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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; 108:1834-1866. [PMID: 38605438 PMCID: PMC11335089 DOI: 10.1097/tp.0000000000004976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 01/10/2024] [Accepted: 01/18/2024] [Indexed: 04/13/2024]
Abstract
BK polyomavirus (BKPyV) remains a significant challenge after kidney transplantation. International experts reviewed current evidence and updated recommendations according to Grading of Recommendations, Assessment, Development, and Evaluations (GRADE). Risk factors for BKPyV-DNAemia and biopsy-proven BKPyV-nephropathy include recipient older age, male sex, donor BKPyV-viruria, BKPyV-seropositive donor/-seronegative recipient, tacrolimus, acute rejection, and higher steroid exposure. To facilitate early intervention with limited allograft damage, all kidney transplant recipients should be screened monthly for plasma BKPyV-DNAemia loads until month 9, then every 3 mo until 2 y posttransplant (3 y for children). In resource-limited settings, urine cytology screening at similar time points can exclude BKPyV-nephropathy, and testing for plasma BKPyV-DNAemia when decoy cells are detectable. For patients with BKPyV-DNAemia loads persisting >1000 copies/mL, or exceeding 10 000 copies/mL (or equivalent), or with biopsy-proven BKPyV-nephropathy, immunosuppression should be reduced according to predefined steps targeting antiproliferative drugs, calcineurin inhibitors, or both. In adults without graft dysfunction, kidney allograft biopsy is not required unless the immunological risk is high. For children with persisting BKPyV-DNAemia, allograft biopsy may be considered even without graft dysfunction. Allograft biopsies should be interpreted in the context of all clinical and laboratory findings, including plasma BKPyV-DNAemia. Immunohistochemistry is preferred for diagnosing biopsy-proven BKPyV-nephropathy. Routine screening using the proposed strategies is cost-effective, improves clinical outcomes and quality of life. Kidney retransplantation subsequent to BKPyV-nephropathy is feasible in otherwise eligible recipients if BKPyV-DNAemia is undetectable; routine graft nephrectomy is not recommended. Current studies do not support the usage of leflunomide, cidofovir, quinolones, or IVIGs. Patients considered for experimental treatments (antivirals, vaccines, neutralizing antibodies, and adoptive T cells) should be enrolled in clinical trials.
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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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BK virus infection and outcome following kidney transplantation in childhood. Sci Rep 2021; 11:2468. [PMID: 33510329 PMCID: PMC7844021 DOI: 10.1038/s41598-021-82160-0] [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: 11/10/2020] [Accepted: 01/14/2021] [Indexed: 11/08/2022] Open
Abstract
BK virus associated nephropathy (BKN) is an important cause of kidney allograft failure. In a cohort of paediatric kidney transplant recipients, we aimed to understand the incidence and clinical outcome associated with BKN, as well as identify risk factors for BKN and BK viraemia development. We retrospectively analysed all patients who received a kidney transplant and received follow up care in our centre between 2009-2019. Among 106 patients included in the study (mean follow up 4.5 years), 32/106 (30.2%) patients experienced BK viraemia. The incidence of BKN was 7/106 (6.6%). The median time of BK viraemia development post-transplant was 279.5 days compared to 90.0 days for BKN. Development of BKN was associated with younger age at transplantation (p = 0.013). Development of BK viraemia was associated with negative recipient serology for cytomegalovirus (CMV) at time of transplantation (p = 0.012) and a higher net level of immunosuppression (p = 0.039). There was no difference in graft function at latest follow up between those who experienced BKN and those without BKN. This study demonstrates that BK virus infection is associated with younger age at transplantation, CMV negative recipient serostatus and higher levels of immunosuppression. Judicious monitoring of BK viraemia in paediatric transplant recipients, coupled with timely clinical intervention can result in similar long-term outcomes for BKN patients compared to controls.
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Demir-Onder K, Avkan-Oguz V, Unek T, Sarioglu S, Sagol O, Astarcioglu I. Monitoring the BK virus in liver transplant recipients: a prospective observational study. EXP CLIN TRANSPLANT 2014; 12:429-36. [PMID: 24679112 DOI: 10.6002/ect.2013.0224] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES Because of the controversy regarding the effects of BK virus on nonrenal solid-organ transplant, we detected the BK virus via different methods and its effect on clinical findings, liver and kidney functions, and graft dysfunction in liver transplant recipients. MATERIALS AND METHODS This prospective cohort study comprised patients over the age of 18, who consecutively received liver transplant from January 1 to December 31, 2011. The patients were examined once, every 2 weeks, for the first 3 months after transplant. Clinical findings were evaluated on each examination; blood and urine samples were collected, BK virus DNA was assessed with real-time polymerase chain reaction, and the presence of decoy cells (which are epithelial cells with large nuclei and large basophilic inclusions) in the urine was investigated. Patients were followed-up for 1 year to see if rejection occurred. RESULTS Five of 39 patients (12.8%) showed BK viremia; 11 patients (28.2%) showed BK viruria, and 13 (33.3%) showed decoy cells. No statistically significant differences were found between BK virus positive and negative groups, respecting demographic variables, kidney and liver functions, and graft survival. BK virus DNA positivity in blood was the standard, while decoy cell assessment in urine and BK virus polymerase chain reaction test sensitivity in urine was 40%. CONCLUSIONS No matter the method used to detect BK virus in the urine, the negativity of the tests is more valuable than their positivity. Although no statistically significant difference was found between the groups, we concluded that BK virus is a factor that should be considered when unexplained deterioration in kidney and liver function tests is observed in liver transplant recipients. Prospective studies with larger numbers of patients are warranted.
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Affiliation(s)
- Kubra Demir-Onder
- From the Department of Infectious Diseases and Clinical Microbiology,Dokuz Eylul University Faculty of Medicine, Izmir, Turkey
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Jung YH, Moon KC, Ha JW, Kim SJ, Ha IS, Cheong HI, Kang HG. Leflunomide therapy for BK virus allograft nephropathy after pediatric kidney transplantation. Pediatr Transplant 2013; 17:E50-4. [PMID: 23210794 DOI: 10.1111/petr.12029] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/22/2012] [Indexed: 12/19/2022]
Abstract
The BK virus (BKV) can be reactivated with immunosuppressive treatment in renal allograft recipients, which can result in interstitial nephritis (BKV-associated nephropathy, BKVAN) and lead to renal allograft failure. Recently, leflunomide has been reported in some case series of BKVAN with favorable results. Most studies have included only adult patients, we herein report a pediatric case and include a literature review. The patient was a nine-yr-old female with end-stage renal disease due to hypoxic kidney injury. A deceased donor renal transplant was performed and good initial allograft function was achieved following treatment with prednisolone, tacrolimus and mycophenolate mofetil. The serum Cr level increased to 1.6 mg/dL over the following four-month period. A kidney biopsy revealed pathologic findings of acute cellular rejection and BK nephropathy. After methylprednisolone pulse therapy was administered to control acute rejection, the tacrolimus dose was reduced, and intravenous immunoglobulin treatment and leflunomide therapy were administered to control the BKVAN. Over the following 18 months, the viral load steadily decreased and remained below 100 copies/mL in the plasma. Leflunomide therapy in addition to a reduction of the immunosuppressive therapies resulted in a significant decline in the BK viral load without further deterioration of renal function.
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Affiliation(s)
- Young H Jung
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
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Comoli P, Ginevri F. Monitoring and managing viral infections in pediatric renal transplant recipients. Pediatr Nephrol 2012; 27:705-17. [PMID: 21359619 DOI: 10.1007/s00467-011-1812-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2010] [Revised: 02/01/2011] [Accepted: 02/04/2011] [Indexed: 12/27/2022]
Abstract
Viral infections remain a significant cause of morbidity and mortality following renal transplantation. The pediatric cohort is at high risk of developing virus-related complications due to immunological naiveté and the increased alloreactivity risk that requires maintaining a heavily immunosuppressive environment. Although cytomegalovirus is the most common opportunistic pathogen seen in transplant recipients, numerous other viruses may affect clinical outcome. Recent technological advances and novel antiviral therapy have allowed implementation of viral and immunological monitoring protocols and adoption of prophylactic or preemptive treatment approaches in high-risk groups. These strategies have led to improved viral infection management in the immunocompromised host, with significant impact on outcome. We review the major viral infections seen following kidney transplantation and discuss strategies for preventing and managing these pathogens.
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Affiliation(s)
- Patrizia Comoli
- Pediatric Hematology/Oncology and Research Laboratories, Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy
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Abstract
SRL, an mTOR inhibitor that inhibits cell cycle progression, represents an important alternative to CNIs, which are still the cornerstones of pediatric solid organ tx. Because there are still limited data on SRL use among pediatric solid organ recipients, further studies are needed to verify the efficacy and safety of SRL. It has unique pharmacokinetic characteristics concerning dosing intervals and reduction of the dose in combination with other immunosuppressants. SRL also has antineoplastic, antiviral, and antiatherogenic advantages over other immunosuppressive agents. The adverse effects of SRL including thrombocytopenia, hyperlipidemia, proteinuria, impaired wound healing, mouth ulcers, edema, male hypogonadism, TMA, and interstitial pneumonitis must be considered carefully in pediatric population. This article reviews the most recent data on SRL application in the field of pediatric renal tx.
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Affiliation(s)
- Belde Kasap
- Division of Pediatric Nephrology, Department of Pediatrics, School of Medicine, Dokuz Eylül University, İzmir, Turkey.
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Dharnidharka VR, Abdulnour HA, Araya CE. The BK virus in renal transplant recipients-review of pathogenesis, diagnosis, and treatment. Pediatr Nephrol 2011; 26:1763-74. [PMID: 21161285 DOI: 10.1007/s00467-010-1716-6] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2010] [Revised: 11/03/2010] [Accepted: 11/09/2010] [Indexed: 12/18/2022]
Abstract
The BK virus, a DNA virus from the Polyomavirus group, represents an opportunistic infection of immunosuppressed transplant recipients. Though the virus was discovered approximately 40 years ago, the emergence of BK virus nephropathy since 1995 onwards, with associated high graft loss rates, has revolutionized renal transplantation medicine. Kidney transplant professionals realized that the consequences of over-immunosuppression were as severe as the consequences of under-immunosuppression and we entered the era of immunosuppressive minimization. Despite this recognition, the optimal testing type for BK virus infections and frequency of testing are hotly debated. Similarly, optimal treatment strategies remain sources of intense controversy. The authors review the current strategies of screening, diagnosis, and possible treatment, and also review the amount and quality of evidence in favor or against. Similarities and differences between cytomegalovirus, Epstein-Barr virus, and BV virus, the three major viral infections in kidney transplantation, are highlighted.
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Affiliation(s)
- Vikas R Dharnidharka
- Division of Pediatric Nephrology, University of Florida College of Medicine & Shands Children's Hospital, 1600 SW Archer Road, PO Box 100296/HD 214, Gainesville, FL 32610-0296, USA.
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Laskin BL, Goebel J. Cost-efficient screening for BK virus in pediatric kidney transplantation: a single-center experience and review of the literature. Pediatr Transplant 2010; 14:589-95. [PMID: 20353405 DOI: 10.1111/j.1399-3046.2010.01318.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BKVNP is an increasingly recognized cause of graft dysfunction and loss in kidney transplant recipients. Protocols for BKV screening and for the diagnosis of BKVNP are still evolving. PCR-based BKV detection became available at our institution in 2007, when we began using it according to published guidelines. We subsequently reviewed our experience with urine and plasma BKV PCR testing in our pediatric kidney transplant recipient population. We found rates of viruria, viremia, and BKVNP that were similar to the published literature. We also conducted a cost analysis suggesting that urine PCR testing, as used by us, is not cost efficient in the detection of BKV. We conclude that plasma only-based PCR testing for BKV may be sufficient in most clinical settings.
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Affiliation(s)
- B L Laskin
- Nephrology and Hypertension Division, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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10
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Abstract
BACKGROUND BK virus (BKV) is a polyomavirus that is associated with nephropathy and graft loss among kidney transplant recipients. The role of BK virus in nonrenal solid organ transplant recipients has not been clearly established; only anecdotal case reports have been published. METHODS From August 2005 to September 2007, all liver transplant (OLT) recipients who gave their consent were enrolled in this prospective longitudinal study. BK viral load was measured using real-time quantitative polymerase chain reaction assays of urine and plasma, using samples collected at week 1 and months 1, 3, 6, 9, 12, 15, 18, 21, and 24 posttransplantation. We also collected demographic and clinical data, including serum creatinine and immunosuppressive therapy. RESULTS The mean age of the 62 patients was 51.4 years including 14 (22.5%) women. Hepatitis C infection was present in 24 patients (38.7%). BK viruria was detected in 14.5% of 290 samples, corresponding to 13 patients (21%). BK viremia was detected in 5.1% of 317 samples, corresponding to 11 patients (18%). Almost all cases of BK viremia (91%) occurred in the first 3 months after OLT. BKV viremia was more common among patients experiencing a rejection episode (10.6 vs 40%, P = .01). We did not observe a relationship between single episodes of BKV replication and renal function: median plasma creatinine 1.1 mg/dL in patients without versus 1.2 mg/dL with BKV viremia. The three patients with persistent viremia displayed renal insufficiency; one of them died due to multiorgan failure of unknown origin. CONCLUSIONS BKV is frequently detected in OLT recipients (viruria 21% and viremia 18%) early after transplantation. It is more common among patients with rejection episodes. Persistent BKV viremia may be related to renal dysfunction in OLT patients.
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Abstract
PURPOSE OF REVIEW Numerous recent advances have been made in the field of infectious diseases and pediatric solid organ transplant. RECENT FINDINGS Although many studies contain somewhat small cohorts of individuals, when summarized together they contribute significantly to our knowledge about pediatric solid organ transplant, especially regarding risk factors for infection, management of BK virus nephropathy, the use of live viral vaccines, and consideration for rare infections as well as donor-derived infections. SUMMARY In sum, these recent advances in infection in the field of pediatric solid organ transplant will help decrease infection, thus improving morbidity and mortality, as well as transplant outcomes, especially by decreasing direct (graft injury) and indirect (immune upregulation) effects on organ transplantation. This review will focus on recent advances in the field of infectious diseases in pediatric solid organ transplant by highlighting some of the most important and interesting articles in the field within the past few years.
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Sharma AP, Moussa M, Casier S, Rehman F, Filler G, Grimmer J. Intravenous immunoglobulin as rescue therapy for BK virus nephropathy. Pediatr Transplant 2009; 13:123-9. [PMID: 18822106 DOI: 10.1111/j.1399-3046.2008.00958.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BKVN has emerged as an important cause of pediatric renal allograft nephropathy, with significant graft dysfunction in majority of the cases. Reduced immunosuppression and cidofovir therapy are the most commonly used therapeutic options for the treatment of BKVN in these patients. Recently, a preliminary study in adult renal allograft recipients with BKVN showed a therapeutic response to a combined approach of immunosuppression reduction and IVIg administration. A therapeutic benefit of IVIg without another concomitant treatment intervention has not been evaluated. We report stabilization of renal functions, histological resolution of BKVN and significant reduction in BK viremia in pediatric renal transplant with the use of IVIg, after an inadequate response to immunosuppression reduction and cidofovir therapy. In addition, we review the current literature on the use of cidofovir in pediatric renal transplant patients with BKVN and the potential of IVIg use in this condition.
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Affiliation(s)
- Ajay P Sharma
- Department of Paediatrics, Division of Nephrology, University of Western Ontario, London, Ontario, Canada.
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Kayler LK, Mohanka R, Morgan C, Basu A, Shapiro R, Randhawa PS. Clinical course of kidney transplant patients with acute rejection and BK virus replication following Campath therapy. Clin Transplant 2008; 22:348-53. [PMID: 18279421 DOI: 10.1111/j.1399-0012.2008.00791.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Kidney transplant recipients with active BK virus (BKV) replication are generally treated with reduction in immunosuppression to allow a successful immune response against the virus. METHODS We inadvertently administered Campath to two patients with BKV viruria, and one patient with BKV nephropathy, since allograft biopsies showed severe tubulitis or intimal arteritis, and results of PCR and in situ hybridization were not available at the time of therapeutic intervention. RESULTS Increased viral replication was observed, but not uniformly in all cases, and follow-up biopsies showed nephropathy in one additional case. Extra-renal dissemination did not occur. With subsequent reduction of immunosuppression or antiviral therapy, it was still possible to obtain clearance of viremia in all cases. Serum creatinine fell transiently after Campath in one patient; however, at one yr post-treatment all had increased levels over baseline. One graft was lost to persistent acute rejection that led to interstitial fibrosis and tubular atrophy. CONCLUSION These cases suggest that Campath treatment does not (i) irreversibly deplete cells believed to be important in mounting an immune response against BKV, or (ii) preclude subsequent eradication of viral DNA from the blood.
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Affiliation(s)
- Liise K Kayler
- Department of Pathology, The Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
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Fidan K, Söylemezoğlu O, Cakir A, Barit G, Dalgiç A, Buyan N. BK virus-associated nephropathy in two pediatric kidney recipients. Transplant Proc 2008; 40:310-2. [PMID: 18261614 DOI: 10.1016/j.transproceed.2007.11.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Posttransplant renal dysfunction episodes can result from a variety of causes, including polyomavirus (BK virus)-associated nephropathy (PVAN). It is a well-recognized entity with a high incidence of graft failure. The delicate balance of viral infection and immune regulation in the transplant population would allow development of successful long-term strategies. In this presentation, we have described two PVAN cases of our institution and reviewed the literature.
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Affiliation(s)
- K Fidan
- Department of Pediatric Nephrology, Gazi University School of Medicine, Ankara, Turkey.
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Giessing M, Muller D, Winkelmann B, Roigas J, Loening SA. Kidney transplantation in children and adolescents. Transplant Proc 2007; 39:2197-201. [PMID: 17889136 DOI: 10.1016/j.transproceed.2007.07.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Worldwide, specific pediatric allocation schemes successfully try to minimize waiting time for children with end-stage renal disease (ESRD). The article is a review of current issues in pediatric kidney transplantation. The procedure is the treatment of choice for children and adolescents with ESRD, with 1- and 3-year graft survival rates of 95% and 90% and recipient survival after 5 and 10 years of 95% and 90%. Preoperative surgery is often necessary to minimize negative effects of congenital anomalies. No minimum age exists for pediatric transplantation, but most often the recipient body weight is ideally above 10 to 15 kg. Technical concepts should include extravesical anastomosis, stenting of the ureter, and potentially intraperitoneal placement of the graft. Immunosuppression has constantly improved. The aim is a tailored regimen to reduce side effects and improve compliance, which necessitates intense counseling of the child and the parents prior to, during, and after transplantation as many adolescents lose their graft due to noncompliance. Intense follow-up must also exclude infections, especially with herpes and polyoma viruses. For the future, age matching may be only one promising concept to improve results. As only a small number of children require the procedure in each country, multinational studies should be initiated to optimize outcomes in children and adolescents.
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Affiliation(s)
- M Giessing
- Charité University Hospital, Department of Urology (Campus Mitte), Berlin, Germany.
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Acott PD, Hirsch HH. BK virus infection, replication, and diseases in pediatric kidney transplantation. Pediatr Nephrol 2007; 22:1243-50. [PMID: 17377822 PMCID: PMC6904397 DOI: 10.1007/s00467-007-0462-x] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2006] [Revised: 01/17/2007] [Accepted: 02/01/2007] [Indexed: 11/28/2022]
Abstract
Polyomavirus-associated nephropathy is diagnosed in 2-8% of pediatric renal transplants and often precedes renal allograft dysfunction. Without intervention, however, significant graft dysfunction is observed in more than 50% of cases, although progressive early graft loss is reported in only three of 32 (9%) of cases. No specific treatment is available, but early decrease in immunosuppression is followed by declining human polyomavirus type 1 (BK virus) replication and improved outcome. The data suggest differences between pediatric and adult kidney transplantation. Possibly, pediatric patients might be able to mount a more vigorous BK virus-specific immune response than adult patients under similar modulation of immunosuppression. Also the role of cidofovir and leflunomide is still unresolved in pediatric patients. Larger prospective trials are needed to better define the impact of BK virus immunity for replication and disease as well as the role of reducing immunosuppression with or without cidofovir or leflunomide in pediatric transplant patients.
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Affiliation(s)
- Philip D. Acott
- Departments of Pediatrics and Pharmacology, Dalhousie University, Halifax, Nova Scotia, Canada
- Division of Pediatric Nephrology, IWK Health Center, 5850 University Avenue, Halifax, Nova Scotia, Canada
| | - Hans H. Hirsch
- Transplantation Virology, Medical Microbiology, University of Basel, Petersplatz 10, 4003 Basel, Switzerland
- Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
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Smith JM, Dharnidharka VR, Talley L, Martz K, McDonald RA. BK Virus Nephropathy in Pediatric Renal Transplant Recipients: An Analysis of the North American Pediatric Renal Trials and Collaborative Studies (NAPRTCS) Registry. Clin J Am Soc Nephrol 2007; 2:1037-42. [PMID: 17702713 DOI: 10.2215/cjn.04051206] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES There is limited information regarding BK virus nephropathy in pediatric kidney transplantation. The objective of this study was to evaluate cases of BK virus nephropathy in the North American Pediatric Renal Trials and Collaborative Studies database. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Using a questionnaire that was sent to North American Pediatric Renal Trials and Collaborative Studies centers, we assessed the incidence, risk factors, clinical features, and outcomes of BK virus nephropathy in pediatric renal transplant recipients who received a transplant between 2000 and 2004. RESULTS BK virus nephropathy was reported in 25 (4.6%) of 542 patients at a median onset of 10.1 mo after transplantation. The median age was 11 yr. All patients who were tested reported BK viruria, and 19 (91%) of 21 who had plasma tested reported BK viremia. Treatment of BK virus nephropathy included reduction of immunosuppression (84%), cidofovir (24%), leflunomide (8%), and intravenous Ig (20%). Simultaneous rejection treatment was reported in four (16%). The median creatinine was 2.0 mg/dl at a mean follow-up of 24 mo. There were six (24%) graft failures in the patients with BK virus nephropathy at a mean of 24 mo after diagnosis. Rejection occurred in eight (32%) after diagnosis. Multivariate analysis showed that use of polyclonal induction therapy and zero HLA DR mismatch were associated with the development of BK virus nephropathy. CONCLUSIONS This first multicenter, retrospective, cohort study of BK virus nephropathy in pediatric renal transplant recipients found a BK virus nephropathy incidence of 4.6% and identified polyclonal induction and zero HLA DR mismatch as significant risk factors for BK virus nephropathy.
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Affiliation(s)
- Jodi M Smith
- Division of Nephrology, Children's Hospital and Regional Medical Center, University of Washington, 4800 Sand Point Way NE, M1-5, Seattle, WA 98105, USA.
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Fogeda M, Muñoz P, Luque A, Morales MD, Bouza E. Cross-sectional study of BK virus infection in pediatric kidney transplant recipients. Pediatr Transplant 2007; 11:394-401. [PMID: 17493219 DOI: 10.1111/j.1399-3046.2006.00671.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BKV reactivation is associated with impaired graft function in adult kidney transplant patients. The clinical impact of BKV infection in the pediatric transplant population has not yet been fully evaluated. The objective of our study was to determine the prevalence of BKV infection in consecutive pediatric kidney transplant recipients in our center. Forty consecutive unselected pediatric kidney transplant recipients were studied. Mean age at screening was 15.6 +/- 5.3 yr and samples were obtained a median of 60.5 months after transplantation (3-123). BKV-DNA was analyzed in urine and plasma by qualitative nested-PCR. A review of the literature was performed. Prevalence of viruria and viremia was 50% and 12.5%, respectively. Viremia was associated with the presence of hematuria (p = 0.02). The mean creatinine level in children without BKV replication was 1.6 mg/dL, BKV viruria was 0.9 mg/dL, and BKV viremia was 0.8 mg/dL. A literature review showed that viruria and viremia were found in 28.2% and 8.5% of cases, respectively; BKV nephropathy was found in 3.8% and graft loss in 11% of the patients with BKV nephropathy and in 0.4% of the children studied. Recipient serostatus was the most important risk factor. The rate of BKV replication and nephropathy among pediatric kidney recipients is similar to that of adults, but the incidence of graft loss is significantly lower.
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Affiliation(s)
- Marta Fogeda
- Department of Clinical Microbiology-Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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