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Huang HX, Xiang Y, George R, Winterberg P, Serluco A, Liverman R, Yildirim I, Garro R. BK polyomavirus DNAemia, allograft rejection, and de novo donor-specific antibodies after lowering target tacrolimus levels in pediatric kidney transplant recipients. Pediatr Transplant 2024; 28:e14791. [PMID: 38808701 DOI: 10.1111/petr.14791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 04/27/2024] [Accepted: 05/12/2024] [Indexed: 05/30/2024]
Abstract
BACKGROUND BK polyomavirus (BKV) DNAemia is a challenging infectious complication after kidney transplant (KT). Reduction of immunosuppression is the mainstay of management, and tacrolimus is often the first immunosuppressive medication adjusted upon the diagnosis of BKV DNAemia. This study aimed to evaluate the impact of a new institutional protocol with lower target tacrolimus levels on BKV DNAemia, allograft rejection, and de novo donor-specific antibodies (dnDSA) among pediatric KT recipients. METHODS We conducted a retrospective chart review of all KT episodes between January 2013 and December 2018. The new protocol with lower target tacrolimus levels was implemented in March 2015. One hundred twenty-seven patients were included in primary analysis. All patients received induction with basiliximab and methylprednisolone and were maintained on a steroid-based immunosuppressive regimen. RESULTS In the post-intervention cohort, cumulative incidence of BKV DNAemia at 100 days (13.4% vs. 17.8%, p = .605) and 18 months post-KT (34.1% vs. 26.7%, p = .504) was not significantly different from the pre-intervention cohort. Biopsy-proven rejection rate did not change. However, we observed a trend toward earlier development of dnDSA in the post-intervention cohort using the Kaplan-Meier survival analysis (log-rank p = .06). Younger recipient age at the time of transplant was found to slightly increase the risk of BKV DNAemia (OR: 1.09, 95% CI [1.01, 1.16], p = .024). There was an association between BKV DNAemia and biopsy-proven rejection of any type (adjustedOR: 2.77, 95% CI [1.26, 6.23], p = .012), especially acute T-cell-mediated rejection grade 1A and above (adjustedOR: 2.95, 95% CI [1.06, 8.30], p = .037), after adjusted for recipient age at the time of transplant. CONCLUSIONS Targeting lower tacrolimus levels did not decrease the incidence of BKV DNAemia within 100 days or 18 months post-KT, nor did it increase the risk of biopsy-proven rejection among pediatric KT recipients in our center. However, there was a trend toward earlier development of dnDSA, which may portend worse long-term graft outcome post-KT. Our findings highlight the need for individualized immunosuppressive regimens based on immunologic and infectious risk factors and the importance of implementing innovative biomarkers to guide therapy and improve outcomes.
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Affiliation(s)
- Hou-Xuan Huang
- Emory University School of Medicine, Atlanta, Georgia, USA
- Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Yijin Xiang
- Emory University School of Medicine, Atlanta, Georgia, USA
| | - Roshan George
- Emory University School of Medicine, Atlanta, Georgia, USA
- Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | | | | | | | - Inci Yildirim
- Yale School of Medicine, New Haven, Connecticut, USA
| | - Rouba Garro
- Emory University School of Medicine, Atlanta, Georgia, USA
- Children's Healthcare of Atlanta, Atlanta, Georgia, USA
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2
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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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3
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Green A, Rubinstein JD, Grimley M, Pfeiffer T. Virus-Specific T Cells for the Treatment of Systemic Infections Following Allogeneic Hematopoietic Cell and Solid Organ Transplantation. J Pediatric Infect Dis Soc 2024; 13:S49-S57. [PMID: 38417086 DOI: 10.1093/jpids/piad077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 09/25/2023] [Indexed: 03/01/2024]
Abstract
Viral infections are a major source of morbidity and mortality in the context of immune deficiency and immunosuppression following allogeneic hematopoietic cell (allo-HCT) and solid organ transplantation (SOT). The pharmacological treatment of viral infections is challenging and often complicated by limited efficacy, the development of resistance, and intolerable side effects. A promising strategy to rapidly restore antiviral immunity is the adoptive transfer of virus-specific T cells (VST). This therapy involves the isolation and ex vivo expansion or direct selection of antigen-specific T cells from healthy seropositive donors, followed by infusion into the patient. This article provides a practical guide to VST therapy by reviewing manufacturing techniques, donor selection, and treatment indications. The safety and efficacy data of VSTs gathered in clinical trials over nearly 30 years is summarized. Current challenges and limitations are discussed, as well as opportunities for further research and development.
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Affiliation(s)
- Abby Green
- Department of Pediatrics, Division of Hematology/Oncology, Washington University School of Medicine, St. Louis, Missouri, USA
- Department of Pediatrics, Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Jeremy D Rubinstein
- Division of Oncology, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Michael Grimley
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Division of Bone Marrow Transplantation and Immune Deficiency, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Thomas Pfeiffer
- Department of Pediatrics, Division of Hematology/Oncology, Washington University School of Medicine, St. Louis, Missouri, USA
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Razizadeh MH, Tabibzadeh A. Human polyomavirus 9 as a potential threat in kidney transplant recipients; lessons from BKPyV. Transpl Immunol 2023; 80:101894. [PMID: 37414266 DOI: 10.1016/j.trim.2023.101894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 06/29/2023] [Accepted: 07/01/2023] [Indexed: 07/08/2023]
Abstract
As a therapeutic method, kidney transplantation significantly improved the life quality and prognosis of patients with the end-stage renal disease. Since a key element in stable kidney transplantation is continuous therapy with immunosuppressive agents, an inhibited immune response makes patients vulnerable to opportunistic viral and bacterial infections. Polyomavirus (PyV), from the Polyomaviridae family, includes a well-known BK virus (BKPyV) and less publicized human polyomavirus 9 (HPyV9). Both these viruses may inflict significant damage to kidney transplants because of their high prevalence and pathogenesis. While a great body of knowledge was accumulated about the BKPyV-caused nephropathy, much less information is about the potential threat from the HPyV9-caused damage to kidney transplants. The current review provides a glimpse of general information about the PyV-associated nephropathy with a special focus on the role of the HPyV9 in pathogenesis of nephropathy in kidney transplants.
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Affiliation(s)
| | - Alireza Tabibzadeh
- Department of Virology, School of Medicine, Iran University of Medical Sciences, Tehran, Iran.
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5
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Ordaya EE, Shaughnessy M, Elkin B, Husmann RL, Stauffer JC, Luengas EM, Chang BH, Tessier KM, Walker PF, Stauffer WM. Transplantation and immigration: Comparing infectious complications and outcomes between foreign-born and US-born kidney transplant recipients in Minnesota. Transpl Infect Dis 2023; 25:e14039. [PMID: 36856346 PMCID: PMC10085839 DOI: 10.1111/tid.14039] [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: 08/26/2022] [Revised: 01/22/2023] [Accepted: 02/09/2023] [Indexed: 03/02/2023]
Abstract
BACKGROUND Foreign-born kidney transplant recipients (FBKTRs) are at increased risk for reactivation of latent infections that may impact outcomes. We aimed to compare the etiology of infections and outcomes between FBKTR and United States KTRs (USKTR). METHODS We performed a retrospective study of patients who underwent kidney transplantation between January 1, 2014 and December 31, 2018 at two transplant centers in Minnesota. Frequency and etiology of infections as well as outcomes (graft function, rejection, and patient survival) at 1-year post-transplant between FBKTR and USKTR were compared. RESULTS Of the 573 transplant recipients, 124 (21.6%) were foreign-born and 449 (78.4%) US-born. At least one infection occurred in 411 (71.7%) patients (38.2% bacterial, 55% viral, 9.4% fungal). Viral infections were more frequent in FBKTR, particularly BK viremia (38.7% vs. 21.2%, p < .001). No statistical differences were found for bacterial or fungal infections; no parasitic infections were identified in either group. No geographically-restricted infections were noted aside from a single case of Madura foot in a FBKTR. Rejection episodes were more common in USKTR (p = .037), but stable/improving graft function (p = .976) and mortality (p = .451) at 1-year posttransplantation were similar in both groups. After adjusting for covariates, previous transplantation was associated with a higher number of infections (IRR 1.35, 95% confidence intervals 1.05-1.73, p = .020). CONCLUSION Although viral infections were more frequent in FBKTR, overall frequency and etiology of most infections and outcomes were similar between FBKTR and USKTR suggesting that comprehensive transplant care is providing timely prevention, diagnosis, and treatment of latent infections in FBKTR.
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Affiliation(s)
- Eloy E. Ordaya
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
- Division of Infectious Diseases, Mayo Clinic, Rochester, Minnesota
| | - Megan Shaughnessy
- Department of Medicine, Hennepin HealthCare, Minneapolis, Minnesota
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Baila Elkin
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
- Department of Medicine, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Rachel L. Husmann
- Department of Medicine, Hennepin HealthCare, Minneapolis, Minnesota
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Jacob C. Stauffer
- School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | | | - Bickey H. Chang
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Katelyn M. Tessier
- Masonic Cancer Center, Biostatistics Core, University of Minnesota, Minneapolis, Minnesota
| | - Patricia F. Walker
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
- HealthPartners Institute, Minneapolis, Minnesota
| | - William M. Stauffer
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, Minnesota
- School of Public Health, University of Minnesota, Minneapolis, Minnesota
- Human Migration and Health, Center for Global Health and Social Responsibility, Minneapolis, Minnesota
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Abstract
Solid organ transplantation is a life-saving treatment for people with end-stage organ disease. Immune-mediated transplant rejection is a common complication that decreases allograft survival. Although immunosuppression is required to prevent rejection, it also increases the risk of infection. Some infections, such as cytomegalovirus and BK virus, can promote inflammatory gene expression that can further tip the balance toward rejection. BK virus and other infections can induce damage that resembles the clinical pathology of rejection, and this complicates accurate diagnosis. Moreover, T cells specific for viral infection can lead to rejection through heterologous immunity to donor antigen directly mediated by antiviral cells. Thus, viral infections and allograft rejection interact in multiple ways that are important to maintain immunologic homeostasis in solid organ transplant recipients. Better insight into this dynamic interplay will help promote long-term transplant survival.
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Affiliation(s)
- Lauren E Higdon
- Department of Medicine/Nephrology, Stanford University, Palo Alto, CA
| | - Jane C Tan
- Department of Medicine/Nephrology, Stanford University, Palo Alto, CA
| | - Jonathan S Maltzman
- Department of Medicine/Nephrology, Stanford University, Palo Alto, CA
- Geriatric Research Education and Clinical Center, VA Palo Alto Health Care System, Palo Alto, CA
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7
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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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8
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Innate Immunity Response to BK Virus Infection in Polyomavirus-Associated Nephropathy in Kidney Transplant Recipients. TRANSPLANTOLOGY 2022. [DOI: 10.3390/transplantology3010003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BK polyomavirus (BKV) mainly causes infection in uroepithelial and renal tubular epithelial cells of either immunocompetent or immunocompromised hosts. Despite asymptomatic or mild clinical features in immunocompetent hosts with BK infection, serious complications are frequently found in immunocompromised patients, especially patients with kidney transplantation. Accordingly, BKV-associated nephropathy (BKVN) demonstrates a wide range of clinical manifestations, including ureteric stenosis and hemorrhagic cystitis. In addition, BKV re-infection in post-kidney transplantation is also a main cause of kidney allograft dysfunction and graft loss. Since the direct anti-BKV is unavailable, immune response against BKV infection is the main mechanism for organism control and might be a novel strategy to treat or suppress BKV. As such, the innate immunity, consisting of immune cells and soluble molecules, does not only suppress BKV but also enhances the subsequent adaptive immunity to eradicate the virus. Furthermore, the re-activation of BKV in BKVN of kidney-transplanted recipients seems to be related to the status of innate immunity. Therefore, this review aims to collate the most recent knowledge of innate immune response against BKV and the association between the innate immunity status of kidney-transplanted recipients and BKV re-activation.
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9
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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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Kavuzlu M, Baştürk B, Ataç FB, Alışkan HE, Kantaroğlu B. Investigation of the Relationship Between BK Virus and Human Leukocyte Antigens in Kidney Transplant Recipients. EXP CLIN TRANSPLANT 2021; 18:51-54. [PMID: 32008495 DOI: 10.6002/ect.tond-tdtd2019.o24] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES The main function of HLA is to present antigens to lymphocytes and to initiate specific immune responses. Autoimmune, viral, allergic, and neurologic diseases have been found to be related to HLA molecules. In renal transplant, the main target of the recipient's immune system is the HLA molecules on the surface of donor cells. HLA also plays a role in the development of an immune response to viral infections. After renal transplant, BK virus infections may occur due to immunosuppression. Here, we investigated the relationship between HLA and BK virus in renal transplant recipients. MATERIALS AND METHODS This retrospective study investigated HLA-A, HLA-B, and HLA-DR tissue typing before renal transplant. DNA was isolated from whole blood, and tissue typing tests were performed based on polymerase chain reaction. Patients were tested for BK virus posttransplant using DNA isolated from urine and/or plasma samples. RESULTS We found HLA-B*13 allele to be a protective factor (P < .049; odds ratio: 0.131; 95% confidence interval, 0.017-1.029) and HLA-DRB1*03 allele to be a possible risk factor (P < .029; odds ratio: 2.521; 95% confidence interval, 1.157-5.490) against BK virus. No significant relationships were found between BK virus and age, sex, donor type, and HLA mismatch. CONCLUSIONS HLA class I molecules are known to be effective against viruses with the help of cytotoxic T cells. HLA-B*13 alleles within the HLA class I molecules were identified as protective factors against BK virus. HLA class II is associated with CD4-positive T cells that help secrete immune system cytokines, playing a role in stimulating and suppressing the immune system. We demonstrated that HLA-DRB1*03 allele could be a risk factor against BK virus. This allele may be associated with immunomodulatory cytokine secretion of the immune system.
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Affiliation(s)
- Miray Kavuzlu
- From the Department of Medical Biology, Baskent University, Ankara, Turkey; and the Tissue Typing and Transplantation Laboratory, Baskent University, Adana, Turkey
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11
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Patel H, Rodig N, Agrawal N, Cardarelli F. Incidence and risk factors of kidney allograft loss due to BK nephropathy in the pediatric population: A retrospective analysis of the UNOS/OPTN database. Pediatr Transplant 2021; 25:e13927. [PMID: 33245596 DOI: 10.1111/petr.13927] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 09/16/2020] [Accepted: 10/29/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND BK virus infection can lead to graft dysfunction and loss in kidney transplant recipients. Risk factors for BKV and BKVN have been inadequately studied in children. Here, we evaluate the incidence and risk factors of allograft loss due to BKVN in the pediatric population of the UNOS data set. METHODS We conducted a retrospective cohort analysis of the UNOS database and identified all pediatric recipients of kidney transplantation between 2000 and 2018. We compared donor and recipient characteristics, including cause of ESRD, among patients who lost their graft due to BKVN or other causes, and those with functioning allograft. Kaplan-Meier curve and Cox regression analysis were performed to evaluate the risk factors. RESULTS A total of 66 patients (0.47%) suffered graft failure from BKVN. Older age, male gender, HLA mismatch, and rejection at 1 year were significantly associated with BKVN graft failure, compared to recipients with functioning allograft. In comparison with graft loss due to other causes, male gender, higher HLA mismatch, rejection in 1st year and tacrolimus use at discharge were significantly associated with BKVN graft loss. Recipients who received mycophenolate at time of discharge were at reduced risk for BKVN graft failure. Compared to graft failure from other causes, BKVN graft failure had shorter death censored graft survival [P = .001]. ESRD due to urologic causes and Alport syndrome had higher rate of BKVN graft failure. CONCLUSION Incidence of graft loss from BKVN in the pediatric population was 10.2 per 10 000 patient-years in this study. BKVN is associated with early allograft failure in the pediatric population, compared to other causes of graft loss. Male gender, HLA mismatch, rejection in 1st year, and urological cause of ESRD are risk factors for graft failure from BKVN in children.
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Affiliation(s)
- Het Patel
- Division of Nephrology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Nancy Rodig
- Division of Nephrology, Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA
| | - Nikhil Agrawal
- Division of Nephrology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Francesca Cardarelli
- Division of Nephrology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
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12
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Kotla SK, Kadambi PV, Hendricks AR, Rojas R. BK polyomavirus-pathogen, paradigm and puzzle. Nephrol Dial Transplant 2021; 36:587-593. [PMID: 31891401 DOI: 10.1093/ndt/gfz273] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Indexed: 12/16/2022] Open
Abstract
BK virus is a polyomavirus with seroprevalence rates of 80% in adults. Infection is usually acquired during childhood, and the virus is benign or pathologic depending on immune status. The virus reactivates in immunodeficiency states, mostly among transplant (either kidney or bone marrow) recipients. There are approximately 15 000 renal transplants every year in the USA, of which 5-10% develop BK polyomavirus nephropathy; 50-80% of patients who develop nephropathy go on to develop graft failure. BK virus is associated with BK polyomavirus nephropathy, ureteral stenosis, late-onset hemorrhagic cystitis, bladder cancer and other nonlytic large T-expressing carcinomas. The renal spectrum begins with viruria and can end with graft failure. The clinical spectrum and outcomes vary among transplant patients. New noninvasive diagnostic methods, such as urinary polyomavirus Haufen detected by electron microscopy, are currently under study. Treatment is primarily directed at decreasing immunosuppression but may be associated with graft rejection. Repeat transplantation is encouraged as long as viral clearance in plasma prior to transplant is accomplished. There remain no definitive data regarding the utility of transplant nephrectomy.
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Affiliation(s)
- Suman Krishna Kotla
- Department of Internal Medicine, Division of Nephrology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Pradeep V Kadambi
- Department of Internal Medicine, Division of Nephrology, University of Florida, Florida, USA
| | - Allen R Hendricks
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Rebecca Rojas
- Department of Internal Medicine, Division of Nephrology, University of Texas Southwestern Medical Center, Dallas, TX, USA
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Udomkarnjananun S, Kerr SJ, Francke MI, Avihingsanon Y, van Besouw NM, Baan CC, Hesselink DA. A systematic review and meta-analysis of enzyme-linked immunosorbent spot (ELISPOT) assay for BK polyomavirus immune response monitoring after kidney transplantation. J Clin Virol 2021; 140:104848. [PMID: 33979739 DOI: 10.1016/j.jcv.2021.104848] [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: 01/05/2021] [Revised: 04/12/2021] [Accepted: 04/21/2021] [Indexed: 12/29/2022]
Abstract
BK virus (BKV) infection after kidney transplantation can cause BKV nephropathy (BKVAN) resulting in graft dysfunction and allograft loss. The treatment for BKVAN is reduction of the immunosuppressive load which increases the risk of kidney transplant rejection. There is no biomarker to monitor BKV activity besides BK viral load. The value of the Enzyme-Linked Immunosorbent Spot (ELISPOT) assay as a tool to monitor the recipient's anti-BKV immune response after transplantation was investigated systematically. Electronic databases, including MEDLINE, Scopus, and the Cochrane Central Register of Controlled Trials were searched for studies of ELISPOT evaluating the immune response against BKV. BKV status was categorized as "active BKV infection" and as "resolving BKV infection". Random-effects model meta-analysis was performed to determine the diagnostic performance of the ELISPOT assay, after stratifying patients into groups based on positive and negative ELISPOT results. One-hundred twenty-seven articles were identified of which nine were included. Patients with negative ELISPOT had an increased risk of having active BKV replication (odds ratio of 71.9 (95%-CI 31.0-167.1). Pooled sensitivity was 0.95 (95%-CI 0.89-0.98) and specificity was 0.88 (95%-CI 0.78-0.94). The standardized mean difference of the number of IFN-γ producing cells between patients with active BKV infection compared with patients who had resolving BKV infection was -2.09 (95%-CI -2.50, -1.68). The ELISPOT assay is a useful tool for BKV risk assessment and in combination with BKV load may support clinicians in guiding immunosuppressive therapy in patients with BKV replication.
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Affiliation(s)
- Suwasin Udomkarnjananun
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand; Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands; Erasmus MC Transplantation Institute, Rotterdam, Netherlands.
| | - Stephen J Kerr
- Research Affairs, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
| | - Marith I Francke
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands; Erasmus MC Transplantation Institute, Rotterdam, Netherlands.
| | - Yingyos Avihingsanon
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand.
| | - Nicole M van Besouw
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands; Erasmus MC Transplantation Institute, Rotterdam, Netherlands.
| | - Carla C Baan
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands; Erasmus MC Transplantation Institute, Rotterdam, Netherlands.
| | - Dennis A Hesselink
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands; Erasmus MC Transplantation Institute, Rotterdam, Netherlands.
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14
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Bae H, Na DH, Chang JY, Park KH, Min JW, Ko EJ, Lee H, Yang CW, Chung BH, Oh EJ. Usefulness of BK virus-specific interferon-γ enzyme-linked immunospot assay for predicting the outcome of BK virus infection in kidney transplant recipients. Korean J Intern Med 2021; 36:164-174. [PMID: 32241081 PMCID: PMC7820663 DOI: 10.3904/kjim.2019.339] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 11/15/2019] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND/AIMS To investigate if BK virus (BKV)-specific T cell immunity measured by an interferon-γ enzyme-linked immunospot (ELISPOT) assay can predict the outcome of BK virus infection in kidney transplant recipients (KTRs). METHODS We included 68 KTRs with different viremia status (no viremia [n = 17], BK viremia [n = 27], and cleared viremia [n = 24]) and 44 healthy controls (HCs). The BK viremia group was divided into controller (< 3 months) and noncontroller (> 3 months) according to sustained duration of BKV infection. We compared BKV-ELISPOT results against five BKV peptides (large tumor antigen [LT], St, VP1-3). RESULTS BKV-ELISPOT results were higher in three KTRs groups with different BKV infection status than the HCs group (p < 0.05). In KTR groups, they were higher in cleared viremia group than no viremia or BK viremia group. Within the BK viremia group, controller group had higher LT-ELISPOT results compared to noncontroller group (p = 0.032). Also, KTRs without BK virus-associated nephropathy (BKVN) had higher LT, St, VP1, and VP2-ELISPOT results than those with BKVN (p < 0.05). CONCLUSION BKV-ELISPOT assay may be effective in predicting clinical outcomes of BKV infection in terms of clearance of BK virus and development of BKVN.
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Affiliation(s)
- Hyunjoo Bae
- Department of Biomedical Science, Graduate School, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Do Hyun Na
- Transplant Research Center, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Division of Nephrology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ji-Yeun Chang
- Transplant Research Center, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Division of Nephrology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ki Hyun Park
- Department of Biomedical Science, Graduate School, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ji Won Min
- Transplant Research Center, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Division of Nephrology, Department of Internal Medicine, Bucheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Bucheon, Korea
| | - Eun Jeong Ko
- Transplant Research Center, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Division of Nephrology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hyeyoung Lee
- Department of Laboratory Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Department of Laboratory Medicine, International St. Mary’s Hospital, Catholic Kwandong University College of Medicine, Incheon, Korea
| | - Chul Woo Yang
- Transplant Research Center, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Division of Nephrology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Byung Ha Chung
- Transplant Research Center, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Division of Nephrology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Eun-Jee Oh
- Department of Laboratory Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Correspondence to Eun-Jee Oh, M.D. Department of Laboratory Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 06591, Korea Tel: +82-2-2258-1641 Fax: +82-2-2258-1719 E-mail:
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15
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Burek Kamenaric M, Ivkovic V, Kovacevic Vojtusek I, Zunec R. The Role of HLA and KIR Immunogenetics in BK Virus Infection after Kidney Transplantation. Viruses 2020; 12:v12121417. [PMID: 33317205 PMCID: PMC7763146 DOI: 10.3390/v12121417] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 12/04/2020] [Accepted: 12/08/2020] [Indexed: 12/13/2022] Open
Abstract
BK virus (BKV) is a polyomavirus with high seroprevalence in the general population with an unremarkable clinical presentation in healthy people, but a potential for causing serious complications in immunosuppressed transplanted patients. Reactivation or primary infection in kidney allograft recipients may lead to allograft dysfunction and subsequent loss. Currently, there is no widely accepted specific treatment for BKV infection and reduction of immunosuppressive therapy is the mainstay therapy. Given this and the sequential appearance of viruria-viremia-nephropathy, screening and early detection are of utmost importance. There are numerous risk factors associated with BKV infection including genetic factors, among them human leukocyte antigens (HLA) and killer cell immunoglobulin-like receptors (KIR) alleles have been shown to be the strongest so far. Identification of patients at risk for BKV infection would be useful in prevention or early action to reduce morbidity and progression to frank nephropathy. Assessment of risk involving HLA ligands and KIR genotyping of recipients in the pre-transplant or early post-transplant period might be useful in clinical practice. This review summarizes current knowledge of the association between HLA, KIR and BKV infection and potential future directions of research, which might lead to optimal utilization of these genetic markers.
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Affiliation(s)
- Marija Burek Kamenaric
- Tissue Typing Center, Clinical Department of Transfusion Medicine and Transplantation Biology, University Hospital Center Zagreb, 10 000 Zagreb, Croatia;
| | - Vanja Ivkovic
- Department of Nephrology, Hypertension, Dialysis and Transplantation, University Hospital Center Zagreb, 10 000 Zagreb, Croatia; (V.I.); (I.K.V.)
- Department of Public Health, Faculty of Health Studies, University of Rijeka, 51 000 Rijeka, Croatia
| | - Ivana Kovacevic Vojtusek
- Department of Nephrology, Hypertension, Dialysis and Transplantation, University Hospital Center Zagreb, 10 000 Zagreb, Croatia; (V.I.); (I.K.V.)
| | - Renata Zunec
- Tissue Typing Center, Clinical Department of Transfusion Medicine and Transplantation Biology, University Hospital Center Zagreb, 10 000 Zagreb, Croatia;
- Correspondence:
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16
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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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17
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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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18
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Hosseini-Moghaddam SM, Xu Q, Jevnikar AM, House AA, Luke P, Campigotto A, Kum JJY, Singh G, Alharbi H, Speechley MR. The effect of human leukocyte antigen A1 and B35-Cw4 on sustained BK polyomavirus DNAemia after renal transplantation. Clin Transplant 2020; 34:e14110. [PMID: 33053214 DOI: 10.1111/ctr.14110] [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: 07/02/2020] [Revised: 10/01/2020] [Accepted: 10/03/2020] [Indexed: 11/30/2022]
Abstract
Human leukocyte antigen (HLA) class I presentation pathway plays a central role in natural killer (NK) cell and cytotoxic T-cell activities against BK polyomavirus (BKPyV) DNAemia. We determined the risk of sustained BKPyV DNAemia in 175 consecutive renal transplant recipients considering the simultaneous effect of donor/recipient HLA class I antigens and pre- or post-transplant variables. Median (IQR) age was 53 (44-64) years, and 37% of patients were female. 40 patients (22.9%) developed sustained BKPyV DNAemia [median (IQR) viral load: 9740 (4350-17 125) copies/ml]. In the Cox proportional hazard analysis, HLA-A1 (HR: 3.06, 95% CI: 1.51-6.17) and HLA-B35-Cw4 (HR: 4.63, 95% CI: 2.12-10.14) significantly increased the risk of sustained BKPyV DNAemia, while 2 HLA-C mismatches provided a marginally protective effect (HR: 0.32, 95% CI: 0.10-0.98). HLA-Cw4 is a ligand for NK cell inhibitory receptor, and HLA-B35 is in strong linkage disequilibrium with the HLA-Cw4 allele. The association between HLA-B35-Cw4 expression and sustained BKPyV DNAemia supports the important role of cytotoxic T cells and NK cells that would normally control BKPyV activation through engagement with immunoglobulin-like killer receptors (KIRs). Further studies are required to investigate the effect of HLA-C alleles along with NK cell activity against BKPyV DNAemia.
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Affiliation(s)
- Seyed M Hosseini-Moghaddam
- Division of Infectious Diseases, Department of Medicine, University Health Network, University of Toronto, Toronto, ON, Canada.,Department of Epidemiology and Biostatistics, Western University, London, ON, Canada.,Multiorgan Transplant Program, London Health Sciences Centre, Western University, London, ON, Canada
| | - Qingyong Xu
- Multiorgan Transplant Program, London Health Sciences Centre, Western University, London, ON, Canada.,Histocompatibility Laboratory, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Anthony M Jevnikar
- Multiorgan Transplant Program, London Health Sciences Centre, Western University, London, ON, Canada
| | - Andrew A House
- Multiorgan Transplant Program, London Health Sciences Centre, Western University, London, ON, Canada
| | - Patrick Luke
- Multiorgan Transplant Program, London Health Sciences Centre, Western University, London, ON, Canada
| | - Aaron Campigotto
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Jina J Y Kum
- Multiorgan Transplant Program, London Health Sciences Centre, Western University, London, ON, Canada.,Department of Pathology and Laboratory Medicine, London Health Sciences Centre, Western University, London, ON, Canada
| | - Gagandeep Singh
- Multiorgan Transplant Program, London Health Sciences Centre, Western University, London, ON, Canada
| | - Hajed Alharbi
- Multiorgan Transplant Program, London Health Sciences Centre, Western University, London, ON, Canada
| | - Mark R Speechley
- Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
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19
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Sharma R, Zachariah M. BK Virus Nephropathy: Prevalence, Impact and Management Strategies. Int J Nephrol Renovasc Dis 2020; 13:187-192. [PMID: 32821148 PMCID: PMC7423353 DOI: 10.2147/ijnrd.s236556] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 07/29/2020] [Indexed: 12/25/2022] Open
Abstract
BK virus reactivation as a result of therapeutic immunosuppression following renal transplant can result in BK polyomavirus nephropathy and renal allograft loss. This is a complex and challenging clinical problem with a range of management options and practices reported in literature. The current standard for early diagnosis and treatment is surveillance by measuring viral DNA in blood using qPCR. Immunosuppression reduction is the cornerstone of effective management but is associated with a risk of acute rejection following treatment.
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Affiliation(s)
- Rajeev Sharma
- School of Medicine, University of Nevada Las Vegas, Las Vegas, NV, USA.,Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
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20
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Günay E, Zeytinoğlu A, Şen S, Yılmaz M, Atay G, Aşcı G, Sezer TO, Töz H. Do Antithymocyte Globulin-Free Acute Rejection Therapies Increase the Risk of Polyoma Nephropathy in Renal Transplant Recipients? Transplant Proc 2019; 51:1112-1114. [PMID: 31101182 DOI: 10.1016/j.transproceed.2019.01.109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 12/29/2018] [Accepted: 01/21/2019] [Indexed: 10/27/2022]
Abstract
INTRODUCTION BK virus nephropathy is a serious complication that can lead to allograft kidney loss. Excessive immunosuppression increases the risk. We aimed to evaluate whether there is an increased risk of BK viremia and nephropathy in patients who underwent high-dose immunosuppression because of the development of acute rejection in the early period after kidney transplantation. METHODS This retrospective cohort study was performed between April 2015 and March 2016. Twenty-nine patients who had biopsy-proven acute rejection in the first 3 months were evaluated for BK viremia and nephropathy. Thirty patients who had transplantations at the same period were the control group. Plasma BK-DNA values were examined at 1, 2, 3, 6, 9, and 12 months after the rejection treatment and at 3, 6, 9, and 12 months in the control group. Presence of polyoma nephropathy was examined with surveillance biopsies at the 6 and 12 months. RESULTS Acute rejection treatment was started on the 12th day after transplantation (2-37 days). Seventeen cellular rejections and 12 humoral rejections were reported by biopsy. Two of the 12 humoral rejections were suspicious. Only pulse steroid (PS) (n = 18); PS, plasmapheresis, and intravenous immunoglobulin (n = 8); PS and intravenous immunoglobulin (n = 2); and PS and plasmapheresis (n = 1) treatments were performed. In 21 patients in the rejection group and 25 patients in the control group, BK-DNA was not positive at all. Two patients had graft loss at 11 and 36 months in the rejection group. Graft losses were secondary to rejection. CONCLUSIONS Treatment with antithymocyte globulin-free regimens after acute rejection episodes did not lead to an increase in BK viremia.
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Affiliation(s)
- Emrah Günay
- Department of Nephrology, Gazi Yasargil Training and Research Hospital, University of Health Sciences, Diyarbakir, Turkey.
| | - Aysin Zeytinoğlu
- Department of Microbiology, Ege University Medical Faculty, İzmir, Turkey
| | - Sait Şen
- Department of Pathology, Ege University Medical Faculty, İzmir, Turkey
| | - Mumtaz Yılmaz
- Department of Nephrology, Ege University Medical Faculty, İzmir, Turkey
| | - Gokhan Atay
- Department of Nephrology, Ege University Medical Faculty, İzmir, Turkey
| | - Gulay Aşcı
- Department of Nephrology, Ege University Medical Faculty, İzmir, Turkey
| | - Taylan Ozgur Sezer
- Department of General Surgery, Ege University Medical Faculty, İzmir, Turkey
| | - Huseyin Töz
- Department of Nephrology, Ege University Medical Faculty, İzmir, Turkey
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21
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El-Husseini A, Hassan W, Yaseen M, Suleiman B, Saleh S, Malik O, Ashqar H, Maibam A, Mei X, Castellanos AL, Cornea V, Gedaly R, Waid T. Impact of human leukocyte antigen and calculated panel reactive antibody on BK viremia in kidney transplant recipients: A single-center experience and literature review. Transpl Infect Dis 2019; 21:e13071. [PMID: 30866136 DOI: 10.1111/tid.13071] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 01/25/2019] [Accepted: 02/15/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND The aim of this retrospective analysis was to investigate the effect of human leukocyte antigen (HLA) and calculated panel reactive antibody (cPRA) on BK virus activation as evidenced by BK viremia (BKV). PATIENTS AND METHODS At our institution, 649 kidney transplant patients were screened for BKV from 2009 to 2017. Patients were considered to have BKV if they had >10 000 copies/mL of BK DNA in their blood. Donor and recipient HLA and cPRA, demographic, clinical and laboratory data, as well as immunosuppressive medications were collected. RESULTS We identified 122 BK positive and 527 BK negative patients. Only 25% of the patients had cPRA of 20% or more, and 64% had more than three HLA-A, -B, and -DR mismatches. In both univariate and multivariate analyses, male gender, age, and maintenance of steroid therapy significantly increased the risk of BKV (P = 0.005, 0.005 and <0.001, respectively). The degree of cPRA and the individual HLA allele and HLA allele matching did not significantly affect BKV. CONCLUSION Neither the degree of HLA mismatching nor cPRA appears to affect BKV. Moreover, no specific HLA allele, HLA allele matching, or cPRA were associated with BKV.
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Affiliation(s)
- Amr El-Husseini
- Division of Nephrology and Transplant Program, University of Kentucky, Lexington, Kentucky
| | - Waleed Hassan
- Division of Nephrology and Transplant Program, University of Kentucky, Lexington, Kentucky
| | - Maria Yaseen
- Division of Nephrology and Transplant Program, University of Kentucky, Lexington, Kentucky
| | - Belal Suleiman
- Division of Nephrology and Transplant Program, University of Kentucky, Lexington, Kentucky
| | - Sherif Saleh
- Division of Nephrology and Transplant Program, University of Kentucky, Lexington, Kentucky
| | - Omar Malik
- Division of Nephrology and Transplant Program, University of Kentucky, Lexington, Kentucky
| | - Hasan Ashqar
- Division of Nephrology and Transplant Program, University of Kentucky, Lexington, Kentucky
| | - Amita Maibam
- Division of Nephrology and Transplant Program, University of Kentucky, Lexington, Kentucky
| | - Xiaonan Mei
- Division of Nephrology and Transplant Program, University of Kentucky, Lexington, Kentucky
| | - Ana L Castellanos
- Division of Nephrology and Transplant Program, University of Kentucky, Lexington, Kentucky
| | - Virgilius Cornea
- Department of Surgical Pathology, University of Kentucky, Lexington, Kentucky
| | - Roberto Gedaly
- Division of Nephrology and Transplant Program, University of Kentucky, Lexington, Kentucky
| | - Thomas Waid
- Division of Nephrology and Transplant Program, University of Kentucky, Lexington, Kentucky
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22
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Chong S, Antoni M, Macdonald A, Reeves M, Harber M, Magee CN. BK virus: Current understanding of pathogenicity and clinical disease in transplantation. Rev Med Virol 2019; 29:e2044. [PMID: 30958614 DOI: 10.1002/rmv.2044] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 02/28/2019] [Accepted: 03/01/2019] [Indexed: 12/19/2022]
Abstract
BK polyomavirus (BKV) is an important cause of graft loss in renal transplant recipients that continues to pose a significant challenge to clinicians due to its frequently unpredictable onset, persistence, and the lack of effective antiviral agents or prevention strategies. This review covers our current understanding of epidemiology, viral transmission and disease progression, and treatment and prevention strategies that have been used to manage this disease.
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Affiliation(s)
- Stephanie Chong
- Department of Renal Medicine, Royal Free Hospital, University College London, London, UK
| | - Michelle Antoni
- School of Molecular and Cellular Biology, Faculty of Biological Sciences, University of Leeds, London, UK
| | - Andrew Macdonald
- School of Molecular and Cellular Biology, Faculty of Biological Sciences, University of Leeds, London, UK
| | - Matthew Reeves
- Institute of Immunity and Transplantation, Royal Free Hospital, University College London, London, UK
| | - Mark Harber
- Department of Renal Medicine, Royal Free Hospital, University College London, London, UK
| | - Ciara N Magee
- Department of Renal Medicine, Royal Free Hospital, University College London, London, UK
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23
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Li P, Cheng D, Wen J, Xie K, Li X, Ni X, Ji S, Chen J. Risk factors for BK virus infection in living-donor renal transplant recipients: a single-center study from China. Ren Fail 2018; 40:442-446. [PMID: 30052479 PMCID: PMC6070965 DOI: 10.1080/0886022x.2018.1489843] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Objectives: BK virus (BKV) infection has become one of the main complications in renal transplant recipients (RTRs) with the arrival of newer potent immunosuppressive agents. However, reports on the epidemiology of BKV infection and risk factors in Chinese population after renal transplantation are scarce. Methods: From June 2015 to July 2016, living-donor renal transplant recipients (LDRTRs) who routinely received the quantitative BKV DNA testing of urine and plasma samples using quantitative real-time polymerase chain reaction (PCR) for the first time after transplantation were selected, while dialysis patients and healthy living donors during that period served as controls. Potential variables were compared and analyzed using logistic regression model multivariate analysis to assess the BKV infection related factors in LDRTRs. Results: Among the 52 LDRTRs identified, BKV DNA was detected in 16 urine samples (30.8%), significantly higher than that of dialysis patients (6.3%) and healthy living donors (4.2%) (p < .001). Nevertheless, no statistically significant difference wax noted between the latter two groups in urine samples (p = .842). Meanwhile, BKV DNA detection in blood samples was all negative in the three groups. Univariate analysis shown tacrolimus (Tac) trough level and lymphocyte percentage were associated with BKV infection in LDRTRs. Multivariate regression analysis also showed Tac trough level (HR, 1.644; p = .03), lymphocyte percentage (HR, 0.878; p = .026) were associated with BKV infection in LDRTRs. Conclusions: In Chinese population, the incidence of BKV infection increased significantly after living-donor renal transplantation. Significantly increased Tac trough level and decreased lymphocyte percentage might be the risk factors for BKV infection in LDRTRs.
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Affiliation(s)
- Ping Li
- a National Clinical Research Center of Kidney Diseases, Jinling Hospital , Medical School of Nanjing University , Nanjing , China
| | - Dongrui Cheng
- a National Clinical Research Center of Kidney Diseases, Jinling Hospital , Medical School of Nanjing University , Nanjing , China
| | - Jiqiu Wen
- a National Clinical Research Center of Kidney Diseases, Jinling Hospital , Medical School of Nanjing University , Nanjing , China
| | - Kenan Xie
- a National Clinical Research Center of Kidney Diseases, Jinling Hospital , Medical School of Nanjing University , Nanjing , China
| | - Xue Li
- a National Clinical Research Center of Kidney Diseases, Jinling Hospital , Medical School of Nanjing University , Nanjing , China
| | - Xuefeng Ni
- a National Clinical Research Center of Kidney Diseases, Jinling Hospital , Medical School of Nanjing University , Nanjing , China
| | - Shuming Ji
- a National Clinical Research Center of Kidney Diseases, Jinling Hospital , Medical School of Nanjing University , Nanjing , China
| | - Jinsong Chen
- a National Clinical Research Center of Kidney Diseases, Jinling Hospital , Medical School of Nanjing University , Nanjing , China
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Abstract
Human BK polyomavirus (BKV) infection is poorly documented in heart and lung transplant patients. BK viruria and viremia have been estimated to affect 19% and 5% of heart transplant recipients, respectively. Data are limited, especially for lung transplantation, but the proportion of patients progressing from BK viruria to viremia or BKV-related nephropathy (BKVN) appears lower than in kidney transplantation. Nevertheless, a number of cases of BKVN have been reported in heart and lung transplant patients, typically with late diagnosis and generally poor outcomes. Risk factors for BKV infection or BKVN in this setting are unclear but may include cytomegalovirus infection and anti-rejection treatment. The relative infrequency of BKVN or other BK-related complications means that routine BKV surveillance in thoracic transplantation is not warranted, but a diagnostic workup for BKV infection may be justified for progressive renal dysfunction with no readily-identifiable cause; after anti-rejection therapy; and for renal dysfunction in patients with cytomegalovirus infection or hypogammaglobulinemia. Treatment strategies in heart or lung transplant recipients rely on protocols developed in kidney transplantation, with reductions in immunosuppression tailored to match the higher risk status of thoracic transplant patients.
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Affiliation(s)
- Markus J Barten
- University Heart Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Andreas Zuckermann
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
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25
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Pinto GG, Poloni JAT, Paskulin DD, Spuldaro F, Paris FD, Barth AL, Manfro RC, Keitel E, Pasqualotto AC. Quantitative detection of BK virus in kidney transplant recipients: a prospective validation study. ACTA ACUST UNITED AC 2018; 40:59-65. [PMID: 29796578 PMCID: PMC6533964 DOI: 10.1590/1678-4685-jbn-3776] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2017] [Accepted: 05/18/2017] [Indexed: 11/21/2022]
Abstract
Introduction: BK virus (BKV) infection in renal transplant patients may cause kidney
allograft dysfunction and graft loss. Accurate determination of BKV viral
load is critical to prevent BKV-associated nephropathy (BKVAN) but the
cut-off that best predicts BKVAN remains controversial. Objective: To evaluate the performance of a commercial and an in-house qPCR test for
quantitative detection of BK virus in kidney transplant recipients. Methods: This was a prospective study with kidney transplant recipients from two large
university hospitals in Brazil. Patients were screened for BKV infection
every 3 months in the first year post-transplant with a commercial and an
in-house real time polymerase chain reaction (qPCR) test. BKVAN was
confirmed based on histopathology. The area under the curve for plasma qPCR
was determined from receiver operating characteristic analysis. Results: A total of 200 patients were enrolled. Fifty-eight percent were male, 19.5%
had diabetes mellitus, and 82% had the kidney transplanted from a deceased
donor. BKV viremia was detected in 32.5% and BKVAN was diagnosed in 8
patients (4%). BKVAN was associated with viremia of 4.1 log copies/mL, using
a commercial kit. The cut-off for the in-house assay was 6.1 log copies/mL.
The linearity between the commercial kit and the in-house assay was
R2=0.83. Conclusion: Our study shows that marked variability occurs in BKV viral load when
different qPCR methodologies are used. The in-house qPCR assay proved
clinically useful, a cheaper option in comparison to commercial qPCR kits.
There is an urgent need to make BKV standards available to the international
community.
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Affiliation(s)
| | - José Antonio Tesser Poloni
- Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Brasil.,Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, Brasil
| | | | - Fabio Spuldaro
- Hospital de Clínicas de Porto Alegre, Porto Alegre, Brasil
| | | | | | | | - Elizete Keitel
- Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Brasil.,Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, Brasil
| | - Alessandro C Pasqualotto
- Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Brasil.,Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, Brasil
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26
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Scadden JRW, Sharif A, Skordilis K, Borrows R. Polyoma virus nephropathy in kidney transplantation. World J Transplant 2017; 7:329-338. [PMID: 29312862 PMCID: PMC5743870 DOI: 10.5500/wjt.v7.i6.329] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 11/17/2017] [Accepted: 12/01/2017] [Indexed: 02/05/2023] Open
Abstract
BK virus (BKV) is a polyomavirus that is able to cause renal dysfunction in transplanted grafts via BK virus-associated nephritis (BKVAN). This condition was mis-diagnosed in the past due to clinical and histopthological similarities with acute rejection. Due to the prevalence of the virus in the population, it is an important pathogen in this context, and so it is important to understand how this virus functions and its' relationship with the pathogenesis of BKVN. Screening for BKV often reveals viruria and/or viremia, which then manifests as BKVN, which can be asymptomatic or result in clinical features namely renal dysfunction. The pathogenesis of BKV infection is still unclear and needs to be further investigated; nevertheless there are a variety of hypotheses that indicate that there are a host of factors that play important roles. Treatments for BKVAN include a reduction in immunosuppression, the use of antiviral therapy or the combination of both treatment options.
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Affiliation(s)
- Jacob RW Scadden
- University of Birmingham, Edgbaston, Birmingham B15 2TH, United Kingdom
| | - Adnan Sharif
- Department of Kidney Transplantation, Queen Elizabeth Hospital Birmingham, Birmingham B15 2TH, United Kingdom
| | - Kassi Skordilis
- Department of Renal Histopathology, Queen Elizabeth Hospital Birmingham, Birmingham B15 2TH, United Kingdom
| | - Richard Borrows
- Department of Kidney Transplantation, Queen Elizabeth Hospital Birmingham, Birmingham B15 2TH, United Kingdom
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27
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Abstract
Similarly to the general population, genitourinary tract infections are common conditions in theimmunocompromised host. They can be furthermore divided into infections of the urinary tract and genital tract infections. Transplant recipients are more likely to have infections of the urinary tract infections while persons with human immunodeficiency virus (HIV) are at higher risk for the second group of infections, especially sexually transmitted infections (STIs). Manifestations of these diseases can be associated with more complications and can be more severe. We provide an overview of manifestations, diagnosis, and management of these disorders.
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28
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Schaenman J, Korin Y, Sidwell T, Kandarian F, Harre N, Gjertson D, Lum E, Reddy U, Huang E, Pham P, Bunnapradist S, Danovitch G, Veale J, Gritsch H, Reed E. Increased Frequency of BK Virus-Specific Polyfunctional CD8+ T Cells Predict Successful Control of BK Viremia After Kidney Transplantation. Transplantation 2017; 101:1479-1487. [PMID: 27391197 PMCID: PMC5219876 DOI: 10.1097/tp.0000000000001314] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND BK virus infection remains an important cause of loss of allograft function after kidney transplantation. We sought to determine whether polyfunctional T cells secreting multiple cytokines simultaneously, which have been shown to be associated with viral control, could be detected early after start of BK viremia, which would provide insight into the mechanism of successful antiviral control. METHODS Peripheral blood mononuclear cells collected during episodes of BK viral replication were evaluated by multiparameter flow cytometry after stimulation by overlapping peptide pools of BK virus antigen to determine frequency of CD8+ and CD4+ T cells expressing 1 or more cytokines simultaneously, as well as markers of T-cell activation, exhaustion, and maturation. RESULTS BK virus controllers, defined as those with episodes of BK viremia of 3 months or less, had an 11-fold increase in frequency of CD8+ polyfunctional T cells expressing multiple cytokines, as compared with patients with prolonged episodes of BK viremia. Patients with only low level BK viremia expressed low frequencies of polyfunctional T cells. Polyfunctional T cells were predominantly of the effector memory maturation subtype and expressed the cytotoxicity marker CD107a. CONCLUSIONS Noninvasive techniques for immune assessment of peripheral blood can provide insight into the mechanism of control of BK virus replication and may allow for future patient risk stratification and customization of immune suppression at the onset of BK viremia.
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Affiliation(s)
- J.M. Schaenman
- Division of Infectious Diseases, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Y. Korin
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - T. Sidwell
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - F. Kandarian
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - N. Harre
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - D. Gjertson
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
- Department of Biostatistics, UCLA School of Public Health, Los Angeles, CA
| | - E. Lum
- Division of Nephrology, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - U. Reddy
- Division of Nephrology, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - E. Huang
- Division of Nephrology, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - P.T. Pham
- Division of Nephrology, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - S. Bunnapradist
- Division of Nephrology, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - G. Danovitch
- Division of Nephrology, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - J. Veale
- Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - H.A. Gritsch
- Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - E.F. Reed
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
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29
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BK Polyomavirus and the Transplanted Kidney: Immunopathology and Therapeutic Approaches. Transplantation 2017; 100:2276-2287. [PMID: 27391196 PMCID: PMC5084638 DOI: 10.1097/tp.0000000000001333] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BK polyomavirus is ubiquitous, with a seropositivity rate of over 75% in the adult population. Primary infection is thought to occur in the respiratory tract, but asymptomatic BK virus latency is established in the urothelium. In immunocompromised host, the virus can reactivate but rarely compromises kidney function except in renal grafts, where it causes a tubulointerstitial inflammatory response similar to acute rejection. Restoring host immunity against the virus is the cornerstone of treatment. This review covers the virus-intrinsic features, the posttransplant microenvironment as well as the host immune factors that underlie the pathophysiology of polyomavirus-associated nephropathy. Current and promising therapeutic approaches to treat or prevent this complication are discussed in relation to the complex immunopathology of this condition.
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30
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Alagoz S, Kuskucu M, Gulcicek S, Yalin SF, Oruc M, Midilli K, Yılmaz E, Altiparmak MR, Seyahi N. The Frequency and Associated Factors for BK Virus Infection in a Center Performing Mainly Living Kidney Transplantations. Prog Transplant 2017; 27:152-159. [PMID: 28617169 DOI: 10.1177/1526924817699969] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE BK virus (BKV) nephropathy has increasingly become an important cause of morbidity in renal transplant recipients. We evaluated the frequency and associated factors for BKV infection in a center performing mainly living donor transplantations over a long time period. METHODS One hundred consecutive renal transplant patients were included. Quarterly visits were planned to examine urine for decoy cells and to measure the BKV DNA in the blood and urine. Renal biopsy was performed in case of deteriorated allograft function. Serological examinations for BKV immunoglobulin G (IgG) were performed in donors. RESULTS Throughout the entire follow-up period, the rates of viruria, viremia, and the positivity of decoy cells were 12%, 6%, and 13%, respectively. The negative and positive predictive values of decoy cells were 93.1% and 69.2%, respectively, for viruria, and 99.2% and 45.5%, respectively, for viremia. Biopsy-proven BKV nephropathy was observed in 1 patient. The BKV IgG was positive in all living donors. Viruria and viremia were associated with deceased donor transplantation, acute rejection, and pulse steroid therapy. In addition, viremia was associated with antithymocyte globulin therapy and a short duration of the posttransplant period. CONCLUSIONS The frequency of BKV infection was lower in our transplant unit compared to previous reports. Reduced doses of immunosuppression seem to be the main factor that may explain the reduced frequency. However, an active screening strategy is still of importance for this patient group.
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Affiliation(s)
- Selma Alagoz
- 1 Division of Nephrology, Department of Internal Medicine, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Mert Kuskucu
- 2 Department of Clinical Microbiology, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Sibel Gulcicek
- 1 Division of Nephrology, Department of Internal Medicine, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Serkan Feyyaz Yalin
- 1 Division of Nephrology, Department of Internal Medicine, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Meric Oruc
- 1 Division of Nephrology, Department of Internal Medicine, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Kenan Midilli
- 2 Department of Clinical Microbiology, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Erkan Yılmaz
- 3 Tissue Typing Laboratory, Department of Organ Transplantation, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Mehmet Riza Altiparmak
- 1 Division of Nephrology, Department of Internal Medicine, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Nurhan Seyahi
- 1 Division of Nephrology, Department of Internal Medicine, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
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31
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Hu J, Li S, Yang M, Xu L, Zhang X, Zhao H, Dong H, Huang Y, Fan J, Li L. Incidence, risk factors and the effect of polyomavirus infection in hematopoietic stem cell transplant recipients. J Int Med Res 2017; 45:762-770. [PMID: 28415933 PMCID: PMC5536654 DOI: 10.1177/0300060517691795] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Objective The effect of polyomavirus infection in HSCT recipients is poorly understood. Methods We evaluated 38 HSCT recipients. Polyomavirus was detected by nested qualitative polymerase chain reaction (PCR) assays of urine. The risk factors for BK virus and JC virus were analysed. The kidney and liver functions of infected and uninfected patients were compared. Results BK virus, JC virus, and simian virus 40 were detected in 21%, 42%, and 0% of HSCT recipients respectively. HCMV infection was found to be an independent risk factor for JC virus infection (odds ratio (OR): 8.528), while transplants with mismatched HLA are more susceptible to BK virus infection (OR: 12.000). Liver function of JC virus-infected subjects was worse than that of uninfected subjects. Conclusion We must be vigilant for opportunistic polyomavirus infections in HSCT recipients, especially those with HCMV co-infection or a mismatched HLA transplant. When unexplained liver function deterioration is observed, JC virus infection should be considered.
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Affiliation(s)
- Jianhua Hu
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, P.R. China
| | - Siying Li
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, P.R. China
| | - Meifang Yang
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, P.R. China
| | - Lichen Xu
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, P.R. China
| | - Xuan Zhang
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, P.R. China
| | - Hong Zhao
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, P.R. China
| | - Huihui Dong
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, P.R. China
| | - Yaping Huang
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, P.R. China
| | - Jun Fan
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, P.R. China
| | - Lanjuan Li
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, P.R. China
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Hsiao CY, Pilmore HL, Zhou L, de Zoysa JR. Outcomes of renal transplant recipients with BK virus infection and BK virus surveillance in the Auckland region from 2006 to 2012. World J Nephrol 2016; 5:497-506. [PMID: 27872831 PMCID: PMC5099595 DOI: 10.5527/wjn.v5.i6.497] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 08/08/2016] [Accepted: 08/29/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate incidence, risk factors and treatment outcome of BK polyomavirus nephropathy (BKVN) in a cohort of renal transplant recipients in the Auckland region without a formal BK polyomavirus (BKV) surveillance programme.
METHODS A cohort of 226 patients who received their renal transplants from 2006 to 2012 was retrospectively reviewed.
RESULTS Seventy-six recipients (33.6%) had a BK viral load (BKVL) test and 9 patients (3.9%) developed BKVN. Cold ischaemia time (HR = 1.18, 95%CI: 1.04-1.35) was found to be a risk factor for BKVN. Four recipients with BKVN had complete resolution of their BKV infection; 1 recipient had BKVL less than 625 copies/mL; 3 recipients had BKVL more than 1000 copies/mL and 1 had graft failure from BKVN. BKVN has a negative impact on graft function [median estimated glomerular filtration rate (eGFR) 22.5 (IQR 18.5-53.0) mL/min per 1.73 m2, P = 0.015), but no statistically significant difference (P = 0.374) in renal allograft function was found among negative BK viraemia group [median eGFR 60.0 (IQR 48.5-74.2) mL/min per 1.73 m2), positive BK viraemia without BKVN group [median eGFR 55.0 (IQR 47.0-76.0) mL/min per 1.73 m2] and unknown BKV status group [median eGFR 54.0 (IQR 43.8-71.0) mL/min per 1.73 m2]. The incidence and treatment outcomes of BKVN were similar to some centres with BKV surveillance programmes.
CONCLUSION Recipients with BVKN have poorer graft function. Although active surveillance for BKV has been shown to be effective in reducing incidence of BKVN, it should be tailored specifically to that transplant centre based on its epidemiology and outcomes of BKVN, particularly in centres with limited resources.
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33
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Risk Factors for BK Polyoma Virus Treatment and Association of Treatment With Kidney Transplant Failure: Insights From a Paired Kidney Analysis. Transplantation 2016; 100:854-61. [PMID: 27003098 DOI: 10.1097/tp.0000000000000890] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Identification of risk factors for BK polyoma virus (BKPyV) without confounding by donor factors and era effects in paired analysis may inform strategies to prevent BKPyV. METHODS In this analysis of 21,575 mate kidney pairs in the Scientific Registry of Transplant Recipients between 2004 and 2010, the presence of a treatment code for BKPyV virus in follow-up forms was used to identify pairs in which 1 of 2 mate kidneys was treated (discordant treatment) or both mate kidneys were treated (concordant treatment). RESULTS Among 1975 discordant pairs, younger than 18 years or 60 years or older, male sex, HLA mismatch or 4 greater, acute rejection, and depleting antibody induction had a higher odds of treatment, whereas diabetes and sirolimus had a lower odds of treatment, and treatment was associated with a higher risk of allograft failure (hazards ratio, 2.01; 95% confidence interval, 1.63-2.48). The rate of concordant treatment (0.81%) was 2.8 times higher than expected. Concordant treatment was associated with nonwhite donor ethnicity, donation after circulatory death, transplantation after 2008, and transplantation of mate kidneys in the same center. CONCLUSIONS This analysis of kidneys from the same donor in which only 1 transplant was treated for BKPyV identifies specific risk factors (age <18 or ≥ 60 years, male sex, depleting antibody, HLA mismatch ≥ 4) for BKPyV and provides an estimate of the BKPyV-associated risk of allograft failure (hazards ratio = 2.01) without confounding by donor factors or era effects. The higher than expected rate of concordant treatment suggests the importance of donor factors in BKPyV pathogenesis and warrants further study.
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Viral Origin, Clinical Course, and Renal Outcomes in Patients With BK Virus Infection After Living-Donor Renal Transplantation. Transplantation 2016; 100:844-53. [PMID: 26720302 DOI: 10.1097/tp.0000000000001066] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND BK virus (BKV) nephropathy remains the main cause of renal graft loss after living-donor renal transplantation. The aim of the study was to investigate the source and factors influencing the course of BKV infection. METHODS We investigated 214 living donor-recipient pairs. Urine and blood of donors and recipients were tested by qPCR for the presence of BKV DNA before and after transplantation; genotyping of BKV subtypes was performed. RESULTS Eighty-five recipients (40%) had posttransplant BK viruria including 61 with additional viremia and 22 with nephropathy. Pretransplant urinary BKV shedding of donor or recipient was a significant risk factor for posttransplant viruria and viremia (OR, 4.52; CI, 2.33-8.77; P < 0.0001) and nephropathy (OR, 3.03; CI, 1.16-7.9; P = 0.02). In the BKV nephropathy group, urine and blood became BKV positive earlier than in the group with viruria and viremia. Renal function was worse in BKV-nephropathy compared with BKV-negative patients beginning at transplantation. Comparing BKV subtypes of donor and recipient before with the subtype of the infected recipient after transplantation, donor-derived transmission was identified in 24 of 28 corresponding pairs. BKV subtype IV had a higher prevalence in recipients with BKV nephropathy than in those with viruria and viremia (P = 0.045). CONCLUSIONS Pretransplant urinary BKV shedding of donor and recipient is a risk for posttransplant infection. Donor-derived BKV transmission is an important mode of infection. BKV subtype IV may be one of the viral determinants. Early BKV positivity of urine and blood indicates later BKV nephropathy. Decreased renal function may favor BKV infection.
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35
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Schwartz SE, Twining LM. BK Virus Infection in Kidney Transplantation: A Case for Early Intervention. Prog Transplant 2016; 16:133-7. [PMID: 16789702 DOI: 10.1177/152692480601600207] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
The prognosis for renal allograft survival in a patient with BK virus–associated nephropathy is distressing because nearly 50% of affected grafts are lost. With these statistics in mind, attempting clinical intervention before BK virus disease develops seems appropriate. Noninvasive screening tools such as tests to detect decoy cells in urine can enable diagnosis of BK viral infection in its early stages. Although it is not entirely clear which patients with BK infection will have BK disease develop, it may be possible to intervene in this early warning period to prevent the further development of BK virus–associated nephropathy. We present a case of a 50-year-old man in whom asymptomatic BK viruria developed 6 weeks after he received a non-HLA matched kidney from a deceased donor. This BK viruria was accompanied, subsequently, by an unexplained increase in serum creatinine level 2 months after transplantation. Following a change in his immunosuppressive regimen as therapy for presumed renal allograft dysfunction associated with BK viral infection, the decoy cells in his urine disappeared and his creatinine levels stabilized.
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Pai D, Mann DM, Malik A, Hoover DR, Fyfe B, Mann RA. Risk Factors for the Development of BK Virus Nephropathy in Renal Transplant Recipients. Transplant Proc 2016; 47:2465-9. [PMID: 26518952 DOI: 10.1016/j.transproceed.2015.08.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Accepted: 08/03/2015] [Indexed: 12/16/2022]
Abstract
The BK polyoma virus has, in recent years, become a significant cause of renal allograft dysfunction and failure. Among 260 adult kidney transplant recipients, those with biopsy-proven BK virus nephropathy (BKVN) were compared with those without BKVN with regard to gender, age, race, rejection episodes, time on dialysis, number of organs transplanted, HLA match, live donor versus deceased donor, cold ischemia time, delayed graft function, cytomegalovirus (CMV) serostatus of donor and recipient, induction therapy, and maintenance immunosuppression. Episodes of rejection (35.7% of patients with BKVN vs 8.5% of patients without BKVN; P = .01), transplantation of >1 organ (35.7% of patients with BKVN vs 9.0% of patients without BKVN; P = .01), positive CMV serology in both donor and recipient (71.4% of patients with BKVN vs 41.1% of patients without BKVN; P = .03), and a greater cumulative dose of daclizumab use at the time of induction (2.24 ± 0.05 mg/kg in patients with BKVN vs 2.03 ± 0.14 mg/kg in patients without BKVN; P = .04) were statistically significant risk factors for the development of BKVN. Those who developed BKVN received a higher mean cumulative dose of rabbit antithymoglobulin for induction therapy, but that difference failed to achieve statistical significance (P = .07).
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Affiliation(s)
- D Pai
- Department of Medicine, Division of Nephrology at Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - D M Mann
- Temple University School of Medicine, Philadelphia, Pennsylvania; Department of Neurosurgery, University of Colorado School of Medicine, Denver, Colorado
| | - A Malik
- Department of Medicine, Division of Nephrology at Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - D R Hoover
- Department of Statistics at Rutgers University, New Brunswick, New Jersey
| | - B Fyfe
- Department of Pathology at Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - R A Mann
- Department of Medicine, Division of Nephrology at Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey.
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Sharma R, Tzetzo S, Patel S, Zachariah M, Sharma S, Melendy T. BK Virus in Kidney Transplant: Current Concepts, Recent Advances, and Future Directions. EXP CLIN TRANSPLANT 2016; 14:377-84. [PMID: 27267780 DOI: 10.6002/ect.2016.0030] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BK virus nephropathy is a challenging clinical problem in kidney transplant recipients with wide range of surveillance and management practices, based on individual experience. BK virus reactivation in kidney transplant recipients can result in BK virus nephropathy and graft loss. The most effective strategy for early diagnosis and treatment of BK virus nephropathy is regular monitoring for BK virus, currently achieved by quantification of viral DNA in blood by quantitative polymerase chain reaction. Immunosuppression reduction remains the mainstay of treatment; however, viral clearance is often followed by acute rejection, likely secondary to a delay between immune reconstitution and viral clearance. Impaired cell-mediated immune response to BK virus has been shown to correlate with progression to BK virus nephropathy, while reconstitution of this response correlates with resolution of nephropathy. There is recent research to support monitoring BK virus-specific cell-mediated immune response as a predictor of disease progression and resolution. In this article, we review the current concepts and recent developments in understanding BK virus-associated disease in the context of kidney transplant and outline areas for future research.
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Affiliation(s)
- Rajeev Sharma
- From the Department of Surgery, State University of New York, Buffalo, New York, USA
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Boukoum H, Nahdi I, Sahtout W, Skiri H, Aloui S, Achour A, Segondy M, Aouni M. BK and JC polyomavirus infections in Tunisian renal transplant recipients. J Med Virol 2015; 87:1788-95. [DOI: 10.1002/jmv.24234] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/09/2015] [Indexed: 12/26/2022]
Affiliation(s)
- Hanen Boukoum
- Laboratoire des Maladies Transmissibles et Substances Biologiquement Actives; LR-99ES27; Faculté de Pharmacie; Monastir Tunisia
| | - Imen Nahdi
- Laboratoire des Maladies Transmissibles et Substances Biologiquement Actives; LR-99ES27; Faculté de Pharmacie; Monastir Tunisia
| | | | - Habib Skiri
- Service de Néphrologie; Hôpital Fattouma Borguiba; Monastir Tunisia
| | - Sabra Aloui
- Service de Néphrologie; Hôpital Fattouma Borguiba; Monastir Tunisia
| | | | - Michel Segondy
- Laboratoire de Virologie; CHU de Montpellier; Université de Montpellier I; hôpital Saint-Éloi; Montpellier France
| | - Mahjoub Aouni
- Laboratoire des Maladies Transmissibles et Substances Biologiquement Actives; LR-99ES27; Faculté de Pharmacie; Monastir Tunisia
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Satyanarayana G, Marty FM, Tan CS. The polyomavirus puzzle: is host immune response beneficial in controlling BK virus after adult hematopoietic cell transplantion? Transpl Infect Dis 2014; 16:521-31. [PMID: 24834968 DOI: 10.1111/tid.12233] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Revised: 01/22/2014] [Accepted: 02/08/2014] [Indexed: 12/14/2022]
Abstract
BK virus (BKV), a ubiquitous human polyomavirus, usually does not cause disease in healthy individuals. BKV reactivation and disease can occur in immunosuppressed individuals, such as those who have undergone renal transplantation or hematopoietic cell transplantation (HCT). Clinical manifestations of BKV disease include graft dysfunction and failure in renal transplant recipients; HCT recipients frequently experience hematuria, cystitis, hemorrhagic cystitis (HC), and renal dysfunction. Studies of HCT patients have identified several risk factors for the development of BKV disease including myeloablative conditioning, acute graft-versus-host disease, and undergoing an umbilical cord blood (uCB) HCT. Although these risk factors indicate that alterations in the immune system are necessary for BKV pathogenesis in HCT patients, few studies have examined the interactions between host immune responses and viral reactivation in BKV disease. Specifically, having BKV immunoglobulin-G before HCT does not protect against BKV infection and disease after HCT. A limited number of studies have demonstrated BKV-specific cytotoxic T cells in healthy adults as well as in post-HCT patients who had experienced HC. New areas of research are required for a better understanding of this emerging infectious disease post HCT, including prospective studies examining BK viruria, viremia, and their relationship with clinical disease, a detailed analysis of urothelial histopathology, and laboratory evaluation of systemic and local cellular and humoral immune responses to BKV in patients receiving HCT from different sources, including uCB and haploidentical donors.
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Affiliation(s)
- G Satyanarayana
- Division of Infectious Disease, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; Division of Infectious Disease, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA; Center for Virology and Vaccine Research, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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Geetha D, Levine SM, Manno RL, Valsamakis A, Ghazarian S, Seo P. BK virus replication in patients with anti-neutrophil cytoplasmic antibody-associated vasculitis. Am J Nephrol 2013; 39:20-6. [PMID: 24401699 DOI: 10.1159/000357409] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2013] [Accepted: 11/15/2013] [Indexed: 01/29/2023]
Abstract
BACKGROUND BK virus (BKV) is an important cause of renal dysfunction in kidney transplant (KTX) recipients. Immunosuppression intensity is a major risk factor for BKV replication in these patients. The prevalence of BKV replication in immunosuppressed patients with granulomatosis with polyangiitis (GPA) and microscopic polyangiitis (MPA) without transplant is not known. METHODS Consecutive patients (n = 37) with a diagnosis of GPA (n = 25) or MPA (n = 12) without history of KTX were evaluated for plasma BKV replication by quantitative PCR (group A). Descriptive data were collected. BKV replication in this nontransplant immunosuppressed vasculitis cohort was compared with a historical cohort of vasculitis KTX recipients (group B). RESULTS Group A patients had mean disease duration of 75 months. Mean age was 57 years and 54% were female. Mean time from vasculitis onset to BKV testing was 36 months, and 19/37 patients were tested within 24 months of induction therapy. At the time of BKV testing, 73% were on prednisone (P) with azathioprine, mycophenolate mofetil (MMF), methotrexate or leflunomide. None of the nontransplanted vasculitis patients had detectable plasma BKV. Among 35 patients in group B, 16 were tested for BKV; 5/16 (31%) had detectable virus in plasma at a mean of 6 months after TX (p = 0.002). Most (94%) were on maintenance therapy with MMF, P and tacrolimus. CONCLUSION Immunosuppressed patients with GPA/MPA without KTX had no evidence of plasma BKV. However, BKV was common in GPA/MPA patients after KTX, suggesting that replication may be related to differences in immunosuppression, alloimmune activation or differences in host defense mechanisms.
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Affiliation(s)
- D Geetha
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Md., USA
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Hässig A, Roos M, Etter A, Bossart W, Müller N, Schiesser M, Wüthrich RP, Fehr T. Association of BK viremia with human leukocyte antigen mismatches and acute rejection, but not with type of calcineurin inhibitor. Transpl Infect Dis 2013; 16:44-54. [PMID: 24134704 DOI: 10.1111/tid.12153] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2013] [Revised: 03/31/2013] [Accepted: 04/21/2013] [Indexed: 12/14/2022]
Abstract
INTRODUCTION BK viremia and polyomavirus-associated nephropathy (PVN) represent a significant problem after kidney transplantation. Both are associated with intensified immunosuppression, but other risk factors and the impact of a screening program on outcome are incompletely understood. METHODS Here, we report on the short- and long-term outcome of a cohort of patients, who were transplanted in 2006/2007 and included in a newly introduced systematic 3-monthly screening for BK viremia at the University Hospital Zurich. In patients testing positive for BK viremia, screening frequency was intensified and immunosuppression reduced. Patients with suspected PVN underwent transplant biopsy. RESULTS Among 152 included patients, 49 (32%) tested positive for BK viremia, but only 8 developed biopsy-proven PVN. BK viremia had a significant impact on estimated glomerular filtration rate and proteinuria in the first 2 years. Acute rejection episodes and the number of human leukocyte antigen (HLA) mismatches were the strongest independent predictors of BK viremia in a multiple logistic model. In contrast, no particular immunosuppressive agent or regimen was associated with enhanced risk. CONCLUSION Taken together, systematic BK viremia screening led to detection of a high percentage of viremic patients. With adjustment of immunosuppression, an excellent outcome was achieved. The independent association of HLA mismatches with BK viremia suggests impaired polyomavirus immunosurveillance in highly mismatched allografts.
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Affiliation(s)
- A Hässig
- Division of Nephrology, University Hospital Zurich, Zurich, Switzerland
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Masutani K, Ninomiya T, Randhawa P. HLA-A2, HLA-B44 and HLA-DR15 are associated with lower risk of BK viremia. Nephrol Dial Transplant 2013. [PMID: 24084328 DOI: 10.1093/ndt/fgt298] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Human leucocyte antigens (HLAs) modulate immunity to polyomavirus BK (BKV). Identification of HLAs that alter the course of infection will facilitate risk stratification, and customization of pre-emptive intervention strategies. METHODS We performed a retrospective cohort study with 998 kidney transplant patients with BKV infection status confirmed by polymerase chain reaction (PCR). Clinical parameters and donor-recipient matching for specific HLAs were examined in relation to occurrence of viremia. An emphasis was placed on donor-recipient matching rather than the actual frequency of specific HLA-alleles, since a successful immune response requires sharing of HLAs between a virus-infected target cell and the anti-viral effector cell. RESULTS Using multivariate statistics, low risk of BK viremia was associated with matching of HLA-A2 [hazard ratio (HR) 0.51, 95% confidence interval (CI) 0.28-0.85], HLA-B44 (HR 0.31, 95% CI 0.076-0.85) and HLA-DR15 (HR 0.35, 95% CI 0.084-0.93) (P < 0.05), whereas high risk of viremia was associated with male gender (HR 2.38, 95% CI 1.46-4.09, P < 0.001). CONCLUSIONS HLAs that associated with a lower predisposition to the development of BK viremia have been identified. Evaluation of donor-recipient mismatching for these HLAs could potentially be used to (i) fine tune virus screening strategies for BKV in individual patients and (ii) facilitate discovery of major histocompatibility complex (MHC) class I and II binding peptides that can elicit clinically meaningful BKV-specific immunity.
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Affiliation(s)
- Kosuke Masutani
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Masutani K, Ninomiya T, Randhawa P. HLA-A2, HLA-B44 and HLA-DR15 are associated with lower risk of BK viremia. Nephrol Dial Transplant 2013; 28:3119-26. [PMID: 24084328 DOI: 10.1093/ndt/gft298] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Human leucocyte antigens (HLAs) modulate immunity to polyomavirus BK (BKV). Identification of HLAs that alter the course of infection will facilitate risk stratification, and customization of pre-emptive intervention strategies. METHODS We performed a retrospective cohort study with 998 kidney transplant patients with BKV infection status confirmed by polymerase chain reaction (PCR). Clinical parameters and donor-recipient matching for specific HLAs were examined in relation to occurrence of viremia. An emphasis was placed on donor-recipient matching rather than the actual frequency of specific HLA-alleles, since a successful immune response requires sharing of HLAs between a virus-infected target cell and the anti-viral effector cell. RESULTS Using multivariate statistics, low risk of BK viremia was associated with matching of HLA-A2 [hazard ratio (HR) 0.51, 95% confidence interval (CI) 0.28-0.85], HLA-B44 (HR 0.31, 95% CI 0.076-0.85) and HLA-DR15 (HR 0.35, 95% CI 0.084-0.93) (P < 0.05), whereas high risk of viremia was associated with male gender (HR 2.38, 95% CI 1.46-4.09, P < 0.001). CONCLUSIONS HLAs that associated with a lower predisposition to the development of BK viremia have been identified. Evaluation of donor-recipient mismatching for these HLAs could potentially be used to (i) fine tune virus screening strategies for BKV in individual patients and (ii) facilitate discovery of major histocompatibility complex (MHC) class I and II binding peptides that can elicit clinically meaningful BKV-specific immunity.
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Affiliation(s)
- Kosuke Masutani
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Abstract
BACKGROUND Overimmunosuppression is a widely recognized risk factor for BK virus (BKV) infection, particularly with the combination of tacrolimus, mycophenolate mofetil (MMF), and steroids. Nevertheless, the exact impact of exposure to tacrolimus and MMF is not well understood. METHODS We examined 240 kidney recipients between 2006 and 2008. BKV was monitored every 2 months in the urine or blood. A kidney biopsy was performed when viremia exceeded 10 copies/mL. RESULTS Ninety-five (40%) patients had sustained viruria, 48 (20%) sustained viremia, and 17 (7%) biopsy-proven polyomavirus-associated nephropathy. The mean time-to-occurrence was 7.6, 7.9, and 9.7 months for viruria, viremia, and polyomavirus-associated nephropathy. Risk factors associated with BKV infection in univariate analyses were retransplantation, panel-reactive antibody more than 0%, cytomegalovirus D+/R-, cold ischemia time, delayed graft function, induction with antithymocyte globulins, acute rejection before month 3 (M3), tacrolimus trough levels more than 10 ng/mL, and M3 AUC0-12 hr more than 50 hr mg/L. Multivariate analyses showed that cytomegalovirus D+/R- (adjusted hazard ratio [AHR], 2.03; P=0.05), acute rejection (AHR, 5.4; P<0.001), and mycophenolic acid AUC0-12 hr more than 50 hr mg/L (AHR, 3.6; P=0.001) were risk factors for BKV. CONCLUSIONS This study identified a link between a state of increased immunosuppression and BKV infection, especially in patients with higher MMF exposure and elevated tacrolimus trough levels at M3.
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Screening for BK viremia reduces but does not eliminate the risk of BK nephropathy: a single-center retrospective analysis. Transplantation 2013; 95:949-54. [PMID: 23545506 DOI: 10.1097/tp.0b013e31828423cd] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND This study reviewed the outcomes of a screening protocol for BK viremia to determine if early diagnosis, followed by immunosuppression minimization, would prevent progression to nephropathy and graft loss. METHODS This review included 369 renal transplant recipients tested for BK virus at serial time points after transplantation. Management included immunosuppression minimization plus cidofovir treatment for BK nephropathy. RESULTS Recipients received tacrolimus-based immunosuppression, with 8% prednisone-free and 6% who received desensitization. With a mean follow-up of 22 ± 10 months, 16% (n = 57) of recipients became BK viremia positive. The median (range) time to diagnosis was 3 (1-17) months. Because renal biopsy was performed selectively, 59% of recipients underwent biopsy, with 47% showing BK nephropathy. Seventy-four percent of recipients cleared the virus at a median (range) time of 9 (3-33) months, with four grafts lost to BK nephropathy. Cidofovir-treated recipients displayed a higher viral load at diagnosis but showed equivalent renal function at last evaluation. In multivariate analysis, recipient age, Asian ethnicity, deceased donor, and prednisone use were factors independently associated with BK viremia. Actuarial survival of BK-positive grafts was worse than that of BK-negative grafts (P<0.01, log-rank test). At 9 and 12 months, the mean estimated glomerular filtration rate of the BK-positive group was lower than that of the BK-negative cohort (P = 0.02). CONCLUSIONS Despite using a screening protocol combined with immunosuppression minimization, BK-positive recipients had a greater risk of graft loss and impaired function than recipients free of infection. Future investigations should focus on practices to prevent BK viremia.
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Elfadawy N, Flechner SM, Liu X, Schold J, Tian D, Srinivas TR, Poggio E, Fatica R, Avery R, Mossad SB. The impact of surveillance and rapid reduction in immunosuppression to control BK virus-related graft injury in kidney transplantation. Transpl Int 2013; 26:822-32. [PMID: 23763289 DOI: 10.1111/tri.12134] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2013] [Revised: 04/20/2013] [Accepted: 05/16/2013] [Indexed: 12/31/2022]
Abstract
We prospectively screened 609 consecutive kidney (538) and kidney-pancreas (71) transplant recipients for BK viremia over a 4-year interval using polymerase chain reaction viral load detection and protocol kidney biopsies. We found that BK viremia is common at our center: total cases 26.7%, cases during first year 21.3% (mean 4 months), and recipients with ≥ 10 000 copies/ml 12.3%. We found few predictive clinical or demographic risk factors for any BK viremia or viral loads ≥ 10,000 copies/ml, other than prior treatment of biopsy confirmed acute rejection and/or higher immunosuppressive blood levels of tacrolimus (P = 0.001) or mycophenolate mofetil (P = 0.007). Viral loads at diagnosis (<10 000 copies/ml) demonstrated little impact on graft function or survival. However, rising copy numbers demand early reductions in immunosuppressive drug doses of at least 30-50%. Viral loads >185 000 copies/ml at diagnosis were predictive of BK virus-associated nephropathy (BKVAN; OR: 113.25, 95% CI: 17.22-744.6, P < 0.001). Surveillance for BK viremia and rapid reduction of immunosuppression limited the incidence of BKVAN to 1.3%. The addition of leflunomide or ciprofloxacin to immunosuppressive dose reduction did not result in greater rates of viral clearance. These data support the role of early surveillance for BK viremia to limit the impact on transplant outcome, although the most effective schedule for screening awaits further investigation.
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Affiliation(s)
- Nissreen Elfadawy
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH 44195, USA
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Helanterä I, Salmela K, Kyllönen L, Räisänen-Sokolowski A, Auvinen E, Mannonen L, Koskinen P, Lautenschlager I. BK virus viremia in a well-HLA-matched kidney transplant population mainly on low-dose cyclosporine-based immunosuppression. Clin Transplant 2012; 26:E596-601. [DOI: 10.1111/ctr.12040] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/05/2012] [Indexed: 11/29/2022]
Affiliation(s)
- Ilkka Helanterä
- Division of Nephrology; Department of Medicine; Helsinki University Central Hospital; Helsinki; Finland
| | - Kaija Salmela
- Department of Transplant Surgery; Helsinki University Central Hospital; Helsinki; Finland
| | - Lauri Kyllönen
- Department of Transplant Surgery; Helsinki University Central Hospital; Helsinki; Finland
| | - Anne Räisänen-Sokolowski
- Department of Pathology; Helsinki University Central Hospital; University of Helsinki; Helsinki; Finland
| | - Eeva Auvinen
- Department of Virology; Helsinki University Central Hospital; University of Helsinki; Helsinki; Finland
| | - Laura Mannonen
- Department of Virology; Helsinki University Central Hospital; University of Helsinki; Helsinki; Finland
| | - Petri Koskinen
- Division of Nephrology; Department of Medicine; Helsinki University Central Hospital; Helsinki; Finland
| | - Irmeli Lautenschlager
- Department of Virology; Helsinki University Central Hospital; University of Helsinki; Helsinki; Finland
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Albrecht J, Dong Y, Wang J, Breeden C, Farris A, Lukacher A, Newell K. Adaptive immunity rather than viral cytopathology mediates polyomavirus-associated nephropathy in mice. Am J Transplant 2012; 12:1419-28. [PMID: 22420885 PMCID: PMC3365603 DOI: 10.1111/j.1600-6143.2012.04005.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Nephropathy associated with BK polyomavirus causes kidney allograft dysfunction and failure. Understanding the pathogenesis of polyomavirus-associated allograft nephropathy (PVAN) is hampered by the species specificity of Polyomaviridae family members. Using a mouse polyomavirus (MPyV) kidney transplant model, we investigated clinically relevant variables that may contribute to PVAN. We found that the timing and source (i.e. donor vs. recipient) of MPyV infection and the titer of the viral inoculum have significant effects on the extent of allograft injury, with acute infection of the recipient by high-titer MPyV inoculums producing the most profound PVAN. In contrast, altering the degree of MHC matching or increasing ischemia/reperfusion injury by prolonging the cold ischemic time of the allograft did not affect the severity of PVAN. Survival correlated positively with serum creatinine levels, but not with viral loads in the kidney allograft. Using splenectomized alymphoplasia mice, which are unable to mount primary adaptive immune responses, we further demonstrate that persistent high viral loads in the kidney are not sufficient to cause advanced PVAN. These findings suggest that the mechanism of PVAN in mice is not a direct consequence of viral cytopathology, but rather involves interplay between viral infection and the recipient antidonor immune response.
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Affiliation(s)
- J.A. Albrecht
- Department of Surgery, Emory Transplant Center; Emory University School of Medicine, Atlanta, GA, USA
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Y. Dong
- Department of Surgery, Emory Transplant Center; Emory University School of Medicine, Atlanta, GA, USA
| | - J. Wang
- Department of Surgery, Emory Transplant Center; Emory University School of Medicine, Atlanta, GA, USA
| | - C. Breeden
- Department of Surgery, Emory Transplant Center; Emory University School of Medicine, Atlanta, GA, USA
| | - A.B. Farris
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - A.E. Lukacher
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - K.A. Newell
- Department of Surgery, Emory Transplant Center; Emory University School of Medicine, Atlanta, GA, USA
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Chung BH, Hong YA, Kim HG, Sun IO, Choi SR, Park HS, Lee SH, Choi BS, Park CW, Choi YJ, Kim YS, Yang CW. Clinical usefulness of BK virus plasma quantitative PCR to prevent BK virus associated nephropathy. Transpl Int 2012; 25:687-695. [DOI: 10.1111/j.1432-2277.2012.01480.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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Lee MC, Lu MC, Lai NS, Liu SC, Yu HC, Lin TY, Hung SP, Huang HB, Yin WY. Renal dysfunction by BK virus infection is correlated with activated T cell level in renal transplantation. J Surg Res 2012; 180:330-6. [PMID: 22658856 DOI: 10.1016/j.jss.2012.04.064] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2012] [Revised: 04/05/2012] [Accepted: 04/26/2012] [Indexed: 12/16/2022]
Abstract
BACKGROUND BK virus (BKV) is known to be associated with nephropathy. Here, we investigated the relationships between BKV levels, T-cell activation, and kidney function in kidney transplant recipients. MATERIALS AND METHODS In renal transplant patients and controls, urine BKV levels were detected by quantitative real-time PCR, and the percentage of activated T lymphocytes in blood was determined by flow cytometry. The correlations between viral load, activated T cell percentage, and renal function were determined. RESULTS Urine BKV viral loads and the activated T cell percentage were significantly elevated in transplant recipients. Correlational analysis indicated that transplant recipients that had BKV levels of more than 10(6) copies/mL and an activated T lymphocyte percentage of less than 20% were likely to have poor renal function. CONCLUSIONS Urine BKV levels and the percentage of activated T lymphocytes can be used as clinical indices to optimize the dosage of immunosuppressive drugs.
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Affiliation(s)
- Ming-Che Lee
- Department of Surgery, Buddhist Hualien Tzu Chi General Hospital, Hualien, Taiwan; Tzu Chi University, Hualien, Taiwan
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