1
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Imlay H, Gnann JW, Rooney J, Peddi VR, Wiseman AC, Josephson MA, Kew C, Young JAH, Adey DB, Samaniego-Picota M, Whitley RJ, Limaye AP. A randomized, placebo-controlled, dose-escalation phase I/II multicenter trial of low-dose cidofovir for BK polyomavirus nephropathy. Transpl Infect Dis 2024:e14367. [PMID: 39226143 DOI: 10.1111/tid.14367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2024] [Revised: 08/13/2024] [Accepted: 08/19/2024] [Indexed: 09/05/2024]
Abstract
BACKGROUND BK polyomavirus-associated nephropathy (BKPyVAN) is an important cause of allograft dysfunction and failure in kidney transplant recipients (KTRs) and there are no proven effective treatments. Case reports and in vitro data support the potential activity of cidofovir against BK polyomavirus (BKPyV). METHODS We report the results of a phase I/II, double-blind, placebo-controlled randomized dose-escalation trial of cidofovir in KTRs with biopsy-confirmed BKPyVAN and estimated glomerular filtration rate ≥30 mL/min. Intravenous cidofovir (0.25 mg/kg/dose or 0.5 mg/kg/dose) or placebo was administered on days 0, 7, 21, and 35, with final follow-up through day 49. RESULTS The trial was prematurely discontinued due to slow accrual after 22 KTRs had completed the study. Cidofovir was safe and tolerated at the doses and duration studied. The proportion of subjects with any adverse event (AE) was similar between groups (9/14 [64%] in the combined cidofovir dose groups and 6/8 [75%] in the placebo group); 84% of AEs were mild. BKPyV DNAemia reduction by day 49 was similar between groups (>1 log10 reduction in (2/9 [22.2%] of 0.25 mg/kg group, 1/5 [20%] of 0.5 mg/kg group, and 2/8 [25%] of placebo group). CONCLUSIONS These preliminary results indicate that low-dose cidofovir was safe and tolerated but had no significant BKPyV-specific antiviral effect in KTRs with BKPyVAN.
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Affiliation(s)
- Hannah Imlay
- Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
| | - John W Gnann
- Department of Medicine, Medical University of South Carolina University Medical Center, Charleston, South Carolina, USA
| | | | - V Ram Peddi
- Department of Transplantation, California Pacific Medical Center, San Francisco, California, USA
| | - Alexander C Wiseman
- Department of Medicine, University of Colorado at Denver Health Sciences Center, Denver, Colorado, USA
| | | | - Clifton Kew
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jo-Anne H Young
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Deborah B Adey
- Department of Medicine, University of California at San Francisco, San Francisco, California, USA
| | | | - Richard J Whitley
- Department of Pediatrics, University of Alabama, Birmingham, Alabama, USA
| | - Ajit P Limaye
- Department of Internal Medicine, University of Washington, Seattle, Washington, 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; 108:1834-1866. [PMID: 38605438 PMCID: PMC11335089 DOI: 10.1097/tp.0000000000004976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 01/10/2024] [Accepted: 01/18/2024] [Indexed: 04/13/2024]
Abstract
BK polyomavirus (BKPyV) remains a significant challenge after kidney transplantation. International experts reviewed current evidence and updated recommendations according to Grading of Recommendations, Assessment, Development, and Evaluations (GRADE). Risk factors for BKPyV-DNAemia and biopsy-proven BKPyV-nephropathy include recipient older age, male sex, donor BKPyV-viruria, BKPyV-seropositive donor/-seronegative recipient, tacrolimus, acute rejection, and higher steroid exposure. To facilitate early intervention with limited allograft damage, all kidney transplant recipients should be screened monthly for plasma BKPyV-DNAemia loads until month 9, then every 3 mo until 2 y posttransplant (3 y for children). In resource-limited settings, urine cytology screening at similar time points can exclude BKPyV-nephropathy, and testing for plasma BKPyV-DNAemia when decoy cells are detectable. For patients with BKPyV-DNAemia loads persisting >1000 copies/mL, or exceeding 10 000 copies/mL (or equivalent), or with biopsy-proven BKPyV-nephropathy, immunosuppression should be reduced according to predefined steps targeting antiproliferative drugs, calcineurin inhibitors, or both. In adults without graft dysfunction, kidney allograft biopsy is not required unless the immunological risk is high. For children with persisting BKPyV-DNAemia, allograft biopsy may be considered even without graft dysfunction. Allograft biopsies should be interpreted in the context of all clinical and laboratory findings, including plasma BKPyV-DNAemia. Immunohistochemistry is preferred for diagnosing biopsy-proven BKPyV-nephropathy. Routine screening using the proposed strategies is cost-effective, improves clinical outcomes and quality of life. Kidney retransplantation subsequent to BKPyV-nephropathy is feasible in otherwise eligible recipients if BKPyV-DNAemia is undetectable; routine graft nephrectomy is not recommended. Current studies do not support the usage of leflunomide, cidofovir, quinolones, or IVIGs. Patients considered for experimental treatments (antivirals, vaccines, neutralizing antibodies, and adoptive T cells) should be enrolled in clinical trials.
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Affiliation(s)
- Camille N. Kotton
- Transplant and Immunocompromised Host Infectious Diseases Unit, Infectious Diseases Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Nassim Kamar
- Department of Nephrology and Organ Transplantation, Toulouse Rangueil University Hospital, INSERM UMR 1291, Toulouse Institute for Infectious and Inflammatory Diseases (Infinity), University Paul Sabatier, Toulouse, France
| | - David Wojciechowski
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Michael Eder
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Helmut Hopfer
- Division of Medical Genetics and Pathology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Parmjeet Randhawa
- Division of Transplantation Pathology, The Thomas E. Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA
| | - Martina Sester
- Department of Transplant and Infection Immunology, Saarland University, Homburg, Germany
| | - Patrizia Comoli
- Cell Factory and Pediatric Hematology/Oncology Unit, Department of Mother and Child Health, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Helio Tedesco Silva
- Division of Nephrology, Hospital do Rim, Fundação Oswaldo Ramos, Paulista School of Medicine, Federal University of São Paulo, Brazil
| | - Greg Knoll
- Department of Medicine (Nephrology), University of Ottawa and The Ottawa Hospital, Ottawa, ON, Canada
| | | | - Jennifer Trofe-Clark
- Renal-Electrolyte Hypertension Division, Associated Faculty of the Perelman School of Medicine, University of Pennsylvania, Pennsylvania, PA
- Transplantation Division, Associated Faculty of the Perelman School of Medicine, University of Pennsylvania, Pennsylvania, PA
| | - Lars Pape
- Pediatrics II, University Hospital of Essen, University of Duisburg-Essen, Essen, Germany
| | - David Axelrod
- Kidney, Pancreas, and Living Donor Transplant Programs at University of Iowa, Iowa City, IA
| | - Bryce Kiberd
- Division of Nephrology, Dalhousie University, Halifax, NS, Canada
| | - Germaine Wong
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia
- Centre for Kidney Research, The Children’s Hospital at Westmead, Sydney, NSW, Australia
- Centre for Transplant and Renal Research, Westmead Hospital, Sydney, NSW, Australia
| | - Hans H. Hirsch
- Division of Transplantation and Clinical Virology, Department of Biomedicine, Faculty of Medicine, University of Basel, Basel, Switzerland
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
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3
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Mineeva-Sangwo O, Van Loon E, Andrei G, Kuypers D, Naesens M, Snoeck R. Time-dependent variations in BK polyomavirus genome from kidney transplant recipients with persistent viremia. Sci Rep 2023; 13:13534. [PMID: 37598256 PMCID: PMC10439958 DOI: 10.1038/s41598-023-40714-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 08/16/2023] [Indexed: 08/21/2023] Open
Abstract
BK polyomavirus (BKPyV) is a human DNA virus that resides latent in the host's renal tissue. Reactivation occurs occasionally and in case of kidney transplantation, it can lead to polyomavirus-associated nephropathy (PVAN). Due to the lack of specific antivirals for BKPyV and despite the risk of allograft rejection, reduction of immunosuppression remains the main approach for treating PVAN. Current data suggests that mutations can accumulate over time in the major capsid protein VP1 and can lead to neutralization escape in kidney transplant recipients. Herein, we show that mutations occur throughout the entire BKPyV genome, including in VP1. Changes were identified by per-patient comparison of viral genome sequences obtained in samples from 32 kidney recipients with persistent viremia collected at different post-transplant time-points. Amino acid changes were observed in both earlier and later post-transplant samples, although some of them were only found in later samples. Changes in VP1 mainly consisted in the introduction of a new amino acid. A switch back to the conservative amino acid was also observed. This should be considered in future approaches for treating BKPyV infection in kidney transplant recipients.
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Affiliation(s)
- Olga Mineeva-Sangwo
- Laboratory of Virology and Chemotherapy, Rega Institute, Department of Microbiology, Immunology and Transplantation, KU Leuven, 3000, Leuven, Belgium
| | - Elisabet Van Loon
- Nephrology and Renal Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, 3000, Leuven, Belgium
| | - Graciela Andrei
- Laboratory of Virology and Chemotherapy, Rega Institute, Department of Microbiology, Immunology and Transplantation, KU Leuven, 3000, Leuven, Belgium.
| | - Dirk Kuypers
- Nephrology and Renal Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, 3000, Leuven, Belgium
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, 3000, Leuven, Belgium
| | - Maarten Naesens
- Nephrology and Renal Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, 3000, Leuven, Belgium
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, 3000, Leuven, Belgium
| | - Robert Snoeck
- Laboratory of Virology and Chemotherapy, Rega Institute, Department of Microbiology, Immunology and Transplantation, KU Leuven, 3000, Leuven, Belgium.
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4
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Hod-Dvorai R, Lee R, Muluhngwi P, Raijmakers M, Shetty A, Tambur AR, Ison MG. Development of de novo donor-specific antibodies in renal transplant recipients with BK viremia managed with immunosuppression reduction. Transpl Infect Dis 2023; 25:e13993. [PMID: 36413505 DOI: 10.1111/tid.13993] [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: 10/08/2022] [Accepted: 10/17/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND Reduction of immunosuppression (IS) upon detection of Polyomavirus (BK) viremia is widely used to prevent BK virus nephropathy. This retrospective case-control study assesses the frequency of de novo donor-specific antibodies (dnDSA) in renal transplant recipients with IS modulation due to BK viremia and the associated risk of antibody mediated rejection. METHODS Our cohort included recipients of kidney transplantation between 2007 and 2017 with clinical, HLA antibody, and biopsy data. BK positivity was defined as viremia >10 000 c/ml or biopsy proven BK nephropathy. A total of 190 BK cases matched our inclusion criteria, each case was matched with two controls based on gender, donor type, and transplant within 1 year (N = 396). RESULTS Despite lower number of HLA antigen mismatches (mean = 3.5 vs. 4.4, p < .001), dnDSA rates were higher in BK cases than in control group (22.1% vs. 13.9%, p = .02), with the majority detected following IS reduction for BK infection, and arising earlier posttransplant compared with no BK infection (294d vs. 434d, p < .001). Antibody mediated rejection rates were similar between cases and controls (8.9% and 8.3%, respectively), but rejection was more likely to occur earlier posttransplant in the BK cases (354d vs. 602d, p = .03). CONCLUSION Our data suggest a link between IS reduction and the generation of dnDSA and/or rejection, supporting close monitoring for DSA in patients with reduced IS due to BK infection given their increased risk to develop dnDSA.
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Affiliation(s)
- Reut Hod-Dvorai
- Department of Pathology, SUNY Upstate Medical University, Syracuse, New York, USA
| | - Ryan Lee
- Northwestern University Comprehensive Transplant Center, Chicago, Illinois, USA
| | - Penn Muluhngwi
- Northwestern University Comprehensive Transplant Center, Chicago, Illinois, USA
| | | | - Aneesha Shetty
- Northwestern University Comprehensive Transplant Center, Chicago, Illinois, USA
| | - Anat R Tambur
- Northwestern University Comprehensive Transplant Center, Chicago, Illinois, USA
| | - Michael G Ison
- Northwestern University Comprehensive Transplant Center, Chicago, Illinois, USA
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5
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BK Virus Nephropathy in Kidney Transplantation: A State-of-the-Art Review. Viruses 2022; 14:v14081616. [PMID: 35893681 PMCID: PMC9330039 DOI: 10.3390/v14081616] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 07/10/2022] [Accepted: 07/22/2022] [Indexed: 11/16/2022] Open
Abstract
BK virus maintains a latent infection that is ubiquitous in humans. It has a propensity for reactivation in the setting of a dysfunctional cellular immune response and is frequently encountered in kidney transplant recipients. Screening for the virus has been effective in preventing progression to nephropathy and graft loss. However, it can be a diagnostic and therapeutic challenge. In this in-depth state-of-the-art review, we will discuss the history of the virus, virology, epidemiology, cellular response, pathogenesis, methods of screening and diagnosis, evidence-based treatment strategies, and upcoming therapeutics, along with the issue of re-transplantation in patients.
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6
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Mineeva-Sangwo O, Martí-Carreras J, Cleenders E, Kuypers D, Maes P, Andrei G, Naesens M, Snoeck R. Polyomavirus BK Genome Comparison Shows High Genetic Diversity in Kidney Transplant Recipients Three Months after Transplantation. Viruses 2022; 14:v14071533. [PMID: 35891513 PMCID: PMC9318200 DOI: 10.3390/v14071533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 07/05/2022] [Accepted: 07/12/2022] [Indexed: 11/16/2022] Open
Abstract
BK polyomavirus (BKPyV) is a human DNA virus generally divided into twelve subgroups based on the genetic diversity of Viral Protein 1 (VP1). BKPyV can cause polyomavirus-associated nephropathy (PVAN) after kidney transplantation. Detection of BKPyV DNA in blood (viremia) is a source of concern and increase in plasma viral load is associated with a higher risk of developing PVAN. In this work, we looked for possible associations of specific BKPyV genetic features with higher plasma viral load in kidney transplant patients. We analyzed BKPyV complete genome in three-month samples from kidney recipients who developed viremia during their follow-up period. BKPyV sequences were obtained by next-generation sequencing and were de novo assembled using the new BKAnaLite pipeline. Based on the data from 72 patients, we identified 24 viral groups with unique amino acid sequences: three in the VP1 subgroup IVc2, six in Ib1, ten in Ib2, one in Ia, and four in II. In none of the groups did the mean plasma viral load reach a statistically significant difference from the overall mean observed at three months after transplantation. Further investigation is needed to better understand the link between the newly described BKPyV genetic variants and pathogenicity in kidney transplant recipients.
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Affiliation(s)
- Olga Mineeva-Sangwo
- Laboratory of Virology and Chemotherapy, Rega Institute, Department of Microbiology, Immunology and Transplantation, KU Leuven, BE3000 Leuven, Belgium;
| | - Joan Martí-Carreras
- Zoonotic Infectious Diseases Unit, Laboratory of Clinical and Epidemiological Virology, Rega Institute, Department of Microbiology, Immunology and Transplantation, KU Leuven, BE3000 Leuven, Belgium; (J.M.-C.); (P.M.)
| | - Evert Cleenders
- Nephrology and Renal Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, BE3000 Leuven, Belgium; (E.C.); (D.K.); (M.N.)
| | - Dirk Kuypers
- Nephrology and Renal Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, BE3000 Leuven, Belgium; (E.C.); (D.K.); (M.N.)
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, BE3000 Leuven, Belgium
| | - Piet Maes
- Zoonotic Infectious Diseases Unit, Laboratory of Clinical and Epidemiological Virology, Rega Institute, Department of Microbiology, Immunology and Transplantation, KU Leuven, BE3000 Leuven, Belgium; (J.M.-C.); (P.M.)
| | - Graciela Andrei
- Laboratory of Virology and Chemotherapy, Rega Institute, Department of Microbiology, Immunology and Transplantation, KU Leuven, BE3000 Leuven, Belgium;
- Correspondence: (G.A.); (R.S.)
| | - Maarten Naesens
- Nephrology and Renal Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, BE3000 Leuven, Belgium; (E.C.); (D.K.); (M.N.)
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, BE3000 Leuven, Belgium
| | - Robert Snoeck
- Laboratory of Virology and Chemotherapy, Rega Institute, Department of Microbiology, Immunology and Transplantation, KU Leuven, BE3000 Leuven, Belgium;
- Correspondence: (G.A.); (R.S.)
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7
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Omić H, Kläger JP, Herkner H, Aberle SW, Regele H, Weseslindtner L, Schrag TA, Bond G, Hohenstein K, Watschinger B, Werzowa J, Strassl R, Eder M, Kikić Ž. Clinical Relevance of Absolute BK Polyoma Viral Load Kinetics in Patients With Biopsy Proven BK Polyomavirus Associated Nephropathy. Front Med (Lausanne) 2022; 8:791087. [PMID: 35071271 PMCID: PMC8770438 DOI: 10.3389/fmed.2021.791087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 12/06/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: The absolute BK viral load is an important diagnostic surrogate for BK polyomavirus associated nephropathy (PyVAN) after renal transplant (KTX) and serial assessment of BK viremia is recommended. However, there is no data indicating which particular viral load change, i.e., absolute vs. relative viral load changes (copies/ml; percentage of the preceding viremia) is associated with worse renal graft outcomes. Materials and Methods: In this retrospective study of 91 biopsy proven PyVAN, we analyzed the interplay of exposure time, absolute and relative viral load kinetics, baseline risk, and treatment strategies as risk factors for graft loss after 2 years using a multivariable Poisson-model. Results: We compared two major treatment strategies: standardized immunosuppression (IS) reduction (n = 53) and leflunomide (n = 30). The median viral load at the index biopsy was 2.15E+04 copies/ml (interquartile range [IQR] 1.70E+03–1.77E+05) and median peak viremia was 3.6E+04 copies/ml (IQR 2.7E+03–3.3E+05). Treatment strategies and IS-levels were not related to graft loss. After correction for baseline viral load and estimated glomerular filtration rate (eGFR), absolute viral load decrease/unit remained an independent risk factor for graft loss [incidence rate ratios [IRR] = 0.77, (95% CI 0.61–0.96), p = 0.02]. Conclusion: This study provides evidence for the prognostic importance of absolute BK viremia kinetics as a dynamic parameter indicating short-term graft survival independently of other established risk factors.
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Affiliation(s)
- Haris Omić
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | | | - Harald Herkner
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Stephan W Aberle
- Center for Virology, Medical University of Vienna, Vienna, Austria
| | - Heinz Regele
- Department of Pathology, Medical University of Vienna, Vienna, Austria
| | | | - Tarek Arno Schrag
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Gregor Bond
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Katharina Hohenstein
- Department of Orthopedics and Trauma Surgery at the Medical University of Vienna in the General Hospital, Vienna, Austria
| | - Bruno Watschinger
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Johannes Werzowa
- Ludwig Boltzmann Institute of Osteology at the Hanusch Hospital of WGKK and AUVA Trauma Centre Meidling, 1st Medical Department, Hanusch Hospital, Vienna, Austria
| | - Robert Strassl
- Division of Clinical Virology, Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Michael Eder
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Željko Kikić
- Department of Urology, Medical University of Vienna, Vienna, Austria
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8
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Funahashi Y. Editorial Comment to Presence of decoy cells for 6 months on urine cytology efficiently predicts BK virus nephropathy in renal transplant recipients. Int J Urol 2021; 28:1246. [PMID: 34587652 DOI: 10.1111/iju.14699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Yasuhito Funahashi
- Department of Urology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
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9
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BK Virus-Associated Nephropathy after Renal Transplantation. Pathogens 2021; 10:pathogens10020150. [PMID: 33540802 PMCID: PMC7913099 DOI: 10.3390/pathogens10020150] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 01/29/2021] [Accepted: 01/29/2021] [Indexed: 02/06/2023] Open
Abstract
Recent advances in immunosuppressive therapy have reduced the incidence of acute rejection and improved renal transplantation outcomes. Meanwhile, nephropathy caused by BK virus has become an important cause of acute or chronic graft dysfunction. The usual progression of infection begins with BK viruria and progresses to BK viremia, leading to BK virus associated nephropathy. To detect early signs of BK virus proliferation before the development of nephropathy, several screening tests are used including urinary cytology and urinary and plasma PCR. A definitive diagnosis of BK virus associated nephropathy can be achieved only histologically, typically by detecting tubulointerstitial inflammation associated with basophilic intranuclear inclusions in tubular and/or Bowman’s epithelial cells, in addition to immunostaining with anti-Simian virus 40 large T-antigen. Several pathological classifications have been proposed to categorize the severity of the disease to allow treatment strategies to be determined and treatment success to be predicted. Since no specific drugs that directly suppress the proliferation of BKV are available, the main therapeutic approach is the reduction of immunosuppressive drugs. The diagnosis of subsequent acute rejection, the definition of remission, the protocol of resuming immunosuppression, and long-term follow-up remain controversial.
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10
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Garcia Urbán J, Gurrado K, Brea Rivas PC, Abou Elrous D, Zubimendi Machain M, Romero Gómez M, García Rodríguez J, Vicandi Plaza B, Yébenes Gregorio L, García Fernández E, Jiménez Martín C, López Oliva MO, González García E, Ledesma Sánchez G, Carreño Cornejo G, Selgas Gutiérrez R, Zarauza Santoveña A, Melgosa Hijosa M, Fernández Camblor C, Mozo Del Castillo Y, Sisinni L, Bueno Sánchez D, Pérez-Martínez A, Sánchez Zapardiel E, López Granados E, Monserrat Villatoro J, Hernández Zabala R, Borobia AM, Frías J, Ramírez E. A case-control study to assess the role of polyomavirus in transplant complications: Where do we stand? Transpl Infect Dis 2020; 22:e13432. [PMID: 32738811 DOI: 10.1111/tid.13432] [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: 05/12/2020] [Revised: 07/22/2020] [Accepted: 07/24/2020] [Indexed: 11/27/2022]
Abstract
PURPOSE The study's aim was to assess whether polyomavirus DNAemia screening was associated with different outcomes in patients with positive viremia compared with negative viremia. METHODS Case-control retrospective study of patients with polyomavirus DNAemia (viremia > 1000 copies/mL) matched 1:1 with controls. Control group consists of the patient who received a transplant immediately before or after each identified case and did have nil viremia. FINDING Ultimately, 120 cases of BK polyomavirus (BKPyV) were detected and matched with 130 controls. Of these, 54 were adult kidney transplant recipients (KTRs), 43 were pediatric KTRs, and 23 were undergoing hemato-oncologic therapy, of which 20 were undergoing hematopoietic stem cell transplantation. The odds ratio (OR) for overall risk of poorer outcomes in cases versus controls was 16.07 (95% CI: 5.55-46.54). The unfavorable outcome of switching the immunosuppressive drug (ISD) (14/40,35%) was no different from that of those treated with reduced ISD doses (31/71, 43.6%, P = .250). Acute rejection or graft-versus-host disease, previous transplant, and intensity of immunosuppression (4 ISDs plus induction or conditioning) were risk factors for BKPyV-DNAemia (OR: 13.96, 95% CI: 11.25-15.18, P < .001; OR: 6.14, 95% CI: 3.91-8.80, P < .001; OR: 5.53, 95% CI: 3.37-7.30, P < .001, respectively). CONCLUSIONS Despite viremia screening, dose reduction, and change in therapeutic protocol, patients with positive BKPyV-DNAemia present poorer outcomes and unfavorable results.
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Affiliation(s)
- Julia Garcia Urbán
- Clinical Pharmacology Department, IdiPaz, School of Medicine, La Paz-Cantoblanco-Carlos III University Hospital, Autonomous University of Madrid, Madrid, Spain
| | - Katia Gurrado
- Clinical Pharmacology Department, IdiPaz, School of Medicine, La Paz-Cantoblanco-Carlos III University Hospital, Autonomous University of Madrid, Madrid, Spain
| | - Paola C Brea Rivas
- Clinical Pharmacology Department, IdiPaz, School of Medicine, La Paz-Cantoblanco-Carlos III University Hospital, Autonomous University of Madrid, Madrid, Spain
| | - Dina Abou Elrous
- Clinical Pharmacology Department, IdiPaz, School of Medicine, La Paz-Cantoblanco-Carlos III University Hospital, Autonomous University of Madrid, Madrid, Spain
| | - Mónica Zubimendi Machain
- Clinical Pharmacology Department, IdiPaz, School of Medicine, La Paz-Cantoblanco-Carlos III University Hospital, Autonomous University of Madrid, Madrid, Spain
| | - María Romero Gómez
- Microbiology Department, IdiPaz, La Paz-Cantoblanco-Carlos III University Hospital, Madrid, Spain
| | - Julio García Rodríguez
- Microbiology Department, IdiPaz, La Paz-Cantoblanco-Carlos III University Hospital, Madrid, Spain
| | - Blanca Vicandi Plaza
- Pathological Anatomy Department, IdiPaz, La Paz-Cantoblanco-Carlos III University Hospital, Madrid, Spain
| | - Laura Yébenes Gregorio
- Pathological Anatomy Department, IdiPaz, La Paz-Cantoblanco-Carlos III University Hospital, Madrid, Spain
| | - Eugenia García Fernández
- Pathological Anatomy Department, IdiPaz, La Paz-Cantoblanco-Carlos III University Hospital, Madrid, Spain
| | - Carlos Jiménez Martín
- Nephrology Department, REDinREN, IRSIN, IdiPaz, La Paz-Cantoblanco-Carlos III University Hospital, Madrid, Spain
| | - María-Ovidia López Oliva
- Nephrology Department, REDinREN, IRSIN, IdiPaz, La Paz-Cantoblanco-Carlos III University Hospital, Madrid, Spain
| | - Elena González García
- Nephrology Department, REDinREN, IRSIN, IdiPaz, La Paz-Cantoblanco-Carlos III University Hospital, Madrid, Spain
| | - Gabriel Ledesma Sánchez
- Nephrology Department, REDinREN, IRSIN, IdiPaz, La Paz-Cantoblanco-Carlos III University Hospital, Madrid, Spain
| | - Gilda Carreño Cornejo
- Nephrology Department, REDinREN, IRSIN, IdiPaz, La Paz-Cantoblanco-Carlos III University Hospital, Madrid, Spain
| | - Rafael Selgas Gutiérrez
- Nephrology Department, REDinREN, IRSIN, IdiPaz, La Paz-Cantoblanco-Carlos III University Hospital, Madrid, Spain
| | | | - Marta Melgosa Hijosa
- Pediatric Nephrology Department, IdiPaz, La Paz-Cantoblanco-Carlos III University Hospital, Madrid, Spain
| | - Carlota Fernández Camblor
- Pediatric Nephrology Department, IdiPaz, La Paz-Cantoblanco-Carlos III University Hospital, Madrid, Spain
| | - Yasmina Mozo Del Castillo
- Pediatric Hematology Oncology Department, IdiPaz, La Paz-Cantoblanco-Carlos III University Hospital, Madrid, Spain
| | - Luisa Sisinni
- Pediatric Hematology Oncology Department, IdiPaz, La Paz-Cantoblanco-Carlos III University Hospital, Madrid, Spain
| | - David Bueno Sánchez
- Pediatric Hematology Oncology Department, IdiPaz, La Paz-Cantoblanco-Carlos III University Hospital, Madrid, Spain
| | - Antonio Pérez-Martínez
- Pediatric Hematology Oncology Department, IdiPaz, La Paz-Cantoblanco-Carlos III University Hospital, Madrid, Spain
| | - Elena Sánchez Zapardiel
- Immunology Department, IdiPaz, La Paz-Cantoblanco-Carlos III University Hospital, Madrid, Spain
| | - Eduardo López Granados
- Immunology Department, IdiPaz, La Paz-Cantoblanco-Carlos III University Hospital, Madrid, Spain
| | - Jaime Monserrat Villatoro
- Clinical Pharmacology Department, IdiPaz, School of Medicine, La Paz-Cantoblanco-Carlos III University Hospital, Autonomous University of Madrid, Madrid, Spain
| | - Rafael Hernández Zabala
- Clinical Pharmacology Department, IdiPaz, School of Medicine, La Paz-Cantoblanco-Carlos III University Hospital, Autonomous University of Madrid, Madrid, Spain
| | - Alberto M Borobia
- Clinical Pharmacology Department, IdiPaz, School of Medicine, La Paz-Cantoblanco-Carlos III University Hospital, Autonomous University of Madrid, Madrid, Spain
| | - Jesús Frías
- Clinical Pharmacology Department, IdiPaz, School of Medicine, La Paz-Cantoblanco-Carlos III University Hospital, Autonomous University of Madrid, Madrid, Spain
| | - Elena Ramírez
- Clinical Pharmacology Department, IdiPaz, School of Medicine, La Paz-Cantoblanco-Carlos III University Hospital, Autonomous University of Madrid, Madrid, Spain
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11
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Screening for BKV-DNAEMIA after renal transplantation in a resource limited setting. Diagn Microbiol Infect Dis 2020; 96:114979. [PMID: 32014346 DOI: 10.1016/j.diagmicrobio.2019.114979] [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: 08/28/2019] [Revised: 12/18/2019] [Accepted: 12/25/2019] [Indexed: 11/21/2022]
Abstract
Costs may hinder the implementation of BK polyomavirus (BKV)-DNAemia screening in resource-limited kidney transplant (KT) centers. We analyzed data from two studies to assess the performance and potential cost saving of a dual-step screening strategy based on the use of a preliminary qualitative semi-nested PCR (snPCR) assay followed by BKV-DNAemia quantification after KT. In the preliminary study, in which 130 samples from 33 KT recipients were screened for BKV-DNAemia, the estimated positive and negative predictive values of snPCR, as compared to quantitative PCR (qPCR), were 88% and 99%, respectively. In the second study, which included 84 KT recipients, BKV-DNAemia was detected by snPCR in 28/472 (5.9%) samples and confirmed by qPCR in 26 samples of 21 (25%) subjects. No graft loss occurred among KT recipients who developed BKV-DNAemia. Cost analyses suggested that this strategy might be a cost saving alternative for BKV-DNAemia screening for some resource-limited settings.
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12
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Chen XT, Wang ZY, Huang Y, Wang JY, Yang SC, Chen WF, Chen PS, Li J, Deng RH, Huang G. Combined detection of urine specific gravity and BK viruria on prediction of BK polyomavirus nephropathy in kidney transplant recipients. Chin Med J (Engl) 2020; 133:33-40. [PMID: 31923102 PMCID: PMC7028210 DOI: 10.1097/cm9.0000000000000579] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND BK polyomavirus (BKPyV)-associated nephropathy (BKPyVAN) is an important cause of dysfunction and failure of renal transplants. This study aimed to assess the diagnostic performance of morning urine specific gravity (MUSG) in diagnosing BKPyVAN in kidney transplant recipients. METHODS A total of 87 patients, including 27 with BKPyVAN, 22 with isolated BKPyV viruria, 18 with T cell-mediated rejection (TCMR), and 20 with stable graft function, were enrolled in the First Affiliated Hospital of Sun Yat-Sen University from March 2015 to February 2017. MUSG at biopsy and during a follow-up period of 24 months after biopsy was collected and analyzed. Receiver operating characteristic (ROC) curve analysis was used to determine the ability of MUSG to discriminate BKPyVAN. RESULTS At biopsy, the MUSG of BKPyVAN group (1.008 ± 0.003) was significantly lower than that of isolated BK viruria group (1.013 ± 0.004, P < 0.001), TCMR group (1.011 ± 0.003, P = 0.027), and control group (1.014 ± 0.006, P < 0.001). There was no significant difference in MUSG among the isolated BK viruria group, TCMR group, and control group (P = 0.253). In BKPyVAN group, the timing and trend of MUSG elevate were consistent with the timing and trend of the decline of viral load in urine and plasma, reaching a statistical difference at 3 months after treatment (1.012 ± 0.003, P < 0.001) compared with values at diagnosis. ROC analysis indicated that the optimal cut-off value of MUSG for diagnosis of BKPyVAN was 1.009, with an area under the ROC curve (AUC) of 0.803 (95% confidence interval [CI]: 0.721-0.937). For differentiating BKPyVAN and TCMR, the optimal MUSG cut-off value was 1.010, with an AUC of 0.811 (95% CI: 0.687-0.934). CONCLUSION Combined detection of MUSG and BKPyV viruria is valuable for predicting BKPyVAN and distinguishing BKPyVAN from TCMR in renal transplant recipients.
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Affiliation(s)
- Xu-Tao Chen
- Department of Organ Transplantation, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong 510080, China
| | - Ze-Yuan Wang
- Zhongshan School of Medicine, Sun Yat-Sen University, Guangzhou, Guangdong 510080, China
| | - Yang Huang
- Department of Organ Transplantation, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong 510080, China
| | - Jin-Yuan Wang
- Zhongshan School of Medicine, Sun Yat-Sen University, Guangzhou, Guangdong 510080, China
| | - Shi-Cong Yang
- Department of Pathology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong 510080, China
| | - Wen-Fang Chen
- Department of Pathology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong 510080, China
| | - Pei-Song Chen
- Department of Clinical Laboratory, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong 510080, China
| | - Jun Li
- Department of Organ Transplantation, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong 510080, China
| | - Rong-Hai Deng
- Department of Organ Transplantation, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong 510080, China
| | - Gang Huang
- Department of Organ Transplantation, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong 510080, China
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13
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Pierrotti LC, Urbano PRP, Nali LHDS, Romano CM, Bicalho CDS, Arnone M, Valente NS, Pannuti CS, David-Neto E, Azevedo LS. Viremia and viruria of trichodysplasia spinulosa-associated polyomavirus before the development of clinical disease in a kidney transplant recipient. Transpl Infect Dis 2019; 21:e13133. [PMID: 31233669 DOI: 10.1111/tid.13133] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Revised: 04/13/2019] [Accepted: 05/12/2019] [Indexed: 12/01/2022]
Abstract
Trichodysplasia spinulosa (TS) is a rare disease associated with immunosuppression and induced by a polyomavirus denominated Tricodisplasia Polyomavirus (TSPyV). We report a case of TS 6 months after kidney transplantation in a 65 years-old woman under immunosuppression therapy with prednisone, mycophenolate and tacrolimus. The patient developed follicular papules on the face with a thickening of the skin and alopecia of the eyebrows, leading to distortion of the face and a leonine appearance characteristic of the disease. The skin biopsy confirmed the clinical diagnosis and the presence of TSPyV DNA in the skin was detected. Staining for SV40 was positive. Immunosuppression was changed: mycophenolate was withdrawn, tacrolimus reduced and everolimus added. Intravenous cidofovir and later on leflunomide were added. Although the literature has reported clinical success with topical cidofovir, we were unable to use it because this drug is not available. There was an improvement of skin lesions and on cosmetic appearance. The patient had three rejections (one clinically diagnosed and two other biopsy proven), progressed with renal failure and graft loss. Retrospective analysis of stored urine and blood samples detected TSPyV DNA in some of those samples two months before the TS clinical development. This case highlights the TSPyV detection in blood and urine samples before the development of skin lesions.
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Affiliation(s)
- Ligia Camera Pierrotti
- Departamento de Doenças Infecciosas e Parasitárias, Faculdade de Medicina, Hospital das Clínicas, Universidade de São Paulo, São Paulo, Brazil
| | | | | | - Camila Malta Romano
- Instituto de Medicina Tropical de São Paulo, Universidade de São Paulo, São Paulo, Brazil
| | - Camila da Silva Bicalho
- Departamento de Doenças Infecciosas e Parasitárias, Faculdade de Medicina, Hospital das Clínicas, Universidade de São Paulo, São Paulo, Brazil
| | - Marcelo Arnone
- Departamento de Dermatologia, Faculdade de Medicina, Hospital das Clínicas, Universidade de São Paulo, São Paulo, Brazil
| | - Neusa Sakai Valente
- Departamento de Dermatologia, Faculdade de Medicina, Hospital das Clínicas, Universidade de São Paulo, São Paulo, Brazil
| | - Cláudio Sérgio Pannuti
- Instituto de Medicina Tropical de São Paulo, Universidade de São Paulo, São Paulo, Brazil
| | - Elias David-Neto
- Divisão de Clínica Urológica, Faculdade de Medicina, Serviço de Transplante Renal, Hospital das Clínicas, Universidade de São Paulo, São Paulo, Brazil
| | - Luiz Sérgio Azevedo
- Divisão de Clínica Urológica, Faculdade de Medicina, Serviço de Transplante Renal, Hospital das Clínicas, Universidade de São Paulo, São Paulo, Brazil
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14
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Hirsch HH, Randhawa PS. BK polyomavirus in solid organ transplantation-Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant 2019; 33:e13528. [PMID: 30859620 DOI: 10.1111/ctr.13528] [Citation(s) in RCA: 227] [Impact Index Per Article: 45.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 02/26/2019] [Indexed: 02/07/2023]
Abstract
The present AST-IDCOP guidelines update information on BK polyomavirus (BKPyV) infection, replication, and disease, which impact kidney transplantation (KT), but rarely non-kidney solid organ transplantation (SOT). As pretransplant risk factors in KT donors and recipients presently do not translate into clinically validated measures regarding organ allocation, antiviral prophylaxis, or screening, all KT recipients should be screened for BKPyV-DNAemia monthly until month 9, and then every 3 months until 2 years posttransplant. Extended screening after 2 years may be considered in pediatric KT. Stepwise immunosuppression reduction is recommended for KT patients with plasma BKPyV-DNAemia of >1000 copies/mL sustained for 3 weeks or increasing to >10 000 copies/mL reflecting probable and presumptive BKPyV-associated nephropathy, respectively. Reducing immunosuppression is also the primary intervention for biopsy-proven BKPyV-associated nephropathy. Hence, allograft biopsy is not required for treating BKPyV-DNAemic patients with baseline renal function. Despite virological rationales, proper randomized clinical trials are lacking to generally recommend treatment by switching from tacrolimus to cyclosporine-A, from mycophenolate to mTOR inhibitors or leflunomide or by the adjunct use of intravenous immunoglobulins, leflunomide, or cidofovir. Fluoroquinolones are not recommended for prophylaxis or therapy. Retransplantation after allograft loss due to BKPyV nephropathy can be successful if BKPyV-DNAemia is definitively cleared, independent of failed allograft nephrectomy.
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Affiliation(s)
- Hans H Hirsch
- Transplantation & Clinical Virology, Department of Biomedicine, University of Basel, Basel, Switzerland.,Infectious Diseases & Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - Parmjeet S Randhawa
- Division of Transplantation Pathology, Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania.,Thomas E Starzl Transplantation Institute, Pittsburgh, Pennsylvania
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