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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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2
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Abstract
BK polyomavirus (BKV) causes frequent infections during childhood and establishes persistent infections within renal tubular cells and the uroepithelium, with minimal clinical implications. However, reactivation of BKV in immunocompromised individuals following renal or hematopoietic stem cell transplantation may cause serious complications, including BKV-associated nephropathy (BKVAN), ureteric stenosis, or hemorrhagic cystitis. Implementation of more potent immunosuppression and increased posttransplant surveillance has resulted in a higher incidence of BKVAN. Antiviral immunity plays a crucial role in controlling BKV replication, and our increasing knowledge about host-virus interactions has led to the development of improved diagnostic tools and clinical management strategies. Currently, there are no effective antiviral agents for BKV infection, and the mainstay of managing reactivation is reduction of immunosuppression. Development of immune-based therapies to combat BKV may provide new and exciting opportunities for the successful treatment of BKV-associated complications.
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3
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Urayama T, Takahashi K, Ideno S, Yunoki M, Saito M, Numakura K, Inoue T, Satoh S, Sakai K. BK polyomavirus‐neutralizing activity of intravenous immunoglobulin products derived from donated blood in Japan. ACTA ACUST UNITED AC 2016. [DOI: 10.1111/voxs.12294] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- T. Urayama
- Research and Development Division Japan Blood Products Organization Hyogo Japan
| | - K. Takahashi
- Research and Development Division Japan Blood Products Organization Hyogo Japan
| | - S. Ideno
- Research and Development Division Japan Blood Products Organization Hyogo Japan
| | - M. Yunoki
- Research and Development Division Japan Blood Products Organization Hyogo Japan
| | - M. Saito
- Department of Urology Akita University Graduate School of Medicine Akita Japan
| | - K. Numakura
- Department of Urology Akita University Graduate School of Medicine Akita Japan
| | - T. Inoue
- Department of Urology Akita University Graduate School of Medicine Akita Japan
| | - S. Satoh
- Center for Kidney Disease and Transplantation Akita University Hospital Akita Japan
| | - K. Sakai
- Research and Development Division Japan Blood Products Organization Hyogo Japan
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4
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Luque Y, Anglicheau D, Rabant M, El Karoui K, Jamme M, Aubert O, Clément R, Noël LH, Bollée G, Brodin-Sartorius A, Martinie M, Kreis H, Timsit MO, Legendre C. Renal safety of high-dose, sucrose-free intravenous immunoglobulin in kidney transplant recipients: an observational study. Transpl Int 2016; 29:1205-1215. [PMID: 27529401 DOI: 10.1111/tri.12833] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Revised: 03/14/2016] [Accepted: 08/01/2016] [Indexed: 11/30/2022]
Abstract
High-dose intravenous immunoglobulin (IVIg) is commonly used during kidney transplantation. Its nephrotoxicity has been attributed to sucrose stabilizers. We evaluated the renal safety of newer formulations of sucrose-free IVIg. We retrospectively studied clinical and histological data from 75 kidney recipients receiving high-dose, sucrose-free IVIg courses. This group was compared with 75 matched kidney recipients not treated with IVIg. Sucrose-free IVIg treatment was not associated with any acute kidney injury episode at 3 months, but an increased frequency of tubular macrovacuoles (28% vs. 2.8%, P < 0.001) was observed. Among IVIg-treated patients, the presence of macrovacuoles at 3 months was associated with increased IF/TA scores at 3 months (1.7 ± 1 vs. 1 ± 1, P = 0.005) and was more often observed in kidneys with higher IF/TA scores on day 0 (0.6 ± 0.9 vs. 0.3 ± 0.8, P = 0.03) at 3 months. Finally, patients treated with amino-acid-stabilized formulations developed fewer macrovacuoles at 3 months (12% vs. 60%; P < 0.001) than those treated with carbohydrate-stabilized IVIg. Our study shows that high-dose, sucrose-free IVIg use in early kidney recipients is clinically well tolerated. Among sucrose-free IVIg, amino-acid-stabilized formulations are associated with less tubular toxicity than carbohydrate-stabilized IVIg.
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Affiliation(s)
- Yosu Luque
- Service de Néphrologie et Transplantation Adulte, Hôpital Necker, Assistance Publique-Hôpitaux de Paris, Paris, France. .,Sorbonne Universités, Université Pierre et Marie Curie Paris 06, Paris, France;, Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche 1155, Paris, France.
| | - Dany Anglicheau
- Service de Néphrologie et Transplantation Adulte, Hôpital Necker, Assistance Publique-Hôpitaux de Paris, Paris, France.,Université Paris Descartes, Sorbonne Paris Cité, Paris, France.,Centaure Foundation and Labex Transplantex, Necker Hospital, Paris, France
| | - Marion Rabant
- Université Paris Descartes, Sorbonne Paris Cité, Paris, France.,Anatomie et Cytologie Pathologiques, Hôpital Necker, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Khalil El Karoui
- Université Paris Descartes, Sorbonne Paris Cité, Paris, France.,Service de Physiologie, Hôpital Necker, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Matthieu Jamme
- Service de Néphrologie et Transplantation Adulte, Hôpital Necker, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Olivier Aubert
- Paris Translational Research Centre for Organ Transplantation, Inserm, UMR-S970, Paris Descartes University, Paris, France
| | - Rozenn Clément
- Pharmacie, Hôpital Necker, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Laure-Hélène Noël
- Anatomie et Cytologie Pathologiques, Hôpital Necker, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Guillaume Bollée
- Division of Nephrology and Research Centre of the Centre Hospitalier de l'Université de Montréal and Université de Montréal, Montréal, QC, Canada
| | | | - Michèle Martinie
- Service de Néphrologie et Transplantation Adulte, Hôpital Necker, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Henri Kreis
- Service de Néphrologie et Transplantation Adulte, Hôpital Necker, Assistance Publique-Hôpitaux de Paris, Paris, France.,Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Marc-Olivier Timsit
- Université Paris Descartes, Sorbonne Paris Cité, Paris, France.,Urologie, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Christophe Legendre
- Service de Néphrologie et Transplantation Adulte, Hôpital Necker, Assistance Publique-Hôpitaux de Paris, Paris, France.,Université Paris Descartes, Sorbonne Paris Cité, Paris, France.,Centaure Foundation and Labex Transplantex, Necker Hospital, Paris, France
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5
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Vu D, Shah T, Ansari J, Naraghi R, Min D. Efficacy of intravenous immunoglobulin in the treatment of persistent BK viremia and BK virus nephropathy in renal transplant recipients. Transplant Proc 2015; 47:394-8. [PMID: 25769580 DOI: 10.1016/j.transproceed.2015.01.012] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Accepted: 01/14/2015] [Indexed: 01/26/2023]
Abstract
BK virus-associated nephropathy (BKVN) can cause clinically significant viral infection in renal transplant recipients, leading to allograft dysfunction and loss. The usual management of BKVN involves the reduction of immunosuppression and the addition of leflunomide, quinolones, and cidofovir, but the rate of graft loss remains high. The aim of this study was to assess the impact of treatment with intravenous human immunoglobulin (IVIG) on the outcome of BKVN in renal transplant recipients. Upon diagnosis of BKVN, patients remained on anti-polyomavirus treatment, consisting of the reduction of immunosuppression and the use of leflunomide therapy. Treatment with IVIG was given only to patients who did not respond to 8 weeks of the adjustment of immunosuppression and leflunomide. All 30 patients had persistent BKV viremia and BKVN with their mean BK viral loads higher than the baseline (range, 15,000-2 million copies/mL). Mean peak BK load was 205,314 copies/mL compared with 697 copies/mL after 1 year of follow-up. Twenty-seven patients (90%) had a positive response in clearing viremia. The actuarial patient and graft survival rates after 12 months were 100% and 96.7%, respectively. IVIG administration appeared to be safe and effective in treating BKV viremia and BKVN and preventing graft loss in patients who had inadequate response to immunosuppression reduction and leflunomide therapy.
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Affiliation(s)
- D Vu
- American University of Health Sciences, Signal Hill, California, United States; National Institute of Transplantation, Los Angeles, California, United States; Western University of Health Sciences, Pomona, California, United States; Transplant Research Institute, Los Angeles, California, United States; St.Vincent Medical Center, Los Angeles, California, United States
| | - T Shah
- Western University of Health Sciences, Pomona, California, United States; Transplant Research Institute, Los Angeles, California, United States; St.Vincent Medical Center, Los Angeles, California, United States; University of Southern California, Los Angeles, California, United States
| | - J Ansari
- Transplant Research Institute, Los Angeles, California, United States
| | - R Naraghi
- Transplant Research Institute, Los Angeles, California, United States; St.Vincent Medical Center, Los Angeles, California, United States
| | - D Min
- Western University of Health Sciences, Pomona, California, United States; St.Vincent Medical Center, Los Angeles, California, United States.
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Pastrana DV, Brennan DC, Çuburu N, Storch GA, Viscidi RP, Randhawa PS, Buck CB. Neutralization serotyping of BK polyomavirus infection in kidney transplant recipients. PLoS Pathog 2012; 8:e1002650. [PMID: 22511874 PMCID: PMC3325208 DOI: 10.1371/journal.ppat.1002650] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2011] [Accepted: 03/02/2012] [Indexed: 12/20/2022] Open
Abstract
BK polyomavirus (BKV or BKPyV) associated nephropathy affects up to 10% of kidney transplant recipients (KTRs). BKV isolates are categorized into four genotypes. It is currently unclear whether the four genotypes are also serotypes. To address this issue, we developed high-throughput serological assays based on antibody-mediated neutralization of BKV genotype I and IV reporter vectors (pseudoviruses). Neutralization-based testing of sera from mice immunized with BKV-I or BKV-IV virus-like particles (VLPs) or sera from naturally infected human subjects revealed that BKV-I specific serum antibodies are poorly neutralizing against BKV-IV and vice versa. The fact that BKV-I and BKV-IV are distinct serotypes was less evident in traditional VLP-based ELISAs. BKV-I and BKV-IV neutralization assays were used to examine BKV type-specific neutralizing antibody responses in KTRs at various time points after transplantation. At study entry, sera from 5% and 49% of KTRs showed no detectable neutralizing activity for BKV-I or BKV-IV neutralization, respectively. By one year after transplantation, all KTRs were neutralization seropositive for BKV-I, and 43% of the initially BKV-IV seronegative subjects showed evidence of acute seroconversion for BKV-IV neutralization. The results suggest a model in which BKV-IV-specific seroconversion reflects a de novo BKV-IV infection in KTRs who initially lack protective antibody responses capable of neutralizing genotype IV BKVs. If this model is correct, it suggests that pre-vaccinating prospective KTRs with a multivalent VLP-based vaccine against all BKV serotypes, or administration of BKV-neutralizing antibodies, might offer protection against graft loss or dysfunction due to BKV associated nephropathy.
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Affiliation(s)
- Diana V. Pastrana
- Laboratory of Cellular Oncology, National Cancer Institute, Bethesda, Maryland, United States of America
| | - Daniel C. Brennan
- Washington University School of Medicine, St. Louis, Missouri, United States of America
| | - Nicolas Çuburu
- Laboratory of Cellular Oncology, National Cancer Institute, Bethesda, Maryland, United States of America
| | - Gregory A. Storch
- Washington University School of Medicine, St. Louis, Missouri, United States of America
| | - Raphael P. Viscidi
- Department of Pediatrics, Johns Hopkins Medical Center, Baltimore, Maryland, United States of America
| | - Parmjeet S. Randhawa
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States of America
| | - Christopher B. Buck
- Laboratory of Cellular Oncology, National Cancer Institute, Bethesda, Maryland, United States of America
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7
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Detection of polyomavirus BK reactivation after renal transplantation using an intensive decoy cell surveillance program is cost-effective. Transplantation 2011; 92:1018-23. [PMID: 21946172 DOI: 10.1097/tp.0b013e318230c09b] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Reactivation of polyomavirus BK (BKV) after renal transplantation can lead to allograft dysfunction or loss with early detection improving outcomes. Current guidelines recommend quantitative polymerase chain reaction for surveillance; however, urinary decoy cell detection is a potentially cost-effective alternative. We present the outcomes from an early intensive BKV surveillance program using decoy cell detection for initial screening starting 2 weeks after transplantation. METHODS Records for all recipients of kidney (n=211) or simultaneous kidney and pancreas (n=102) transplants performed over 2 years in a single center were reviewed. Follow-up was for a minimum of 1 year. Urine cytology screening was performed fortnightly from 0 to 3 months after transplantation, monthly from 3 to 6 months then every 2 months from 6 to 12 months. RESULTS Decoy cell positivity occurred in 56 of 313 patients (17.9%) with sustained decoy cell positivity (≥2 positive urine samples >2 weeks apart) present in 32 patients (10.2%). Twenty-four patients (7.6%) became viremic and three patients (1%) developed polyoma virus nephropathy. The median time after transplantation until decoy cell positivity was 78 days, decreasing to 67 days for patients with sustained positivity and 57 days for patients who developed polyoma virus nephropathy. No grafts were lost due to BKV during the study period. Decoy cell screening resulted in savings of approximately £135,000 over 2 years, when compared with routine surveillance by quantitative polymerase chain reaction. CONCLUSIONS Clinically significant BKV reactivation occurs early after transplantation and can be reliably detected by decoy cell screening. A surveillance strategy for detecting BKV reactivation based on urine cytology is cost-effective.
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Jordan SC, Toyoda M, Kahwaji J, Vo AA. Clinical aspects of intravenous immunoglobulin use in solid organ transplant recipients. Am J Transplant 2011; 11:196-202. [PMID: 21219579 DOI: 10.1111/j.1600-6143.2010.03400.x] [Citation(s) in RCA: 137] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Intravenous immunoglobulin products (IVIG) are derived from pooled human plasma from thousands of donors and have been used for the treatment of primary immunodeficiency disorders for nearly 30 years. IVIG products are also effective in the treatment of autoimmune and inflammatory disorders, however the precise mechanism(s) of immune modulation are unknown. Recent data suggests that IVIG has a much broader ability to regulate cellular immunity, including innate and adaptive components. IVIG is also a recently recognized modifier of complement activation and injury. These attributes suggests IVIG would have clinical applications in solid organ transplantation. Analysis of clinical studies examining the use of IVIG in desensitization protocols and for treatment of antibody-mediated rejection (AMR) are supportive for kidney transplant recipients, although no clinical trials using IVIG in sensitized patients were performed seeking an Federal Drug Administration indication. Data regarding the use of IVIG for desensitization and treatment of AMR in cardiac and lung allograft recipients is not conclusive. IVIG is useful in the treatment and prevention of posttransplant infectious complications including cytomegalovirus, parvovirus B19 and polyoma BK virus. In addition, we address the risk of adverse events associated with IVIG use in sensitized end-stage renal disease and transplant patients.
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Affiliation(s)
- S C Jordan
- Comprehensive Transplant Center Transplant Immunology Laboratory, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
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9
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Abstract
BACKGROUND Polyomavirus BK (BKV) infection can cause nephropathy in the allograft kidney. No well-established drug treatment is available at this time. Human intravenous immunoglobulins (IVIG) have been used as an empiric therapy without proof of effectiveness. METHODS We tested five lots of commercially available IVIG preparations from two different suppliers for polyomavirus neutralizing activity. BKV and mouse polyomavirus were used to infect human and murine host cells, respectively, with or without prior treatment with IVIG. Neutralization activity was measured by quantitation of viral DNA after 7 days in culture. RESULTS Coincubation of BKV but not mouse polyomavirus with clinically relevant concentrations of IVIG derived from healthy and hepatitis B vaccinated subjects caused more than 90% inhibition of viral DNA yield after 7 days in culture. Consistent with a direct neutralizing mechanism, this effect was significantly diminished if viral infection was performed in immunoglobulin pretreated cells or if immunoglobulin treatment was delayed 2 hr after addition of infectious virus. CONCLUSION Human IVIG preparations contain BKV neutralizing antibodies. Data on neutralizing capacity of these antibodies are presented to aid dose exploration in clinical trials seeking to validate the use of IVIG in patients with BKV infection.
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