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Goodlet KJ, McCreary EK, Nailor MD, Barnes D, Brokhof MM, Bova S, Clemens E, Kelly B, Lichvar A, Pluckrose DM, Summers BB, Szempruch KR, Tchen S. Therapeutic Myths in Solid Organ Transplantation Infectious Diseases. Open Forum Infect Dis 2024; 11:ofae342. [PMID: 38983710 PMCID: PMC11232700 DOI: 10.1093/ofid/ofae342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2024] [Accepted: 06/12/2024] [Indexed: 07/11/2024] Open
Abstract
Infection management in solid organ transplantation poses unique challenges, with a diverse array of potential pathogens and associated antimicrobial therapies. With limited high-quality randomized clinical trials to direct optimal care, therapeutic "myths" may propagate and contribute to suboptimal or excessive antimicrobial use. We discuss 6 therapeutic myths with particular relevance to solid organ transplantation and provide recommendations for infectious diseases clinicians involved in the care of this high-risk population.
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Affiliation(s)
- Kellie J Goodlet
- Department of Pharmacy Practice, Midwestern University, Glendale, Arizona, USA
| | - Erin K McCreary
- Department of Medicine, Division of Infectious Diseases, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Michael D Nailor
- Department of Pharmacy Services, St Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Darina Barnes
- Department of Pharmacy, Comprehensive Transplant Center, Cedars Sinai Medical Center, Los Angeles, California, USA
| | - Marissa M Brokhof
- Department of Pharmacy, Rush University Medical Center, Chicago, Illinois, USA
| | - Sarah Bova
- Department of Pharmacy, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Evan Clemens
- Department of Pharmacy, University of Washington Medical Center, Seattle, Washington, USA
| | - Beth Kelly
- Department of Pharmacy, Indiana University Health, Indianapolis, Indiana, USA
| | - Alicia Lichvar
- Center for Transplantation, UC San Diego Health, San Diego, California, USA
| | - Dawn M Pluckrose
- Department of Pharmacy, Tufts Medical Center, Boston, Massachusetts, USA
| | - Bryant B Summers
- Comprehensive Transplant Center, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Kristen R Szempruch
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, North Carolina, USA
| | - Stephanie Tchen
- Department of Pharmacy, Froedtert Hospital, Milwaukee, Wisconsin, USA
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2
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Chandraker A, Regmi A, Gohh R, Sharma A, Woodle ES, Ansari MJ, Nair V, Chen LX, Alhamad T, Norman S, Cibrik D, Singh M, Alper A, Jain D, Zaky Z, Knechtle S, Sharfuddin A, Gupta G, Lonze BE, Young JAH, Adey D, Faravardeh A, Dadhania DM, Rossi AP, Florescu D, Cardarelli F, Ma J, Gilmore S, Vasileiou S, Jindra PT, Wojciechowski D. Posoleucel in Kidney Transplant Recipients with BK Viremia: Multicenter, Randomized, Double-Blind, Placebo-Controlled Phase 2 Trial. J Am Soc Nephrol 2024; 35:618-629. [PMID: 38470444 PMCID: PMC11149047 DOI: 10.1681/asn.0000000000000329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 03/05/2024] [Indexed: 03/13/2024] Open
Abstract
Key Points Posoleucel was generally safe, well tolerated, and associated with a greater reduction of BK viremia compared with placebo. BK viremia reduction occurred coincident with an increase in the circulating frequency of BK virus–specific T cells in posoleucel recipients. The presence and persistence of posoleucel was confirmed by T-cell receptor variable β sequencing. Background Kidney transplant recipients with BK virus infection are at risk of developing BK virus–associated nephropathy, allograft rejection, and subsequent graft loss. There are no approved treatments for BK virus infection. Posoleucel is an off-the-shelf, allogeneic, multivirus-specific T-cell investigational therapy targeting BK virus, as well as five other opportunistic viruses: adenovirus, cytomegalovirus, Epstein–Barr virus, human herpesvirus 6, and John Cunningham virus. Methods In this phase 2, double-blind study, kidney transplant recipients with BK viremia were randomized 1:1:1 to receive posoleucel weekly for 3 weeks and then every 14 days (bi-weekly dosing) or every 28 days (monthly dosing) or placebo for 12 weeks. Participants were followed for 12 weeks after completing treatment. The primary objective was safety; the secondary objective was plasma BK viral load reduction. Results Sixty-one participants were randomized and dosed. Baseline characteristics were similar across groups. No deaths, graft-versus-host disease, or cytokine release syndrome occurred. The proportion of patients who had adverse events (AEs) judged by the investigators to be treatment-related was slightly lower in recipients of posoleucel: 20% (4 of 20 patients) and 18% (4 of 22) in those infused on a bi-weekly and monthly schedule, respectively, and 26% (5 of 19) in placebo recipients. None of the grade 3–4 AEs or serious AEs in any group were deemed treatment-related. No deaths, graft-versus-host disease, or cytokine release syndrome occurred. Three participants had allograft rejection, but none were deemed treatment-related by investigators. In posoleucel recipients, BK viremia reduction was associated with an increase in the circulating frequency of BK virus–specific T cells, and the presence and persistence of posoleucel was confirmed by T-cell receptor sequencing. Conclusions Posoleucel was generally safe, well tolerated, and associated with a larger reduction of BK viremia compared with placebo. Limitations of this study include the relatively short duration of follow-up and lack of power to detect significant differences in clinical outcomes. Clinical Trial registry name and registration number: Study of Posoleucel (Formerly Known as ALVR105; Viralym-M) in Kidney Transplant Patients With BK Viremia, NCT04605484 .
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Affiliation(s)
- Anil Chandraker
- Division of Renal Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Division of Renal Medicine, Department of Medicine, University of Massachusetts Chan Medical School, Worcester, Massachusetts
| | - Anil Regmi
- Inova Transplant Center, Falls Church, Virginia
| | | | - Akhil Sharma
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | | | - Vinay Nair
- Northwell Health, New Hyde Park, New York
| | - Ling-Xin Chen
- University of California Davis, Sacramento, California
| | - Tarek Alhamad
- Washington University School of Medicine at St. Louis, St. Louis, Missouri
| | | | | | | | | | | | | | | | - Asif Sharfuddin
- Indiana University School of Medicine, Indianapolis, Indiana
| | - Gaurav Gupta
- Virginia Commonwealth University, Richmond, Virginia
| | | | | | - Deborah Adey
- University of California, San Francisco, California
| | - Arman Faravardeh
- SHARP Kidney and Pancreas Transplant Center, San Diego, California
| | | | | | | | | | - Julie Ma
- AlloVir, Inc., Waltham, Massachusetts
| | | | - Spyridoula Vasileiou
- AlloVir, Inc., Waltham, Massachusetts
- Center for Cell and Gene Therapy, Baylor College of Medicine, Houston, Texas
| | - Peter T. Jindra
- Immune Evaluation Laboratory, Baylor College of Medicine, Houston, Texas
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Kotton CN, Kamar N, Wojciechowski D, Eder M, Hopfer H, Randhawa P, Sester M, Comoli P, Tedesco Silva H, Knoll G, Brennan DC, Trofe-Clark J, Pape L, Axelrod D, Kiberd B, Wong G, Hirsch HH. The Second International Consensus Guidelines on the Management of BK Polyomavirus in Kidney Transplantation. Transplantation 2024:00007890-990000000-00727. [PMID: 38605438 DOI: 10.1097/tp.0000000000004976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/13/2024]
Abstract
BK polyomavirus (BKPyV) remains a significant challenge after kidney transplantation. International experts reviewed current evidence and updated recommendations according to Grading of Recommendations, Assessment, Development, and Evaluations (GRADE). Risk factors for BKPyV-DNAemia and biopsy-proven BKPyV-nephropathy include recipient older age, male sex, donor BKPyV-viruria, BKPyV-seropositive donor/-seronegative recipient, tacrolimus, acute rejection, and higher steroid exposure. To facilitate early intervention with limited allograft damage, all kidney transplant recipients should be screened monthly for plasma BKPyV-DNAemia loads until month 9, then every 3 mo until 2 y posttransplant (3 y for children). In resource-limited settings, urine cytology screening at similar time points can exclude BKPyV-nephropathy, and testing for plasma BKPyV-DNAemia when decoy cells are detectable. For patients with BKPyV-DNAemia loads persisting >1000 copies/mL, or exceeding 10 000 copies/mL (or equivalent), or with biopsy-proven BKPyV-nephropathy, immunosuppression should be reduced according to predefined steps targeting antiproliferative drugs, calcineurin inhibitors, or both. In adults without graft dysfunction, kidney allograft biopsy is not required unless the immunological risk is high. For children with persisting BKPyV-DNAemia, allograft biopsy may be considered even without graft dysfunction. Allograft biopsies should be interpreted in the context of all clinical and laboratory findings, including plasma BKPyV-DNAemia. Immunohistochemistry is preferred for diagnosing biopsy-proven BKPyV-nephropathy. Routine screening using the proposed strategies is cost-effective, improves clinical outcomes and quality of life. Kidney retransplantation subsequent to BKPyV-nephropathy is feasible in otherwise eligible recipients if BKPyV-DNAemia is undetectable; routine graft nephrectomy is not recommended. Current studies do not support the usage of leflunomide, cidofovir, quinolones, or IVIGs. Patients considered for experimental treatments (antivirals, vaccines, neutralizing antibodies, and adoptive T cells) should be enrolled in clinical trials.
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Affiliation(s)
- Camille N Kotton
- Transplant and Immunocompromised Host Infectious Diseases Unit, Infectious Diseases Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Nassim Kamar
- Department of Nephrology and Organ Transplantation, Toulouse Rangueil University Hospital, INSERM UMR 1291, Toulouse Institute for Infectious and Inflammatory Diseases (Infinity), University Paul Sabatier, Toulouse, France
| | - David Wojciechowski
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Michael Eder
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Helmut Hopfer
- Division of Medical Genetics and Pathology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Parmjeet Randhawa
- Division of Transplantation Pathology, The Thomas E. Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA
| | - Martina Sester
- Department of Transplant and Infection Immunology, Saarland University, Homburg, Germany
| | - Patrizia Comoli
- Cell Factory and Pediatric Hematology/Oncology Unit, Department of Mother and Child Health, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Helio Tedesco Silva
- Division of Nephrology, Hospital do Rim, Fundação Oswaldo Ramos, Paulista School of Medicine, Federal University of São Paulo, Brazil
| | - Greg Knoll
- Department of Medicine (Nephrology), University of Ottawa and The Ottawa Hospital, Ottawa, ON, Canada
| | | | - Jennifer Trofe-Clark
- Renal-Electrolyte Hypertension Division, Associated Faculty of the Perelman School of Medicine, University of Pennsylvania, Pennsylvania, PA
- Transplantation Division, Associated Faculty of the Perelman School of Medicine, University of Pennsylvania, Pennsylvania, PA
| | - Lars Pape
- Pediatrics II, University Hospital of Essen, University of Duisburg-Essen, Essen, Germany
| | - David Axelrod
- Kidney, Pancreas, and Living Donor Transplant Programs at University of Iowa, Iowa City, IA
| | - Bryce Kiberd
- Division of Nephrology, Dalhousie University, Halifax, NS, Canada
| | - Germaine Wong
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, NSW, Australia
- Centre for Transplant and Renal Research, Westmead Hospital, Sydney, NSW, Australia
| | - Hans H Hirsch
- Division of Transplantation and Clinical Virology, Department of Biomedicine, Faculty of Medicine, University of Basel, Basel, Switzerland
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
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Karatas M, Tatar E, Okut G, Yildirim AM, Kocabas E, Tasli Alkan F, Simsek C, Dogan SM, Uslu A. Efficacy of mTOR Inhibitors and Intravenous Immunoglobulin for Treatment of Polyoma BK Nephropathy in Kidney Transplant Recipients: A Biopsy-Proven Study. EXP CLIN TRANSPLANT 2024; 22:118-127. [PMID: 38385385 DOI: 10.6002/ect.mesot2023.o29] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2024]
Abstract
OBJECTIVES We investigated the efficacy of a predetermined protocol that consisted of immunosuppressive drug reduction/withdrawal and intravenous immunoglobulin administration for the treatment of polyoma BK virus nephropathy. MATERIALS AND METHODS Patients with biopsy-proven polyoma BK virus nephropathy received a treatment regimen based on discontinuation of both calcineurin inhibitors and antiproliferative agents and switching to mTOR inhibitors accompanied by intravenous immunoglobulin administration. RESULTS Our study included 508 patients, with polyoma BK viremia detected in 80 patients. The mean age was 45.3 ± 9.5 years (range, 18-71 y), 64% were male, and mean follow-up was 37 ± 21 months (6-94 mo). All 16 patients who developed polyoma BK virus nephropathy and 9 patients who had highgrade polyoma BK viremia without nephropathy received intravenous immunoglobulin treatment. Compared with patients with viremia, patients with polyoma BK virus nephropathy had significantly higher rates of graft loss due to rejection (18.8% vs 1.6%; P = .024) and all-cause graft loss (31.2% vs 6.3%; P = .014). Histopathologically, viral inclusion bodies disappeared and SV40 became negative after treatment in all 13 patients who underwent protocol biopsies. Unfortunately, histopathologically complete recovery without chronic tubular and interstitial tissue damage was achieved in only 4 patients after treatment. In addition, 3 patients lost their grafts due to acute antibody-mediated or mixed-type rejection (18.8%). CONCLUSIONS In patients with polyoma BK virus nephropathy, clearance of viremia and SV40 should not be the sole outcomes to obtain. Aggressive reductions in maintenance immunosuppression and switching to double-drug therapy combined with high-dose intravenous immunoglobulin leads to high rates of graft loss/rejection and sequalae of chronic histological changes.
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Affiliation(s)
- Murat Karatas
- From the Department of General Surgery and Transplantation, University of Health Sciences, Izmir Bozyaka Education and Research Hospital, Izmir, Turkey
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Gorriceta JH, Lopez Otbo A, Uehara G, Posadas Salas MA. BK viral infection: A review of management and treatment. World J Transplant 2023; 13:309-320. [PMID: 38174153 PMCID: PMC10758681 DOI: 10.5500/wjt.v13.i6.309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 11/15/2023] [Accepted: 11/30/2023] [Indexed: 12/15/2023] Open
Abstract
BK viral infection remains to be a challenging post-transplant infection, which can result in kidney dysfunction. The mainstay approach to BK infection is reduction of immunosuppression. Alterations in immunosuppressive regimen with minimization of calcineurin inhibitors, use of mechanistic target of rapamycin inhibitors, and leflunomide have been attempted with variable outcomes. Over the past few years, investigators have explored potential therapeutic options for BK infection. Fluoroquinolone prophylaxis and treatment was found to have no benefit in kidney transplant recipients. The utility of cidofovir is limited by its nephrotoxicity. Intravenous immunoglobulin is becoming a popular option for treatment and prophylaxis for BK infection, as it increases the neutralizing antibody titers against the most common BK virus serotypes. Virus-specific T cell therapy is an emerging treatment option for BK viremia. In this review, we will explore management and therapeutic options for BK infection and recent evidence available in literature.
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Affiliation(s)
| | - Amy Lopez Otbo
- Department of Medicine, St. Luke’s Medical Center, Quezon 1112, Philippines
| | - Genta Uehara
- Department of Medicine, Division of Nephrology, Medical University of South Carolina, Charleston, SC 29425, United States
| | - Maria Aurora Posadas Salas
- Department of Medicine, Division of Nephrology, Medical University of South Carolina, Charleston, SC 29425, United States
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6
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Madill-Thomsen KS, Böhmig GA, Bromberg J, Einecke G, Eskandary F, Gupta G, Myslak M, Viklicky O, Perkowska-Ptasinska A, Solez K, Halloran PF. Relating Molecular T Cell-mediated Rejection Activity in Kidney Transplant Biopsies to Time and to Histologic Tubulitis and Atrophy-fibrosis. Transplantation 2023; 107:1102-1114. [PMID: 36575574 PMCID: PMC10125115 DOI: 10.1097/tp.0000000000004396] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 08/29/2022] [Accepted: 09/12/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND We studied the variation in molecular T cell-mediated rejection (TCMR) activity in kidney transplant indication biopsies and its relationship with histologic lesions (particularly tubulitis and atrophy-fibrosis) and time posttransplant. METHODS We examined 175 kidney transplant biopsies with molecular TCMR as defined by archetypal analysis in the INTERCOMEX study ( ClinicalTrials.gov #NCT01299168). TCMR activity was defined by a molecular classifier. RESULTS Archetypal analysis identified 2 TCMR classes, TCMR1 and TCMR2: TCMR1 had higher TCMR activity and more antibody-mediated rejection ("mixed") activity and arteritis but little hyalinosis, whereas TCMR2 had less TCMR activity but more atrophy-fibrosis. TCMR1 and TCMR2 had similar levels of molecular injury and tubulitis. Both TCMR1 and TCMR2 biopsies were uncommon after 2 y posttransplant and were rare after 10 y, particularly TCMR1. Within late TCMR biopsies, TCMR classifier activity and activity molecules such as IFNG fell progressively with time, but tubulitis and molecular injury were sustained. Atrophy-fibrosis was increased in TCMR biopsies, even in the first year posttransplant, and rose with time posttransplant. TCMR1 and TCMR2 both reduced graft survival, but in random forests, the strongest determinant of survival after biopsies with TCMR was molecular injury, not TCMR activity. CONCLUSIONS TCMR varies in intensity but is always strongly related to molecular injury and atrophy-fibrosis, which ultimately explains its effect on survival. We hypothesize, based on the reciprocal relationship with hyalinosis, that the TCMR1-TCMR2 gradient reflects calcineurin inhibitor drug underexposure, whereas the time-dependent decline in TCMR activity and frequency after the first year reflects T-cell exhaustion.
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Affiliation(s)
| | - Georg A. Böhmig
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | | | - Gunilla Einecke
- Department of Nephrology, Hannover Medical School, Hannover, Germany
| | - Farsad Eskandary
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Gaurav Gupta
- Division of Nephrology, Virginia Commonwealth University, Richmond, VA
| | - Marek Myslak
- Department of Clinical Interventions, Department of Nephrology and Kidney Transplantation SPWSZ Hospital, Pomeranian Medical University, Szczecin, Poland
| | - Ondrej Viklicky
- Department of Nephrology and Transplant Center, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | | | - Kim Solez
- Department of Laboratory Medicine and Pathology, Division of Anatomical Pathology, University of Alberta, Edmonton, Canada
| | - Philip F. Halloran
- Alberta Transplant Applied Genomics Centre, Edmonton, AB, Canada
- Division of Nephrology and Transplant Immunology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
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Elalouf A. Infections after organ transplantation and immune response. Transpl Immunol 2023; 77:101798. [PMID: 36731780 DOI: 10.1016/j.trim.2023.101798] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 01/08/2023] [Accepted: 01/26/2023] [Indexed: 01/31/2023]
Abstract
Organ transplantation has provided another chance of survival for end-stage organ failure patients. Yet, transplant rejection is still a main challenging factor. Immunosuppressive drugs have been used to avoid rejection and suppress the immune response against allografts. Thus, immunosuppressants increase the risk of infection in immunocompromised organ transplant recipients. The infection risk reflects the relationship between the nature and severity of immunosuppression and infectious diseases. Furthermore, immunosuppressants show an immunological impact on the genetics of innate and adaptive immune responses. This effect usually reactivates the post-transplant infection in the donor and recipient tissues since T-cell activation has a substantial role in allograft rejection. Meanwhile, different infections have been found to activate the T-cells into CD4+ helper T-cell subset and CD8+ cytotoxic T-lymphocyte that affect the infection and the allograft. Therefore, the best management and preventive strategies of immunosuppression, antimicrobial prophylaxis, and intensive medical care are required for successful organ transplantation. This review addresses the activation of immune responses against different infections in immunocompromised individuals after organ transplantation.
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Affiliation(s)
- Amir Elalouf
- Bar-Ilan University, Department of Management, Ramat Gan 5290002, Israel.
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8
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Gras J, Nere ML, Peraldi MN, Bonnet-Madin L, Salmona M, Taupin JL, Desgrandchamps F, Verine J, Brochot E, Amara A, Molina JM, Delaugerre C. BK virus genotypes and humoral response in kidney transplant recipients with BKV associated nephropathy. Transpl Infect Dis 2023; 25:e14012. [PMID: 36748721 DOI: 10.1111/tid.14012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 10/12/2022] [Accepted: 10/24/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND Among kidney transplant recipients (KTR) with BK virus associated nephropathy (BKVN), BKV genotypes' evolution and anti-BKV humoral response are not well established. We aim to analyze BKV replication and genetic evolution following transplantation, and characterize concomitant anti-BKV-VP1 humoral response. METHODS We retrospectively analyzed 32 cases of biopsy-proven BKVN. Stored plasma and kidney biopsies were tested for BKV viral load, and VP1 sequencing performed on positive samples. BKV-VP1 genotype-specific neutralizing antibodies (NAbs) titers were determined at transplantation and BKVN. RESULTS At the time of BKVN diagnosis, BKV viral load was 8.2 log10 IU/106 cells and 5.4 log10 IU/mL in kidney and plasma, respectively. VP1 sequencing identified the same BKV-subtype in both compartments in 31/32 cases. At the time of transplantation, 8/20 (40%) of biopsies tested positive for BKV detection, whereas concomitant BKV viremia was negative. VP1 sequencing identified a different subtype compared to BKVN in 5/6 of these samples. This was confirmed following transplantation: 8 patients had a BKV+ biopsy before BKV viremia, and VP1 sequencing identified a different subtype compared to BKVN in all of them. After the onset of BKV viremia and prior to BKVN diagnosis, the BKV subtype in BKV+ plasma and kidney biopsy was the same as the one isolated at BKVN. BKV-VP1 NAbs titers were significantly higher at the time of BKVN compared to transplantation (p = .0031), with similar titers across genotypes. CONCLUSION Altogether, our data suggest that among some KTR with BKVN, the BKV genotype from the donor may not be responsible for BKVN pathogenesis.
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Affiliation(s)
- Julien Gras
- Infectious Disease Department, APHP-Saint-Louis Hospital, Paris, France.,INSERM U944, Biology of Emerging Viruses Team, Institut de Recherche Saint Louis, APHP-Saint-Louis Hospital, Paris, France.,Université Paris Cité, Paris, France
| | | | - Marie Noëlle Peraldi
- Université Paris Cité, Paris, France.,Nephrology and Kidney Transplant Department, APHP-Saint Louis Hospital, Paris, France
| | - Lucie Bonnet-Madin
- INSERM U944, Biology of Emerging Viruses Team, Institut de Recherche Saint Louis, APHP-Saint-Louis Hospital, Paris, France
| | - Maud Salmona
- Université Paris Cité, Paris, France.,Virology Department, APHP-Saint Louis Hospital, Paris, France
| | - Jean Luc Taupin
- Université Paris Cité, Paris, France.,Immunology Department, APHP-Saint Louis Hospital, Paris, France
| | - François Desgrandchamps
- Université Paris Cité, Paris, France.,Urology Department, APHP-Saint Louis Hospital, Paris, France
| | - Jérôme Verine
- Pathology Department, APHP-Saint Louis Hospital, Paris, France
| | | | - Ali Amara
- INSERM U944, Biology of Emerging Viruses Team, Institut de Recherche Saint Louis, APHP-Saint-Louis Hospital, Paris, France.,Université Paris Cité, Paris, France
| | - Jean Michel Molina
- Infectious Disease Department, APHP-Saint-Louis Hospital, Paris, France.,INSERM U944, Biology of Emerging Viruses Team, Institut de Recherche Saint Louis, APHP-Saint-Louis Hospital, Paris, France.,Université Paris Cité, Paris, France
| | - Constance Delaugerre
- INSERM U944, Biology of Emerging Viruses Team, Institut de Recherche Saint Louis, APHP-Saint-Louis Hospital, Paris, France.,Université Paris Cité, Paris, France.,Virology Department, APHP-Saint Louis Hospital, Paris, France
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9
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Characteristics, risk factors and outcome of BKV nephropathy in kidney transplant recipients: a case-control study. BMC Infect Dis 2023; 23:74. [PMID: 36747162 PMCID: PMC9903532 DOI: 10.1186/s12879-023-08043-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 01/30/2023] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Following kidney transplantation, BK virus associated nephropathy (BKVN) occurs in 1 to 10% of kidney transplant recipients (KTR) and represents a major cause of graft loss. We aim at identifying factors associated with biopsy proven BKVN among KTR. METHODS We conducted a retrospective case-control study including all KTR with a biopsy-proven diagnosis of BKVN between 2005 and 2019. Clinical characteristics and outcome were described. For each case, one control KTR without BKV infection was identified and matched by age, transplant date, and donor status. Factors associated with BKVN diagnosis were identified using exact conditional logistic regression. Comparative survival was described using Kaplan-Meier estimator. RESULTS Sixty-four cases of BKVN were identified among 1737 new kidney transplantation (3.7% prevalence). Clinical characteristics did not differ between groups, except for a higher c-PRA among cases. BKVN occurred in a median time of 11 (5-14.5) months after KT, and was associated with a significantly impaired graft function at diagnosis. Following BKVN, 61 (95%) of the patients had immunosuppression reduction, which led to BKV DNAemia resolution in 49% of cases. In multivariate analysis, factors associated with BKVN diagnosis were lymphopenia < 500/mm3 and a prednisone dose > 7.5 mg/day. Median duration of follow-up was 40 months for both groups. BKVN was associated with a significantly increased risk of graft rejection (P = 0.02) and return to dialysis (P = 0.01). CONCLUSIONS BKVN remains a severe complication in KTR and is associated with an increased risk for acute rejection and return to dialysis. Lymphopenia below 500/mm3 and corticosteroid maintenance therapy are significantly associated with biopsy-proven BKVN diagnosis.
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10
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Smith DM, Schafer JR, Tullius B, Witkam L, Paust S. Natural killer cells for antiviral therapy. Sci Transl Med 2023; 15:eabl5278. [PMID: 36599006 DOI: 10.1126/scitranslmed.abl5278] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Natural killer (NK) cell-based immunotherapy is being explored for treating infectious diseases, including viral infections. Here, we discuss evidence of NK cell responses to different viruses, ongoing clinical efforts to treat such infections with NK cell products, and review platforms to generate NK cell products.
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Affiliation(s)
- Davey M Smith
- Department of Medicine, University of California, San Diego, La Jolla, CA 92093, USA
| | | | | | - Laura Witkam
- Kiadis Pharma, Sanofi, 1105BP Amsterdam, Netherlands
| | - Silke Paust
- Department of Immunology and Microbiology, Scripps Research Institute, La Jolla, CA 92037, USA
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11
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Ganesh K, Abraham MA, Thomas R, Kumar J, Simon S. BK virus nephropathy in renal transplantation and the effect of intravenous immunoglobulin: A prospective longitudinal single-center study in South Asia. INDIAN JOURNAL OF TRANSPLANTATION 2023. [DOI: 10.4103/ijot.ijot_43_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023] Open
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12
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Munjal RS, Munjal J, Gandhi P, Gupta N. BK Polyomavirus-Induced Nephropathy in Native Kidney. Cureus 2023; 15:e34410. [PMID: 36874648 PMCID: PMC9977576 DOI: 10.7759/cureus.34410] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2023] [Indexed: 02/01/2023] Open
Abstract
BK polyomavirus has been well-studied as an opportunistic infection in immunocompromised kidney transplant patients. In the majority of the population, BK polyomavirus establishes a lifelong infection in renal tubular and uroepithelial cells; however, in an immunocompromised state, the virus can reactivate and can lead to BK polyomavirus-associated nephropathy (BKN). In this case, the patient was a 46-year-old male with a past medical history of HIV, compliant with antiretroviral therapy (ART), and B-cell lymphoma treated with chemotherapy. The patient presented with worsening kidney function of unknown etiology. This prompted further assessment with a kidney biopsy. Kidney biopsy findings were consistent with BKN. In the literature, BKN has been studied in renal transplant patients; however, it rarely involves native kidneys.
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Affiliation(s)
| | - Jaskaran Munjal
- Internal Medicine, Shri Ram Murti Smarak Institute of Medical Sciences, Bareilly, IND
| | - Pulkit Gandhi
- Nephrology, Lake Erie College of Osteopathic Medicine, Erie, USA.,Nephrology, Rochester Regional Health, Rochester, USA
| | - Nikhil Gupta
- Internal Medicine, San Joaquin General Hospital, Stockton, USA
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13
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ALTUN E, ULU S, APAYDIN S, GÜVEN B. Biopsy-proven BK virus nephropathy in kidney transplant patients: risk factors, prevalence and treatment approach. CUKUROVA MEDICAL JOURNAL 2022. [DOI: 10.17826/cumj.1133550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Purpose: BK virus nephropathy (BKVN) is a latent infection and it is closely associated with immunsuppressive therapy. We aimed in this study to evaluate biopsy-proven BKVN and investigate frequency, risk factors and treatment management.
Materials and Methods: In this study, 422 kidney transplant recipients were analysed retrospectively between April 2014 and April 2020 for biopsy-proven BK virus nephropathy. Group I included 16 kidney transplant patients with biopsy-proven BK nephropathy and group II included 36 kidney transplant patients with negative BK virus nephropathy. We aimed demographic, clinical features of kidney transplant recipients with BKVN (group I, n: 16 ) and non-BKVN (group II, n:36) were compared and the factors affecting of BKVN.
Results: The mean age of grup I and group II were were 41±14.8 years and 39±15.2 respectively. The patients mean follow-up period of 43±11.2 months. Serum creatinine and proteinuria degree were significantly higher in the group with BKVN. In order to reduce the dose of immunosuppression in patients with BKVN, tacrolimus treatment was discontinued in 8 patients, and they were switched to everolimus + MMF + prednisone treatment, leflunamide + MMF + prednisone treatment in 4 patients, and sirolimus + MMF + prednisone treatment in 4 patients. The mean serum creatinine level of the patients who were followed up were observed as 1.78±0.98 mg/dl in group I.
Conclusion: In our center, the prevalance of BKVN was found 3.92% during the study period. Reduction of dose immunosuppressive therapy is the most effective treatment. It is thought that there was no differences between Leflunamide and other approaches for treatment. Early diagnosis and screening (frequently intervals) seems to be most effective way for BKVN.
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Affiliation(s)
- Eda ALTUN
- Bahçeşehir Üniversitesi Tıp Fakültesi İç Hastalıkları Nefroloji
| | - Sena ULU
- Bahçeşehir Üniversitesi Tıp Fakültesi, Nefroloji Bilim Dalı
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14
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Conversion to mTOR-Inhibitors Plus IV Immunoglobulins in Kidney-Transplant Recipients with BKV Infection: A Retrospective Comparative Study. J Clin Med 2022; 11:jcm11247292. [PMID: 36555909 PMCID: PMC9785214 DOI: 10.3390/jcm11247292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 12/02/2022] [Accepted: 12/06/2022] [Indexed: 12/13/2022] Open
Abstract
BK virus-associated nephropathy (PvAN) increases the risk of graft failure justifying treatment. Conversion to mammalian target of rapamycin inhibitors (mTORi) and Human polyclonal immunoglobulins (IVIg) could prevent the risk of PvAN. Our retrospective study assessed the efficacy of mTORi associated with IVIg therapy (mTORi±IVIg group) versus standard immunosuppression reduction to clear BKV DNAemia. Among forty-three kidney-transplanted patients with positive BKV DNAemia, we included twenty-six patients in the mTORi±IVIg group and reduced immunosuppression therapy for seventeen patients. We focused on BKV DNAemia clearance on the first-year. Renal function, rejection rate, evolution to PvAN, and complications of immunosuppression were assessed. BKV DNAemia decreased faster and significantly in the control group as compared to the mTORi±IVIg group (p < 0.001). Viral clearance was significantly higher in the control group compared to the mTORi±IVIg group (88% vs. 58%; p = 0.033). Death-censored graft loss, rejection rates and kidney-graft function at 12 months did not significantly differ. Multivariate analyses significantly associated BKV DNAemia clearance with reducing immunosuppression (OR = 0.11 (0.06−0.9), p = 0.045), female kidney donor (OR = 0.10 (0.01−0.59/)], p = 0.018) and time to first DNAemia, (OR = 0.88 (0.76−0.96), p = 0.019). In our study, the standard treatment for BKV DNAemia had better outcomes than an mTORi±IVIg conversion.
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15
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Muacevic A, Adler JR. Kidney Allograft Dysfunction Due to John Cunningham (JC) Virus Nephropathy. Cureus 2022; 14:e32021. [PMID: 36600814 PMCID: PMC9799239 DOI: 10.7759/cureus.32021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/29/2022] [Indexed: 11/30/2022] Open
Abstract
John Cunningham (JC) polyomavirus-associated nephropathy (JC-PVAN) is a rare cause of polyomavirus-associated nephropathy (PVAN). Although BK polyomavirus (BKPyV) is a relatively proven common infection post kidney transplantation, JC polyomavirus (JCPyV) infection and its impact on graft function have been less studied. Here, we report a case of a deceased donor kidney transplant recipient who was diagnosed with allograft dysfunction due to JC-PVAN six years after transplantation. JC viremia resolved after a reduction in immunosuppression and treatment with intravenous immunoglobulin (IVIG); however, she developed an acute cellular rejection with moderate fibrosis resulting in chronic kidney disease in the allograft.
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16
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Non-Immunologic Causes of Late Death-Censored Kidney Graft Failure: A Personalized Approach. J Pers Med 2022; 12:jpm12081271. [PMID: 36013220 PMCID: PMC9410103 DOI: 10.3390/jpm12081271] [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: 04/01/2022] [Revised: 07/28/2022] [Accepted: 07/28/2022] [Indexed: 11/29/2022] Open
Abstract
Despite continuous advances in surgical and immunosuppressive protocols, the long-term survival of transplanted kidneys is still far from being satisfactory. Antibody-mediated rejection, recurrent autoimmune diseases, and death with functioning graft are the most frequent causes of late-kidney allograft failure. However, in addition to these complications, a number of other non-immunologic events may impair the function of transplanted kidneys and directly or indirectly lead to their failure. In this narrative review, we will list and discuss the most important nonimmune causes of late death-censored kidney graft failure, including quality of the donated kidney, adherence to prescriptions, drug toxicities, arterial hypertension, dyslipidemia, new onset diabetes mellitus, hyperuricemia, and lifestyle of the renal transplant recipient. For each of these risk factors, we will report the etiopathogenesis and the potential consequences on graft function, keeping in mind that in many cases, two or more risk factors may negatively interact together.
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17
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BK Virus Nephropathy in Kidney Transplantation: A State-of-the-Art Review. Viruses 2022; 14:v14081616. [PMID: 35893681 PMCID: PMC9330039 DOI: 10.3390/v14081616] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 07/10/2022] [Accepted: 07/22/2022] [Indexed: 11/16/2022] Open
Abstract
BK virus maintains a latent infection that is ubiquitous in humans. It has a propensity for reactivation in the setting of a dysfunctional cellular immune response and is frequently encountered in kidney transplant recipients. Screening for the virus has been effective in preventing progression to nephropathy and graft loss. However, it can be a diagnostic and therapeutic challenge. In this in-depth state-of-the-art review, we will discuss the history of the virus, virology, epidemiology, cellular response, pathogenesis, methods of screening and diagnosis, evidence-based treatment strategies, and upcoming therapeutics, along with the issue of re-transplantation in patients.
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18
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In Vitro Study Evaluating the Effect of Different Immunosuppressive Agents on Human Polyomavirus BK Replication. Transplant Proc 2022; 54:2035-2041. [PMID: 35659782 DOI: 10.1016/j.transproceed.2022.04.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Accepted: 04/08/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Human polyomavirus BK (BKPyV) is the etiologic agent of polyomavirus-associated nephropathy, a leading cause of kidney transplant dysfunction. Because of the lack of antiviral therapies, immunosuppression minimization is the recommended treatment. This strategy offers suboptimal outcomes and entails a significant risk of rejection. Our aim was to evaluate the effect of different immunosuppressive drugs (leflunomide, tacrolimus, mycophenolic acid, sirolimus, and everolimus) and their combinations in an in vitro model of BKPyV infection. METHODS Human renal tubular epithelial cells were infected with BKPyV and treated with leflunomide, tacrolimus, mycophenolic acid, sirolimus, and everolimus, administered alone or in some combination thereof. Viral replication was assessed every 24 hours (up to 72 hours) by BKPyV-specific quantitative real-time polymerized chain reaction for the VIRAL PROTEIN 1 sequence in cell supernatants and by western blot analysis targeting the viral protein 1 and the glyceraldehyde 3-phosphate dehydrogenase on total protein lysates. Results were described as viral copies/mL and compared between treatments at any prespecified time point of the study. RESULTS The highest inhibitory effects were observed using leflunomide or everolimus plus mycophenolic acid (mean BKPyV replication log reduction 0.28). The antiviral effect of everolimus persisted when it was used in combination with tacrolimus (mean BKPyV replication log reduction 0.27). CONCLUSIONS Our experience confirms that everolimus has anti-BKPyV properties and prompts future research to investigate possible mechanisms of action. It also provides a rational basis for targeted clinical trials evaluating alternative immunosuppressive modification strategies.
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19
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Mohammad D, Kim DY, Baracco R, Kapur G, Jain A. Treatment of BK virus with a stepwise immunosuppression reduction and intravenous immunoglobulin in pediatric kidney transplant. Pediatr Transplant 2022; 26:e14241. [PMID: 35122460 DOI: 10.1111/petr.14241] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 11/04/2021] [Accepted: 01/14/2022] [Indexed: 12/22/2022]
Abstract
BACKGROUND BKV and BKVN are common in pediatric kidney transplant, but there is limited data on treatment approaches. Our objective was to study the prevalence of BKV and BKVN utilizing only plasma qPCR and report treatment outcomes with stepwise IR and IVIG. METHODS A retrospective study of all pediatric kidney transplants from 2013 to 2020. Excluded patients >21 years at transplant and immediate graft failure. Surveillance was conducted using only plasma BK qPCR at 1, 3, 6, 9, 12, 18, and 24 months and annually. BKV defined as ≥250 copies/ml and resolution as <250 copies/ml. Presumed BKVN as >10 000 copies/ml despite IR; and BKVN if confirmed on histology. RESULTS Fifty-six patients were included in the study; 20 (35.7%) had BKV. BKV was associated with longer duration of stent, 40 vs. 33.5 days (p = .004). Two patients (3.5%) had confirmed, and 2(3.5%) had presumed BKVN. The first-line treatment was IR in 100% of patients. BKVN confirmed and presumed received IVIG every month for six doses. Viral resolution was achieved in 70%, and no difference was noted in estimated glomerular filtration rate between BKV and non-BKV group (p = .438). There were no rejection episodes, and graft survival was 100% over median follow-up of 3 years. CONCLUSIONS Plasma qPCR alone is adequate for screening and monitoring treatment of BKV and BKVN. A stepwise IR and IVIG resulted in BKV resolution in the majority of patients. Larger studies are required to study the role of IVIG in the treatment of BKVN.
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Affiliation(s)
- Dunya Mohammad
- Division of Pediatrics, Children's and Women's Hospital, University of South Alabama, Mobile, Alabama, USA
| | - Dean Y Kim
- Division of Kidney Transplant Surgery, Department of Transplant Services, Children's Hospital of Michigan, Detroit, Michigan, USA
| | - Rossana Baracco
- Division of Pediatric Nephrology and Hypertension, Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, Michigan, USA
| | - Gaurav Kapur
- Division of Pediatric Nephrology and Hypertension, Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, Michigan, USA
| | - Amrish Jain
- Division of Pediatric Nephrology and Hypertension, Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, Michigan, USA
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20
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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: 1.0] [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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21
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Zhao J, You X, Zeng X. Research progress of BK virus and systemic lupus erythematosus. Lupus 2022; 31:522-531. [PMID: 35264023 DOI: 10.1177/09612033221084259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Systemic lupus erythematosus (SLE) is an autoimmune disease in which patients are often infected by viruses due to deficient immunity or immunosuppressant use. BK virus (BKV)mainly affects the kidney and can also cause multiple organ involvement throughout the body, which is similar to SLE. BKV is mostly a latent infection in vivo. The incidence of virus reactivation is higher in SLE patients. Reactivation of BKV can induce the production of autoantibodies, thereby promoting the occurrence and development of SLE.Purpose: Aim of this article is to review the prevalence and pathegenesis of BKV infection in SLE patients.Method: The literature search was conducted using four different databases including PubMed, Cochrane Library, Scopus and Web of Science.Results: BK virus is higher infection and reactivation in SLE patients. The "hapten carrier" mechanism may lead to the production of autoantibodies. Some immunosuppressive drugs, like leflumide and hydroxychloroquine, may show a protective effect.Conclusions: BKV infection plays a role in the occurrence and development of SLE, and its significance deserves further exploration.
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Affiliation(s)
- Jiawei Zhao
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, 34732Peking Union Medical College, Beijing, China
| | - Xin You
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, 34732Peking Union Medical College, Beijing, China
| | - Xiaofeng Zeng
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, 34732Peking Union Medical College, Beijing, China
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22
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Ge S, Chu M, Tang J, Kahwaji J, Karasyov A, Lovato D, Vo A, Choi J, Jordan SC, Zhang R, Toyoda M. Viral-specific cytotoxic T-cell responses in HLA-sensitized kidney transplant patients maintained on everolimus and low dose tacrolimus. Transpl Infect Dis 2022; 24:e13805. [PMID: 35213773 DOI: 10.1111/tid.13805] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 01/21/2022] [Accepted: 01/31/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Maintenance with "everolimus + reduced dose tacrolimus" (Ev + Taclow ) was reported to reduce the risk of viral infections compared to (Tac + MMF). Here we examined viremia and viral-specific T-cell (viral-Tc) responses in patients treated with Ev + Taclow v. Tac + MMF in highly-HLA sensitized patients. METHODS HLA sensitized (HS) kidney transplant patients were monitored pre- and post-transplant for viremia (CMV, BK and EBV) by PCR in 19 Ev + Taclow and 48 Tac + MMF patients. For CMV PCR analysis, we compared infection rates in 19 Ev + Taclow patients to 48 CMV D+/R- (#28) or CMV D-/R- (#20) Tac + MMF patients. CMV-Tc and EBV-Tc were evaluated by cytokine flow cytometry, and DSA levels by Luminex for selected patients in both groups. RESULTS CMV, EBV viremia rates were similar in Ev + Taclow v. Tac + MMF patients, but BKV rates were significantly higher in Ev + Taclow patients. No patient in either group developed BKAN or PTLD. CMV- & EBV-Tc decreased significantly after alemtuzumab induction but returned to pre-treatment levels 1-2 months post-transplant in most patients. de novo DSA was similar in both groups as were patient and graft survival and graft rejection. CONCLUSIONS CMV-Tc, EBV-Tc were similar in Ev + Taclow and Tac + MMF patients. EBV and CMV viremia rates were similar over 1 year. BKV rates were significantly higher in Ev + Taclow patients suggesting no benefit for Ev + Taclow in enhancing viral specific Tc effector functions or limiting viral infections. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Shili Ge
- Transplant Immunology Laboratory, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Maggie Chu
- Transplant Immunology Laboratory, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Jacqueline Tang
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California, 90048, USA
| | - Joseph Kahwaji
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California, 90048, USA
| | - Artur Karasyov
- Transplant Immunology Laboratory, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Darly Lovato
- Transplant Immunology Laboratory, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Ashley Vo
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California, 90048, USA
| | - Jua Choi
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California, 90048, USA
| | - Stanley C Jordan
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California, 90048, USA
| | - Ruan Zhang
- Transplant Immunology Laboratory, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Mieko Toyoda
- Transplant Immunology Laboratory, Cedars-Sinai Medical Center, Los Angeles, California, USA
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Wang J, Li J, Chen Z, Xu M, Yang C, Rong R, Zhu T. A Nomogram for Predicting BK Virus Activation in Kidney Transplantation Recipients Using Clinical Risk Factors. Front Med (Lausanne) 2022; 9:770699. [PMID: 35223891 PMCID: PMC8866320 DOI: 10.3389/fmed.2022.770699] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Accepted: 01/10/2022] [Indexed: 12/13/2022] Open
Abstract
BK virus is a common opportunistic viral infection that could cause BK virus-associated nephropathy in renal transplant recipients. Thus, we retrospectively analyzed clinical and laboratory data associated with a higher risk of BK virus activation from 195 renal transplant recipients by the multivariate logistic regression analysis and performed the external validation. Results showed that patients with BK virus active infection were associated with a deceased donor, had lower direct bilirubin levels, a higher proportion of albumin in serum protein electrophoresis, and lower red blood cells and neutrophil counts. The multivariate logistic regression analyses revealed that the living donor, direct bilirubin, and neutrophil counts were significantly associated with BK virus activation. The logistic regression model displayed a modest discriminability with the area under the receiver operating characteristic curve of 0.689 (95% CI: 0.607–0.771; P < 0.01) and also demonstrated a good performance in the external validation dataset (the area under the receiver operating characteristic curve was 0.699, 95% CI: 0.5899–0.8081). The novel predictive nomogram achieved a good prediction of BK virus activation in kidney transplant recipients.
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Affiliation(s)
- Jiyan Wang
- Department of Urology, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Key Laboratory of Organ Transplantation, Shanghai, China
| | - Jiawei Li
- Department of Urology, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Key Laboratory of Organ Transplantation, Shanghai, China
| | - Zhongli Chen
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ming Xu
- Department of Urology, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Key Laboratory of Organ Transplantation, Shanghai, China
| | - Cheng Yang
- Department of Urology, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Key Laboratory of Organ Transplantation, Shanghai, China
- Zhangjiang Institute of Fudan University, Shanghai, China
- *Correspondence: Cheng Yang ;
| | - Ruiming Rong
- Department of Urology, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Key Laboratory of Organ Transplantation, Shanghai, China
- Department of Transfusion, Zhongshan Hospital, Fudan University, Shanghai, China
- Ruiming Rong
| | - Tongyu Zhu
- Department of Urology, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Key Laboratory of Organ Transplantation, Shanghai, China
- Tongyu Zhu ;
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24
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Agrawal A, Ison MG, Danziger-Isakov L. Long-Term Infectious Complications of Kidney Transplantation. Clin J Am Soc Nephrol 2022; 17:286-295. [PMID: 33879502 PMCID: PMC8823942 DOI: 10.2215/cjn.15971020] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Infections remain a common complication of solid-organ transplantation. Most infections in the first month after transplant are typically health care-associated infections, whereas late infections, beyond 6-12 months, are community-acquired infections. Opportunistic infections most frequently present in the first 12 months post-transplant and can be modulated on prior exposures and use of prophylaxis. In this review, we summarize the current epidemiology of postkidney transplant infections with a focus on key viral (BK polyomavirus, cytomegalovirus, Epstein-Barr virus, and norovirus), bacterial (urinary tract infections and Clostridioides difficile colitis), and fungal infections. Current guidelines for safe living post-transplant are also summarized. Literature supporting prophylaxis and vaccination is also provided.
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Affiliation(s)
- Akansha Agrawal
- Division of Nephrology, Northwestern University Feinberg School of Medicine, Chicago, Illinois,Division of Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Michael G. Ison
- Division of Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, Illinois,Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Lara Danziger-Isakov
- Division of Pediatric Infectious Diseases, Cincinnati Children’s Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio
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25
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Uppin M, Veduruvada R, Madireddy N, Koyya S, Guditi S, Taduri G, Raju S. Clinicopathologic features of polyomavirus nephropathy: Our experience - A retrospective observational study. INDIAN JOURNAL OF TRANSPLANTATION 2022. [DOI: 10.4103/ijot.ijot_115_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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26
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Myint TM, Chong CHY, Wyld M, Nankivell B, Kable K, Wong G. Polyoma BK Virus in Kidney Transplant Recipients: Screening, Monitoring, and Management. Transplantation 2022; 106:e76-e89. [PMID: 33908382 DOI: 10.1097/tp.0000000000003801] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Polyomavirus BK virus (BKPyV) infection is an important complication of kidney transplantation and allograft failure. The prevalence of viremia is 10%-15%, compared with BK-associated nephropathy (BKPyVAN) at 3%-5%. Given that there are no effective antiviral prophylaxis or treatment strategies for BKPyVAN, active screening to detect BKPyV viremia is recommended, particularly during the early posttransplant period. Immunosuppression reduction to allow viral clearance may avoid progression to severe and irreversible allograft damage. The frequency and duration of screening are highly variable between transplant centers because the evidence is reliant largely on observational data. While the primary treatment goals center on achieving viral clearance through immunosuppression reduction, prevention of subsequent acute rejection, premature graft loss, and return to dialysis remain as major challenges. Treatment strategies for BKPyV infection should be individualized to the recipient's underlying immunological risk and severity of the allograft infection. Efficacy data for adjuvant therapies including intravenous immunoglobulin and cidofovir are sparse. Future well-powered and high-quality randomized controlled trials are needed to inform evidence-based clinical practice for the management of BKPy infection.
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Affiliation(s)
- Thida Maung Myint
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia
- Newcastle Transplant Unit, John Hunter Hospital, Newcastle, NSW, Australia
| | - Chanel H Y Chong
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia
| | - Melanie Wyld
- Department of Renal Medicine, Centre for Transplant and Renal Research, Westmead Hospital, Westmead, NSW, Australia
| | - Brian Nankivell
- Department of Renal Medicine, Centre for Transplant and Renal Research, Westmead Hospital, Westmead, NSW, Australia
| | - Kathy Kable
- Department of Renal Medicine, Centre for Transplant and Renal Research, Westmead Hospital, Westmead, NSW, Australia
| | - Germaine Wong
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia
- Department of Renal Medicine, Centre for Transplant and Renal Research, Westmead Hospital, Westmead, NSW, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, NSW, Australia
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27
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Albasha W, Vahdani G, Ashoka A, Bracamonte E, Yau AA. Native BK virus nephropathy in lung transplant: a case report and literature review. Clin Kidney J 2021; 15:808-811. [PMID: 35371460 PMCID: PMC8967672 DOI: 10.1093/ckj/sfab251] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Indexed: 11/14/2022] Open
Abstract
Classically described in renal allografts, BK virus nephropathy is increasingly recognized in native kidneys of other non-renal solid organ transplants. We discuss a 68-year-old woman with a history of bilateral lung transplant referred for worsening renal function, confirmed to have BK virus nephropathy by biopsy with a serum BK virus polymerase chain reaction of over 59 million copies/mL. She was managed with a reduction in immunosuppression and intravenous cidofovir with no improvement in her clinical parameters. The seven prior reported cases of polyoma virus nephropathy in lung transplant recipients are reviewed, and the challenges of screening and management are discussed.
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Affiliation(s)
- Waseem Albasha
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, University of Arizona College of Medicine, USA
| | - Golnaz Vahdani
- Division of Nephrology, Department of Medicine, The Ohio State University, USA
| | - Ankita Ashoka
- Department of Medicine, University of Arizona College of Medicine, USA
| | - Erika Bracamonte
- Department of Pathology, University of Arizona College of Medicine, USA
| | - Amy A Yau
- Division of Nephrology, Department of Medicine, The Ohio State University, USA
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28
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Jayant K, Reccia I, Bachul PJ, Al-Salmay Y, Pyda JS, Podda M, Perez-Gutierrez A, Dor FJMF, Becker Y, di Sabato D, LaMattina J, Barth R, Fung J, Witkowski P. The Impact of COVID-19 on Kidney Transplant Recipients in Pre-Vaccination and Delta Strain Era: A Systematic Review and Meta-Analysis. J Clin Med 2021; 10:4533. [PMID: 34640552 PMCID: PMC8509345 DOI: 10.3390/jcm10194533] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 09/24/2021] [Accepted: 09/25/2021] [Indexed: 01/08/2023] Open
Abstract
Herein, we performed a meta-analysis of published clinical outcomes of corona virus disease 2019 (COVID-19) in hospitalized kidney transplant recipients. A systematic database search was conducted between December 1, 2019 and April 20, 2020. We analyzed 48 studies comprising 3137 kidney transplant recipients with COVID-19. Fever (77%), cough (65%), dyspnea (48%), and gastrointestinal symptoms (28%) were predominant on hospital admission. The most common comorbidities were hypertension (83%), diabetes mellitus (34%), and cardiac disease (23%). The pooled prevalence of acute respiratory distress syndrome and acute kidney injury were 58% and 48%, respectively. Invasive ventilation and dialysis were required in 24% and 22% patients, respectively. In-hospital mortality rate was as high as 21%, and increased to over 50% for patients in intensive care unit (ICU) or requiring invasive ventilation. Risk of mortality in patients with acute respiratory distress syndrome (ARDS), on mechanical ventilation, and ICU admission was increased: OR = 19.59, OR = 3.80, and OR = 13.39, respectively. Mortality risk in the elderly was OR = 3.90; however, no such association was observed in terms of time since transplantation and gender. Fever, cough, dyspnea, and gastrointestinal symptoms were common on admission for COVID-19 in kidney transplant patients. Mortality was as high as 20% and increased to over 50% in patients in ICU and required invasive ventilation.
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Affiliation(s)
- Kumar Jayant
- Transplantation Institute, Department of Surgery, University of Chicago, Chicago, IL 60637, USA; (K.J.); (P.J.B.); (Y.A.-S.); (A.P.-G.); (Y.B.); (D.d.S.); (J.L.); (R.B.); (J.F.)
- Department of Surgery and Cancer, Imperial College Healthcare NHS Trust, London W12 0HS, UK;
| | - Isabella Reccia
- Department of Surgery and Cancer, Imperial College Healthcare NHS Trust, London W12 0HS, UK;
| | - Piotr J. Bachul
- Transplantation Institute, Department of Surgery, University of Chicago, Chicago, IL 60637, USA; (K.J.); (P.J.B.); (Y.A.-S.); (A.P.-G.); (Y.B.); (D.d.S.); (J.L.); (R.B.); (J.F.)
| | - Yaser Al-Salmay
- Transplantation Institute, Department of Surgery, University of Chicago, Chicago, IL 60637, USA; (K.J.); (P.J.B.); (Y.A.-S.); (A.P.-G.); (Y.B.); (D.d.S.); (J.L.); (R.B.); (J.F.)
| | - Jordan S. Pyda
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA;
| | - Mauro Podda
- Department of Emergency Surgery, Azienda Ospedaliero-Universitaria Di Cagliari, University Hospital Policlinico Duilio Casula, 09124 Cagliari, Italy;
| | - Angelica Perez-Gutierrez
- Transplantation Institute, Department of Surgery, University of Chicago, Chicago, IL 60637, USA; (K.J.); (P.J.B.); (Y.A.-S.); (A.P.-G.); (Y.B.); (D.d.S.); (J.L.); (R.B.); (J.F.)
| | - Frank J. M. F. Dor
- Imperial College Renal and Transplant Centre, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London W12 0HS, UK;
| | - Yolanda Becker
- Transplantation Institute, Department of Surgery, University of Chicago, Chicago, IL 60637, USA; (K.J.); (P.J.B.); (Y.A.-S.); (A.P.-G.); (Y.B.); (D.d.S.); (J.L.); (R.B.); (J.F.)
| | - Diego di Sabato
- Transplantation Institute, Department of Surgery, University of Chicago, Chicago, IL 60637, USA; (K.J.); (P.J.B.); (Y.A.-S.); (A.P.-G.); (Y.B.); (D.d.S.); (J.L.); (R.B.); (J.F.)
| | - John LaMattina
- Transplantation Institute, Department of Surgery, University of Chicago, Chicago, IL 60637, USA; (K.J.); (P.J.B.); (Y.A.-S.); (A.P.-G.); (Y.B.); (D.d.S.); (J.L.); (R.B.); (J.F.)
| | - Rolf Barth
- Transplantation Institute, Department of Surgery, University of Chicago, Chicago, IL 60637, USA; (K.J.); (P.J.B.); (Y.A.-S.); (A.P.-G.); (Y.B.); (D.d.S.); (J.L.); (R.B.); (J.F.)
| | - John Fung
- Transplantation Institute, Department of Surgery, University of Chicago, Chicago, IL 60637, USA; (K.J.); (P.J.B.); (Y.A.-S.); (A.P.-G.); (Y.B.); (D.d.S.); (J.L.); (R.B.); (J.F.)
| | - Piotr Witkowski
- Transplantation Institute, Department of Surgery, University of Chicago, Chicago, IL 60637, USA; (K.J.); (P.J.B.); (Y.A.-S.); (A.P.-G.); (Y.B.); (D.d.S.); (J.L.); (R.B.); (J.F.)
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29
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Torres R, Montero C, Escobar C, Reina M, Acevedo A, Yomayusa N, Gayón D, Pérez J. Early Detection Strategy of BK Polyomavirus Nephropathy in Patients undergoing Renal Transplant: A Single-Center Retrospective Study. TRANSPLANTATION REPORTS 2021. [DOI: 10.1016/j.tpr.2021.100077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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30
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Chk1 and the Host Cell DNA Damage Response as a Potential Antiviral Target in BK Polyomavirus Infection. Viruses 2021; 13:v13071353. [PMID: 34372559 PMCID: PMC8310304 DOI: 10.3390/v13071353] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 06/30/2021] [Accepted: 07/07/2021] [Indexed: 12/26/2022] Open
Abstract
The human BK polyomavirus (BKPyV) is latent in the kidneys of most adults, but can be reactivated in immunosuppressed states, such as following renal transplantation. If left unchecked, BK polyomavirus nephropathy (PyVAN) and possible graft loss may result from viral destruction of tubular epithelial cells and interstitial fibrosis. When coupled with regular post-transplant screening, immunosuppression reduction has been effective in limiting BKPyV viremia and the development of PyVAN. Antiviral drugs that are safe and effective in combating BKPyV have not been identified but would be a benefit in complementing or replacing immunosuppression reduction. The present study explores inhibition of the host DNA damage response (DDR) as an antiviral strategy. Immunohistochemical and immunofluorescent analyses of PyVAN biopsies provide evidence for stimulation of a DDR in vivo. DDR pathways were also stimulated in vitro following BKPyV infection of low-passage human renal proximal tubule epithelial cells. The role of Chk1, a protein kinase known to be involved in the replication stress-induced DDR, was examined by inhibition with the small molecule LY2603618 and by siRNA-mediated knockdown. Inhibition of Chk1 resulted in decreased replication of BKPyV DNA and viral spread. Activation of mitotic pathways was associated with the reduction in BKPyV replication. Chk1 inhibitors that are found to be safe and effective in clinical trials for cancer should also be evaluated for antiviral activity against BKPyV.
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31
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Wang X, Patel SA, Haddadin M, Cerny J. Post-allogeneic hematopoietic stem cell transplantation viral reactivations and viremias: a focused review on human herpesvirus-6, BK virus and adenovirus. Ther Adv Infect Dis 2021; 8:20499361211018027. [PMID: 34104434 PMCID: PMC8155777 DOI: 10.1177/20499361211018027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 04/27/2021] [Indexed: 12/30/2022] Open
Abstract
Human cytomegalovirus and Epstein-Barr virus have been recognized as potential drivers of morbidity and mortality of patients undergoing allogeneic stem cell transplantation for years. Specific protocols for monitoring, prophylaxis and pre-emptive therapy are in place in many transplant settings. In this review, we focus on the next three most frequent viruses, human herpesvirus-6, BK virus and adenovirus, causing reactivation and/or viremia after allogeneic transplant, which are increasingly detected in patients in the post-transplant period owing to emerging techniques of molecular biology, recipients' characteristics, treatment modalities used for conditioning and factors related donors or stem cell source. Given the less frequent detection of an illness related to these viruses, there are often no specific protocols in place for the management of affected patients. While some patients develop significant morbidity (generally older), others may not need therapy at all (generally younger or children). Furthermore, some of the antiviral therapies used are potentially toxic. With the addition of increased risk of secondary infections, risk of graft failure or increased risk of graft-versus-host disease as well as the relationship with other post-transplant complications, the outcomes of patients with these viremias remain unsatisfactory and even long-term survivors experience increased morbidity.
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Affiliation(s)
- Xin Wang
- Department of Medicine, UMass Memorial Medical Center, Worcester, MA, USA
| | - Shyam A Patel
- Division of Hematology-Oncology, Department of Medicine, UMass Memorial Medical Center, Worcester, MA, USA
| | - Michael Haddadin
- Division of Hematology-Oncology, Department of Medicine, UMass Memorial Medical Center, Worcester, MA, USA
| | - Jan Cerny
- Division of Hematology and Oncology, Department of Medicine, UMass Memorial Medical Center, 55 Lake Avenue North, Worcester, MA, 01655, USA
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32
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Hall IE, Reese PP, Mansour SG, Mohan S, Jia Y, Thiessen-Philbrook HR, Brennan DC, Doshi MD, Muthukumar T, Akalin E, Harhay MN, Schröppel B, Singh P, Weng FL, Bromberg JS, Parikh CR. Deceased-Donor Acute Kidney Injury and BK Polyomavirus in Kidney Transplant Recipients. Clin J Am Soc Nephrol 2021; 16:765-775. [PMID: 33692117 PMCID: PMC8259491 DOI: 10.2215/cjn.18101120] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 01/18/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVES BK polyomavirus (BKV) infection commonly complicates kidney transplantation, contributing to morbidity and allograft failure. The virus is often donor-derived and influenced by ischemia-reperfusion processes and disruption of structural allograft integrity. We hypothesized that deceased-donor AKI associates with BKV infection in recipients. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We studied 1025 kidney recipients from 801 deceased donors transplanted between 2010 and 2013, at 13 academic centers. We fitted Cox proportional-hazards models for BKV DNAemia (detectable in recipient blood by clinical PCR testing) within 1 year post-transplantation, adjusting for donor AKI and other donor- and recipient-related factors. We validated findings from this prospective cohort with analyses for graft failure attributed to BKV within the Organ Procurement and Transplantation Network (OPTN) database. RESULTS The multicenter cohort mean kidney donor profile index was 49±27%, and 26% of donors had AKI. Mean recipient age was 54±13 years, and 25% developed BKV DNAemia. Donor AKI was associated with lower risk for BKV DNAemia (adjusted hazard ratio, 0.53; 95% confidence interval, 0.36 to 0.79). In the OPTN database, 22,537 (25%) patients received donor AKI kidneys, and 272 (0.3%) developed graft failure from BKV. The adjusted hazard ratio for the outcome with donor AKI was 0.7 (95% confidence interval, 0.52 to 0.95). CONCLUSIONS In a well-characterized, multicenter cohort, contrary to our hypothesis, deceased-donor AKI independently associated with lower risk for BKV DNAemia. Within the OPTN database, donor AKI was also associated with lower risk for graft failure attributed to BKV. PODCAST This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2021_03_10_CJN18101120_final.mp3.
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Affiliation(s)
- Isaac E. Hall
- Division of Nephrology and Hypertension, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Peter Philip Reese
- Renal-Electrolyte and Hypertension Division, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania,Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania,Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania,Center for Health Incentives and Behavioral Economics at the Leonard Davis Institute, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sherry G. Mansour
- Clinical and Translational Research Accelerator, Yale University School of Medicine, New Haven, Connecticut,Department of Internal Medicine, Section of Nephrology, Yale University School of Medicine, New Haven, Connecticut
| | - Sumit Mohan
- The Columbia University Renal Epidemiology Group, New York, New York,Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York,Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
| | - Yaqi Jia
- Division of Nephrology, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | | | - Daniel C. Brennan
- Division of Nephrology, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Mona D. Doshi
- Division of Nephrology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan
| | - Thangamani Muthukumar
- Division of Nephrology and Hypertension, Department of Medicine, New York Presbyterian Hospital–Weill Cornell Medical Center, New York, New York,Department of Transplantation Medicine, New York Presbyterian Hospital–Weill Cornell Medical Center, New York, New York
| | - Enver Akalin
- Einstein/Montefiore Abdominal Transplant Program, Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York
| | - Meera Nair Harhay
- Department of Medicine, Drexel University College of Medicine, Philadelphia, Pennsylvania,Department of Epidemiology and Biostatistics, Drexel University Dornsife School of Public Health, Philadelphia, Pennsylvania,Tower Health Transplant Institute, Tower Health System, Philadelphia, Pennsylvania
| | | | - Pooja Singh
- Division of Nephrology, Department of Medicine, Sidney Kimmel Medical College, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Francis L. Weng
- Saint Barnabas Medical Center, RWJ Barnabas Health, Livingston, New Jersey
| | - Jonathan S. Bromberg
- Division of Transplantation, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland,Department of Microbiology and Immunology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Chirag R. Parikh
- Division of Nephrology, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
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33
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BK Polyomavirus Nephropathy in Kidney Transplantation: Balancing Rejection and Infection. Viruses 2021; 13:v13030487. [PMID: 33809472 PMCID: PMC7998398 DOI: 10.3390/v13030487] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 03/12/2021] [Accepted: 03/14/2021] [Indexed: 12/16/2022] Open
Abstract
BK polyomavirus nephropathy (BKVN) and allograft rejection are two closely-associated diseases on opposite ends of the immune scale in kidney transplant recipients. The principle of balancing the immune system remains the mainstay of therapeutic strategy. While patient outcomes can be improved through screening, risk factors identification, and rapid reduction of immunosuppressants, a lack of standard curative therapy is the primary concern during clinical practice. Additionally, difficulty in pathological differential diagnosis and clinicopathology’s dissociation pose problems for a definite diagnosis. This article discusses the delicate evaluation needed to optimize immunosuppression and reviews recent advances in molecular diagnosis and immunological therapy for BKVN patients. New biomarkers for BKVN diagnosis are under development. For example, measurement of virus-specific T cell level may play a role in steering immunosuppressants. The development of cellular therapy may provide prevention, even a cure, for BKVN, a complex post-transplant complication.
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34
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Mallavarapu RK, Sanoff SL, Howell DN, Roberts JK. BK virus nephropathy in non-renal solid organ transplant recipients: Are we looking hard enough? Clin Transplant 2021; 35:e14265. [PMID: 33615555 DOI: 10.1111/ctr.14265] [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: 01/06/2021] [Revised: 02/06/2021] [Accepted: 02/11/2021] [Indexed: 01/02/2023]
Abstract
We retrospectively examined the clinical characteristics, pathological features, and outcomes of BK viremia and nephropathy in a population of non-renal solid organ transplant patients (NRSOT) referred for outpatient nephrology consultation over a period of 5 years. In the entire cohort of liver, heart, and lung transplant recipients referred to this clinic, 14% percent were found to have BK viremia with a median peak serum BK viral load of 35 500 copies/ml (range 250 to 21 100 000 copies/ml). BK viremia resolved in six of the seventeen patients (35%). Four out of five patients biopsied showed BK virus (BKV) nephropathy. Eleven out of seventeen patients with BK viremia developed advanced (stage 4 or 5) chronic kidney disease. Four patients developed rejection of their solid organ transplant within the first year post detection of BK viremia after immunosuppression reduction. We conclude that a multi-center study is required to evaluate whether implementation of a systematic BK screening program would be effective in early detection and management of this problem in the NRSOT population.
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Affiliation(s)
- Ravi K Mallavarapu
- Division of Transplant Nephrology, Augusta University-Medical College of Georgia, Augusta, GA, USA
| | - Scott L Sanoff
- Division of Nephrology, Duke University School of Medicine, Durham, NC, USA
| | - David N Howell
- Department of Pathology, Duke University School of Medicine, Durham, NC, USA
| | - John K Roberts
- Division of Nephrology, Duke University School of Medicine, Durham, NC, USA
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35
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Lebel E, Chen C, Paul H, Trudel S, Tiedemann R. Symptomatic BK Virus Disease in Patients With Heavily Pretreated Multiple Myeloma. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2021; 21:e506-e509. [PMID: 33608216 DOI: 10.1016/j.clml.2021.01.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 12/31/2020] [Accepted: 01/11/2021] [Indexed: 11/19/2022]
Affiliation(s)
- Eyal Lebel
- Princess Margaret Cancer Centre, Toronto, Canada.
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36
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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: 4.0] [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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37
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Benotmane I, Solis M, Velay A, Cognard N, Olagne J, Gautier Vargas G, Perrin P, Marx D, Soulier E, Gallais F, Moulin B, Fafi-Kremer S, Caillard S. Intravenous immunoglobulin as a preventive strategy against BK virus viremia and BKV-associated nephropathy in kidney transplant recipients-Results from a proof-of-concept study. Am J Transplant 2021; 21:329-337. [PMID: 32741096 DOI: 10.1111/ajt.16233] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Revised: 07/20/2020] [Accepted: 07/20/2020] [Indexed: 01/25/2023]
Abstract
BK virus (BKV) replication occurs frequently in kidney transplant recipients (KTR), potentially leading to BKV-associated nephropathy (BKVAN) and graft loss. Patients with high titers of BKV-neutralizing antibodies (NAbs) are protected against BKV replication, and intravenous immunoglobulin (IVIg) infusion can increase NAb titers. We investigated whether early IVIg administration prevents BKV replication in patients with low NAb titers (<4 log10 against the BKV-specific genotype). Based on NAb titers on the day of transplantation, KTR followed in the Strasbourg University Hospital (n = 174) were retrospectively divided into the following 3 risk categories for BKV replication: (1) patients with low NAb titers ("high-risk") who received IVIg for the first 3 posttransplant months (n = 44), (2) patients with low NAb titers ("high-risk") who did not undergo IVIg treatment (n = 41), and (3) patients with high NAb titers ("low-risk") who did not receive IVIg (n = 89). At 12 posttransplant months, the incidence of BKV viremia in the high-risk group treated with IVIg (6.8%) was similar to that observed in the low-risk group (10.1%) and markedly lower than that of the untreated high-risk group (36.6%; P < .001). Similar results were observed with regard to BKVAN. We conclude that IVIg may be a valuable strategy for preventing BKV replication.
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Affiliation(s)
- Ilies Benotmane
- Service de Néphrologie et Transplantation, Hôpitaux Universitaires de Strasbourg, Strasbourg, France.,Laboratoire de Virologie, Hôpitaux Universitaires de Strasbourg, Strasbourg, France.,Inserm UMR S1109, LabEx Transplantex, Fédération de Médecine Translationnelle de Strasbourg (FMTS), Université de Strasbourg, Strasbourg, France
| | - Morgane Solis
- Laboratoire de Virologie, Hôpitaux Universitaires de Strasbourg, Strasbourg, France.,Inserm UMR S1109, LabEx Transplantex, Fédération de Médecine Translationnelle de Strasbourg (FMTS), Université de Strasbourg, Strasbourg, France
| | - Aurélie Velay
- Laboratoire de Virologie, Hôpitaux Universitaires de Strasbourg, Strasbourg, France.,Inserm UMR S1109, LabEx Transplantex, Fédération de Médecine Translationnelle de Strasbourg (FMTS), Université de Strasbourg, Strasbourg, France
| | - Noëlle Cognard
- Service de Néphrologie et Transplantation, Hôpitaux Universitaires de Strasbourg, Strasbourg, France.,Inserm UMR S1109, LabEx Transplantex, Fédération de Médecine Translationnelle de Strasbourg (FMTS), Université de Strasbourg, Strasbourg, France
| | - Jérôme Olagne
- Service de Néphrologie et Transplantation, Hôpitaux Universitaires de Strasbourg, Strasbourg, France.,Inserm UMR S1109, LabEx Transplantex, Fédération de Médecine Translationnelle de Strasbourg (FMTS), Université de Strasbourg, Strasbourg, France.,Service de Pathologie, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Gabriela Gautier Vargas
- Service de Néphrologie et Transplantation, Hôpitaux Universitaires de Strasbourg, Strasbourg, France.,Inserm UMR S1109, LabEx Transplantex, Fédération de Médecine Translationnelle de Strasbourg (FMTS), Université de Strasbourg, Strasbourg, France
| | - Peggy Perrin
- Service de Néphrologie et Transplantation, Hôpitaux Universitaires de Strasbourg, Strasbourg, France.,Inserm UMR S1109, LabEx Transplantex, Fédération de Médecine Translationnelle de Strasbourg (FMTS), Université de Strasbourg, Strasbourg, France
| | - David Marx
- Service de Néphrologie et Transplantation, Hôpitaux Universitaires de Strasbourg, Strasbourg, France.,Inserm UMR S1109, LabEx Transplantex, Fédération de Médecine Translationnelle de Strasbourg (FMTS), Université de Strasbourg, Strasbourg, France
| | - Eric Soulier
- Inserm UMR S1109, LabEx Transplantex, Fédération de Médecine Translationnelle de Strasbourg (FMTS), Université de Strasbourg, Strasbourg, France
| | - Floriane Gallais
- Laboratoire de Virologie, Hôpitaux Universitaires de Strasbourg, Strasbourg, France.,Inserm UMR S1109, LabEx Transplantex, Fédération de Médecine Translationnelle de Strasbourg (FMTS), Université de Strasbourg, Strasbourg, France
| | - Bruno Moulin
- Service de Néphrologie et Transplantation, Hôpitaux Universitaires de Strasbourg, Strasbourg, France.,Inserm UMR S1109, LabEx Transplantex, Fédération de Médecine Translationnelle de Strasbourg (FMTS), Université de Strasbourg, Strasbourg, France
| | - Samira Fafi-Kremer
- Laboratoire de Virologie, Hôpitaux Universitaires de Strasbourg, Strasbourg, France.,Inserm UMR S1109, LabEx Transplantex, Fédération de Médecine Translationnelle de Strasbourg (FMTS), Université de Strasbourg, Strasbourg, France
| | - Sophie Caillard
- Service de Néphrologie et Transplantation, Hôpitaux Universitaires de Strasbourg, Strasbourg, France.,Inserm UMR S1109, LabEx Transplantex, Fédération de Médecine Translationnelle de Strasbourg (FMTS), Université de Strasbourg, Strasbourg, France
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Fischer-Barnicol B, Oechtering J, Kuhle J, Lorscheider J, Kappos L, Derfuss T. Combination of teriflunomide and interferon as follow-up therapy after fingolimod-associated PML. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2020; 8:8/1/e927. [PMID: 33272956 PMCID: PMC7803336 DOI: 10.1212/nxi.0000000000000927] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Accepted: 09/30/2020] [Indexed: 11/26/2022]
Affiliation(s)
- Bettina Fischer-Barnicol
- From the Neurologic Clinic and Policlinic, Departments of Medicine, Biomedicine and Clinical Research, University Hospital Basel, University of Basel, Switzerland.
| | - Johanna Oechtering
- From the Neurologic Clinic and Policlinic, Departments of Medicine, Biomedicine and Clinical Research, University Hospital Basel, University of Basel, Switzerland
| | - Jens Kuhle
- From the Neurologic Clinic and Policlinic, Departments of Medicine, Biomedicine and Clinical Research, University Hospital Basel, University of Basel, Switzerland
| | - Johannes Lorscheider
- From the Neurologic Clinic and Policlinic, Departments of Medicine, Biomedicine and Clinical Research, University Hospital Basel, University of Basel, Switzerland
| | - Ludwig Kappos
- From the Neurologic Clinic and Policlinic, Departments of Medicine, Biomedicine and Clinical Research, University Hospital Basel, University of Basel, Switzerland
| | - Tobias Derfuss
- From the Neurologic Clinic and Policlinic, Departments of Medicine, Biomedicine and Clinical Research, University Hospital Basel, University of Basel, Switzerland
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Saleh A, El Din Khedr MS, Ezzat A, Takou A, Halawa A. Update on the Management of BK Virus Infection. EXP CLIN TRANSPLANT 2020; 18:659-670. [DOI: 10.6002/ect.2019.0254] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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40
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Cohen-Bucay A, Ramirez-Andrade SE, Gordon CE, Francis JM, Chitalia VC. Advances in BK Virus Complications in Organ Transplantation and Beyond. Kidney Med 2020; 2:771-786. [PMID: 33319201 PMCID: PMC7729234 DOI: 10.1016/j.xkme.2020.06.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Reactivation of BK virus (BKV) remains a dreaded complication in immunosuppressed states. Conventionally, BKV is known as a cause for BKV-associated nephropathy and allograft dysfunction in kidney transplant recipients. However, emerging studies have shown its negative impact on native kidney function and patient survival in other transplants and its potential role in diseases such as cancer. Because BKV-associated nephropathy is driven by immunosuppression, reduction in the latter is a convenient standard of care. However, this strategy is risk prone due to the development of donor-specific antibodies affecting long-term allograft survival. Despite its pathogenic role, there is a distinct lack of effective anti-BKV therapeutics. This limitation combined with increased morbidity and health care cost of BKV-associated diseases add to the complexity of BKV management. While summarizing recent advances in the pathogenesis of BKV-associated nephropathy and its reactivation in other organ transplants, this review illustrates the limitations of current and emerging therapeutic options and provides a compelling argument for an effective targeted anti-BKV drug.
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Affiliation(s)
- Abraham Cohen-Bucay
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico City, Mexico
- Nephrology Department, American British Cowdray Medical Center, Mexico City, Mexico
| | - Silvia E. Ramirez-Andrade
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico City, Mexico
| | | | - Jean M. Francis
- Section of Nephrology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
- Renal Section, Boston University Medical Center, Boston, MA
| | - Vipul C. Chitalia
- Renal Section, Boston University Medical Center, Boston, MA
- Institute of Medical Engineering and Sciences, Massachusetts Institute of Technology, Cambridge, MA
- Veteran Affairs Boston Healthcare System, Boston, MA
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41
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Cotiguala L, Masood A, Park JM, Samaniego-Picota MD, Kaul DR, Naik AS. Increasing net immunosuppression after BK polyoma virus infection. Transpl Infect Dis 2020; 23:e13472. [PMID: 32959930 DOI: 10.1111/tid.13472] [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] [Received: 06/18/2020] [Revised: 08/21/2020] [Accepted: 09/06/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Reducing immunosuppression can effectively treat BK viremia (BKV) and BK nephropathy, but has been associated with increased risks for acute rejection and development of donor-specific antibodies (DSA). To date there have been no systematic evaluations of re-escalating immunosuppression in transplant patients with resolving BKV. Importantly, the safety of this approach and impact on graft survival is unclear. METHODS We performed a single-center retrospective review of kidney transplant recipients between July 2011 and June 2013 who had immunosuppression reduction after developing BKV (plasma PCR ≥ 1000 copies/ml). Changes in immunosuppression and patient outcomes were tracked until occurrence of a complication event: biopsy-proven acute rejection (BPAR), detection of de novo DSA, or recurrent BKV. Patients were grouped according to whether or not net immunosuppression was eventually increased. RESULTS Out of 88 patients with BKV, 44 (50%) had net immunosuppression increased while the other 44 did not. Duration of viremia, peak viremia, induction, and sensitization status were similar between the two groups. In a Kaplan-Meier analysis, increasing immunosuppression was associated with less BPAR (P = .001) and a trend toward less de novo DSA development (P = .06). Death-censored graft survival (P = .27) was not different between the two groups. In the net immunosuppression increase group, recurrent BKV occurred in 22.7% without any BKV-related graft losses. CONCLUSION These findings support potential benefits of increasing immunosuppression in patients with low-level or resolved BKV, but prospective trials are needed to better understand such an approach.
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Affiliation(s)
- Laura Cotiguala
- Department of Pharmacy Services, Michigan Medicine, Ann Arbor, MI, USA
| | - Ahmad Masood
- Nephrology Associates of Michigan, Ypsilanti, MI, USA
| | - Jeong M Park
- Department of Pharmacy Services, Michigan Medicine, Ann Arbor, MI, USA.,Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI, USA
| | | | - Daniel R Kaul
- Division of Infectious Diseases, Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA
| | - Abhijit S Naik
- Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI, USA
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Schneidewind L, Neumann T, Dräger DL, Kranz J, Hakenberg OW. Leflunomide in the treatment of BK polyomavirus associated nephropathy in kidney transplanted patients - A systematic review. Transplant Rev (Orlando) 2020; 34:100565. [PMID: 32611496 DOI: 10.1016/j.trre.2020.100565] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 06/09/2020] [Accepted: 06/15/2020] [Indexed: 12/25/2022]
Abstract
BK polyomavirus (BKPyV) associated nephropathy (BKVAN) is seen in about 5% of renal transplant patients and can lead to chronic graft failure or graft loss. No effective therapy is available. Leflunomide has shown promising results in BKVAN. We performed a systematic review about the use of leflunomide for the treatment of BKVAN. The recommendations of the Cochrane Handbook of systematic Reviews were followed. Due to different study designs and endpoints no meta-analysis was performed. The literature search for primary studies yielded 274 results. Finally, twelve studies were included with a total of 267 patients. Clearance of BKPyV viremia was reported in 33.3% to 92.3% of cases and 27 graft losses (10.1%). The included studies were very heterogeneous, especially in terms of leflunomide dosing. Pharmacokinetics seem to have an important impact on the efficacy of leflunomide in BKVAN. There was no correlation between leflunomide serum levels and virus reduction. New adverse events of leflunomide have been described, e.g. haemolytic anaemia and thrombotic microangiopathy. Overall, the risk of bias in the studies was assessed as high and the quality of evidence was rated low. The role of leflunomide in BKVAN remains unclear, but further studies seem reasonable and should address pharmacokinetic aspects.
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Affiliation(s)
| | - Thomas Neumann
- University Hospital Greifswald, Dept. Haematology/Oncology, Greifswald, Germany
| | | | - Jennifer Kranz
- St. Antonius Hospital Eschweiler, Dept. of Urology, Eschweiler, Germany; Department of Urology and Kidney Transplantation, Martin-Luther-University, Halle (Saale), Germany
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Bush R, Johns F, Betty Z, Goldstein S, Horn B, Shoemaker L, Upadhyay K. BK virus encephalitis and end-stage renal disease in a child with hematopoietic stem cell transplantation. Pediatr Transplant 2020; 24:e13739. [PMID: 32412694 DOI: 10.1111/petr.13739] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 03/09/2020] [Accepted: 04/20/2020] [Indexed: 01/07/2023]
Abstract
BK virus encephalitis after HSCT is uncommon. Several reports of native kidney BKVN in patients with HSCT, hematologic malignancies, human immunodeficiency virus infection, and non-renal solid organ transplantation have been described. However, an uncommon combination of BK encephalitis and ESRD of native kidneys secondary to BK virus in a child with HSCT has not been described. We report a 10-year-old boy who presented with a gradually rising serum creatinine during treatment for severe autoimmune hemolytic anemia, which he developed 9 months after receiving an allogeneic HSCT for aplastic anemia. There was no proteinuria or hematuria present. Serum BK virus load was 5 × 106 copies/mL. A renal biopsy showed evidence of BKVN. He developed fever, seizures, and confusion, and the (CSF) showed significant presence of the BK virus (1 × 106 copies/mL) along with biochemical evidence of viral encephalitis. Cerebrospinal fluid cultures were negative. Despite significant clinical symptoms and presence of BK virus in CSF, the magnetic resonance brain imaging findings were minimal. With reduction of immunosuppression, there was resolution of BK encephalitis but BKVN remained resistant to multiple anti-BK virus agents, including leflunomide and cidofovir. He eventually became dialysis-dependent and, 6 years later, received a renal transplant from his mother. This case illustrates that BK virus in severely immunocompromised HSCT recipient may lead to BK encephalitis and BKVN of native kidneys, even without hemorrhagic cystitis, leading to ESRD. Knowledge of such is important for appropriate timely evaluation and management.
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Affiliation(s)
- Rachel Bush
- Division of Pediatric Nephrology, Department of Pediatrics, University of Florida, Gainesville, FL, USA
| | - Felicia Johns
- Division of Pediatric Nephrology, Department of Pediatrics, University of Florida, Gainesville, FL, USA
| | - Zachary Betty
- Division of Pediatric Nephrology, Department of Pediatrics, University of Florida, Gainesville, FL, USA
| | - Steven Goldstein
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida, Gainesville, FL, USA
| | - Biljana Horn
- Division of Pediatric Hematology-Oncology, Department of Pediatrics, University of Florida, Gainesville, FL, USA
| | - Lawrence Shoemaker
- Division of Pediatric Nephrology, Department of Pediatrics, University of Florida, Gainesville, FL, USA
| | - Kiran Upadhyay
- Division of Pediatric Nephrology, Department of Pediatrics, University of Florida, Gainesville, FL, USA
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Perricone C, Triggianese P, Bartoloni E, Cafaro G, Bonifacio AF, Bursi R, Perricone R, Gerli R. The anti-viral facet of anti-rheumatic drugs: Lessons from COVID-19. J Autoimmun 2020; 111:102468. [PMID: 32317220 PMCID: PMC7164894 DOI: 10.1016/j.jaut.2020.102468] [Citation(s) in RCA: 74] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 04/07/2020] [Accepted: 04/10/2020] [Indexed: 02/07/2023]
Abstract
The outbreak of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has posed the world at a pandemic risk. Coronavirus-19 disease (COVID-19) is an infectious disease caused by SARS-CoV-2, which causes pneumonia, requires intensive care unit hospitalization in about 10% of cases and can lead to a fatal outcome. Several efforts are currently made to find a treatment for COVID-19 patients. So far, several anti-viral and immunosuppressive or immunomodulating drugs have demonstrated some efficacy on COVID-19 both in vitro and in animal models as well as in cases series. In COVID-19 patients a pro-inflammatory status with high levels of interleukin (IL)-1B, IL-1 receptor (R)A and tumor necrosis factor (TNF)-α has been demonstrated. Moreover, high levels of IL-6 and TNF-α have been observed in patients requiring intensive-care-unit hospitalization. This provided rationale for the use of anti-rheumatic drugs as potential treatments for this severe viral infection. Other agents, such as hydroxychloroquine and chloroquine might have a direct anti-viral effect. The anti-viral aspect of immunosuppressants towards a variety of viruses has been known since long time and it is herein discussed in the view of searching for a potential treatment for SARS-CoV-2 infection.
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Affiliation(s)
- Carlo Perricone
- Rheumatology, Department of Medicine, University of Perugia, Piazzale Giorgio Menghini, 1, 06129, Perugia, Italy
| | - Paola Triggianese
- Rheumatology, Allergology and Clinical Immunology, Department of "Medicina dei Sistemi", University of Rome Tor Vergata, Via Montpellier 1, 00133, Rome, Italy
| | - Elena Bartoloni
- Rheumatology, Department of Medicine, University of Perugia, Piazzale Giorgio Menghini, 1, 06129, Perugia, Italy
| | - Giacomo Cafaro
- Rheumatology, Department of Medicine, University of Perugia, Piazzale Giorgio Menghini, 1, 06129, Perugia, Italy
| | - Angelo F Bonifacio
- Rheumatology, Department of Medicine, University of Perugia, Piazzale Giorgio Menghini, 1, 06129, Perugia, Italy
| | - Roberto Bursi
- Rheumatology, Department of Medicine, University of Perugia, Piazzale Giorgio Menghini, 1, 06129, Perugia, Italy
| | - Roberto Perricone
- Rheumatology, Allergology and Clinical Immunology, Department of "Medicina dei Sistemi", University of Rome Tor Vergata, Via Montpellier 1, 00133, Rome, Italy
| | - Roberto Gerli
- Rheumatology, Department of Medicine, University of Perugia, Piazzale Giorgio Menghini, 1, 06129, Perugia, Italy.
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Lee S, Lee KW, Kim SJ, Park JB. Clinical Characteristic and Outcomes of BK Virus Infection in Kidney Transplant Recipients Managed Using a Systematic Surveillance and Treatment Strategy. Transplant Proc 2020; 52:1749-1756. [DOI: 10.1016/j.transproceed.2020.01.158] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Accepted: 01/22/2020] [Indexed: 02/07/2023]
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Hisadome Y, Noguchi H, Nakafusa Y, Sakihama K, Mei T, Kaku K, Okabe Y, Masutani K, Ohara Y, Ikeda K, Oda Y, Nakamura M. Association of Pretransplant BK Polyomavirus Antibody Status with BK Polyomavirus Infection After Kidney Transplantation: A Prospective Cohort Pilot Study of 47 Transplant Recipients. Transplant Proc 2020; 52:1762-1768. [PMID: 32611487 DOI: 10.1016/j.transproceed.2020.01.164] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 01/26/2020] [Indexed: 01/06/2023]
Abstract
BACKGROUND Prevention and early detection of BK polyomavirus (BKV) infection is important for long-term kidney graft survival; hence, pretransplant screening methods are essential to identify recipients at high risk for BKV infection. This study investigated the association of pretransplant donor and recipient BKV antibody status with the occurrence of post-transplant BKV infection. METHODS We prospectively enrolled 47 adult living donor kidney transplant pairs from December 2014 to January 2016. Recipient and donor pretransplant BKV antibody titer was measured by hemagglutination inhibition (HI) test. Donor and recipient median HI titer of 1:20 was used as a cutoff to define seropositivity. Recipients were divided into 2 groups (BKV antibody donor-seropositive/recipient-seronegative (D+/R-) and non-D+/R-). Urinary cytology was used to screen for BKV infection. Plasma polymerase chain reaction testing for BKV DNA was used when decoy cells in urine were persistently detected. RESULTS Nine (19.2%) of 47 patients belonged to the D+/R- group. Decoy cells were observed in 32 recipients (68.1%) during follow-up. BK viremia occurred in 3 (6.4%) cases. The maximum decoy cell count was significantly higher in the D+/R- group than in the non-D+/R- group (P = .0002). Decoy-cell-free survival was significantly shorter in the D+/R- group (P = .0220). Multivariate analysis identified only BKV antibody serostatus as an independent risk factor for decoy cell appearance (P = .0491). CONCLUSIONS Pretransplant donor and recipient BKV antibody status was associated with higher maximum decoy cell count and shorter decoy-cell-free survival after kidney transplantation.
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Affiliation(s)
- Yu Hisadome
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Hiroshi Noguchi
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yuki Nakafusa
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kukiko Sakihama
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Department of Anatomic Pathology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takanori Mei
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Keizo Kaku
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yasuhiro Okabe
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
| | - Kosuke Masutani
- Department of Nephrology and Rheumatology, Fukuoka University, Fukuoka, Japan
| | - Yuki Ohara
- The Chemo-Sero-Therapeutic Research Institute, Kumamoto, Japan
| | - Kazuyuki Ikeda
- The Chemo-Sero-Therapeutic Research Institute, Kumamoto, Japan
| | - Yoshinao Oda
- Department of Anatomic Pathology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Masafumi Nakamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Nankivell BJ, Renthawa J, Shingde M, Khan A. The Importance of Kidney Medullary Tissue for the Accurate Diagnosis of BK Virus Allograft Nephropathy. Clin J Am Soc Nephrol 2020; 15:1015-1023. [PMID: 32601093 PMCID: PMC7341776 DOI: 10.2215/cjn.13611119] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 05/15/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND OBJECTIVES The published tissue adequacy requirement of kidney medulla for BK virus allograft nephropathy diagnosis lacks systematic verification and competes against potential increased procedural risks from deeper sampling. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We evaluated whether the presence of kidney medulla improved the diagnostic rate of BK nephropathy in 2244 consecutive biopsy samples from 856 kidney transplants with detailed histologic and virologic results. RESULTS Medulla was present in 821 samples (37%) and correlated with maximal core length (r=0.35; P<0.001). BK virus allograft nephropathy occurred in 74 (3% overall) but increased to 5% (42 of 821) with medulla compared with 2% (32 of 1423) for cortical samples (P<0.001). Biopsy medulla was associated with infection after comprehensive multivariable adjustment of confounders, including core length, glomerular number, and number of cores (adjusted odds ratio, 1.81; 95% confidence interval, 1.02 to 3.21; P=0.04). In viremic cases (n=275), medulla was associated with BK virus nephropathy diagnosis (39% versus 19% for cortex; P<0.001) and tissue polyomavirus load (Banff polyomavirus score 0.64±0.96 versus 0.33±1.00; P=0.006). Biopsy medulla was associated with BK virus allograft nephropathy using generalized estimating equation (odds ratio, 2.04; 95% confidence interval, 1.05 to 3.96; n=275) and propensity matched score comparison (odds ratio, 2.24; 95% confidence interval, 1.11 to 4.54; P=0.03 for 156 balanced pairs). Morphometric evaluation of Simian virus 40 large T immunohistochemistry found maximal infected tubules within the inner cortex and medullary regions (P<0.001 versus outer cortex). CONCLUSIONS Active BK virus replication concentrated around the corticomedullary junction can explain the higher detection rates for BK virus allograft nephropathy with deep sampling. The current adequacy requirement specifying targeting medulla can be justified to minimize a missed diagnosis from undersampling.
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Affiliation(s)
- Brian J Nankivell
- Department of Renal Medicine, Westmead Hospital, Sydney, New South Wales, Australia
| | - Jasveen Renthawa
- Department of Tissue Pathology and Diagnostic Oncology, Institute of Clinical Pathology and Medical Research, Sydney, New South Wales, Australia
| | - Meena Shingde
- Department of Tissue Pathology and Diagnostic Oncology, Institute of Clinical Pathology and Medical Research, Sydney, New South Wales, Australia
| | - Asrar Khan
- Department of Renal Medicine, Westmead Hospital, Sydney, New South Wales, Australia
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48
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Kovacevic Vojtusek I, Burek Kamenaric M, Ivkovic V, Bulimbasic S, Marekovic I, Coric M, Bosnjak Z, Grubic Z, Zunec R. Combined association of recipient killer cell immunoglobulin-like haplotype AA and donor HLA-C*07 gene with BK virus associated nephropathy in kidney transplant patients. HLA 2020; 94 Suppl 2:4-10. [PMID: 31361395 DOI: 10.1111/tan.13645] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 07/25/2019] [Accepted: 07/26/2019] [Indexed: 12/25/2022]
Abstract
Kidney transplant recipient killer cell immunoglobulin-like receptors (KIR) genotype and HLA-C status of their donors have been separately associated with BK virus-associated nephropathy (BKVAN) and BK virus infection. Our aim was to determine whether different combinations of recipients KIR genes and donor HLA-C ligands influence the risk of BKVAN. Retrospective case-control study included 23 recipients with BKVAN and 46 recipients with persistently negative BK virus. Donor HLA-C*07 positivity was associated with lower odds for BKVAN, recipients bearing KIR haplotype AA or lacking any activating KIR genes were more frequent in BKVAN while recipient/donor combination HLA-C*07 negative/KIR AA positive was significantly associated with BKVAN. Our study complements and confirms results from several previously published studies, suggesting potential clinical usefulness.
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Affiliation(s)
- Ivana Kovacevic Vojtusek
- Department of Nephrology, Arterial Hypertension, Dialysis and Transplantation, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Marija Burek Kamenaric
- Tissue Typing Centre, Clinical Department of Transfusion Medicine and Transplantation Biology, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Vanja Ivkovic
- Department of Nephrology, Arterial Hypertension, Dialysis and Transplantation, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Stela Bulimbasic
- Clinical Department of Pathology and Cytology, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Ivana Marekovic
- Department for Clinical and Molecular Microbiology, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Marijana Coric
- Clinical Department of Pathology and Cytology, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Zrinka Bosnjak
- Department for Clinical and Molecular Microbiology, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Zorana Grubic
- Tissue Typing Centre, Clinical Department of Transfusion Medicine and Transplantation Biology, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Renata Zunec
- Tissue Typing Centre, Clinical Department of Transfusion Medicine and Transplantation Biology, University Hospital Centre Zagreb, Zagreb, Croatia
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Reischig T, Kacer M, Hes O, Machova J, Nemcova J, Kormunda S, Pivovarcikova K, Bouda M. Viral load and duration of BK polyomavirus viraemia determine renal graft fibrosis progression: histologic evaluation of late protocol biopsies. Nephrol Dial Transplant 2020; 34:1970-1978. [PMID: 31071208 DOI: 10.1093/ndt/gfz061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Accepted: 03/01/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Polyomavirus BK (BKV) infection of the renal allograft causes destructive tissue injury with inflammation and subsequent fibrosis. METHODS Using a prospective cohort of patients after kidney transplantation performed between 2003 and 2012, we investigated the role of BKV viraemia in the development and progression of interstitial fibrosis and tubular atrophy (IFTA). The primary outcome was moderate-to-severe IFTA assessed by protocol biopsy at 36 months. RESULTS A total of 207 consecutive recipients were enrolled. Of these, 57 (28%) developed BKV viraemia with 10 (5%) cases of polyomavirus-associated nephropathy (PVAN). Transient (<3 months) BKV viraemia occurred in 70% of patients, and persistent (≥3 months) BKV viraemia in 30%. A high viral load (≥10 000 copies/mL) was detected in 18% and a low viral load (<10 000 copies/mL) in 61%, while the viral load could not be determined in 21%. Moderate-to-severe IFTA was significantly increased in high [71%; odds ratio (OR) = 12.1; 95% confidence interval (CI) 1.62-90.0; P = 0.015] or persistent BKV viraemia (67%; OR = 6.33; 95% CI 1.19-33.7; P = 0.031) with corresponding rise in 'interstitial fibrosis + tubular atrophy' scores. Only patients with transient low BKV viraemia showed similar incidence and progression of IFTA to the no-BKV group. Persistent low BKV viraemia was uncommon yet the progression of fibrosis was significant. Only recipients with PVAN experienced inferior graft survival at 5 years. CONCLUSIONS These data suggest that only transient low BKV viraemia does not negatively affect the progression of allograft fibrosis in contrast to excessive risk of severe fibrosis after high or persistent BKV viraemia.
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Affiliation(s)
- Tomas Reischig
- Department of Internal Medicine I, Faculty of Medicine in Pilsen, Charles University, Czech Republic and Teaching Hospital, Pilsen, Czech Republic.,Biomedical Centre, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
| | - Martin Kacer
- Department of Internal Medicine I, Faculty of Medicine in Pilsen, Charles University, Czech Republic and Teaching Hospital, Pilsen, Czech Republic.,Biomedical Centre, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
| | - Ondrej Hes
- Biomedical Centre, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic.,Department of Pathology, Faculty of Medicine in Pilsen, Charles University, Czech Republic and Teaching Hospital, Pilsen, Czech Republic
| | - Jana Machova
- Department of Internal Medicine I, Faculty of Medicine in Pilsen, Charles University, Czech Republic and Teaching Hospital, Pilsen, Czech Republic.,Biomedical Centre, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
| | - Jana Nemcova
- Biomedical Centre, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
| | - Stanislav Kormunda
- Biomedical Centre, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic.,Division of Information Technologies and Statistics, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
| | - Kristyna Pivovarcikova
- Department of Pathology, Faculty of Medicine in Pilsen, Charles University, Czech Republic and Teaching Hospital, Pilsen, Czech Republic
| | - Mirko Bouda
- Department of Internal Medicine I, Faculty of Medicine in Pilsen, Charles University, Czech Republic and Teaching Hospital, Pilsen, Czech Republic.,Biomedical Centre, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
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Piburn KH, Al-Akash S. Use of intravenous immunoglobulin in a highly sensitized pediatric renal transplant recipient with severe BK DNAemia and rising DSA. Pediatr Transplant 2020; 24:e13600. [PMID: 31657100 DOI: 10.1111/petr.13600] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 08/24/2019] [Accepted: 09/13/2019] [Indexed: 01/15/2023]
Abstract
BK DNAemia in renal transplant recipients is a significant cause of allograft dysfunction and can lead to graft loss due to BK polyomavirus-associated nephropathy or to graft rejection due to immunosuppression reduction. Currently, the first-line treatment for BK DNAemia is immunosuppression reduction. Second-line treatment for BK DNAemia has not been well-established. In this report, we present a case of a highly sensitized second-time pediatric renal transplant recipient with severe and persistent BK DNAemia and rising DSA, who was treated with IVIG and subsequently found to have clearance of BK viremia with concomitant reduction in DSA.
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Affiliation(s)
- Kim Huynh Piburn
- Pediatric Residency Program, Driscoll Children's Hospital, Corpus Christi, TX, USA
| | - Samhar Al-Akash
- Division of Pediatric Nephrology, Driscoll Children's Hospital, Corpus Christi, TX, USA
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