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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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Lin F, Zhang Z, Wang C, Liu F, Chen R, Chen J, Fang X, Sun Y, Zhai Y, Xu H, Shen Q. Risk factors and outcome of BK polyomavirus infection in pediatric kidney transplantation. Pediatr Nephrol 2024:10.1007/s00467-024-06473-8. [PMID: 39088057 DOI: 10.1007/s00467-024-06473-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Revised: 06/30/2024] [Accepted: 07/18/2024] [Indexed: 08/02/2024]
Abstract
BACKGROUND BK polyomavirus (BKV) infection is a critical complication hindering graft survival after kidney transplantation. We aimed to investigate the risk factors and outcome of BKV infection in pediatric kidney transplantation. METHODS The clinical and follow-up data of pediatric kidney transplant recipients at the Children's Hospital of Fudan University from Jan 2015 to June 2023 were retrospectively analyzed. RESULTS A total of 217 patients were included in the study with mean follow-up time of 24.3 ± 19.9 months. The mean age at transplantation was 9.7 ± 4.2 years. The patient survival rate and graft survival rate were 98.2% and 96.8%, respectively. Twenty-nine patients (13.4%) developed BKV infection, which was detected at 5.8 ± 3.2 months after transplantation. Among these 29 patients with BKV infection, 8 patients (3.6%) developed BKV nephropathy (BKVN), which was diagnosed at 8.3 ± 2.9 months after transplantation, and 2 patients developed graft failure eventually. Compared with the non-BKV infection group (eGFR 76.7 ± 26.1 mL/min/1.73 m2) and BKV infection without BKVN group (eGFR 85.2 ± 23.8 mL/min/1.73 m2), BKVN group had lowest eGFR during follow-up (33.5 ± 11.0 ml/min/1.73 m2, P < 0.001). Younger age at transplant (OR 0.850, 95%CI 0.762-0.948, P = 0.005), CAKUT disease of primary etiology (OR 2.890, 95%CI 1.200-6.961, P = 0.018), and CMV negative recipient serostatus before transplantation (OR 3.698, 95%CI 1.583-8.640, P = 0.003) were independent risk factors for BKV infection. CONCLUSIONS Incidence of BKV infection is quite high within 12 months after pediatric kidney transplantation and children with BKVN have poor graft function. Younger age at transplant, CAKUT disease, and CMV negative recipient serostatus before transplantation increase the risk of BKV infection after kidney transplantation.
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Affiliation(s)
- Fang Lin
- Department of Nephrology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, 201102, China
- Shanghai Kidney Development & Pediatric Kidney Disease Research Center, Shanghai, China
| | - Zhiqing Zhang
- Department of Nephrology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, 201102, China
- Shanghai Kidney Development & Pediatric Kidney Disease Research Center, Shanghai, China
| | - Chunyan Wang
- Department of Nephrology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, 201102, China
- Shanghai Kidney Development & Pediatric Kidney Disease Research Center, Shanghai, China
| | - Feng Liu
- Department of Nephrology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, 201102, China
- Shanghai Kidney Development & Pediatric Kidney Disease Research Center, Shanghai, China
| | - Rui Chen
- Department of Nephrology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, 201102, China
- Shanghai Kidney Development & Pediatric Kidney Disease Research Center, Shanghai, China
| | - Jing Chen
- Department of Nephrology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, 201102, China
- Shanghai Kidney Development & Pediatric Kidney Disease Research Center, Shanghai, China
| | - Xiaoyan Fang
- Department of Nephrology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, 201102, China
- Shanghai Kidney Development & Pediatric Kidney Disease Research Center, Shanghai, China
| | - Yubo Sun
- Shanghai Kidney Development & Pediatric Kidney Disease Research Center, Shanghai, China
- Department of Urology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Yihui Zhai
- Department of Nephrology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, 201102, China.
- Shanghai Kidney Development & Pediatric Kidney Disease Research Center, Shanghai, China.
| | - Hong Xu
- Department of Nephrology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, 201102, China.
- Shanghai Kidney Development & Pediatric Kidney Disease Research Center, Shanghai, China.
- National Key Laboratory of Kidney Diseases, Shanghai, China.
| | - Qian Shen
- Department of Nephrology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, 201102, China.
- Shanghai Kidney Development & Pediatric Kidney Disease Research Center, Shanghai, China.
- National Key Laboratory of Kidney Diseases, Shanghai, China.
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Chiodini B, Guillaume-Gentil P, Vanhomwegen C, Hennaut E, Lolin K, Tram N, Le Moine A, Ismaili K. BK Polyomavirus in Pediatric Renal Transplantation-What We Know and What We Do Not. Biomedicines 2024; 12:1093. [PMID: 38791055 PMCID: PMC11118040 DOI: 10.3390/biomedicines12051093] [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: 04/05/2024] [Revised: 05/08/2024] [Accepted: 05/13/2024] [Indexed: 05/26/2024] Open
Abstract
BK polyomavirus (BKPyV) is still a real threat in the management of kidney transplantation. Immunosuppressive treatment disrupts the equilibrium between virus replication and immune response, and uncontrolled BKPyV replication leads to nephropathy (BKPyV nephropathy). The first evidence of BKPyV reactivation in transplant recipients is the detection of viral shedding in urine, which appears in 20% to 60% of patients, followed by BKPyV viremia in 10-20% of kidney transplant recipients. BKPyV nephropathy eventually occurs in 1-10% of this population, mainly within the first 2 years post-transplantation, causing graft loss in about half of those patients. Few data exist regarding the pediatric population and we focus on them. In this paper, we review the existing diagnostic methods and summarize the evidence on the role of BKPyV humoral and cellular immunity in modulating the clinical course of BKPyV infection and as potential predictors of the outcome. We look at the known risk factors for BKPyV nephropathy in the immunosuppressed patient. Finally, we propose a sensible clinical attitude in order to screen and manage BKPyV infection in kidney transplant children.
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Affiliation(s)
- Benedetta Chiodini
- Department of Pediatric Nephrology, Hôpital Universitaire de Bruxelles-HUDERF (HUB-HUDERF), Université Libre de Bruxelles (ULB), 1050 Brussels, Belgium
| | - Pauline Guillaume-Gentil
- Department of Pediatric Nephrology, Hôpital Universitaire de Bruxelles-HUDERF (HUB-HUDERF), Université Libre de Bruxelles (ULB), 1050 Brussels, Belgium
| | - Charlotte Vanhomwegen
- Department of Nephrology, Hôpital Universitaire de Bruxelles-Erasme (HUB-Erasme), European Plotkin Institute for Vaccinology, Université Libre de Bruxelles (ULB), 1050 Brussels, Belgium
| | - Elise Hennaut
- Department of Pediatric Nephrology, Hôpital Universitaire de Bruxelles-HUDERF (HUB-HUDERF), Université Libre de Bruxelles (ULB), 1050 Brussels, Belgium
| | - Ksenija Lolin
- Department of Pediatric Nephrology, Hôpital Universitaire de Bruxelles-HUDERF (HUB-HUDERF), Université Libre de Bruxelles (ULB), 1050 Brussels, Belgium
| | - Nathalie Tram
- Department of Pediatric Nephrology, Hôpital Universitaire de Bruxelles-HUDERF (HUB-HUDERF), Université Libre de Bruxelles (ULB), 1050 Brussels, Belgium
| | - Alain Le Moine
- Department of Nephrology, Hôpital Universitaire de Bruxelles-Erasme (HUB-Erasme), European Plotkin Institute for Vaccinology, Université Libre de Bruxelles (ULB), 1050 Brussels, Belgium
| | - Khalid Ismaili
- Department of Pediatric Nephrology, Hôpital Universitaire de Bruxelles-HUDERF (HUB-HUDERF), Université Libre de Bruxelles (ULB), 1050 Brussels, Belgium
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Aldieri A, Chandran M, Matossian D, Hariprasad A, Magella B, Lazear D, Blanchette E, Benz E, Bock M. Leflunomide as adjunct therapy for BK viremia management in pediatric kidney transplant recipients. Pediatr Transplant 2024; 28:e14724. [PMID: 38450793 DOI: 10.1111/petr.14724] [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: 10/20/2023] [Revised: 02/02/2024] [Accepted: 02/09/2024] [Indexed: 03/08/2024]
Abstract
BACKGROUND BK viremia after kidney transplantation (KT) poses significant risk for BK virus-associated nephropathy and impacts graft survival. Conventional treatment involves reduction of immunosuppression, which in turn may increase risk for rejection. To address this dilemma, use of anti-viral therapy with immunosuppressive properties such as leflunomide is an attractive option. METHODS We performed a multi-center, retrospective chart review to report tolerability and effectiveness of leflunomide use for the eradication of BK viremia and prevention of BK virus-associated nephropathy in pediatric KT recipients. RESULTS Seventy patients prescribed leflunomide were included and were followed up from initiation until 1 year following leflunomide completion. BK viremia was eradicated in 64 (91.4%) patients including 8 of 11 with nephropathy (BKVN) on initial biopsy. Reduced anti-proliferative medication (AP) dosing was not associated with increase in biopsy proven rejection (BPAR). However, complete discontinuation of AP during leflunomide therapy was associated with increase in BPAR in uni- and multivariate logistic regression, as was targeted reduction in calcineurin inhibitor (CNI) trough goals. One graft was lost to BKVN. There was no significant association found between time to BK eradication and leflunomide trough concentration, mycophenolate dose reduction, or steroid use (univariate logistic regression). Few leflunomide adverse drug reactions (ADR) were reported (most commonly: gastrointestinal, hematologic). CONCLUSION Leflunomide is a promising adjunctive treatment to immunosuppression reduction for BK virus eradication with minimal ADR. AP reduction, not discontinuation, and judicious reduction in CNI trough goals with close monitoring, is a promising strategy for treatment of BK viremia with concomitant use of leflunomide therapy.
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Affiliation(s)
| | - Mary Chandran
- Pharmacy, University of North Carolina Health, Chapel Hill, North Carolina, USA
| | - Debora Matossian
- Pediatrics, Nephrology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University, Chicago, Illinois, USA
| | - Aparna Hariprasad
- Pediatrics, Nephrology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University, Chicago, Illinois, USA
| | - Bliss Magella
- Pediatrics, Endocrinology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
| | - Danielle Lazear
- Pharmacy, Horizon Therapeutics, Thousand Oaks, California, USA
| | - Eliza Blanchette
- Pediatrics, Nephrology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Eric Benz
- Pediatrics, Nephrology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Margret Bock
- Pediatrics, Nephrology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
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Pollack S, Plonsky-Toder M, Tibi R, Yakubov R, Libinson-Zebegret I, Magen D. Protocolized polyoma BK viral load monitoring and high-dose immunoglobulin treatment in children after kidney transplant. Clin Kidney J 2024; 17:sfad293. [PMID: 38213487 PMCID: PMC10783260 DOI: 10.1093/ckj/sfad293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Indexed: 01/13/2024] Open
Abstract
Background BKPyV virus nephropathy (BKPyVAN) is diagnosed in 5%-16% of pediatric renal transplant recipients (PRTR) and preceded by BKPyV-viruria and DNAemia. Despite the risk of irreversible transplant damage associated with BKPyVAN, evidence-based consensus guidelines for BKPyVAN prevention are still lacking. In this retrospective study, we examined the safety and efficacy of high-dose intravenous immunoglobulin (HD-IVIG) therapy for prevention of BKPyVAN in PRTR with significant BKPyV-viruria/DNAemia. Methods Between January 2013 and December 2022, all PRTR under our care underwent routine urine and blood testing for BKPyV viral load, using specific polymerase chain reaction (PCR). BKPyV DNAemia, with <103 copies/mL, with BKPyV viruria <107 copies/mL, with no evidence of BKPyVAN, were managed with 50% dose reduction of mycophenolate mofetil (MMF). Patients showing no decline in BKPyV viral load within two months of MMF dose reduction were managed with HD-IVIG (2 g/kg). Results Seventy patients were recruited during a ten-year period and 31/70 patients (44%) demonstrated significant post-transplantation BKPyV-viruria/DNAemia, while 13/31 (42%) patients were unresponsive to MMF dose reduction, and were administered HD-IVIG. Of these, 12/13 (92%) patients achieved BKPyV viral clearance within six months from completion of HD-IVIG therapy and 1/13 patient (8%) was unresponsive to HD-IVIG therapy, showing increased BKPyV viral load. There were no major adverse events associated with HD-IVIG, and none of our patients developed BKPyVAN during the study period. Conclusions Prophylactic HD-IVIG therapy in PRTR with significant BKPyV-viruria/DNAemia unresponsive to MMF dose reduction is safe and might be effective in preventing BKPyVAN. Our findings remain to be established by large-scale prospective studies.
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Affiliation(s)
- Shirley Pollack
- Pediatric Nephrology Institute, Ruth Children's Hospital, Rambam Health Care Campus, Technion Faculty of Medicine, Haifa, Israel
| | - Moran Plonsky-Toder
- Pediatric Nephrology Institute, Ruth Children's Hospital, Rambam Health Care Campus, Technion Faculty of Medicine, Haifa, Israel
| | - Rami Tibi
- Pediatric Nephrology Institute, Ruth Children's Hospital, Rambam Health Care Campus, Technion Faculty of Medicine, Haifa, Israel
| | - Renata Yakubov
- Pediatric Nephrology Institute, Ruth Children's Hospital, Rambam Health Care Campus, Technion Faculty of Medicine, Haifa, Israel
| | - Irina Libinson-Zebegret
- Pediatric Nephrology Institute, Ruth Children's Hospital, Rambam Health Care Campus, Technion Faculty of Medicine, Haifa, Israel
| | - Daniella Magen
- Pediatric Nephrology Institute, Ruth Children's Hospital, Rambam Health Care Campus, Technion Faculty of Medicine, Haifa, Israel
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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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