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Barrett-Chan E, Wang L, Bone J, Thachil A, Vytlingam K, Blydt-Hansen T. Optimizing the approach to monitoring allograft inflammation using serial urinary CXCL10/creatinine testing in pediatric kidney transplant recipients. Pediatr Transplant 2024; 28:e14718. [PMID: 38553815 DOI: 10.1111/petr.14718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 01/04/2024] [Accepted: 02/05/2024] [Indexed: 04/02/2024]
Abstract
BACKGROUND Urinary CXCL10/creatinine (uCXCL10/Cr) is proposed as an effective biomarker of subclinical rejection in pediatric kidney transplant recipients. This study objective was to model implementation in the clinical setting. METHODS Banked urine samples at a single center were tested for uCXCL10/Cr to validate published thresholds for rejection diagnosis (>80% specificity). The positive predictive value (PPV) for rejection diagnosis for uCXCL10/Cr-indicated biopsy was modeled with first-positive versus two-test-positive approaches, with accounting for changes associated with urinary tract infection (UTI), BK and CMV viremia, and subsequent recovery. RESULTS Seventy patients aged 10.5 ± 5.6 years at transplant (60% male) had n = 726 urine samples with n = 236 associated biopsies (no rejection = 167, borderline = 51, and Banff 1A = 18). A threshold of 12 ng/mmol was validated for Banff 1A versus no-rejection diagnosis (AUC = 0.74, 95% CI = 0.57-0.92). The first-positive test approach (n = 69) did not resolve a clinical diagnosis in 38 cases (55%), whereas the two-test approach resolved a clinical diagnosis in the majority as BK (n = 17/60, 28%), CMV (n = 4/60, 7%), UTI (n = 8/60, 13%), clinical rejection (n = 5/60, 8%), and transient elevation (n = 18, 30%). In those without a resolved clinical diagnosis, PPV from biopsy for subclinical rejection is 24% and 71% (p = .017), for first-test versus two-test models, respectively. After rejection treatment, uCXCL10/Cr level changes were all concordant with change in it-score. Sustained uCXCL10/Cr after CMV and BK viremia resolution was associated with later acute rejection. CONCLUSIONS Urinary CXCL10/Cr reliably identifies kidney allograft inflammation. These data support a two-test approach to reliably exclude other clinically identifiable sources of inflammation, for kidney biopsy indication to rule out subclinical rejection.
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Affiliation(s)
| | - Li Wang
- University of British Columbia, Vancouver, British Columbia, Canada
- BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada
| | - Jeffrey Bone
- BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada
| | - Amy Thachil
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Kevin Vytlingam
- BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada
| | - Tom Blydt-Hansen
- University of British Columbia, Vancouver, British Columbia, Canada
- BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada
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2
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Wong G, Myint TM, Lee YJ, Craig JC, Axelrod D, Kiberd B. Economic Evaluation of Screening for Polyomavirus Infection in Kidney Transplant Recipients: A Cost-Utility Analysis. Transplant Direct 2022; 8:e1318. [PMID: 35464876 PMCID: PMC9018998 DOI: 10.1097/txd.0000000000001318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 02/15/2022] [Accepted: 03/02/2022] [Indexed: 11/25/2022] Open
Abstract
Screening for polyomavirus infection after kidney transplantation is recommended by clinical practice guidelines, but cost-effectiveness of this strategy is uncertain. The aim of this study was to estimate the incremental costs and benefits of routine screening for polyomavirus infection compared with no screening in kidney transplant recipients.
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Shanmugham S, Bhadauria D, Agrawal V, Jain M, Yaccha M, Kaul A, Vamsidhar V, Meyappan J, Prasad N. The diagnostic and therapeutic dilemma of the co-existence of BK virus nephropathy with acute rejection - an experience from a single Centre and review of the literature. Transpl Immunol 2022; 72:101581. [PMID: 35301106 DOI: 10.1016/j.trim.2022.101581] [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: 02/17/2022] [Revised: 03/07/2022] [Accepted: 03/07/2022] [Indexed: 11/29/2022]
Abstract
INTRODUCTION BKV nephropathy (BKVN) is one of the major causes of graft loss with the advent of potent immunosuppressive drugs. The literature on the co-existence of acute rejection (AR) and BKVN is scarce. MATERIALS AND METHODS This is a single-center retrospective analysis, where the allograft biopsies of patients transplanted between 2011 and 2021 were reviewed. The biopsies, which showed evidence of coexistent AR and BKVN, were included. In addition, demographic profiles, clinical presentation, treatment details, response to therapy, and follow-up were analyzed. RESULTS Out of 1175 live transplants done between January 2011 and March 2021, 49 had BKVN representing 4.17%. Only seven patients (0.59%) had coexistent BKVN with AR. The mean serum creatinine at presentation was 2.3 mg/dl. The mean duration to diagnosis from transplant was seven months (range 3-22 months). All had significant viremia at presentation (17450-4,750,000 copies/ml). All biopsies showed type 1 inclusion bodies with SV40 positivity except one. Coexistent acute T cell-mediated rejection (TCMR) was found in five and acute ABMR in two patients. Three patients received pulse IV methylprednisolone, five received 2 g/kg IVIG, two received plasma exchange as upfront therapies. Maintenance immunosuppression reduction was made in all. Viremia clearance was noted at a mean duration of 3.5 months. However, three patients lost their grafts on follow-up. Four had stable graft function with a mean serum creatinine of 1.54 mg/dl. CONCLUSION Intensifying immunosuppression to treat AR followed by a reduction in maintenance immunosuppression and IVIG and antiviral therapies seems optimal strategy and showed good long-term graft survival in patients with coexistent BKVN and AR.
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Affiliation(s)
- Sabarinath Shanmugham
- Department of Nephrology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Dharmendra Bhadauria
- Department of Nephrology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India.
| | - Vinita Agrawal
- Pathology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Manoj Jain
- Pathology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Monika Yaccha
- Department of Nephrology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Anupma Kaul
- Pathology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Veeranki Vamsidhar
- Department of Nephrology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Jeykumar Meyappan
- Department of Nephrology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Narayan Prasad
- Department of Nephrology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
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4
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Shen J, Guo L, Lei W, Liu S, Yan P, Liu H, Zhou J, Zhou Q, Liu F, Jiang T, Wang H, Wu J, Chen J, Wang R. Urinary donor-derived cell-free DNA as a non-invasive biomarker for BK polyomavirus-associated nephropathy. J Zhejiang Univ Sci B 2021; 22:917-928. [PMID: 34783222 DOI: 10.1631/jzus.b2100131] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BK polyomavirus-associated nephropathy (BKPyVAN) is a common cause of allograft failure. However, differentiation between BKPyVAN and type I T cell-mediated rejection (TCMR) is challenging when simian virus 40 (SV40) staining is negative, because of the similarities in histopathology. This study investigated whether donor-derived cell-free DNA (ddcfDNA) can be used to differentiate BKPyVAN. Target region capture sequencing was applied to detect the ddcfDNAs of 12 recipients with stable graft function, 22 with type I TCMR, 21 with proven BKPyVAN, and 5 with possible PyVAN. We found that urinary ddcfDNA levels were upregulated in recipients with graft injury, whereas plasma ddcfDNA levels were comparable for all groups. The median urinary concentrations and fractions of ddcfDNA in proven BKPyVAN recipients were significantly higher than those in type I TCMR recipients (10.4 vs. 6.1 ng/mL, P<0.001 and 68.4% vs. 55.3%, P=0.013, respectively). Urinary ddcfDNA fractions (not concentrations) were higher in the BKPyVAN-pure subgroup than in the BKPyVAN-rejection-like subgroup (81.30% vs. 56.64%, P=0.025). With a cut-off value of 7.81 ng/mL, urinary ddcfDNA concentrations distinguished proven BKPyVAN from type I TCMR (area under the curve (AUC)=0.848, 95% confidence interval (95% CI): 0.734 to 0.963). These findings suggest that urinary ddcfDNA is a non-invasive biomarker which can reliably differentiate BKPyVAN from type I TCMR.
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Affiliation(s)
- Jia Shen
- Kidney Disease Center, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China.,National Key Clinical Department of Kidney Diseases, Hangzhou 310003, China.,Key Laboratory of Kidney Disease Prevention and Control Technology of Zhejiang Province, Hangzhou 310003, China.,Zhejiang University Institute of Nephrology, Hangzhou 310003, China
| | - Luying Guo
- Kidney Disease Center, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China.,National Key Clinical Department of Kidney Diseases, Hangzhou 310003, China.,Key Laboratory of Kidney Disease Prevention and Control Technology of Zhejiang Province, Hangzhou 310003, China.,Zhejiang University Institute of Nephrology, Hangzhou 310003, China
| | - Wenhua Lei
- Kidney Disease Center, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China.,National Key Clinical Department of Kidney Diseases, Hangzhou 310003, China.,Key Laboratory of Kidney Disease Prevention and Control Technology of Zhejiang Province, Hangzhou 310003, China.,Zhejiang University Institute of Nephrology, Hangzhou 310003, China
| | - Shuaihui Liu
- Kidney Disease Center, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China.,National Key Clinical Department of Kidney Diseases, Hangzhou 310003, China.,Key Laboratory of Kidney Disease Prevention and Control Technology of Zhejiang Province, Hangzhou 310003, China.,Zhejiang University Institute of Nephrology, Hangzhou 310003, China
| | - Pengpeng Yan
- Kidney Disease Center, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China.,National Key Clinical Department of Kidney Diseases, Hangzhou 310003, China.,Key Laboratory of Kidney Disease Prevention and Control Technology of Zhejiang Province, Hangzhou 310003, China.,Zhejiang University Institute of Nephrology, Hangzhou 310003, China
| | - Haitao Liu
- AlloDx (Shanghai) Biotech., Co., Ltd., Shanghai 201100, China
| | - Jingyi Zhou
- Kidney Disease Center, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China.,National Key Clinical Department of Kidney Diseases, Hangzhou 310003, China.,Key Laboratory of Kidney Disease Prevention and Control Technology of Zhejiang Province, Hangzhou 310003, China.,Zhejiang University Institute of Nephrology, Hangzhou 310003, China
| | - Qin Zhou
- Kidney Disease Center, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China.,National Key Clinical Department of Kidney Diseases, Hangzhou 310003, China.,Key Laboratory of Kidney Disease Prevention and Control Technology of Zhejiang Province, Hangzhou 310003, China.,Zhejiang University Institute of Nephrology, Hangzhou 310003, China
| | - Feng Liu
- AlloDx (Shanghai) Biotech., Co., Ltd., Shanghai 201100, China
| | - Tingya Jiang
- AlloDx (Shanghai) Biotech., Co., Ltd., Shanghai 201100, China
| | - Huiping Wang
- Kidney Disease Center, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China.,National Key Clinical Department of Kidney Diseases, Hangzhou 310003, China.,Key Laboratory of Kidney Disease Prevention and Control Technology of Zhejiang Province, Hangzhou 310003, China.,Zhejiang University Institute of Nephrology, Hangzhou 310003, China
| | - Jianyong Wu
- Kidney Disease Center, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China.,National Key Clinical Department of Kidney Diseases, Hangzhou 310003, China.,Key Laboratory of Kidney Disease Prevention and Control Technology of Zhejiang Province, Hangzhou 310003, China.,Zhejiang University Institute of Nephrology, Hangzhou 310003, China
| | - Jianghua Chen
- Kidney Disease Center, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China.,National Key Clinical Department of Kidney Diseases, Hangzhou 310003, China.,Key Laboratory of Kidney Disease Prevention and Control Technology of Zhejiang Province, Hangzhou 310003, China.,Zhejiang University Institute of Nephrology, Hangzhou 310003, China
| | - Rending Wang
- Kidney Disease Center, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China. .,National Key Clinical Department of Kidney Diseases, Hangzhou 310003, China. .,Key Laboratory of Kidney Disease Prevention and Control Technology of Zhejiang Province, Hangzhou 310003, China. .,Zhejiang University Institute of Nephrology, Hangzhou 310003, China. .,Organ Donation and Coordination Office, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China.
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5
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Parajuli S, Jorgenson M, Meyers RO, Djamali A, Galipeau J. Role of Virus-Specific T Cell Therapy for Cytomegalovirus and BK Infections in Kidney Transplant Recipients. KIDNEY360 2021; 2:905-915. [PMID: 35373059 PMCID: PMC8791350 DOI: 10.34067/kid.0001572021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 03/24/2021] [Indexed: 02/04/2023]
Abstract
Cytomegalovirus (CMV) and BK virus (BKV) are common viral infections after kidney transplant. Their negative effects on patient and graft outcomes have been well described. However, despite improvement in screening and prophylaxis strategies, CMV and BKV continue to negatively affect both short- and long-term graft survival. Adequate cell-mediated immunity is essential for the control and prevention of opportunistic viral infections, such as CMV and BKV. Therefore, immune reconstitution, in particular T cell recovery, is a key factor in antiviral control after kidney transplantation. Cell-based immunotherapy offers an attractive alternative approach to traditional interventions. Adoptive T cell transfer, via infusions of allogeneic virus-specific T lymphocytes is capable of restoring virus-specific T cell immunity, and are safe and effective in the treatment of viral infections after hematopoietic stem cell transplantation. In this article, we review the emerging role of virus-specific T cell therapy in the management of CMV and BKV after kidney transplantation. On the basis of the available data, virus-specific T cell therapy may be a promising addition to the antiviral treatment armamentarium after kidney transplantation. Future studies are needed to more clearly define the efficacy and risks of virus-specific T cell therapy in the kidney transplant population.
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Affiliation(s)
- Sandesh Parajuli
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Margaret Jorgenson
- Department of Pharmacy, University of Wisconsin Hospital and Clinics, Madison, Wisconsin
| | - Ross O. Meyers
- Division of Pharmacy Professional Development, University of Wisconsin-Madison School of Pharmacy, Madison, Wisconsin,Program for Advanced Cell Therapy, University of Wisconsin Hospital and Clinics and School of Medicine and Public Health, Madison Wisconsin
| | - Arjang Djamali
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Jacques Galipeau
- Program for Advanced Cell Therapy, University of Wisconsin Hospital and Clinics and School of Medicine and Public Health, Madison Wisconsin,Division of Hematology and Oncology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin,University of Wisconsin Carbone Cancer Center, Madison, Wisconsin
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6
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Molecular Analysis of Renal Allograft Biopsies: Where Do We Stand and Where Are We Going? Transplantation 2021; 104:2478-2486. [PMID: 32150035 DOI: 10.1097/tp.0000000000003220] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
A renal core biopsy for histological evaluation is the gold standard for diagnosing renal transplant pathology. However, renal biopsy interpretation is subjective and can render insufficient precision, making it difficult to apply a targeted therapeutic regimen for the individual patient. This warrants a need for additional methods assessing disease state in the renal transplant. Significant research activity has been focused on the role of molecular analysis in the diagnosis of renal allograft rejection. The identification of specific molecular expression patterns in allograft biopsies related to different types of allograft injury could provide valuable information about the processes underlying renal transplant dysfunction and can be used for the development of molecular classifier scores, which could improve our diagnostic and prognostic ability and could guide treatment. Molecular profiling has the potential to be more precise and objective than histological evaluation and may identify injury even before it becomes visible on histology, making it possible to start treatment at the earliest time possible. Combining conventional diagnostics (histology, serology, and clinical data) and molecular evaluation will most likely offer the best diagnostic approach. We believe that the use of state-of-the-art molecular analysis will have a significant impact in diagnostics after renal transplantation. In this review, we elaborate on the molecular phenotype of both acute and chronic T cell-mediated rejection and antibody-mediated rejection and discuss the additive value of molecular profiling in the setting of diagnosing renal allograft rejection and how this will improve transplant patient care.
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7
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BK Virus-Associated Nephropathy after Renal Transplantation. Pathogens 2021; 10:pathogens10020150. [PMID: 33540802 PMCID: PMC7913099 DOI: 10.3390/pathogens10020150] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 01/29/2021] [Accepted: 01/29/2021] [Indexed: 02/06/2023] Open
Abstract
Recent advances in immunosuppressive therapy have reduced the incidence of acute rejection and improved renal transplantation outcomes. Meanwhile, nephropathy caused by BK virus has become an important cause of acute or chronic graft dysfunction. The usual progression of infection begins with BK viruria and progresses to BK viremia, leading to BK virus associated nephropathy. To detect early signs of BK virus proliferation before the development of nephropathy, several screening tests are used including urinary cytology and urinary and plasma PCR. A definitive diagnosis of BK virus associated nephropathy can be achieved only histologically, typically by detecting tubulointerstitial inflammation associated with basophilic intranuclear inclusions in tubular and/or Bowman’s epithelial cells, in addition to immunostaining with anti-Simian virus 40 large T-antigen. Several pathological classifications have been proposed to categorize the severity of the disease to allow treatment strategies to be determined and treatment success to be predicted. Since no specific drugs that directly suppress the proliferation of BKV are available, the main therapeutic approach is the reduction of immunosuppressive drugs. The diagnosis of subsequent acute rejection, the definition of remission, the protocol of resuming immunosuppression, and long-term follow-up remain controversial.
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8
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Donor-derived Cell-free DNA and the Prediction of BK Virus-associated Nephropathy. Transplant Direct 2020; 6:e622. [PMID: 33134498 PMCID: PMC7587413 DOI: 10.1097/txd.0000000000001061] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 08/03/2020] [Accepted: 08/05/2020] [Indexed: 12/23/2022] Open
Abstract
Approximately 15% of kidney transplant recipients (KTRs) develop BK viremia (BKV), with 1%-10% developing BK virus-associated nephropathy (BKVAN), which histologically resembles rejection. The Diagnosing Acute Rejection in Kidney Transplant Recipients (DART) study showed that donor-derived cell-free DNA (dd-cfDNA) levels <1% have a negative predictive value of 85% for active allograft rejection. Using data from this study, we evaluated the association of dd-cfDNA with plasma BK viral loads and biopsy findings to determine if dd-cfDNA can distinguish asymptomatic BKV from BKVAN. Methods Data on dd-cfDNA, plasma BK viral loads, and biopsy findings from patients from the DART study were retrospectively examined. BKV was defined as 500-10 000 copies/mL. Presumptive BKVAN was defined as BK >10 000 copies/mL. Results Of 102 participants with biopsies, 10 patients with BKV and BKVAN had paired dd-cfDNA, and viral loads available for analysis. Patients diagnosed with BKV and BKVAN had a median dd-cfDNA of 0.58% (IQR 0.43-1.15) and 3.38% (IQR 2.3-4.56, P = 0.001), respectively. dd-cfDNA titers correlated with BK PCR viral loads (R = 0.874, P = 0.01) and the presence of histologic evidence of BKVAN (100% sensitivity, 50% specificity). Five of 7 patients with BKVAN, but only 2 of 7 with BKV, had biopsies meeting Banff criteria for T-cell-mediated rejection. Median dd-cfDNA in nonrejection patients was 0.43% versus 2.84% in rejection patients (P = 0.001). Conclusion Higher dd-cfDNA titers were associated with higher BK viral loads, biopsy-diagnosed BVAN, as well histologic changes meeting Banff criteria for as T-cell-mediated rejection. dd-cfDNA may be a useful noninvasive test to assess for progression of BKV to BKVAN.
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9
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Gomes RM, Barbosa WB, Godman B, Costa JDO, Ribeiro Junior NG, Simão Filho C, Cherchiglia ML, Acurcio FDA, Guerra Júnior AA. Effectiveness of Maintenance Immunosuppression Therapies in a Matched-Pair Analysis Cohort of 16 Years of Renal Transplant in the Brazilian National Health System. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E1974. [PMID: 32192172 PMCID: PMC7142921 DOI: 10.3390/ijerph17061974] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 03/09/2020] [Accepted: 03/11/2020] [Indexed: 12/11/2022]
Abstract
The maintenance of patients with renal transplant typically involves two or more drugs to prevent rejection and prolong graft survival. The calcineurin inhibitors (CNI) are the most commonly recommended medicines in combinations with others. While immunosuppressive treatment regimens are well established, there is insufficient long-term effectiveness data to help guide future management decisions. The study analyzes the effectiveness of treatment regimens containing CNI after renal transplantation during 16 years of follow-up with real-world data from the Brazilian National Health System (SUS). This was a retrospective study of 2318 SUS patients after renal transplantion. Patients were propensity score-matched (1:1) by sex, age, type and year of transplantation. Kaplan-Meier analysis was used to estimate the cumulative probabilities of survival. A Cox proportional hazard model was used to evaluate factors associated with progression to graft loss. Multivariable analysis, adjusted for diabetes mellitus and race/color, showed a greater risk of graft loss for patients using tacrolimus plus mycophenolate compared to patients treated with cyclosporine plus azathioprine. In conclusion, this Brazilian real-world study, with a long follow-up period using matched analysis for relevant clinical features and the representativeness of the sample, demonstrated improved long-term effectiveness for therapeutic regimens containing cyclosporine plus azathioprine. Consequently, we recommend that protocols and clinical guidelines for renal transplantation should consider the cyclosporine plus azathioprine regimen as a potential first line option, along with others.
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Affiliation(s)
- Rosângela Maria Gomes
- Department of Social Pharmacy, College of Pharmacy, Federal University of Minas Gerais, Belo Horizonte 31270-901, Brazil
- SUS Collaborating Centre—Technology Assessment & Excellence in Health, College of Pharmacy, Federal University of Minas Gerais, Belo Horizonte 31270-901, Brazil
- Programa de Pós-graduação em Medicamentos e Assistência Farmacêutica, Departamento de Farmácia Social, Faculdade de Farmácia, Universidade Federal de Minas Gerais—UFMG. Av. Presidente Antônio Carlos, 6627 Campus Pampulha, Belo Horizonte, MG 31270-901 Brazil
| | - Wallace Breno Barbosa
- Department of Social Pharmacy, College of Pharmacy, Federal University of Minas Gerais, Belo Horizonte 31270-901, Brazil
- SUS Collaborating Centre—Technology Assessment & Excellence in Health, College of Pharmacy, Federal University of Minas Gerais, Belo Horizonte 31270-901, Brazil
| | - Brian Godman
- Strathclyde Institute of Pharmacy and Biomedical Sciences, Strathclyde University, Glasgow G4 ORE, UK
- Department of Laboratory Medicine, Division of Clinical Pharmacology, Karolinska Institute, Karolinska University Hospital Huddinge, SE-141 86 Stockholm, Sweden
- Health Economics Centre, Liverpool University Management School, Chatham Street, Liverpool L69 7ZH, UK
- School of Pharmacy, Sefako Makgatho Health Sciences University, Ga-Rankuwa, South Africa
| | - Juliana de Oliveira Costa
- SUS Collaborating Centre—Technology Assessment & Excellence in Health, College of Pharmacy, Federal University of Minas Gerais, Belo Horizonte 31270-901, Brazil
- Department of Preventive and Social Medicine, College of Medicine, Federal University of Minas Gerais, Belo Horizonte 31270-901, Brazil
| | - Nélio Gomes Ribeiro Junior
- SUS Collaborating Centre—Technology Assessment & Excellence in Health, College of Pharmacy, Federal University of Minas Gerais, Belo Horizonte 31270-901, Brazil
| | - Charles Simão Filho
- Department of Surgery, College of Medicine, Federal University of Minas Gerais, Belo Horizonte 31270-901, Brazil
| | - Mariângela Leal Cherchiglia
- Department of Preventive and Social Medicine, College of Medicine, Federal University of Minas Gerais, Belo Horizonte 31270-901, Brazil
| | - Francisco de Assis Acurcio
- Department of Social Pharmacy, College of Pharmacy, Federal University of Minas Gerais, Belo Horizonte 31270-901, Brazil
- SUS Collaborating Centre—Technology Assessment & Excellence in Health, College of Pharmacy, Federal University of Minas Gerais, Belo Horizonte 31270-901, Brazil
| | - Augusto Afonso Guerra Júnior
- Department of Social Pharmacy, College of Pharmacy, Federal University of Minas Gerais, Belo Horizonte 31270-901, Brazil
- SUS Collaborating Centre—Technology Assessment & Excellence in Health, College of Pharmacy, Federal University of Minas Gerais, Belo Horizonte 31270-901, Brazil
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10
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Patel SJ, Knight RJ, Kuten SA, Graviss EA, Nguyen DT, Moore LW, Musick WL, Gaber AO. Ciprofloxacin for BK viremia prophylaxis in kidney transplant recipients: Results of a prospective, double-blind, randomized, placebo-controlled trial. Am J Transplant 2019; 19:1831-1837. [PMID: 30811872 DOI: 10.1111/ajt.15328] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 01/18/2019] [Accepted: 02/06/2019] [Indexed: 01/25/2023]
Abstract
In kidney transplantation, BK virus infection has historically resulted in high rates of graft dysfunction and graft loss. Unlike other opportunistic infections, no therapies have been shown to prevent BK. The purpose of the current study was to evaluate the safety and efficacy of ciprofloxacin for the prevention of BK viremia in kidney transplant recipients. Two hundred kidney transplant recipients were enrolled in a prospective, randomized, double-blind, placebo-controlled trial comparing a 3-month course of ciprofloxacin (n = 133) vs placebo (n = 67) for the prevention of BK viremia. The primary endpoint of BK viremia at month 6 posttransplant occurred in 25 (18.8%) patients in the ciprofloxacin group and 5 (7.5%) in the placebo group (P = .03). Higher rates of BK viremia (23.3% vs 11.9%; P = .06) and BK nephropathy (5.8% vs 1.5%; P = .26) remained at 12 months in the ciprofloxacin group. Ciprofloxacin use was associated with a significantly higher rate of fluoroquinolone-resistant gram-negative infections (83.3% vs 50%; P = .04). A 3-month course of ciprofloxacin was ineffective at preventing BK viremia in kidney transplant recipients and was associated with an increased risk of fluoroquinolone-resistant infections. Clinical trial registration number: NCT01789203.
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Affiliation(s)
- Samir J Patel
- Department of Pharmacy, Houston Methodist Hospital, Houston, Texas
| | - Richard J Knight
- Department of Surgery, Houston Methodist Hospital, Houston, Texas
| | - Samantha A Kuten
- Department of Pharmacy, Houston Methodist Hospital, Houston, Texas
| | - Edward A Graviss
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Texas
| | - Duc T Nguyen
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, Texas
| | - Linda W Moore
- Department of Surgery, Houston Methodist Hospital, Houston, Texas
| | - William L Musick
- Department of Pharmacy, Houston Methodist Hospital, Houston, Texas
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11
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Abstract
Abstract
Background: BK virus infection is common but is usually asymptomatic. However, it can become life threatening as severe hemorrhagic cystitis (HC) or the polyomavirus-associated nephropathy (PVAN) particularly in immune compromised and transplant recipients. Some investigators have studied the pathophysiology and there are anecdotal and uncontrolled studies of therapy with few conclusions allowing treatment guidelines. Objectives: Summarize literature review of current knowledge concerning the nature, epidemiology, pathophysiology, diagnosis and treatment of this common virus infection. Results: HC is a not uncommon and often misdiagnosed infection from BK virus. It is usually self limited but can become life threatening in immune compromised patients. PVAN threatens survival of transplanted kidneys and is difficult to differentiate from rejection without sophisticated molecular diagnostic technology. We have sufficient information for making a diagnosis of BK virus disease by using clinical, serological and molecular technology. Studies using manipulation of immunosuppression and a variety of antiviral agents, including cidofovir, leflunomide, intravenous immunoglobulin, vidarabine, fluroquinolones, have been published but most were uncontrolled reports of few cases. Cidofovir offers some promise but more must be learned before there is hope for evidence-based treatment guidelines.
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Nankivell BJ, Renthawa J, Sharma RN, Kable K, O'Connell PJ, Chapman JR. BK Virus Nephropathy: Histological Evolution by Sequential Pathology. Am J Transplant 2017; 17:2065-2077. [PMID: 28371308 DOI: 10.1111/ajt.14292] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Revised: 03/09/2017] [Accepted: 03/18/2017] [Indexed: 01/25/2023]
Abstract
Reactivation of BK virus in renal allografts causes a destructive chronic infection. This single-center retrospective cohort study describes the evolution of BK virus allograft nephropathy (BKVAN) from 63 kidneys (from 61 patients) using sequential histopathology (454 biopsies, averaging 7.8 ± 2.6 per kidney) followed for 60.1 mo. Uninfected protocol biopsies formulated time-matched control Banff scores (n = 975). Interstitial inflammation occurred in 73% at diagnosis, correlating with viral histopathology (r = 0.413, p = 0.008) and amplifying early injury with accelerated interstitial fibrosis and tubular atrophy (IF/TA, p = 0.017) by 3 mo. Prodromal simian virus 40 large T antigen (SV40T)-negative inflammation with viremia preceded the histological diagnosis in 23.8%. Persistent subacute injury from viral cytopathic effect was associated with acute tubular necrosis and ongoing interstitial inflammation, culminating in IF/TA in 86.9%. Overall, cellular interstitial infiltration mitigated the intensity of subsequent tubular injury, SV40T, and tissue viral load, assessed by sequential paired histology (p < 0.001). Graft loss was predicted by high-level viremia (hazard ratio [HR] 4.996, 95% CI 2.19-11.396, p < 0.001), deceased donor (HR 3.201, 95% CI 1.149-8.915, p = 0.026), and late acute rejection (HR 3.124, 95% CI 1.037-9.413, p = 0.043). Transplant failure occurred in 38.1%, with uncontrolled infection (58.3%) and SV40T-negative chronic rejection (41.7%) causing losses. BKVAN is characterized by subacute virus-induced tubular injury, inflammation, and progressive nephron destruction. Effective antiviral therapy remains an unmet clinical need.
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Affiliation(s)
- B J Nankivell
- Department of Renal Medicine, Westmead Hospital, Westmead, Australia
| | - J Renthawa
- Department of Tissue Pathology and Diagnostic Oncology, ICPMR, Sydney, Australia
| | - R N Sharma
- Department of Tissue Pathology and Diagnostic Oncology, ICPMR, Sydney, Australia
| | - K Kable
- Department of Renal Medicine, Westmead Hospital, Westmead, Australia
| | - P J O'Connell
- Department of Renal Medicine, Westmead Hospital, Westmead, Australia
| | - J R Chapman
- Department of Renal Medicine, Westmead Hospital, Westmead, Australia
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Abstract
Polyomavirus-associated nephropathy (PVAN) occurs in a significant percentage of renal transplant recipients, with BK virus reactivation as the main causative agent. PVAN leads to tubular damage and may result in allograft loss. In this study, we analyzed the antiviral immune response in PVAN. Transcription of the proinflammatory cytokine interleukin-18 (IL-18) was significantly higher in PVAN biopsies compared with T cell-mediated rejection (TCMR) (1.42 ± 0.20 and 0.69 ± 0.10, respectively; *P = 0.0021). Tubular expression of IL-18 was significantly increased in PVAN compared with TCMR (2.00 ± 0.24 and 1.333 ± 0.13, respectively; *P = 0.028). In contrast, in TCMR, IL-18 was expressed predominantly by CD163-positive macrophages. These data suggest that the antiviral immune response in PVAN is partly coordinated by the tubular epithelium, whereas in TCMR, this may be controlled by inflammatory cells.
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BK Polyomavirus and the Transplanted Kidney: Immunopathology and Therapeutic Approaches. Transplantation 2017; 100:2276-2287. [PMID: 27391196 PMCID: PMC5084638 DOI: 10.1097/tp.0000000000001333] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BK polyomavirus is ubiquitous, with a seropositivity rate of over 75% in the adult population. Primary infection is thought to occur in the respiratory tract, but asymptomatic BK virus latency is established in the urothelium. In immunocompromised host, the virus can reactivate but rarely compromises kidney function except in renal grafts, where it causes a tubulointerstitial inflammatory response similar to acute rejection. Restoring host immunity against the virus is the cornerstone of treatment. This review covers the virus-intrinsic features, the posttransplant microenvironment as well as the host immune factors that underlie the pathophysiology of polyomavirus-associated nephropathy. Current and promising therapeutic approaches to treat or prevent this complication are discussed in relation to the complex immunopathology of this condition.
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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: 1.4] [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.
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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
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Trofe J, Gordon J, Roy-Chaudhury P, Koralnik IJ, Atwood WJ, Alloway RR, Khalili K, Woodle ES. Polyomavirus Nephropathy in Kidney Transplantation. Prog Transplant 2016; 14:130-40; quiz 141-2. [PMID: 15264457 DOI: 10.1177/152692480401400207] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Polyomavirus nephropathy has become an important complication in kidney transplantation, with a prevalence of 1% to 8%. Unfortunately, the risk factors for polyomavirus nephropathy and renal allograft loss are not well defined. The definitive diagnosis is made through assessment of a kidney transplant biopsy. Recently, noninvasive urine and serum markers have been used to assist in polyomavirus nephropathy diagnosis and monitoring. Primary treatment is immunosuppression reduction, but must be balanced with the risks of rejection. No antiviral treatments for polyomavirus nephropathy have been approved by the Food and Drug Administration. Although cidofovir has shown in vitro activity against murine polyomaviruses, and has been effective in some patients, it is associated with significant nephrotoxicity. Graft loss due to polyomavirus nephropathy should not be a contraindication to retransplantation; however, experience is limited. This review presents potential risk factors, screening, diagnostic and monitoring methods, therapeutic management, and retransplantation experience for polyomavirus nephropathy.
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Affiliation(s)
- Jennifer Trofe
- University of Cincinnati, Division of Transplantation, Ohio, USA
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Qiao L, Qu Q, Jiang X. Clinical significance of quantitative and qualitative detection of BK and JC virus in blood and urine of renal transplantation recipients. Pak J Med Sci 2016; 32:435-9. [PMID: 27182256 PMCID: PMC4859039 DOI: 10.12669/pjms.322.8978] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Objective: To evaluate value of quantitative and qualitative detection of BK virus (BKV) and JC virus (JCV) in timely diagnosing polyomavirus-associated nephropathy (PVAN) occurring inrenal transplantation recipients. Methods: We collected 306 cases of urine specimen and 310 cases of blood specimen from 306 patients who underwent renal transplant. Levels of BKV and JCV in blood and urine were detected using real-time quantitative polymerase chain reaction (PCR). Results: Detection rate of BKV DNA was 33.3% (102/306) in urine and 34.8% (108/310); while that of JCV DNA was 30.7% (94/306) and 33.5% (104/310) respectively. The lowest detectable limit of BCK and JCV detection for patients who underwent renal transplant was 2×103 copies/ml, suggesting high specificity and sensitivity. Conclusion: Real-time quantitative PCR is able to monitor BCV and JCV in renal transplant recipients in a convenient and rapid way, thus it is beneficial for early discovery, diagnosis and treatment of PVAN.
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Affiliation(s)
- Liangwei Qiao
- Liangwei Qiao, Department of Kidney Transplantation, People's Hospital of Zhengzhou, Zhengzhou, Henan, 450000, China
| | - Qingshan Qu
- Qingshan Qu, Department of Kidney Transplantation, People's Hospital of Zhengzhou, Zhengzhou, Henan, 450000, China
| | - Xin Jiang
- Xin Jiang, Department of Kidney Transplantation, People's Hospital of Zhengzhou, Zhengzhou, Henan, 450000, China
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Yapici Ü, Kers J, Slavujevic-Letic I, Stokman G, Roelofs JJTH, van Aalderen MC, Groothoff JW, de Boer OJ, van der Pant KAMI, Claessen N, Hilbrands LB, Bemelman FJ, Ten Berge IJM, Florquin S. Intragraft Blood Dendritic Cell Antigen-1-Positive Myeloid Dendritic Cells Increase during BK Polyomavirus-Associated Nephropathy. J Am Soc Nephrol 2015; 27:2502-10. [PMID: 26701980 DOI: 10.1681/asn.2015040442] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2015] [Accepted: 11/07/2015] [Indexed: 12/31/2022] Open
Abstract
Although both polyomavirus infection and T cell-mediated rejection (TCMR) are characterized by tubulointerstitial inflammation in the renal allograft, these conditions are treated with opposing therapeutic regimens. To gain more insight into the differences between antiviral and alloimmune responses, we performed a case-control study, in which we immunophenotyped the inflammatory infiltrates in renal biopsy specimens with BK polyomavirus-associated nephropathy (BKPyVAN) and specimens with TCMR. Compared with TCMR, BKPyVAN was diagnosed later after transplantation; therefore, BKPyVAN specimens showed more chronic damage than TCMR specimens showed. However, TCMR and BKPyVAN specimens had comparable levels of tubulointerstitial inflammation. Adjustment for confounders in various multivariable models revealed more blood dendritic cell antigen-1(+) (BDCA-1(+)) myeloid dendritic cells (mDCs) present during BKPyVAN (odds ratio, 2.31; 95% confidence interval, 1.03 to 5.16; P=0.04) than during TCMR. Double immunostaining for SV40 and BDCA-1 showed that, during BKPyVAN, BDCA-1(+) mDCs localized in proximity to the polyomavirus-infected tubular epithelial cells. We ensured that time of biopsy after transplantation was not a confounding factor by including additional specimens with late TCMR and protocol biopsy specimens matched for biopsy time. These additional specimens showed amounts of BDCA-1(+) mDCs comparable with amounts in the early TCMR specimens. These results suggest that BDCA-1(+) mDCs, known to be involved in the antiviral immune response during various viral infections, might have a pivotal role during BKPyVAN infection in the grafted kidney.
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Affiliation(s)
| | | | | | | | | | | | - Jaap W Groothoff
- Emma Children's Hospital, Academic Medical Center, Amsterdam, The Netherlands; and
| | | | | | | | - Luuk B Hilbrands
- Department of Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands
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Lee HM, Jang IA, Lee D, Kang EJ, Choi BS, Park CW, Choi YJ, Yang CW, Kim YS, Chung BH. Risk factors in the progression of BK virus-associated nephropathy in renal transplant recipients. Korean J Intern Med 2015; 30:865-72. [PMID: 26552462 PMCID: PMC4642016 DOI: 10.3904/kjim.2015.30.6.865] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Revised: 05/16/2014] [Accepted: 07/22/2014] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND/AIMS BK virus-associated nephropathy (BKVAN) is an important cause of allograft dysfunction in kidney transplant recipients. It has an unfavorable clinical course, and no definite treatment guidelines have yet been established. Here, we report our center's experience with biopsy-proven BKVAN and investigate factors associated with its progression. METHODS From January 2004 to April 2013, 25 patients with BKVAN were diagnosed by biopsy at Seoul St. Mary's Hospital. Of the 25 patients, 10 were deceased-donor transplant recipients and 15 were living-donor transplant recipients. Three of the patients underwent retransplantation. The primary immunosuppressant used was tacrolimus in 17 patients and cyclosporine in eight patients. RESULTS BKVAN was observed at a mean duration of 22.8 ± 29.1 months after transplantation. The mean serum creatinine level at biopsy was 2.2 ± 0.7 mg/dL. BKVAN occurred with acute rejection in eight patients (28%). Immunosuppression modification was performed in 21 patients (84%). Additionally, leflunomide and intravenous immunoglobulin were administered to 13 patients (52%) and two (8%), respectively. Allograft loss occurred in five patients (27.8%) during the follow- up period at 0.7, 17.1, 21.8, 39.8, and 41.5 months after the BKVAN diagnosis. Advanced stages of BKVAN, increased creatinine levels, and accompanying acute rejection at the time of BKVAN diagnosis increased the risk of allograft failure. CONCLUSIONS The clinical outcomes in patients with biopsy-proven BKVAN were unfavorable in the present study, especially in patients with advanced-stage BKVAN, poor renal function, and acute allograft rejection.
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Affiliation(s)
- Hae Min Lee
- Division of Nephrology, Department of Internal Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea
| | - In-Ae Jang
- Division of Nephrology, Department of Internal Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea
| | - Dongjae Lee
- Division of Nephrology, Department of Internal Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea
| | - Eun Jin Kang
- Division of Nephrology, Department of Internal Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea
| | - Bum Soon Choi
- Division of Nephrology, Department of Internal Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea
| | - Cheol Whee Park
- Division of Nephrology, Department of Internal Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea
| | - Yeong Jin Choi
- Department of Hospital Pathology, College of Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea
| | - Chul Woo Yang
- Division of Nephrology, Department of Internal Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea
| | - Yong-Soo Kim
- Division of Nephrology, Department of Internal Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea
| | - Byung Ha Chung
- Division of Nephrology, Department of Internal Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea
- Correspondence to Byung Ha Chung, M.D. Division of Nephrology, Department of Internal Medicine, College of Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea, 222 Banpodaero, Seocho-gu, Seoul 06591, Korea Tel: +82-2-2258-6066 Fax: +82-2-599-3589 E-mail :
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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]
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Kuten SA, Patel SJ, Knight RJ, Gaber LW, DeVos JM, Gaber AO. Observations on the use of cidofovir for BK virus infection in renal transplantation. Transpl Infect Dis 2014; 16:975-83. [PMID: 25412701 DOI: 10.1111/tid.12313] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Revised: 08/19/2014] [Accepted: 09/01/2014] [Indexed: 12/16/2022]
Abstract
BACKGROUND In renal transplantation, BK virus infection can result in significant graft nephropathy and loss. While reduction in immunosuppression (IS) is considered standard therapy, adjunct agents may be warranted. Data are suggestive of a possible role of cidofovir for the management of BK. This study aims to describe the course of BK viremia (BKV) in a large cohort of renal transplant patients receiving adjunct cidofovir. METHODS We evaluated kidney and kidney-pancreas recipients who received cidofovir combined with reduced IS for management of high-level BKV or BK virus nephropathy (BKVN). We examined the rate and timing of BKV clearance, and performed a multivariate analysis to identify risk factors associated with long-term (>6 months) viremia. RESULTS In total, 75 patients received a median of 13 doses of cidofovir in conjunction with reduced IS; 32 patients (43%) had short-term BKV (≤6 months), and 43 (57%) had long-term BKV. Overall, 53 of 75 patients (71%) eventually cleared BKV at a median of 4.2 months (interquartile range 2.1-9.3 months). Independent factors associated with long-term BKV included older age (odds ratio [OR] 1.1, P = 0.02), delayed graft function (OR 31.4, P = 0.01), and higher peak BKV (OR 12.8, P = 0.02), while BKV reduction by at least 1 log(10) copies/mL at 1 month of treatment was associated with clearance within 6 months (OR 49.3, P < 0.01). Patients with earlier clearance maintained stable graft function and no graft losses, while long-term BKV was associated with a 15% decline in estimated glomerular filtration rate. CONCLUSIONS Adjunct cidofovir resulted in preservation of renal function when viral clearance occurred within 6 months of initiation. This retrospective review defines factors predicting response to cidofovir in conjunction with reduced IS for BKVN or high-level BKV. Still, considering cost, frequency of administration, and treatment duration, a randomized trial is necessary to define the exact utility of cidofovir in the setting of BK virus infection.
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Affiliation(s)
- S A Kuten
- Department of Pharmacy, Houston Methodist J.C. Walter Jr. Transplant Center, Houston Methodist Hospital, Houston, Texas, USA
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Abstract
This review discusses the various gross and histologic findings seen in renal infections due to bacteria, viruses, fungi, and mycobacteria. It is crucially important to separate infectious processes in the kidney from other inflammatory or neoplastic processes, as this will have a major impact on therapy. We describe the diagnostic features of renal infections with a specific focus on the differential diagnosis and other processes that may mimic infection. The topics discussed include acute bacterial pyelonephritis, chronic bacterial pyelonephritis, xanthogranulomatous pyelonephritis, malacoplakia, viral infections in the kidney, fungal pyelonephritis and mycobacterial infection of the kidney.
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Affiliation(s)
- Jean Hou
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York Presbyterian Hospital, VC14-224, New York, NY 10032, USA
| | - Leal C Herlitz
- Division of Renal Pathology, Department of Pathology and Cell Biology, Columbia University Medical Center, New York Presbyterian Hospital, VC14-224, New York, NY 10032, USA.
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Varon NF, Alangaden GJ. Emerging trends in infections among renal transplant recipients. Expert Rev Anti Infect Ther 2014; 2:95-109. [PMID: 15482175 DOI: 10.1586/14787210.2.1.95] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Outcomes following renal and simultaneous kidney-pancreas transplants have improved significantly due to better surgical techniques and improved modalities of antirejection therapy. However, infection remains a significant cause of morbidity and mortality. The use of new modalities of immunosuppression and routine use of antimicrobial prophylaxis has changed the pattern of infections post-transplantation. Cytomegalovirus remains a significant problem and BK virus has emerged as an important pathogen. New antimicrobial agents are now available to treat infection, however, antimicrobial resistance remains a concern.
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Affiliation(s)
- Nestor F Varon
- Division of Infectious Diseases, Wayne State University School of Medicine, Detroit, MI, USA
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Elfadawy N, Flechner SM, Schold JD, Srinivas TR, Poggio E, Fatica R, Avery R, Mossad SB. Transient versus persistent BK viremia and long-term outcomes after kidney and kidney-pancreas transplantation. Clin J Am Soc Nephrol 2014. [PMID: 24408118 DOI: 10.2215/cjn.09420813] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND OBJECTIVES The objective was to study the long-term impact of transient versus persistent BK viremia on kidney transplant outcomes. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS In total, 609 recipients who underwent kidney transplant from 2007 to 2011 were screened at months 1-12 for the occurrence of polyomavirus BK viremia; 130 patients (21.7%) developed BK viremia during the first year post-transplant. BK viremia patients were classified according to duration of infection (more or less than 3 months), and BK viral loads (more or less than 10,000 copies/ml) were classified as transient low viremia (n=42), transient high viremia (n=18), persistent low viremia (n=23), and persistent high viremia (n=47). All patients were followed a median of 36 (3-66) months. The rates of BK polyomavirus-associated nephropathy, acute rejection, and 1-year graft function were compared with the polyomavirus BK-negative control group. RESULTS Patient and graft survival were not significantly different among the groups. Graft function (creatinine; milligrams per deciliter) at 1 year was significantly worse in the persistent high viremia (1.75±0.6) and transient high viremia (1.85±0.7) groups compared with aviremic controls (1.47±0.4; P=0.01 and P=0.01, respectively). The incidence of BK polyomavirus-associated nephropathy was limited to the persistent high viremia group (1.3%, P<0.001). The transient high viremia (50%) and persistent high viremia (34%) groups showed significantly (P=0.01) increased incidence of acute rejection versus aviremic controls (21.5%), transient low viremia (19%), or persistent low viremia (17.3%) groups. CONCLUSION Low viral load BK viremia, either transient or persistent, was not associated with long-term transplant outcomes. Persistent high viremia was associated with a greater risk for BK polyomavirus-associated nephropathy and subsequent graft dysfunction. Although transient high viremia was not associated with BK polyomavirus-associated nephropathy, it was associated with worse graft function. These data support the role of surveillance for BK viremia after transplant.
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Affiliation(s)
- Nissreen Elfadawy
- Glickman Urological and Kidney Institute,, †Department of Quantitative Health Sciences, and, ‖Department of Infectious Disease in the Medicine Institute, Cleveland Clinic, Cleveland, Ohio;, ‡Division of Nephrology, Medical University of South Carolina, Charleston, South Carolina, §Division of Infectious Diseases, Johns Hopkins University, Baltimore, Maryland
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Elfadawy N, Flechner SM, Schold JD, Srinivas TR, Poggio E, Fatica R, Avery R, Mossad SB. Transient versus persistent BK viremia and long-term outcomes after kidney and kidney-pancreas transplantation. Clin J Am Soc Nephrol 2014; 9:553-61. [PMID: 24408118 DOI: 10.2215/cjn.08420813] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND AND OBJECTIVES The objective was to study the long-term impact of transient versus persistent BK viremia on kidney transplant outcomes. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS In total, 609 recipients who underwent kidney transplant from 2007 to 2011 were screened at months 1-12 for the occurrence of polyomavirus BK viremia; 130 patients (21.7%) developed BK viremia during the first year post-transplant. BK viremia patients were classified according to duration of infection (more or less than 3 months), and BK viral loads (more or less than 10,000 copies/ml) were classified as transient low viremia (n=42), transient high viremia (n=18), persistent low viremia (n=23), and persistent high viremia (n=47). All patients were followed a median of 36 (3-66) months. The rates of BK polyomavirus-associated nephropathy, acute rejection, and 1-year graft function were compared with the polyomavirus BK-negative control group. RESULTS Patient and graft survival were not significantly different among the groups. Graft function (creatinine; milligrams per deciliter) at 1 year was significantly worse in the persistent high viremia (1.75±0.6) and transient high viremia (1.85±0.7) groups compared with aviremic controls (1.47±0.4; P=0.01 and P=0.01, respectively). The incidence of BK polyomavirus-associated nephropathy was limited to the persistent high viremia group (1.3%, P<0.001). The transient high viremia (50%) and persistent high viremia (34%) groups showed significantly (P=0.01) increased incidence of acute rejection versus aviremic controls (21.5%), transient low viremia (19%), or persistent low viremia (17.3%) groups. CONCLUSION Low viral load BK viremia, either transient or persistent, was not associated with long-term transplant outcomes. Persistent high viremia was associated with a greater risk for BK polyomavirus-associated nephropathy and subsequent graft dysfunction. Although transient high viremia was not associated with BK polyomavirus-associated nephropathy, it was associated with worse graft function. These data support the role of surveillance for BK viremia after transplant.
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Affiliation(s)
- Nissreen Elfadawy
- Glickman Urological and Kidney Institute,, †Department of Quantitative Health Sciences, and, ‖Department of Infectious Disease in the Medicine Institute, Cleveland Clinic, Cleveland, Ohio;, ‡Division of Nephrology, Medical University of South Carolina, Charleston, South Carolina, §Division of Infectious Diseases, Johns Hopkins University, Baltimore, Maryland
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Immunophenotyping in BK virus allograft nephropathy distinct from acute rejection. Clin Dev Immunol 2013; 2013:412902. [PMID: 24194773 PMCID: PMC3806154 DOI: 10.1155/2013/412902] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2013] [Revised: 08/22/2013] [Accepted: 08/27/2013] [Indexed: 12/25/2022]
Abstract
Differentiating BK virus nephropathy (BKVN) from acute rejection (AR) is crucial in clinical practice, as both of them have interstitial inflammation in the grafts. The purpose of the study is to describe the inflammatory cellular constituents of BKVN and to determine the clinical utility of immunophenotyping findings in distinguishing BKVN from AR. In addition, the expression of the HLA-DR was investigated. Sixty-five renal allograft recipients were included in this study, including 22 cases of BKVN, 31 cases of AR, and 12 cases of stable allograft. Immunostaining for infiltrating lymphocytes showed that the number of CD20 cells (P < 0.001) and the percentages of CD3 (P < 0.001), CD4 (P = 0.004), CD8 (P = 0.005), and CD20 (P = 0.002) cells were all significantly different between BKVN and AR. Moreover, there were no statistically significant differences in tubule cell HLA-DR expression (P = 0.156). This observation suggests that the number of CD20 cells and the percentages of CD3, CD4, CD8, and CD20 cells in renal biopsies would aid the distinction between BKVN and AR. On the other hand, the presence of HLA-DR upregulation may not only be specific for acute rejection but also be a response to BKVN.
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Yamanaka K, Oka K, Nakazawa S, Hirai T, Kishikawa H, Nishimura K, Kyo M, Ichikawa Y. Immunohistochemical features of BK virus nephropathy in renal transplant recipients. Clin Transplant 2012; 26 Suppl 24:20-4. [DOI: 10.1111/j.1399-0012.2012.01636.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Kazuaki Yamanaka
- The Department of Urology; Hyogo Prefectural Nishinomiya Hospital; Osaka; Japan
| | - Kazumasa Oka
- Pathology Hyogo Prefectural Nishinomiya Hospital; Osaka; Japan
| | - Shigeaki Nakazawa
- The Department of Urology; Hyogo Prefectural Nishinomiya Hospital; Osaka; Japan
| | - Toshiaki Hirai
- The Department of Urology; Hyogo Prefectural Nishinomiya Hospital; Osaka; Japan
| | - Hidefumi Kishikawa
- The Department of Urology; Hyogo Prefectural Nishinomiya Hospital; Osaka; Japan
| | - Kenji Nishimura
- The Department of Urology; Hyogo Prefectural Nishinomiya Hospital; Osaka; Japan
| | | | - Yasuji Ichikawa
- The Department of Urology; Hyogo Prefectural Nishinomiya Hospital; Osaka; Japan
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Chung BH, Hong YA, Kim HG, Sun IO, Choi SR, Park HS, Lee SH, Choi BS, Park CW, Choi YJ, Kim YS, Yang CW. Clinical usefulness of BK virus plasma quantitative PCR to prevent BK virus associated nephropathy. Transpl Int 2012; 25:687-695. [DOI: 10.1111/j.1432-2277.2012.01480.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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Predominance of TH2 cells and plasma cells in polyoma virus nephropathy: a role for humoral immunity? Hum Pathol 2012; 43:1453-62. [PMID: 22406372 DOI: 10.1016/j.humpath.2011.11.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2011] [Revised: 11/02/2011] [Accepted: 11/03/2011] [Indexed: 11/24/2022]
Abstract
The differential diagnosis of T cell-mediated rejection (TCMR) and BK-virus nephropathy (BKVN) in renal transplant biopsies is notoriously difficult. Therefore, attempts were made to differentiate between the two by characterizing the immune cell infiltrate. Using immunohistochemistry, the distribution of immune cell (sub)populations such as CD4(+) T helper (TH), TH1, TH2, CD8(+) cytotoxic T cells, regulatory T cells, B cells, plasma cells and follicular dendritic cells was determined in a total of 38 renal biopsy specimens. In addition, the expression of the HLA class I antigen presentation machinery (APM) components was investigated. In general, the frequency of T cells was higher than B cells, and TH cells outnumbered cytotoxic T cells with a predominance of TH2 over TH1 cells. In BKVN, a significantly higher number of plasma cells was observed (P = .028), and interstitial fibrosis and tubular atrophy was more pronounced in BKVN (P = .007) compared to TCMR. The expression of components of the HLA class I APM was not affected by the infection with BK virus compared to TCMR. These findings indicate a TH2 shift in renal transplants in the context of alloreactive and virus-induced inflammation maybe as a consequence of immunosuppression, which usually targets T cell reaction. The predominance of plasma cells might underline an important role of humoral immunity in BKVN. Moreover, BK virus does not seem to modulate the expression of HLA class I APM as a strategy of immune evasion.
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Ji SM, Liu ZH, Wu D, Wen JQ, Xie KN, Sun QQ, Chen JS. Surveillance Renal Allograft Biopsy on Diagnosis of BK Virus Nephropathy in Chinese Renal Transplant Recipients. ACTA ACUST UNITED AC 2012. [DOI: 10.4236/ojots.2012.24015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Ito Y, Nishi S, Imai N, Yoshita K, Saito K, Nakagawa Y, Takahashi K, Narita I. The case of BK virus infection in which it was difficult to differentiate from acute rejection. Clin Transplant 2011; 25 Suppl 23:44-8. [PMID: 21623914 DOI: 10.1111/j.1399-0012.2011.01481.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BK virus (BKV) nephropathy is one of the major causes of allograft dysfunction or graft loss in kidney transplant recipients. Early diagnosis and timely reduction in immunosuppressant is important for proper treatment. We report a 35-yr-old male case of cadaveric renal transplantation with BK viral related tubulointerstitial nephritis complicated by acute rejection. The diagnostic biopsy showed severe inflammatory infiltrates, tubulitis, and peritubular capillaritis. Discontinuation of mycophenolate mofetil, prednisone pulse therapy, and r-globulin was successful in relieving allograft dysfunction.
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Affiliation(s)
- Yumi Ito
- Division of Clinical Nephrology, Niigata University Graduate School of Medical and Dental Sciences, Chuo-ku, Niigata, Japan.
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Prosser S, Hariharan S. Pathogenesis of BK virus infection after renal transplantation. Expert Rev Clin Immunol 2010; 2:833-7. [PMID: 20476968 DOI: 10.1586/1744666x.2.6.833] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Treatment of polyomavirus infection in kidney transplant recipients: a systematic review. Transplantation 2010; 89:1057-70. [PMID: 20090569 DOI: 10.1097/tp.0b013e3181d0e15e] [Citation(s) in RCA: 165] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND.: Polyomavirus-associated nephropathy (PVAN) is an important cause of kidney graft loss but there is no consensus on its management. This study aimed to systematically document all published treatments for PVAN to determine the most effective therapy. METHODS.: A computerized search in MEDLINE, EMBASE, and Cochrane databases (1950-2008) was performed. References from review articles and published abstracts from the American Transplant Congress (2005-2008) were also included. Study selection criteria included (a) population: adult (>18 years) kidney-only, primary or repeat renal transplant recipients; (b) setting: polyoma viruria, viremia or biopsy-proven PVAN or both; and (c) treatment: immunosuppression reduction alone or with adjuvant agents. The primary outcome was graft failure rate, and secondary outcomes included acute rejection rate, elimination of viruria and viremia, graft function, patient survival, and adverse events. RESULTS.: Of 555 identified citations, 40 studies examining the effect of immunosuppression reduction alone or in combination with cidofovir, leflunomide, intravenous immunoglobulin, or ciprofloxacin were included for appraisal. Pooled results found a death-censored graft loss rate of 8/100 patient-years for immunosuppression reduction alone and 8 and 13/100 patient-years for the addition of cidofovir or leflunomide, respectively. CONCLUSIONS.: There does not seem to be a graft survival benefit of adding cidofovir or leflunomide to immunosuppression reduction for the management of PVAN. However, the evidence base is poor and highlights the urgent need for adequately powered randomized trials to define the optimal treatment of this important condition.
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Höcker B, Tönshoff B. Treatment strategies to minimize or prevent chronic allograft dysfunction in pediatric renal transplant recipients: an overview. Paediatr Drugs 2010; 11:381-96. [PMID: 19877724 DOI: 10.2165/11316100-000000000-00000] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Long-term allograft survival poses a major problem in pediatric renal transplantation, with allograft nephropathy being the principal cause of graft failure after the first post-transplant year. The mechanisms of nephron loss resulting in graft dysfunction are multiple, comprising both immunologic factors such as acute and chronic antibody- or T-cell-mediated rejection and non-immunologic components. The latter include peri-transplant injuries and renovascular lesions (renal artery stenosis, thrombosis) as well as cardiovascular risk factors such as arterial hypertension and hyperlipidemia. Another relevant issue leading to progressive nephron loss and declining kidney transplant function is acute and chronic nephrotoxicity induced by the calcineurin inhibitors (CNIs) ciclosporin (cyclosporine microemulsion) and tacrolimus. Furthermore, the presence of an abnormal lower urinary tract as well as bacterial (recurrent pyelonephritis) and viral (cytomegalovirus [CMV], polyomavirus [BK virus; BKV]) infections are crucial factors involved in the incidence of chronic allograft dysfunction and graft failure. Renovascular lesions and lower urinary tract obstruction are typical indicators for surgical intervention. The aim of treatment in pediatric patients with renal failure secondary to a dysfunctional lower urinary tract is to create a sterile, continent, and nonrefluxive reservoir. Surgical techniques such as bladder augmentation and the introduction of intermittent catheterization and anticholinergic therapy have significantly improved graft outcome. Arterial hypertension, another factor responsible for graft function deterioration in pediatric renal transplant recipients, is controlled preferably by the use of angiotensin converting enzyme (ACE) inhibitors or angiotensin II receptor antagonists, which are known to possess nephroprotective properties in addition to their potent antihypertensive effects. Although treatment of subclinical rejection with augmented immunosuppression has been associated with better graft survival, an increase of the immunosuppressive level to avoid subclinical rejection should be weighed against the risk of infection. The majority of viral infections affecting kidney allografts are caused by CMV and BKV. Antiviral CMV prophylaxis or pre-emptive therapy with ganciclovir has been shown to have beneficial effects in the pediatric renal transplant population. Treatment of BKV-induced nephropathy is based on reduction of the immunosuppressant therapy, although specific antiviral agents such as cidofovir and leflunomide are known to inhibit BKV. However, cidofovir itself is nephrotoxic and should therefore be administered cautiously to pediatric renal transplant patients. Since CNIs are likewise known for their nephrotoxic effects, especially with long-term use, alteration of the immunosuppressant regimen is necessary in case of deteriorating graft function due to CNI-induced histopathologic changes. Complete CNI avoidance seems inappropriate because, in this situation in pediatric renal transplant recipients, other relatively potent immunosuppressant agents such as lymphocyte-depleting antibodies, which are frequently accompanied by a higher incidence of infections, are needed for rejection prophylaxis. CNI withdrawal and switching of the immunosuppressant regimen from CNI therapy to sirolimus may be an option for some pediatric renal transplant patients with less advanced graft function deterioration. Nevertheless, potential adverse events such as aggravation of proteinuria, hyperlipidemia, myelosuppression, and hypergonadotropic hypogonadism have to be considered, and controlled studies are lacking. At present, an immunosuppressant maintenance therapy composed of low-dose tacrolimus or ciclosporin (CNI minimization) and mycophenolate mofetil with low-dose corticosteroids appears to be the most promising strategy to adopt in pediatric renal transplant recipients at low or normal immunologic risk.
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Affiliation(s)
- Britta Höcker
- University Children's Hospital, Im Neuenheimer Feld 430, D-69120 Heidelberg, Germany.
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38
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Cimbaluk D, Pitelka L, Kluskens L, Gattuso P. Update on human polyomavirus BK nephropathy. Diagn Cytopathol 2009; 37:773-9. [PMID: 19626630 DOI: 10.1002/dc.21147] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Polyomavirus BK (BKV) has ebeen identified as the main cause of polyomavirus-associated nephropathy, a major cause of renal allograft failure. Although BKV-associated nephropathy develops in only 2% to 5% of renal transplant recipients, its prognosis when present is very poor, with irreversible graft failure developing in 45% of affected patients. While the use of urine cytology for the detection of decoy cells has been in use for decades, other diagnostic modalities to detect BKV have emerged, including tissue biopsy, polymerase chain reaction, viral culture, and serology. Currently, there is no consensus regarding the laboratory technique best suited for clinical monitoring. This review article will discuss essential and clinical features of polyomavirus, followed by a discussion pertaining to the various diagnostic modalities that contribute to detecting polyomavirus-associated nephropathy.
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Affiliation(s)
- David Cimbaluk
- Department of Pathology, Rush University Medical Center, Chicago, Illinois 60612, USA
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The significance of renal C4d staining in patients with BK viruria, viremia, and nephropathy. Mod Pathol 2009; 22:1468-76. [PMID: 19734851 DOI: 10.1038/modpathol.2009.118] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Peritubular capillary C4d staining in allograft kidney is an important criterion for antibody-mediated rejection. Whether BK virus infection can result in complement activation is not known. We studied 113 renal allograft biopsies from 52 recipients with a history of BK virus activation. The samples were classified into four groups according to the concurrent detection of BK virus DNA in urine, plasma, and/or biopsy: BK-negative (n=37), viruria (n=53), viremia (n=7), and nephropathy (n=16) groups. The histological semiquantitative peritubular capillary C4d scores in the viremia (0.3+/-0.8) and BK nephropathy (0.6+/-0.9) groups were lower than those in the BK-negative group (1.2+/-1.1, P=0.05 and P=0.06, respectively) and the viruria group (1.2+/-1.1, P=0.04 and P=0.06, respectively). Diffuse or focal peritubular capillary C4d staining was present in 9/76 (12%) and 14/76 (19%) of all samples with concurrent BK virus reactivation (viruria, viremia, and nephropathy). The diagnosis of antibody-mediated rejection could be established in 7/9 (78%) and 5/14 (36%) of these samples, respectively. Diffuse tubular basement membrane C4d staining was restricted to BK nephropathy cases (4/16, 25%). Semiquantitative tubular basement membrane C4d scores were higher in BK nephropathy (1.2+/-1.3) compared with BK-negative (0.05+/-0.3, P=0.017) and viruria (0.0+/-0.0, P=0.008) groups. Bowman's capsule C4d staining was more frequent in BK nephropathy (5/16) compared with the aforementioned groups (2/36 (P=0.023) and 4/51 (P=0.03), respectively). Within the BK nephropathy group, samples with tubular basement membrane stain had more infected tubular epithelial cells (12.1+/-7.6% vs 4.4+/-5.0%, P=0.03) and a trend toward higher interstitial inflammation scores. In conclusion, peritubular capillary C4d staining remains a valid marker for the diagnosis of antibody-mediated rejection in the presence of concurrent BK virus infection. A subset of biopsies with BK nephropathy shows tubular basement membrane C4d staining, which correlates with marked viral cytopathic effect.
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40
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Batal I, Franco ZM, Shapiro R, Basu A, Tan H, Kayler L, Zeevi A, Morgan C, Randhawa P. Clinicopathologic analysis of patients with BK viruria and rejection-like graft dysfunction. Hum Pathol 2009; 40:1312-9. [DOI: 10.1016/j.humpath.2009.01.018] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2008] [Revised: 01/26/2009] [Accepted: 01/28/2009] [Indexed: 11/15/2022]
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41
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Li YJ, Chen YC, Lai PC, Fang JT, Yang CW, Chiang YJ, Chu SH, Wu MJ, Tian YC. A direct association of polyomavirus BK viruria with deterioration of renal allograft function in renal transplant patients. Clin Transplant 2009; 23:505-10. [DOI: 10.1111/j.1399-0012.2009.00982.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Herrera GA, Veeramachaneni R, Turbat-Herrera EA. Electron Microscopy in the Diagnosis of BK-Polyoma Virus Infection in the Transplanted Kidney. Ultrastruct Pathol 2009; 29:469-74. [PMID: 16316947 DOI: 10.1080/01913120500323399] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BK polyomavirus has become an important etiologic agent responsible for significant morbidity in renal transplant recipients. This virus can be detected in transitional cells in the urine (decoy cells) using cytology, but correlation with allograft function status and histologic evidence of renal involvement is poor. Accurate diagnosis of BK polyomavirus infection requires a high index of suspicion and utilization of ancillary diagnostic techniques in many cases. Electron microscopy is very sensitive in depicting the presence of BK virions, but the finding of viral particles is not by itself diagnostic of BK interstitial nephritis. Management of patients with polyoma virus nephropathy is difficult since there is no specific antiviral therapy available at this time.
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Affiliation(s)
- Guillermo A Herrera
- Department of Pathology, Louisiana State University Health Sciences Center, Shreveport, USA.
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Petrov R, Elbahloul O, Gallichio MH, Stellrecht K, Conti DJ. Monthly screening for polyoma virus eliminates BK nephropathy and preserves renal function. Surg Infect (Larchmt) 2009; 10:85-90. [PMID: 19298172 DOI: 10.1089/sur.2008.052] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Polyoma BK virus nephropathy is a serious complication after renal transplantation and is associated with a high rate of allograft failure. Progressive infection with BK virus in immunocompromised renal transplant recipients occurs in detectable stages: Viruria, viremia, then nephropathy. METHODS In January, 2006, we initiated a plasma screening policy for all new transplant recipients, with monthly blood testing for BK virus by polymerase chain reaction (PCR). Between January 1, 2006, and February 28, 2007, 66 renal transplants were performed at our center. The 11 patients with a positive plasma BK PCR test underwent prompt reduction in baseline immunotherapy consisting of a 50% daily dose reduction (n = 6) or complete discontinuation of therapy with mycophenolate mofetil (n = 5). RESULTS After reduction or discontinuation of mycophenolate mofetil, 10 patients became negative for BK virus in the plasma within 6 months. Progression to BK nephropathy has not occurred, and renal transplant dysfunction secondary to acute cellular rejection developed in only 1 patient (9%). One year post-transplant, the mean serum creatinine values for these 11 patients remained stable at 1.5 mg/dL. CONCLUSION Monthly plasma screening for BK virus by PCR together with immunosuppressive regimen reduction prevents BK nephropathy. In addition, this intensive screening protocol is associated with a low rate of acute rejection and excellent preservation of renal function.
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Affiliation(s)
- Roman Petrov
- Department of Surgery, Albany Medical College, Albany, New York 12208, USA
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Rogers NM, Russ GR, Cooper J, Coates PT. Immunophenotyping of interstitial infiltrate does not distinguish between BK virus nephropathy and acute cellular rejection. Nephrology (Carlton) 2009; 14:118-22. [PMID: 19143944 DOI: 10.1111/j.1440-1797.2008.01050.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION BK virus nephropathy (BKVN) is a significant cause of late renal allograft loss. It is characterized histologically by an interstitial nephritis that can be difficult to distinguish from acute cellular rejection (ACR). We investigated whether immunophenotyping of the infiltrate would aid this distinction. METHODS Ten cases of biopsy-proven BKVN, following renal transplantation, were identified from a single transplant centre. The infection was confirmed by renal biopsy and staining for SV-40 T-antigen. Biopsies from 20 consecutive patients with ACR were identified and used as controls. There was no evidence of BK infection serologically or histologically in these patients. Immunohistochemical staining with anti-CD20, perforin and granzyme B was performed on remaining tissue samples. RESULTS Clustered B cells were demonstrated in both BKVN and ACR. Hence, the CD20-stained component within the interstitial infiltrate was not useful in distinguishing these biopsies. Perforin-stained slides demonstrated fewer cytotoxic T cells in the biopsies with BK virus (average 2.4 +/- 1.4 cells per 100 lymphocytes per field) compared with those samples with acute rejection (8.6 +/- 5.7 cells per 100 lymphocytes, P < 0.0001). No significant difference in granzyme B staining was detected between ACR and BKVN. CONCLUSION Clustered B cells and granzyme B staining did not differentiate between ACR and BKVN. However, ACR cellular infiltrate was rich in perforin positive cells suggesting that perforin staining may be a useful marker to discriminate between these conditions.
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Affiliation(s)
- Natasha M Rogers
- Department of Nephrology and Transplantation Services, Basil Hetzel Institute, The Queen Elizabeth Hospital, Woodville, South Australia, Australia
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45
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Prince O, Savic S, Dickenmann M, Steiger J, Bubendorf L, Mihatsch MJ. Risk factors for polyoma virus nephropathy. Nephrol Dial Transplant 2008; 24:1024-33. [PMID: 19073658 PMCID: PMC2644630 DOI: 10.1093/ndt/gfn671] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Polyoma virus-associated nephropathy (PVN) is a common cause of renal transplant failure. The risk factors for the development of PVN have not yet been studied in large cohorts of patients for periods of 20 years. METHODS We collected clinical, renal biopsy and urinary cytology data from all patients with renal transplantations performed at the University Hospital of Basel from 1985 to 2005. All patients with a renal biopsy and urine cytology were included (n = 880). Renal transplants were divided into three groups, according to evidence of polyoma virus (PV) infection (decoy cells in the urine) and biopsy-proven PVN: Renal transplants without evidence of a PV infection (n = 751). Renal transplants with PV reactivation, e.g. decoy cell (DC) found by urinary cytology, but without PVN (n = 90). Renal transplants with PVN (n = 39). RESULTS The prevalence of biopsy-proven PVN in this cohort of patients was 3.3%. Immunosuppression with mycophenolate and/or tacrolimus, ATGAM, male gender of the recipient and a higher number of transplant rejection episodes were factors significantly associated with PVN development. CONCLUSIONS The most important risk factors for the development of PVN are acute rejection and ATGAM used as induction therapy as well as tacrolimus and mycophenolate as maintenance therapy. Therefore, we conclude that patients with tacrolimus and mycophenolate maintenance therapy should be carefully monitored for the development of PVN.
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Affiliation(s)
- Olivier Prince
- Geriatric Medicine, University Hospital Basel, Switzerland
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Sung H, Choi BH, Pyo YJ, Kim MN, Han DJ. Quantitation of BK virus DNA for diagnosis of BK virus-associated nephropathy in renal transplant recipients. J Korean Med Sci 2008; 23:814-8. [PMID: 18955787 PMCID: PMC2580024 DOI: 10.3346/jkms.2008.23.5.814] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Quantitative measurement of BK virus DNA (Q-BKDNA) has been used for the early diagnosis and monitoring of BK virus-associated nephropathy (BKVAN). This study was designed to determine the BKDNA cutoff for the diagnosis of BKVAN. Between June 2005 and February 2007, 64 renal transplant recipients taken renal biopsies due to renal impairment submitted plasma and urine for Q-BKDNA. Eight BKVAN patients (12.5%) had median viral loads of 6.0 log10 copies/mL in plasma and 7.3 log10 copies/mL in urine. Among 56 non-BKVAN patients, 45 were negative for Q-BKDNA; 4 were positive in plasma with a median viral load of 4.8 log10 copies/ mL, and 10 were positive in urine with a median viral load of 4.8 log10 copies/mL. Receiver operating characteristic curve analysis showed that a cutoff of 4.5 log10 copies/mL in plasma and a cutoff of 5.9 log10 copies/mL in urine had a sensitivity of 100% and a specificity of 96.4%, respectively. A combined cutoffs of 4 log10 copies/ mL in plasma and 6 log10 copies/mL in urine had better performance with a sensitivity of 100% and a specificity of 98.2% than each cutoff of urine or plasma. QBKDNA with the combined cutoffs could reliably diagnose BKVAN in renal transplant recipients.
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Affiliation(s)
- Heungsup Sung
- Department of Laboratory Medicine, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea
| | - Byung Hoo Choi
- Department of Laboratory Medicine, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea
| | - Yeon Jung Pyo
- Department of Laboratory Medicine, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea
| | - Mi-Na Kim
- Department of Laboratory Medicine, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea
| | - Duck Jong Han
- Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea
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Dall A, Hariharan S. BK virus nephritis after renal transplantation. Clin J Am Soc Nephrol 2008; 3 Suppl 2:S68-75. [PMID: 18309005 DOI: 10.2215/cjn.02770707] [Citation(s) in RCA: 106] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BK virus nephritis is an increasing problem and is posing a threat to improving renal transplant graft survival. The pathogenesis of this condition remains to be investigated. Higher prevalence of BK virus infection in recent years has been correlated with declining acute rejection rates and the use of potent immunosuppressive agents. Patients with this infection usually have asymptomatic viremia and/or nephritis with or without worsening of renal function. The diagnosis of this disease is based on detecting the virus or its effects in urine, blood, and renal tissue. In the past, approximately 30 to 60% of patients with BK virus nephritis developed graft failure. In recent years, the combination of early detection, prompt diagnosis, and therapies including preventive measures have resulted in better outcomes.
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Affiliation(s)
- Aaron Dall
- Division of Nephrology, Medical College of Wisconsin, 9200 West Wisconsin Avenue, Milwaukee, WI 53226, USA
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Kayler LK, Mohanka R, Morgan C, Basu A, Shapiro R, Randhawa PS. Clinical course of kidney transplant patients with acute rejection and BK virus replication following Campath therapy. Clin Transplant 2008; 22:348-53. [PMID: 18279421 DOI: 10.1111/j.1399-0012.2008.00791.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Kidney transplant recipients with active BK virus (BKV) replication are generally treated with reduction in immunosuppression to allow a successful immune response against the virus. METHODS We inadvertently administered Campath to two patients with BKV viruria, and one patient with BKV nephropathy, since allograft biopsies showed severe tubulitis or intimal arteritis, and results of PCR and in situ hybridization were not available at the time of therapeutic intervention. RESULTS Increased viral replication was observed, but not uniformly in all cases, and follow-up biopsies showed nephropathy in one additional case. Extra-renal dissemination did not occur. With subsequent reduction of immunosuppression or antiviral therapy, it was still possible to obtain clearance of viremia in all cases. Serum creatinine fell transiently after Campath in one patient; however, at one yr post-treatment all had increased levels over baseline. One graft was lost to persistent acute rejection that led to interstitial fibrosis and tubular atrophy. CONCLUSION These cases suggest that Campath treatment does not (i) irreversibly deplete cells believed to be important in mounting an immune response against BKV, or (ii) preclude subsequent eradication of viral DNA from the blood.
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Affiliation(s)
- Liise K Kayler
- Department of Pathology, The Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
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Abstract
Nephropathy from BK virus (BKV) infection is an evolving challenge in kidney transplant recipients. It is the consequence of modern potent immunosuppression aimed at reducing acute rejection and improving allograft survival. Untreated BKV infections lead to kidney allograft dysfunction or loss. Decreased immunosuppression is the principle treatment but predisposes to acute and chronic rejection. Screening protocols for early detection and prevention of symptomatic BKV nephropathy have improved outcomes. Although no approved antiviral drug is available, leflunomide, cidofovir, quinolones, and intravenous Ig have been used. Retransplantation after BKV nephropathy has been successful.
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Affiliation(s)
- Daniel L Bohl
- Department of Internal Medicine, Washington University School of Medicine, St. Louis, Missouri 63110, USA
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