin, Italy; (A.A.); (E.G.); (L.B.)
| | - Antonella Barreca
- Pathology Unit, University Hospital City of Health and Science of Turin, Corso Bramante 88, 10126 Turin, Italy;
| | - Francesca Sidoti
- Microbiology and Virology Unit, University Hospital City of Health and Science of Turin, Corso Bramante 88, 10126 Turin, Italy; (F.S.); (P.B.); (M.I.); (G.B.); (R.C.); (C.C.)
| | - Ester Gallo
- Nephrology Unit, University Hospital City of Health and Science of Turin, Corso Bramante 88, 10126 Turin, Italy; (A.A.); (E.G.); (L.B.)
| | - Paolo Bottino
- Microbiology and Virology Unit, University Hospital City of Health and Science of Turin, Corso Bramante 88, 10126 Turin, Italy; (F.S.); (P.B.); (M.I.); (G.B.); (R.C.); (C.C.)
| | - Marco Iannaccone
- Microbiology and Virology Unit, University Hospital City of Health and Science of Turin, Corso Bramante 88, 10126 Turin, Italy; (F.S.); (P.B.); (M.I.); (G.B.); (R.C.); (C.C.)
| | - Gabriele Bianco
- Microbiology and Virology Unit, University Hospital City of Health and Science of Turin, Corso Bramante 88, 10126 Turin, Italy; (F.S.); (P.B.); (M.I.); (G.B.); (R.C.); (C.C.)
| | - Luigi Biancone
- Nephrology Unit, University Hospital City of Health and Science of Turin, Corso Bramante 88, 10126 Turin, Italy; (A.A.); (E.G.); (L.B.)
| | - Rossana Cavallo
- Microbiology and Virology Unit, University Hospital City of Health and Science of Turin, Corso Bramante 88, 10126 Turin, Italy; (F.S.); (P.B.); (M.I.); (G.B.); (R.C.); (C.C.)
| | - Cristina Costa
- Microbiology and Virology Unit, University Hospital City of Health and Science of Turin, Corso Bramante 88, 10126 Turin, Italy; (F.S.); (P.B.); (M.I.); (G.B.); (R.C.); (C.C.)
| |
Collapse
|
11
|
Sharma R, Zachariah M. BK Virus Nephropathy: Prevalence, Impact and Management Strategies. Int J Nephrol Renovasc Dis 2020; 13:187-192. [PMID: 32821148 PMCID: PMC7423353 DOI: 10.2147/ijnrd.s236556] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 07/29/2020] [Indexed: 12/25/2022] Open
Abstract
BK virus reactivation as a result of therapeutic immunosuppression following renal transplant can result in BK polyomavirus nephropathy and renal allograft loss. This is a complex and challenging clinical problem with a range of management options and practices reported in literature. The current standard for early diagnosis and treatment is surveillance by measuring viral DNA in blood using qPCR. Immunosuppression reduction is the cornerstone of effective management but is associated with a risk of acute rejection following treatment.
Collapse
Affiliation(s)
- Rajeev Sharma
- School of Medicine, University of Nevada Las Vegas, Las Vegas, NV, USA.,Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | | |
Collapse
|
12
|
Choi J, Chandraker A. Immunologic Risk Assessment and Approach to Immunosuppression Regimen in Kidney Transplantation. Clin Lab Med 2019; 39:643-656. [PMID: 31668275 DOI: 10.1016/j.cll.2019.07.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The outcomes of kidney transplantation show a steady improvement with an increasing number of transplantations and decreasing incidence of acute rejection episodes. Successful transplantation begins with a comprehensive immunologic risk assessment and judicious choice of therapeutic agents. In this review, we discuss the trends in transplant immunosuppression practices and outcomes in the United States. We discuss practical testing algorithms for clinical decision making in induction therapy and fine-tuning maintenance immunosuppression. We introduce assessment tools for immune monitoring after transplantation and speculate on future directions in management.
Collapse
Affiliation(s)
- John Choi
- Transplantation Research Center, Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Anil Chandraker
- Transplantation Research Center, Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| |
Collapse
|
13
|
Zakaria ZE, Elokely AM, Ghorab AA, Bakr AI, Halim MA, Gheith OA, Nagib AM, Makkeyah Y, Balaha MA, Magdy MM, Al-Otaibi T. Screening for BK Viremia/Viruria and the Impact of Management of BK Virus Nephropathy in Renal Transplant Recipients. EXP CLIN TRANSPLANT 2019; 17:83-91. [PMID: 30777529 DOI: 10.6002/ect.mesot2018.o17] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES The prevalence of BK-induced nephritis in renal transplant recipients is estimated to be 1% to 10%; the rate of graft loss within 1 year is 30% to 65%. We conducted this study to evaluate screening of BK virus in blood and/or urine among renal transplant recipients and to assess the effects of different therapeutic modalities in renal transplant recipients with BK nephropathy. MATERIALS AND METHODS Kidney transplant recipients were screened at the time of transplant and then at 1, 2, 3, 6, 9, 12, 18, and 24 months posttransplant. Fiftynine patients were diagnosed with BK virus viremia. Patients were divided into 2 groups according to treatment: group 1 (n = 29) received an active treatment and group 2 (n = 30) received minimized immunosuppression. RESULTS Most patients required graft biopsies to confirm diagnosis (86.2% in group 1 vs 50% in group 2; P = .03). Both groups were comparable regarding demographic data. Initial posttransplant graft function was significantly better in group 1 (P = .017); ultimately, there was no significant difference between both groups regarding graft survival (P= .51). Fifty percent of patients had biopsy-proven acute T-cell-mediated rejection before BK virus-associated nephropathy diagnosis (significantly higher in group 1). Serum creatinine levels were significantly better in group 2 at 3, 4, and 5 years after BK nephropathy (P = .001, .017, and .003, respectively). CONCLUSIONS The prevalence of BK nephropathy in our renal transplant recipients was 5.9% with a rate of graft loss ranging from 43% to 51%. Regular screening, less intensive immunosuppressive therapy, and early intervention by reduction of immunosuppressive medications are advisable to obtain early diagnosis and to have better outcomes of BK virus-associated nephropathy with antiviral agents.
Collapse
|
14
|
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
| |
Collapse
|
15
|
Ji J, Feng S, Jiang Y, Wang W, Zhang X. Prevalence and Risk Factors of BK Viremia and Clinical Impact of BK Virus Surveillance on Outcomes in Kidney Transplant Recipients: A Single-Center Cross-Sectional Study. EXP CLIN TRANSPLANT 2019; 17:727-731. [PMID: 30995893 DOI: 10.6002/ect.2018.0262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES BK virus is a polyomavirus that can cause nephropathy and graft loss after kidney transplant. The aim of our study was to screen the BK viremia prevalence, to understand the value of the inter-vention for BK virus nephropathy, and to determine the risk factors associated with BK viremia after kidney transplant in our center. MATERIALS AND METHODS Our retrospective cross-sectional study included 91 adult kidney transplant recipients who were seen between 2015 and 2017 and who had follow-up from 1 month to over 2 years. BK viremia was evaluated by use of plasma quantitative polymerase chain reaction. The prevalence of BK viremia and the clinical treatments and outcomes of BK virus nephropathy were assessed. RESULTS The prevalence of BK viremia was 5.5% (5/91 patients). BK virus nephropathy was confirmed by allograft biopsy in 4.4% (4/91 patients) of all patients. Delayed graft function was found to be an independent risk factor for BK viremia (P < .001). Patients with BK viremia had significantly higher serum creatinine levels (P = .04). Patients who were diagnosed with BK viremia at 1 to 5 years after kidney transplant had higher serum creatinine (P = .02) and uric acid levels (P = .02). After reduction or discontinuation of calcineurin inhibitor, BK virus was cleared in all patients with BK virus nephropathy, with higher level of serum creatinine but no graft loss. CONCLUSIONS Delayed graft function was considered as a risk factor for viremia. Early detection of BK viremia replication is important. The strategy of reduction of immunosuppression was effective for BK virus nephropathy and graft function improvement.
Collapse
Affiliation(s)
- Jiawei Ji
- From the Urology Institute of Capital Medical University, Department of Urology, Capital Medical University Beijing Chaoyang Hospital, Beijing, China
| | | | | | | | | |
Collapse
|
16
|
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.
Collapse
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
| |
Collapse
|
17
|
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.
Collapse
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
| |
Collapse
|
18
|
Fan Y, Bai H, Qian Y, Sun Z, Shi B. CD4+ T Cell Immune Response to VP1 and VP3 in BK Virus Infected Recipients of Renal Transplantation. Surg Infect (Larchmt) 2019; 20:236-243. [PMID: 30707648 DOI: 10.1089/sur.2018.116] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE To investigate the characteristics of BK virus (BKV) specific cellular immune response in the recipients who have early infection with BKV after renal transplantation. METHODS The recipients of renal allografts (n = 30) were divided into groups of BK virus nephropathy (BKVN), viruria, and viremia. The BKV load was observed with real-time fluorescence quantitative polymerase chain reaction in urine and blood every three months. The values of serum creatinine (SCr) were detected. The peripheral blood mononuclear cells (PBMCs) were cultivated with overlapping peptide pool containing BKV structural proteins VP1, VP2, and VP3, and regulatory proteins large tumor antigen (LT-Ag) and small tumor antigen (st-Ag), to stimulate in vitro specific cellular immunoresponse. Flow cytometry was used to measure the proliferation of CD3+/CD4+/CD8+ T and interferon [INF]-γ/interleukin [IL]-2/tumor necrosis factor [TNF]-α T cell subsets. RESULTS The BKV infection increased SCr values in recipients of renal transplantation. CD4+ T cells were dominant (>90%) in the in vitro cellular immunoresponse to VP1, VP2, VP3, LT-Ag, and st-Ag. At the presence of viremia and BKVN, IL-2/IFN-γ+/TNF-α+ CD4+ T cells showed significantly decreased in vitro cellular immunoresponse to VP1, VP2, and VP3 (p < 0.05), but insignificantly changed to LT-Ag and st-Ag (p > 0.05). For the cases of viruria and viremia, IL-2/IFN-γ+/TNF-α+ CD4+ T cells showed significantly higher in vitro cellular immunoresponse to VP1, VP2, and VP3 than to LT-Ag and st-Ag (p < 0.05). The immunogenicity of VP1 and VP3 was significantly higher than that of VP2 (p < 0.05). CONCLUSIONS The BKV infection increases SCr values, and CD4+ T cells are dominant in the in vitro BKV specific cellular immunoresponse in the recipients of renal transplantation. Viremia significantly decreased the immunoresponse to VP1, VP2, and VP3. There is the significantly stronger immunoresponse to VP1 and VP3 when compared with that to VP2, LT-Ag, and st-Ag, suggesting that VP1 and VP3 may be the major targets for the BKV specific immune response.
Collapse
Affiliation(s)
- Yu Fan
- Department of Transplantation Surgery, The 309th Hospital of Chinese People's Liberation Army, Beijing, China
| | - Hongwei Bai
- Department of Transplantation Surgery, The 309th Hospital of Chinese People's Liberation Army, Beijing, China
| | - Yeyong Qian
- Department of Transplantation Surgery, The 309th Hospital of Chinese People's Liberation Army, Beijing, China
| | - Zhongwei Sun
- Department of Transplantation Surgery, The 309th Hospital of Chinese People's Liberation Army, Beijing, China
| | - Bingyi Shi
- Department of Transplantation Surgery, The 309th Hospital of Chinese People's Liberation Army, Beijing, China
| |
Collapse
|
19
|
Miettinen J, Lautenschlager I, Weissbach F, Wernli M, Auvinen E, Mannonen L, Lauronen J, Hirsch HH, Jalanko H. BK polyomavirus viremia and antibody responses of pediatric kidney transplant recipients in Finland. Pediatr Transplant 2019; 23:e13324. [PMID: 30447046 DOI: 10.1111/petr.13324] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2018] [Revised: 09/14/2018] [Accepted: 10/15/2018] [Indexed: 12/27/2022]
Abstract
BACKGROUND BKPyV is an important cause of premature graft failure after KT. Most clinical studies describe BKPyV infection in adult KT patients. We studied the prevalence of post-transplant BKPyV viremia, serology, and graft function in pediatric KT recipients. METHODS Forty-six pediatric patients transplanted between 2009 and 2014 were followed up for BKPyV DNAemia by plasma PCR for median 2.3 (range: 1-6) years. BKPyV-specific antibodies were retrospectively analyzed using virus-like particle ELISA. GFR was measured annually by 51 Cr-EDTA clearance, and serum samples were screened for DSAs by Luminex assay. RESULTS BKPyV viremia was demonstrated in nine patients at a median of 6 months post-KT. Early BKPyV viremia at 3 months post-KT associated with decreased concomitant GFR and tendency for decreased subsequent graft function. Three of nine patients with BKPyV viremia developed DSA, all against class II antigens. PyVAN developed to four patients and responded to judicious reduction in IS. One graft was lost later due to ABMR. BKPyV-IgG was found in 18 of 31 patients (58%) tested at transplantation, and seven recipients seroconverted after transplantation with a significant increase in IgG levels with IgM. Finally, BKPyV-IgG was detectable in 31 of 40 patients (78%) at the end of the study. CONCLUSIONS Post-transplant BKPyV viremia in pediatric KT patients may alter graft function and contribute to progression of chronic allograft injury. BKPyV-IgG predicts past exposure. Low or absent BKPyV-specific antibody levels were seen pretransplant in 42% of tested patients, but were not predictive of prolonged replication or poor outcome.
Collapse
Affiliation(s)
- Jenni Miettinen
- Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Irmeli Lautenschlager
- Department of Virology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Fabian Weissbach
- Transplantation & Clinical Virology, Department of Biomedicine, University of Basel, Basel, Switzerland.,Infectious Diseases & Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - Marion Wernli
- Transplantation & Clinical Virology, Department of Biomedicine, University of Basel, Basel, Switzerland.,Infectious Diseases & Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - Eeva Auvinen
- Department of Virology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Laura Mannonen
- Department of Virology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Jouni Lauronen
- Histocompatibility Laboratory, Finnish Red Cross Blood Service, Helsinki, Finland
| | - Hans H Hirsch
- Transplantation & Clinical Virology, Department of Biomedicine, University of Basel, Basel, Switzerland.,Infectious Diseases & Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - Hannu Jalanko
- Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| |
Collapse
|
20
|
Demey B, Tinez C, François C, Helle F, Choukroun G, Duverlie G, Castelain S, Brochot E. Risk factors for BK virus viremia and nephropathy after kidney transplantation: A systematic review. J Clin Virol 2018; 109:6-12. [PMID: 30343190 DOI: 10.1016/j.jcv.2018.10.002] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Revised: 09/13/2018] [Accepted: 10/08/2018] [Indexed: 01/15/2023]
Abstract
In the last 20 years, the management of BK polyomavirus (BKPyV) reactivation in kidney transplant patients has become a true challenge for the transplant community. The only treatment option is based on the early identification of at-risk patients. The number of reported risk factors for BKPyV reactivation has increased markedly in the literature last years, although they are sometimes in an unclear or contradictory manner. Our purpose is to provide a systematic review and meta-analysis of risk factors for BKPyV viremia and nephropathy described in multivariate analyses. The PubMed database was searched for prospective or prospectively-based observational studies on risk factors for BKPyV viremia and/or nephropathy. Our qualitative assessment of risk factors was based on the odds ratios and hazard ratios calculated in multivariate regression analyses. Of the 241 publications screened, 34 were included in the qualitative analysis. In all, 144 and 19 distinct factors were analyzed for BKPyV viremia and for BKPyV nephropathy, respectively. Our evaluation highlighted eight risk factors for BKPyV viremia: a tacrolimus regimen, a deceased donor, a male recipient, a history of previous transplant, age at transplantation, ureteral stent use, delayed graft function, and acute rejection episodes increased the risk of BKV viremia to varying extents. Tacrolimus and acute rejection episodes were also associated with a higher incidence of BKPyV nephropathy. BKPyV reactivation is a serious complication after renal transplantation. With a view to combating this problem, existing data should be published in full, and new prospective international multicenter studies should be performed.
Collapse
Affiliation(s)
- Baptiste Demey
- Department of Virology, Amiens University Medical Center, Amiens, France; AGIR Research Unit, EA 4294, Jules Verne University of Picardie, Amiens, France
| | - Claire Tinez
- Department of Virology, Amiens University Medical Center, Amiens, France; AGIR Research Unit, EA 4294, Jules Verne University of Picardie, Amiens, France
| | - Catherine François
- Department of Virology, Amiens University Medical Center, Amiens, France; AGIR Research Unit, EA 4294, Jules Verne University of Picardie, Amiens, France
| | - François Helle
- AGIR Research Unit, EA 4294, Jules Verne University of Picardie, Amiens, France
| | - Gabriel Choukroun
- Department of Nephrology, Amiens University Medical Center, Amiens, France
| | - Gilles Duverlie
- Department of Virology, Amiens University Medical Center, Amiens, France; AGIR Research Unit, EA 4294, Jules Verne University of Picardie, Amiens, France
| | - Sandrine Castelain
- Department of Virology, Amiens University Medical Center, Amiens, France; AGIR Research Unit, EA 4294, Jules Verne University of Picardie, Amiens, France
| | - Etienne Brochot
- Department of Virology, Amiens University Medical Center, Amiens, France; AGIR Research Unit, EA 4294, Jules Verne University of Picardie, Amiens, France.
| |
Collapse
|
21
|
Do W, Lee JH, Kim KJ, Han MH, Jung HY, Choi JY, Park SH, Kim YL, Kim CD, Cho JH, Yang Y, Kim M, Hwang I, Kim KY, Yim T, Kim YJ. Bortezomib Treatment for Refractory Antibody-Mediated Rejection Superimposed with BK Virus-Associated Nephropathy during the Progression of Recurrent C3 Glomerulonephritis. KOREAN JOURNAL OF TRANSPLANTATION 2018. [DOI: 10.4285/jkstn.2018.32.3.57] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Wonseok Do
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Jong-Hak Lee
- Department of Internal Medicine, Daegu Fatima Hospital, Daegu, Korea
| | - Kyung Joo Kim
- Department of Pathology, Yeungnam University Medical Center, Yeungnam University College of Medicine, Daegu, Korea
| | - Man-Hoon Han
- Department of Pathology, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Hee-Yeon Jung
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Ji-Young Choi
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Sun-Hee Park
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Yong-Lim Kim
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Chan-Duck Kim
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Jang-Hee Cho
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Youngae Yang
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Minjung Kim
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Inryang Hwang
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Kyu Yeun Kim
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Taehoon Yim
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Yong-Jin Kim
- Department of Pathology, School of Medicine, Kyungpook National University, Daegu, Korea
| |
Collapse
|
22
|
Janphram C, Worawichawong S, Disthabanchong S, Sumethkul V, Rotjanapan P. Absence of JC polyomavirus (JCPyV) viremia in early post-transplant JCPyV nephropathy: A case report. Transpl Infect Dis 2017; 19. [PMID: 28805990 DOI: 10.1111/tid.12761] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Revised: 05/21/2017] [Accepted: 06/01/2017] [Indexed: 02/05/2023]
Abstract
JC polyomavirus (JCPyV)-associated nephropathy (JCPyVAN) occurs in <3% of PVAN cases after renal transplantation. We report the first confirmed case to our knowledge of JCPyVAN diagnosed by kidney biopsy in the early 6 months post transplant in Thailand. In this case report, recovery of renal allograft function was not observed after reduction of immunosuppressive agents and administration of intravenous immunoglobulin and cidofovir. Despite persistent JCPyV viruria, no significant further decline in allograft function was documented at 15 months post transplant.
Collapse
Affiliation(s)
- Chitimaporn Janphram
- Division of Nephrology, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Suchin Worawichawong
- Division of Renal-Pathology, Department of Pathology, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Sinee Disthabanchong
- Division of Nephrology, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Vasant Sumethkul
- Division of Nephrology, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Porpon Rotjanapan
- Division of Infectious Diseases, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| |
Collapse
|
23
|
BK virus replication in renal transplant recipients: Analysis of potential risk factors may contribute in reactivation. J Clin Virol 2017; 96:7-11. [PMID: 28915452 DOI: 10.1016/j.jcv.2017.09.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 09/05/2017] [Accepted: 09/07/2017] [Indexed: 01/27/2023]
Abstract
BACKGROUND Considering the increasing problem of BK virus infection during post renal transplant surveillance, it is necessary to distinguish the main risk factors leading to reactivation of latent BK virus. Up to now, some probable risk factors have been investigated in some studies, but the results have been confusing and contradictory. OBJECTIVES The goal of the present study was to determine the frequency and potential risk factors that may play a role in BK polyomavirus reactivation and nephropathy. STUDY DESIGN In this cross-sectional study, 110 patients, who underwent consecutive transplantation between 2010 and 2013, were enrolled without preliminary screening. Urine and blood samples were taken, and quantitative Real-time PCR assay was used to detect and measure the viral load. Demographic and clinical characteristics of the patients who had BK viremia and/or viruria were documented. RESULTS Among 110 cases of renal transplant recipients, BK viruria and viremia were found in 54 (49%) and 22 people (20%) respectively. The pre-transplant durations of dialysis among patients with BK viruia were found longer in comparison to BK negative patients. Treatment with Tacrolimus (p=0.03) was found to be a risk factor for development of BK viruria. In patients with viruria and viremia the median creatinine levels were 1.45mg/dl and 1.35mg/dl respectively, which were higher than those in the patients with negative results for BK viruria (p=0.002) and viremia (p=0.02). Also, treatment with Cyclosporine could significantly increase the incidence of BK virus shedding in both urine and blood among patients who received it (p=0.01). Significant relation between reactivation of BK virus and other factors such as age, sex, acute rejection and diabetes was not found. CONCLUSION Based on our findings, the main potential risk factors for shedding of BK virus into urine in renal transplant recipients were prolonged pre-transplant dialysis and Tacrolimus regimen. Cyclosporine regimens could be considered as risk factor for both BK viruria and viremia. A significant correlation between BK virus replication and elevated creatinine level was seen among our patients.
Collapse
|
24
|
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
| |
Collapse
|
25
|
Momper JD, Misel ML, McKay DB. Sex differences in transplantation. Transplant Rev (Orlando) 2017; 31:145-150. [PMID: 28262425 DOI: 10.1016/j.trre.2017.02.003] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Revised: 01/30/2017] [Accepted: 02/13/2017] [Indexed: 01/01/2023]
Abstract
Sex plays a role in the incidence and progression of a wide variety of diseases and conditions related to transplantation. Additionally, a growing body of clinical and experimental evidence suggests that sex can impact the pharmacokinetics and pharmacodynamics of several commonly used immunosuppressive and anti-infective drugs in transplant recipients. A better understanding of these sex differences will facilitate advances in individualizing treatment for patients and improve outcomes of solid organ transplantation. Here, we provide a review of sex-related differences in transplantation and highlight opportunities for future research directions.
Collapse
Affiliation(s)
- Jeremiah D Momper
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego/La Jolla, CA
| | - Michael L Misel
- Kidney Transplant/Department of Pharmacy Services, UC San Diego Health System, University of California, San Diego/La Jolla, CA
| | - Dianne B McKay
- Division of Nephrology-Hypertension, School of Medicine, University of California, San Diego/La Jolla, CA.
| |
Collapse
|
26
|
Radtke J, Dietze N, Fischer L, Achilles EG, Li J, Scheidat S, Thaiss F, Nashan B, Koch M. Incidence of BK polyomavirus infection after kidney transplantation is independent of type of immunosuppressive therapy. Transpl Infect Dis 2016; 18:850-855. [PMID: 27639176 DOI: 10.1111/tid.12611] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2015] [Revised: 05/06/2016] [Accepted: 07/04/2016] [Indexed: 01/03/2023]
Abstract
BACKGROUND BK polyomavirus (BKV) infection and BKV nephropathy (BKVN) are risk factors for allograft function and survival. METHODS We retrospectively analyzed BK viremia and BKVN in 348 patients who received a kidney transplantation donated after brain death (n=232) or living donation (n=116) between 2008 and 2013. A total of 266 patients were treated with standard immunosuppression consisting of basiliximab induction, calcineurin inhibitor (CNI), and mycophenolic acid (MPA, n=219) or everolimus (n=47); 82 patients received more intense immunosuppression with lymphocyte depletion, CNI and MPA (n=38) or everolimus (n=44). RESULTS BK viremia occurred in 33 (9.5%) patients in the first year and in 7 (2.0%) recipients in the second year after transplantation. BKVN occurred in 4 (1.1%) patients in the first year. Donor and recipient age, diabetes, previous transplantation, and type of transplantation (donated after brain death vs living donation) were not risk factors (P>.05). BK incidence did not differ depending on induction or maintenance immunosuppression. CONCLUSION Incidence of BK viremia is independent of recipient characteristics, type of transplantation as well as induction and maintenance immunosuppression.
Collapse
Affiliation(s)
- Josephine Radtke
- Department of Hepatobiliary and Transplant Surgery, University Medical Center Hamburg-Eppendorf UKE, University Transplantation-Center UTC, Hamburg, Germany
| | - Nina Dietze
- Department of Hepatobiliary and Transplant Surgery, University Medical Center Hamburg-Eppendorf UKE, University Transplantation-Center UTC, Hamburg, Germany
| | - Lutz Fischer
- Department of Hepatobiliary and Transplant Surgery, University Medical Center Hamburg-Eppendorf UKE, University Transplantation-Center UTC, Hamburg, Germany
| | - Eike-Gert Achilles
- Department of Hepatobiliary and Transplant Surgery, University Medical Center Hamburg-Eppendorf UKE, University Transplantation-Center UTC, Hamburg, Germany
| | - Jun Li
- Department of Hepatobiliary and Transplant Surgery, University Medical Center Hamburg-Eppendorf UKE, University Transplantation-Center UTC, Hamburg, Germany
| | - Silke Scheidat
- Department of Internal Medicine III, University Medical Center Hamburg-Eppendorf UKE, University Transplantation-Center UTC, Hamburg, Germany
| | - Friedrich Thaiss
- Department of Internal Medicine III, University Medical Center Hamburg-Eppendorf UKE, University Transplantation-Center UTC, Hamburg, Germany
| | - Bjoern Nashan
- Department of Hepatobiliary and Transplant Surgery, University Medical Center Hamburg-Eppendorf UKE, University Transplantation-Center UTC, Hamburg, Germany
| | - Martina Koch
- Department of Hepatobiliary and Transplant Surgery, University Medical Center Hamburg-Eppendorf UKE, University Transplantation-Center UTC, Hamburg, Germany
| |
Collapse
|
27
|
Ranzi AD, Introíni GO, Prolla JC, Brackmann R, Bassani NC, Pasqualotto AC, Bica CG. Correlation between the presence of degenerated inclusion-bearing cells in voided urine samples and the occurrence of polyomavirus infection. Cytopathology 2016; 28:103-108. [PMID: 27500467 DOI: 10.1111/cyt.12358] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/24/2016] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The purpose of the present, prospective, cohort study was to monitor urine cytology samples from recipients of renal transplants to search for the occurrence of decoy cells and degenerated inclusion-bearing cells with an aim to correlate the existence of these cells with molecular detection of polyomavirus BK (BKV) DNA in urine. MATERIAL AND METHODS This study included patients who underwent renal transplantation. Patients had their urine tested quarterly, during the first year post-transplantation, for the presence of decoy cells and degenerated cells, as well as by quantitative determination of BKV load in the urine and plasma. RESULTS Three hundred and sixty-one examinations were performed on 101 patients within 12 months of attendance. Urine cytology results were: 198 (54.9%) negative and 60 (16.6%) positive for the presence of viral cytopathic effects depending on the presence of BKV infection, 72 (19.9%) positive for the manifestation of degenerated cells and 31 (8.6%) unsatisfactory for analysis. There was a subtle tendency towards the presence of degenerated inclusion-bearing cells in cases in which the virus was detected in voided urine. However, the presence of degenerated cells exhibited a tendency to BKV positivity in months 3, 6 and 9 and, exclusively in month 12, this trend was statistically significant. CONCLUSIONS There were not enough strong morphological and staining elements to state the origin of the degenerated cells or to describe the nature of the infection (viral or bacterial), given that these cells were undergoing an apoptotic process in post renal transplant patients.
Collapse
Affiliation(s)
- A D Ranzi
- Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Brazil
| | - G O Introíni
- Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Brazil
| | - J C Prolla
- Irmandade da Santa Casa de Misericórdia de Porto Alegre (ISCMPA), Porto Alegre, Brazil
| | - R Brackmann
- Irmandade da Santa Casa de Misericórdia de Porto Alegre (ISCMPA), Porto Alegre, Brazil
| | - N C Bassani
- Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Brazil
| | - A C Pasqualotto
- Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Brazil.,Irmandade da Santa Casa de Misericórdia de Porto Alegre (ISCMPA), Porto Alegre, Brazil
| | - C G Bica
- Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Brazil
| |
Collapse
|
28
|
Viral Origin, Clinical Course, and Renal Outcomes in Patients With BK Virus Infection After Living-Donor Renal Transplantation. Transplantation 2016; 100:844-53. [PMID: 26720302 DOI: 10.1097/tp.0000000000001066] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND BK virus (BKV) nephropathy remains the main cause of renal graft loss after living-donor renal transplantation. The aim of the study was to investigate the source and factors influencing the course of BKV infection. METHODS We investigated 214 living donor-recipient pairs. Urine and blood of donors and recipients were tested by qPCR for the presence of BKV DNA before and after transplantation; genotyping of BKV subtypes was performed. RESULTS Eighty-five recipients (40%) had posttransplant BK viruria including 61 with additional viremia and 22 with nephropathy. Pretransplant urinary BKV shedding of donor or recipient was a significant risk factor for posttransplant viruria and viremia (OR, 4.52; CI, 2.33-8.77; P < 0.0001) and nephropathy (OR, 3.03; CI, 1.16-7.9; P = 0.02). In the BKV nephropathy group, urine and blood became BKV positive earlier than in the group with viruria and viremia. Renal function was worse in BKV-nephropathy compared with BKV-negative patients beginning at transplantation. Comparing BKV subtypes of donor and recipient before with the subtype of the infected recipient after transplantation, donor-derived transmission was identified in 24 of 28 corresponding pairs. BKV subtype IV had a higher prevalence in recipients with BKV nephropathy than in those with viruria and viremia (P = 0.045). CONCLUSIONS Pretransplant urinary BKV shedding of donor and recipient is a risk for posttransplant infection. Donor-derived BKV transmission is an important mode of infection. BKV subtype IV may be one of the viral determinants. Early BKV positivity of urine and blood indicates later BKV nephropathy. Decreased renal function may favor BKV infection.
Collapse
|
29
|
El Ansary M, Abd Elhamid S, Saadi G, Ismail W, Ibrahim N, Bahaa El-Din N, Alhsyek S. Prevalence of polyoma BK virus infection among living-donor renal transplant recipients. Transpl Infect Dis 2016; 18:529-37. [PMID: 27226063 DOI: 10.1111/tid.12557] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 02/25/2016] [Accepted: 03/17/2016] [Indexed: 02/05/2023]
Abstract
BACKGROUND Polyomavirus nephropathy (PVN) mainly caused by BK polyomavirus (BKPyV) remains the most common productive viral infection of the kidney in immunosuppressed patients. The diagnosis of PVN is based on the detection of BK viruria and BK viremia in conjunction with histological findings in the graft biopsy. METHODS Our study was aimed to estimate the prevalence of productive BKPyV infection among renal transplant patients within the first year post-transplant and identify those at risk of developing PVN. Our cross-sectional study was conducted on 134 kidney transplant patients. Evidence of BKPyV replication was assessed by viral quantification of blood and urine samples of studied patients using a quantitative real-time polymerase chain reaction (Q-PCR)PCR), detection of decoy cells in urine cytology smears, histological examination of graft biopsies from Q-PCR BKPyV-positive patients, and immunohistochemical staining by simian virus 40 (SV40) antibody. RESULTS Significant BKPyV infection was prevalent in 8% (n = 11) of our patients, with a peak of BKPyV infection about 8 months post transplant. BKPyV viral load by Q-PCR assay in these patients varied from 1350 to 20,000,000 (1.35 × 10(3) to 2 × 10(7) ) copies/mL for urine samples and 935 to 18,920 (9.35 × 10(2) to 1.89 × 10(4) ) copies/mL for blood samples. All the 11 patients were positive for decoy cells but only 3 developed PVN based on histology and positive SV40 staining. BKPyV infection was more prevalent in older patients. All patients responded to reduction in their immunosuppressive regimens, apart from 2 patients who required replacement of calcineurin inhibitors-based regimen with mammalian target of ramapycin inhibitors with an overall good response. CONCLUSION Protocol screening programs based on detection of viral replication by viruria, viremia, and decoy cells in urine are necessary to shed light on patients with high virus replication and hence increased risk of developing PVN, and to allow early diagnosis and intervention.
Collapse
Affiliation(s)
- M El Ansary
- Department of Clinical Pathology, Kasr El-Aini, Cairo University, Cairo, Egypt
| | - S Abd Elhamid
- Department of Clinical Pathology, Kasr El-Aini, Cairo University, Cairo, Egypt
| | - G Saadi
- Department of Internal Medicine & Nephrology, Kasr El-Aini, Cairo University, Cairo, Egypt
| | - W Ismail
- Department of Pathology, Faculty of Medicine, BeniSuef University, BeniSuef, Egypt
| | - N Ibrahim
- Department of Clinical Pathology, Kasr El-Aini, Cairo University, Cairo, Egypt
| | - N Bahaa El-Din
- Department of Clinical Pathology, Kasr El-Aini, Cairo University, Cairo, Egypt
| | - S Alhsyek
- Department of Biochemistry, Faculty of Science, Trebles University, Trebles, Libya
| |
Collapse
|
30
|
Pai D, Mann DM, Malik A, Hoover DR, Fyfe B, Mann RA. Risk Factors for the Development of BK Virus Nephropathy in Renal Transplant Recipients. Transplant Proc 2016; 47:2465-9. [PMID: 26518952 DOI: 10.1016/j.transproceed.2015.08.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Accepted: 08/03/2015] [Indexed: 12/16/2022]
Abstract
The BK polyoma virus has, in recent years, become a significant cause of renal allograft dysfunction and failure. Among 260 adult kidney transplant recipients, those with biopsy-proven BK virus nephropathy (BKVN) were compared with those without BKVN with regard to gender, age, race, rejection episodes, time on dialysis, number of organs transplanted, HLA match, live donor versus deceased donor, cold ischemia time, delayed graft function, cytomegalovirus (CMV) serostatus of donor and recipient, induction therapy, and maintenance immunosuppression. Episodes of rejection (35.7% of patients with BKVN vs 8.5% of patients without BKVN; P = .01), transplantation of >1 organ (35.7% of patients with BKVN vs 9.0% of patients without BKVN; P = .01), positive CMV serology in both donor and recipient (71.4% of patients with BKVN vs 41.1% of patients without BKVN; P = .03), and a greater cumulative dose of daclizumab use at the time of induction (2.24 ± 0.05 mg/kg in patients with BKVN vs 2.03 ± 0.14 mg/kg in patients without BKVN; P = .04) were statistically significant risk factors for the development of BKVN. Those who developed BKVN received a higher mean cumulative dose of rabbit antithymoglobulin for induction therapy, but that difference failed to achieve statistical significance (P = .07).
Collapse
Affiliation(s)
- D Pai
- Department of Medicine, Division of Nephrology at Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - D M Mann
- Temple University School of Medicine, Philadelphia, Pennsylvania; Department of Neurosurgery, University of Colorado School of Medicine, Denver, Colorado
| | - A Malik
- Department of Medicine, Division of Nephrology at Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - D R Hoover
- Department of Statistics at Rutgers University, New Brunswick, New Jersey
| | - B Fyfe
- Department of Pathology at Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - R A Mann
- Department of Medicine, Division of Nephrology at Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey.
| |
Collapse
|
31
|
Sharma R, Tzetzo S, Patel S, Zachariah M, Sharma S, Melendy T. BK Virus in Kidney Transplant: Current Concepts, Recent Advances, and Future Directions. EXP CLIN TRANSPLANT 2016; 14:377-84. [PMID: 27267780 DOI: 10.6002/ect.2016.0030] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BK virus nephropathy is a challenging clinical problem in kidney transplant recipients with wide range of surveillance and management practices, based on individual experience. BK virus reactivation in kidney transplant recipients can result in BK virus nephropathy and graft loss. The most effective strategy for early diagnosis and treatment of BK virus nephropathy is regular monitoring for BK virus, currently achieved by quantification of viral DNA in blood by quantitative polymerase chain reaction. Immunosuppression reduction remains the mainstay of treatment; however, viral clearance is often followed by acute rejection, likely secondary to a delay between immune reconstitution and viral clearance. Impaired cell-mediated immune response to BK virus has been shown to correlate with progression to BK virus nephropathy, while reconstitution of this response correlates with resolution of nephropathy. There is recent research to support monitoring BK virus-specific cell-mediated immune response as a predictor of disease progression and resolution. In this article, we review the current concepts and recent developments in understanding BK virus-associated disease in the context of kidney transplant and outline areas for future research.
Collapse
Affiliation(s)
- Rajeev Sharma
- From the Department of Surgery, State University of New York, Buffalo, New York, USA
| | | | | | | | | | | |
Collapse
|
32
|
Gonzalez S, Escobar-Serna DP, Suarez O, Benavides X, Escobar-Serna JF, Lozano E. BK Virus Nephropathy in Kidney Transplantation: An Approach Proposal and Update on Risk Factors, Diagnosis, and Treatment. Transplant Proc 2016; 47:1777-85. [PMID: 26293050 DOI: 10.1016/j.transproceed.2015.05.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2015] [Revised: 04/30/2015] [Accepted: 05/14/2015] [Indexed: 12/16/2022]
Abstract
BK virus belongs to Polyomaviridae family; it causes 95% of nephropathy cases related to polyomavirus, with the other 5% caused by JC virus. Nephropathy jeopardizes graft function, causing a premature failure of the graft in 1%-10% of patients with kidney transplants. Nowadays, antiviral effective treatment is unknown, which is why blood and urine screening of renal transplantation patients has become the most important recommendation to guide the decrease of immunosuppression, and the only proven method to decrease poor outcomes. Different interventions, such as cidofovir, leflunomide, fluoroquinolones, and intravenous immunoglobulin, have been attempted with no improvement at all. This review aims to summarize the most relevant features of BK virus, historical issues, transmission mechanisms, risk factors, and therapeutic interventions.
Collapse
Affiliation(s)
- S Gonzalez
- Organ and Tissues Transplant Group, Surgery Department, Medical School, National University of Colombia, Bogotá, Colombia.
| | - D P Escobar-Serna
- Organ and Tissues Transplant Group, Surgery Department, Medical School, National University of Colombia, Bogotá, Colombia
| | - O Suarez
- Organ and Tissues Transplant Group, Surgery Department, Medical School, National University of Colombia, Bogotá, Colombia
| | - X Benavides
- Organ and Tissues Transplant Group, Surgery Department, Medical School, National University of Colombia, Bogotá, Colombia
| | - J F Escobar-Serna
- Internal Medicine and Critical Care, Universidad de Antioquia, Medellín, Colombia
| | - E Lozano
- Organ and Tissues Transplant Group, Surgery Department, Medical School, National University of Colombia, Bogotá, Colombia; Hospital Universitario San Ignacio, Bogotá, Colombia
| |
Collapse
|
33
|
Koch M, Wiech T, Marget M, Peine S, Thude H, Achilles EG, Fischer L, Lehnhardt A, Thaiss F, Nashan B. De novomTOR inhibitor-based immunosuppression in ABO-incompatible kidney transplantation. Clin Transplant 2015; 29:1021-8. [DOI: 10.1111/ctr.12624] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/28/2015] [Indexed: 01/05/2023]
Affiliation(s)
- Martina Koch
- Department of Hepatobiliary Surgery and Transplantation; Universitätsklinikum Hamburg Eppendorf; Hamburg Germany
| | - Thorsten Wiech
- Section Nephropathology; Institute of Pathology; Universitätsklinikum Hamburg Eppendorf; Hamburg Germany
| | - Matthias Marget
- HLA Laboratory; Institute of Transfusion Medicine; Universitätsklinikum Hamburg Eppendorf; Hamburg Germany
| | - Sven Peine
- HLA Laboratory; Institute of Transfusion Medicine; Universitätsklinikum Hamburg Eppendorf; Hamburg Germany
| | - Hansjörg Thude
- Department of Hepatobiliary Surgery and Transplantation; Universitätsklinikum Hamburg Eppendorf; Hamburg Germany
| | - Eike G. Achilles
- Department of Hepatobiliary Surgery and Transplantation; Universitätsklinikum Hamburg Eppendorf; Hamburg Germany
| | - Lutz Fischer
- Department of Hepatobiliary Surgery and Transplantation; Universitätsklinikum Hamburg Eppendorf; Hamburg Germany
| | - Anja Lehnhardt
- Department of Hepatobiliary Surgery and Transplantation; Universitätsklinikum Hamburg Eppendorf; Hamburg Germany
| | - Friedrich Thaiss
- III. Medical Clinic/Nephrology; Universitätsklinikum Hamburg Eppendorf; Hamburg Germany
| | - Bjoern Nashan
- Department of Hepatobiliary Surgery and Transplantation; Universitätsklinikum Hamburg Eppendorf; Hamburg Germany
| |
Collapse
|
34
|
Helfrich M, Ison M. Opportunistic infections complicating solid organ transplantation with alemtuzumab induction. Transpl Infect Dis 2015; 17:627-36. [DOI: 10.1111/tid.12428] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2014] [Revised: 04/26/2015] [Accepted: 07/17/2015] [Indexed: 12/12/2022]
Affiliation(s)
- M. Helfrich
- Northwestern University Transplant Outcomes Research Collaborative; Northwestern University Feinberg School of Medicine; Chicago Illinois USA
| | - M.G. Ison
- Northwestern University Transplant Outcomes Research Collaborative; Northwestern University Feinberg School of Medicine; Chicago Illinois USA
- Divisions of Infectious Diseases & Organ Transplantation; Northwestern University Feinberg School of Medicine; Chicago Illinois USA
| |
Collapse
|
35
|
Querido S, Jorge C, Sousa H, Birne R, Matias P, Weigert A, Adragão T, Bruges M, Ramos S, Santos M, Paixão P, Curran M, Machado D. JC polyomavirus nephropathy confirmed by using an in-house polymerase chain reaction method. Transpl Infect Dis 2015. [DOI: 10.1111/tid.12426] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- S. Querido
- Department of Nephrology; Médio Tejo Hospitalar Center; Torres Novas Portugal
| | - C. Jorge
- Department of Nephrology; Santa Cruz Hospital; Carnaxide Portugal
| | - H. Sousa
- Department of Nephrology; Santa Cruz Hospital; Carnaxide Portugal
| | - R. Birne
- Department of Nephrology; Santa Cruz Hospital; Carnaxide Portugal
| | - P. Matias
- Department of Nephrology; Santa Cruz Hospital; Carnaxide Portugal
| | - A. Weigert
- Department of Nephrology; Santa Cruz Hospital; Carnaxide Portugal
| | - T. Adragão
- Department of Nephrology; Santa Cruz Hospital; Carnaxide Portugal
| | - M. Bruges
- Department of Nephrology; Santa Cruz Hospital; Carnaxide Portugal
| | - S. Ramos
- Department of Pathology; Lisbon Ocidental Hospitalar Center; Lisbon Portugal
| | - M. Santos
- Department of Clinical Pathology; Lisbon Central Hospitalar Center; Lisbon Portugal
| | - P. Paixão
- Nova Medical School; Lisbon Portugal
| | - M.D. Curran
- Clinical Microbiology and Public Health Laboratory; Public Health England; Addenbrooke's Hospital; Cambridge UK
| | - D. Machado
- Department of Nephrology; Santa Cruz Hospital; Carnaxide Portugal
| |
Collapse
|
36
|
Huang G, Zhang L, Liang X, Qiu J, Deng R, Li J, Chen G, Dong Y, Chen L. Risk factors for BK virus infection and BK virus-associated nephropathy under the impact of intensive monitoring and pre-emptive immunosuppression reduction. Transplant Proc 2015; 46:3448-54. [PMID: 25498070 DOI: 10.1016/j.transproceed.2014.08.036] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Accepted: 08/19/2014] [Indexed: 12/16/2022]
Abstract
BACKGROUND BK virus (BKV) nephropathy (BKVN) is an increasingly recognized cause of kidney allograft loss and is thought to be related to the newer, more potent immunosuppressive agents. However, the risk factors for different types of BKV infection under the impact of intensive monitoring and reduction of maintenance immunosuppression are not well understood. METHODS Quantitative BKV DNA surveillance in plasma/urine and cytological testing in urine were performed regularly within the first year post-transplantation in 229 kidney recipients. Patients with BK viremia and BKVAN treated with immunosuppression reduction were monitored for BKV every 3-6 months. All the patients were followed up for a minimum of 5 years to exclude later development of BKVAN. Potential variables were compared and analyzed using logistic regression model multivariate analysis to assess and rank the BKV infection-related factors. RESULTS Seventy-eight (34.1%) patients had decoy cells, 99 (43.2%) BK viruria, 38 (16.6%) BK viremia, and 7 (3.1%) BKVAN. Risk for decoy cells, BK viruria, and viremia, and BKVAN in univariate analyses were higher with tacrolimus (Tac) and deceased kidney donation. Multivariate analysis showed that Tac ([HR, 2.7; P = .008], [HR, 2.3; P = .016], [HR, 2.9; P = .032]) and deceased kidney donation ([HR, 2.5; P = .004], [HR, 2.6; P = .002], [HR, 2.1; P = .071]) were risk factors for BK decoy cells, BK viruria, and viremia, respectively. BKVAN was inclined to the patients with the combination of Tac and mycophenolate mofetil and longer BKV clearance time. CONCLUSIONS Tac and deceased kidney donation are independent risk factors for BKV infection under the impact of therapeutic drug monitoring.
Collapse
Affiliation(s)
- G Huang
- Department of Organ Transplantation, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - L Zhang
- Department of Kidney Transplantation, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - X Liang
- North Campus, Faculty of Medical Sciences, Sun Yat-sen University, Guangzhou, China
| | - J Qiu
- Department of Organ Transplantation, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - R Deng
- Department of Organ Transplantation, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - J Li
- Department of Organ Transplantation, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - G Chen
- Department of Organ Transplantation, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Y Dong
- Department of Pathology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.
| | - L Chen
- Department of Organ Transplantation, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| |
Collapse
|
37
|
EXP CLIN TRANSPLANTExp Clin Transplant 2015; 13. [DOI: 10.6002/ect.mesot2014.p236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
|
38
|
Wang Z, Vathsala A, Tiong HY. Haematuria in postrenal transplant patients. BIOMED RESEARCH INTERNATIONAL 2015; 2015:292034. [PMID: 25918706 PMCID: PMC4395992 DOI: 10.1155/2015/292034] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/24/2014] [Revised: 02/20/2015] [Accepted: 02/20/2015] [Indexed: 12/25/2022]
Abstract
Haematuria has a prevalence of 12% in the postrenal transplant patient population. It heralds potentially dangerous causes which could threaten graft loss. It is important to consider causes in light of the unique, urological, and immunological standpoints of these patients. We review the literature on common causes of haematuria in postrenal transplant patients and suggest the salient approach to the evaluation of this condition. A major cause of haematuria is urinary tract infections. There should be a higher index of suspicion for mycobacterial, fungal, and viral infection in this group of immunosuppressed patients. Measures recommended in the prevention of urinary tract infections include early removal of foreign bodies as well as prophylactic antibiotics during the early transplant phase. Another common cause of haematuria is that of malignancies, in particular, renal cell carcinomas. When surgically managing cancer in the setting of a renal transplant, one has to be mindful of the limited retropubic space and the need to protect the anastomoses. Other causes include graft rejections, recurrences of primary disease, and calculus formation. It is important to perform a comprehensive evaluation with the aid of an experienced multidisciplinary transplant team.
Collapse
Affiliation(s)
- Ziting Wang
- Department of Urology, National University Health System, 5 Lower Kent Ridge Road, Singapore 119074
| | - Anantharaman Vathsala
- Division of Nephrology, Department of Medicine, National University Health System, 5 Lower Kent Ridge Road, Singapore 119074
- National University Centre for Organ Transplantation, National University Health System, 5 Lower Kent Ridge Road, Singapore 119074
| | - Ho Yee Tiong
- Department of Urology, National University Health System, 5 Lower Kent Ridge Road, Singapore 119074
- National University Centre for Organ Transplantation, National University Health System, 5 Lower Kent Ridge Road, Singapore 119074
| |
Collapse
|
39
|
Guerra AA, Silva GD, Andrade EIG, Cherchiglia ML, Costa JDO, Almeida AM, Acurcio FDA. Cyclosporine versus tacrolimus: cost-effectiveness analysis for renal transplantation in Brazil. Rev Saude Publica 2015; 49:13. [PMID: 25741648 PMCID: PMC4386555 DOI: 10.1590/s0034-8910.2015049005430] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Accepted: 11/09/2014] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVE To analyze the cost-effectiveness of treatment regimens with cyclosporine or tacrolimus, five years after renal transplantation. METHODS This cost-effectiveness analysis was based on historical cohort data obtained between 2000 and 2004 and involved 2,022 patients treated with cyclosporine or tacrolimus, matched 1:1 for gender, age, and type and year of transplantation. Graft survival and the direct costs of medical care obtained from the National Health System (SUS) databases were used as outcome results. RESULTS Most of the patients were women, with a mean age of 36.6 years. The most frequent diagnosis of chronic renal failure was glomerulonephritis/nephritis (27.7%). In five years, the tacrolimus group had an average life expectancy gain of 3.96 years at an annual cost of R$78,360.57 compared with the cyclosporine group with a gain of 4.05 years and an annual cost of R$61,350.44. CONCLUSIONS After matching, the study indicated better survival of patients treated with regimens using tacrolimus. Moreover, regimens containing cyclosporine were more cost-effective [corrected].
Collapse
Affiliation(s)
- Augusto Afonso Guerra
- Departamento de Medicina Preventiva e Social. Faculdade de Medicina. Universidade Federal de Minas Gerais. Belo Horizonte, MG, Brasil
- Departamento de Farmácia Social. Faculdade de Farmácia. Universidade Federal de Minas Gerais. Belo Horizonte, MG, Brasil
| | - Grazielle Dias Silva
- Superintendência de Assistência Farmacêutica. Secretaria de Estado de Saúde de Minas Gerais. Belo Horizonte, MG, Brasil
| | - Eli Iola Gurgel Andrade
- Departamento de Medicina Preventiva e Social. Faculdade de Medicina. Universidade Federal de Minas Gerais. Belo Horizonte, MG, Brasil
| | - Mariângela Leal Cherchiglia
- Departamento de Medicina Preventiva e Social. Faculdade de Medicina. Universidade Federal de Minas Gerais. Belo Horizonte, MG, Brasil
| | - Juliana de Oliveira Costa
- Departamento de Farmácia Social. Faculdade de Farmácia. Universidade Federal de Minas Gerais. Belo Horizonte, MG, Brasil
| | - Alessandra Maciel Almeida
- Departamento de Medicina Preventiva e Social. Faculdade de Medicina. Universidade Federal de Minas Gerais. Belo Horizonte, MG, Brasil
| | - Francisco de Assis Acurcio
- Departamento de Medicina Preventiva e Social. Faculdade de Medicina. Universidade Federal de Minas Gerais. Belo Horizonte, MG, Brasil
- Departamento de Farmácia Social. Faculdade de Farmácia. Universidade Federal de Minas Gerais. Belo Horizonte, MG, Brasil
| |
Collapse
|
40
|
Ducharme-Smith A, Katz BZ, Bobrowski AE, Backer CL, Rychlik K, Pahl E. Prevalence of BK polyomavirus infection and association with renal dysfunction in pediatric heart transplant recipients. J Heart Lung Transplant 2014; 34:222-6. [PMID: 25540880 DOI: 10.1016/j.healun.2014.09.043] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2014] [Revised: 09/09/2014] [Accepted: 09/30/2014] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND BK polyomavirus (BKV) infection and nephropathy complicate renal allografts; however, their effect in the native kidneys of pediatric heart transplant (HTx) recipients is unknown. We assessed the prevalence of BKV infection and its association with kidney dysfunction in survivors of pediatric HTx. METHODS A single-center retrospective study compared pediatric (aged <18 years ) HTx recipients, with and without BKV (controls), who received an allograft from May 1989 to July 2013. Screening of urine for BKV was performed in patients with chronic kidney disease (CKD) stage ≥2 since 2006, and since April 2012 in all HTx recipients at least at an annual evaluation. Serum for BKV DNA was assayed if BK viruria was present. Data collected included recipient and donor demographics, the immunosuppressive regimen, and history of Epstein-Bar virus (EBV) and cytomegalovirus infection. Statistics included Fisher's exact test, chi-square test, Student's t-test, and multivariate logistic regression. RESULTS Of 98 eligible recipients, 83 (85%) were screened: 28 (34%) had BK viruria, and 7 had BK viremia. One viremic patient had biopsy-proven BKV nephropathy that progressed to end-stage renal disease. Risk factors for BK viruria were (1) longer duration since HTx (6.02 vs 2.95 years; p = 0.01), (2) worsening estimated glomerular filtration rate (71.3 vs 86.3 ml/min/1.73 m(2), p = 0.03), (3) history of EBV infection (p = 0.0002), and (4) use of sirolimus (p = 0.0003). After multivariate logistic-regression, only history of EBV infection remained associated with BKV infection (p = 0.015). CONCLUSIONS BKV may lead to BK viremia and BK nephropathy in pediatric HTx patients. Routine screening for BK viruria should be considered.
Collapse
Affiliation(s)
| | | | | | - Carl L Backer
- Departments of b?>Pediatrics; Surgery; c?>Siragusa Transplant Center, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | | | | |
Collapse
|
41
|
|
42
|
Hässig A, Roos M, Etter A, Bossart W, Müller N, Schiesser M, Wüthrich RP, Fehr T. Association of BK viremia with human leukocyte antigen mismatches and acute rejection, but not with type of calcineurin inhibitor. Transpl Infect Dis 2013; 16:44-54. [PMID: 24134704 DOI: 10.1111/tid.12153] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2013] [Revised: 03/31/2013] [Accepted: 04/21/2013] [Indexed: 12/14/2022]
Abstract
INTRODUCTION BK viremia and polyomavirus-associated nephropathy (PVN) represent a significant problem after kidney transplantation. Both are associated with intensified immunosuppression, but other risk factors and the impact of a screening program on outcome are incompletely understood. METHODS Here, we report on the short- and long-term outcome of a cohort of patients, who were transplanted in 2006/2007 and included in a newly introduced systematic 3-monthly screening for BK viremia at the University Hospital Zurich. In patients testing positive for BK viremia, screening frequency was intensified and immunosuppression reduced. Patients with suspected PVN underwent transplant biopsy. RESULTS Among 152 included patients, 49 (32%) tested positive for BK viremia, but only 8 developed biopsy-proven PVN. BK viremia had a significant impact on estimated glomerular filtration rate and proteinuria in the first 2 years. Acute rejection episodes and the number of human leukocyte antigen (HLA) mismatches were the strongest independent predictors of BK viremia in a multiple logistic model. In contrast, no particular immunosuppressive agent or regimen was associated with enhanced risk. CONCLUSION Taken together, systematic BK viremia screening led to detection of a high percentage of viremic patients. With adjustment of immunosuppression, an excellent outcome was achieved. The independent association of HLA mismatches with BK viremia suggests impaired polyomavirus immunosurveillance in highly mismatched allografts.
Collapse
Affiliation(s)
- A Hässig
- Division of Nephrology, University Hospital Zurich, Zurich, Switzerland
| | | | | | | | | | | | | | | |
Collapse
|
43
|
Kim H, Yang W, Han D, Park S. Clinical Courses of Renal Transplant Recipients with High BK Viremia. Transplant Proc 2013; 45:2975-9. [DOI: 10.1016/j.transproceed.2013.08.033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
44
|
Umbro I, Anzivino E, Tinti F, Zavatto A, Bellizzi A, Rodio DM, Mancini C, Pietropaolo V, Mitterhofer AP. Possible antiviral effect of ciprofloxacin treatment on polyomavirus BK replication and analysis of non-coding control region sequences. Virol J 2013; 10:274. [PMID: 24004724 PMCID: PMC3766702 DOI: 10.1186/1743-422x-10-274] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2013] [Accepted: 08/26/2013] [Indexed: 01/02/2023] Open
Abstract
Acute renal dysfunction (ARD) is a common complication in renal transplant recipients. Multiple factors contribute to ARD development, including acute rejection and microbial infections. Many viral infections after kidney transplantation result from reactivation of “latent” viruses in the host or from the graft, such as the human Polyomavirus BK (BKV). We report the case of a 39 year-old recipient of a 2nd kidney graft who experienced BKV reactivation after a second episode of acute humoral rejection. A 10-day treatment with the quinolone antibiotic ciprofloxacin was administered with an increase of immunosuppressive therapy despite the active BKV replication. Real Time PCR analysis performed after treatment with ciprofloxacin, unexpectedly showed clearance of BK viremia and regression of BK viruria. During the follow-up, BK viremia persisted undetectable while viruria decreased further and disappeared after 3 months. BKV non-coding control region sequence analysis from all positive samples always showed the presence of archetypal sequences, with two single-nucleotide substitutions and one nucleotide deletion that, interestingly, were all representative of the subtype/subgroup I/b-1 we identified by the viral protein 1 sequencing analysis. We report the potential effect of the quinolone antibiotic ciprofloxacin in the decrease of the BKV load in both blood and urine.
Collapse
Affiliation(s)
- Ilaria Umbro
- Department of Clinical Medicine, Nephrology and Dialysis Unit, "Sapienza" University of Rome, Viale dell'Università 37, Rome 00185, Italy.
| | | | | | | | | | | | | | | | | |
Collapse
|
45
|
Myint TMM, Turner RM, Craig JC, Cross NB, Kable K, Nankivell BJ, Chapman JR, Webster AC, O'Connell P, Dwyer DE, Jeoffreys N, Roger SD, Wong G. Test performance characteristics of quantitative nucleic acid testing for polyomaviruses in kidney and kidney-pancreas transplant recipients. Clin Transplant 2013; 27:E571-9. [PMID: 23952788 DOI: 10.1111/ctr.12195] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/19/2013] [Indexed: 12/16/2022]
Abstract
Screening for polyoma BK virus (BK) using nucleic testing (NAT) is recommended for kidney and kidney-pancreas transplant recipients, but the performance characteristics of quantitative BK NAT at different thresholds of plasma BK viral loads are unclear. We aim to evaluate the diagnostic accuracy of quantitative BK NAT as an add-on test to qualitative polyoma NAT for the diagnosis of BK virus-associated nephropathy (BKVAN) in kidney and kidney transplant recipients. We calculated the test sensitivity, specificity, and predictive values at the different thresholds of plasma BK viral load for BKVAN. At the recommended threshold of >1 × 10(3) serum BK copies/mL serum for test positivity, the sensitivity for BKVAN was 92.9% (95% confidence intervals [CI]: 66.1-99.8) and specificity 79.1% (95%: CI 67.4-88.1), with corresponding positive and negative predictive values of 42.0% (95% CI: 24.8-57.7%) and 98.6% (95% CI: 98.3-99.9%), respectively. The overall area under curve for the quantitative BK NAT was 0.92 (95% CI: 0.85-0.97). Quantitative BK NAT displays properties of high sensitivity and specificity that are fit for purpose as an add-on test to qualitative polyomavirus NAT for kidney and kidney-pancreas transplant recipients at risk of BKVAN.
Collapse
Affiliation(s)
- T M M Myint
- Department of Renal Medicine and Transplantation, Westmead Hospital, Westmead, NSW, Australia
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
46
|
Screening for BK viremia reduces but does not eliminate the risk of BK nephropathy: a single-center retrospective analysis. Transplantation 2013; 95:949-54. [PMID: 23545506 DOI: 10.1097/tp.0b013e31828423cd] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND This study reviewed the outcomes of a screening protocol for BK viremia to determine if early diagnosis, followed by immunosuppression minimization, would prevent progression to nephropathy and graft loss. METHODS This review included 369 renal transplant recipients tested for BK virus at serial time points after transplantation. Management included immunosuppression minimization plus cidofovir treatment for BK nephropathy. RESULTS Recipients received tacrolimus-based immunosuppression, with 8% prednisone-free and 6% who received desensitization. With a mean follow-up of 22 ± 10 months, 16% (n = 57) of recipients became BK viremia positive. The median (range) time to diagnosis was 3 (1-17) months. Because renal biopsy was performed selectively, 59% of recipients underwent biopsy, with 47% showing BK nephropathy. Seventy-four percent of recipients cleared the virus at a median (range) time of 9 (3-33) months, with four grafts lost to BK nephropathy. Cidofovir-treated recipients displayed a higher viral load at diagnosis but showed equivalent renal function at last evaluation. In multivariate analysis, recipient age, Asian ethnicity, deceased donor, and prednisone use were factors independently associated with BK viremia. Actuarial survival of BK-positive grafts was worse than that of BK-negative grafts (P<0.01, log-rank test). At 9 and 12 months, the mean estimated glomerular filtration rate of the BK-positive group was lower than that of the BK-negative cohort (P = 0.02). CONCLUSIONS Despite using a screening protocol combined with immunosuppression minimization, BK-positive recipients had a greater risk of graft loss and impaired function than recipients free of infection. Future investigations should focus on practices to prevent BK viremia.
Collapse
|
47
|
Chehadeh W, Nampoory MR. Genotypic diversity of polyomaviruses circulating among kidney transplant recipients in Kuwait. J Med Virol 2013; 85:1624-31. [PMID: 23775307 DOI: 10.1002/jmv.23639] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/04/2013] [Indexed: 11/10/2022]
Abstract
BK virus (BKV) and JC virus (JCV) are human polyomaviruses that cause asymptomatic latent infections. Under immunosuppression, BKV-associated nephropathy has been documented in Kuwait and elsewhere. Even though different BKV and JCV genotypes with distinct geographical distribution have been described, the genotype of polyomavirus detected in Kuwait is still unknown. The aim of this study was to determine the genotypes of BKV and JCV detected in renal transplant recipients. The detection of polyomavirus DNA was carried out in serum and urine samples of 200 post-transplant recipients during a 1-year follow-up period. Fifty-one (25.5%) post-transplant recipients were tested positive for polyomavirus DNA by semi-nested PCR. JCV DNA could be detected in 29 (57%) patients, and BKV DNA in 22 (43%) patients. In two renal transplant recipients, both BKV and JCV were detected. According to the Bayesian phylogenetic analysis of polyomavirus VP1 sequences, the majority of detected BKV sequences were most closely related to genotypes I and IV, whereas the majority of JCV sequences were most closely related to genotype 3. Polyomavirus VP1 sequences showed strong stability for up to 12 months in most patients; however, in one patient, an amino acid substitution in the BKV VP1 protein was identified over time. The results suggest a close relationship of BKV sequences with the Asian and European strains, and of JCV sequences with the African strains. Long follow-up studies are needed to investigate the association of polyomavirus polymorphism or genotypic shift with the development of nephropathy.
Collapse
Affiliation(s)
- Wassim Chehadeh
- Virology Unit, Department of Microbiology, Faculty of Medicine, Kuwait University, Jabriya, Kuwait.
| | | |
Collapse
|
48
|
Cristelli M, Tedesco-Silva H, Medina-Pestana J, Franco M. Safety profile comparing azathioprine and mycophenolate in kidney transplant recipients receiving tacrolimus and corticosteroids. Transpl Infect Dis 2013; 15:369-78. [DOI: 10.1111/tid.12095] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2012] [Revised: 08/16/2012] [Accepted: 01/08/2013] [Indexed: 11/26/2022]
Affiliation(s)
- M.P. Cristelli
- Transplant Division; Hospital do Rim e Hipertensão; UNIFESP; São Paulo; SP; Brazil
| | - H. Tedesco-Silva
- Transplant Division; Hospital do Rim e Hipertensão; UNIFESP; São Paulo; SP; Brazil
| | - J.O. Medina-Pestana
- Transplant Division; Hospital do Rim e Hipertensão; UNIFESP; São Paulo; SP; Brazil
| | - M.F. Franco
- Transplant Division; Hospital do Rim e Hipertensão; UNIFESP; São Paulo; SP; Brazil
| |
Collapse
|
49
|
Abstract
The human BK polyomavirus (BKV) is the major cause of polyomavirus-associated nephropathy (PyVAN) putting 1-15% of kidney transplant patients at risk of premature allograft failure, but is less common in other solid organ transplants. Because effective antiviral therapies are lacking, screening kidney transplant patients for BKV replication in urine and blood has become the key recommendation to guide the reduction of immunosuppression in patients with BKV viremia. This intervention allows for expanding BKV-specific cellular immune responses, curtailing of BKV replication in the graft, and clearance of BKV viremia in 70-90% patients. Postintervention rejection episodes occur in 8-12%, most of which are corticosteroid responsive. Late diagnosis is faced with irreversible functional decline, poor treatment response, and graft loss. Adjunct therapies such as cidofovir, leflunomide and intravenous immunoglobulins have been used, but the benefit is not documented in trials. Retransplantation after PyVAN is largely successful, but requires close monitoring for recurrent BKV viremia.
Collapse
Affiliation(s)
- H H Hirsch
- Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland.
| | | | | |
Collapse
|
50
|
Brennan DC, Aguado JM, Potena L, Jardine AG, Legendre C, Säemann MD, Mueller NJ, Merville P, Emery V, Nashan B. Effect of maintenance immunosuppressive drugs on virus pathobiology: evidence and potential mechanisms. Rev Med Virol 2012; 23:97-125. [PMID: 23165654 DOI: 10.1002/rmv.1733] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2012] [Revised: 09/07/2012] [Accepted: 09/20/2012] [Indexed: 12/11/2022]
Abstract
Recent evidence suggesting a potential anti-CMV effect of mTORis is of great interest to the transplant community. However, the concept of an immunosuppressant with antiviral properties is not new, with many accounts of the antiviral properties of several agents over the years. Despite these reports, to date, there has been little effort to collate the evidence into a fuller picture. This manuscript was developed to gather the evidence of antiviral activity of the agents that comprise a typical immunosuppressive regimen against viruses that commonly reactivate following transplant (HHV1 and 2, VZV, EBV, CMV and HHV6, 7, and 8, HCV, HBV, BKV, HIV, HPV, and parvovirus). Appropriate immunosuppressive regimens posttransplant that avoid acute rejection while reducing risk of viral reactivation are also reviewed. The existing literature was disparate in nature, although indicating a possible stimulatory effect of tacrolimus on BKV, potentiation of viral reactivation by steroids, and a potential advantage of mammalian target of rapamycin (mTOR) inhibition in several viral infections, including BKV, HPV, and several herpesviruses.
Collapse
|