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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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Rasmussen DB, Møller DL, Hamm SR, Borges ÁH, Nielsen ACY, Kirkby NS, Sørensen SS, Nielsen SD. BKPyV DNAemia in Kidney Transplant Recipients Undergoing Regular Screening: A Single-Centre Cohort Study. Microorganisms 2023; 12:65. [PMID: 38257892 PMCID: PMC10819282 DOI: 10.3390/microorganisms12010065] [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: 11/15/2023] [Revised: 12/16/2023] [Accepted: 12/22/2023] [Indexed: 01/24/2024] Open
Abstract
Infection with BK polyomavirus (BKPyV) is a common opportunistic infection after kidney transplantation (KT) and may affect graft function. We aimed to determine the incidence, risk factors, and clinical outcomes of BKPyV DNAemia in a prospective cohort of 601 KT recipients transplanted from 2012 to 2020. BKPyV PCR on plasma was performed at days 60, 90, 180, 270, and 360 post-KT. Any BKPyV DNAemia was defined as a single BKPyV DNA of ≥1000 copies/mL. Severe BKPyV DNAemia was defined as two consecutive BKPyV DNA of ≥10,000 copies/mL. Cumulative incidences were investigated using the Aalen-Johansen estimator, and the risk factors were investigated in Cox proportional hazard models. The incidence of any BKPyV DNAemia and severe BKPyV DNAemia was 21% (18-25) and 13% (10-16) at one year post-KT, respectively. Recipient age > 50 years (aHR, 1.72; 95% CI 1.00-2.94; p = 0.049), male sex (aHR, 1.96; 95% CI 1.17-3.29; p = 0.011), living donors (aHR, 1.65; 95% CI 1.03-2.74; p = 0.045), and >3 HLA-ABDR mismatches (aHR, 1.72; 95% CI 1.01-2.94; p = 0.046) increased the risk of severe BKPyV DNAemia. Any BKPyV DNAemia was associated with an increased risk of graft function decline (aHR, 2.26; 95% CI 1.00-5.12; p = 0.049), and severe BKPyV DNAemia was associated with an increased risk of graft loss (aHR, 3.18; 95% CI 1.06-9.58; p = 0.039). These findings highlight the importance of BKPyV monitoring post-KT.
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Affiliation(s)
- Daniel B. Rasmussen
- Viro-Immunology Research Unit, Department of Infectious Diseases 8632, Rigshospitalet, University of Copenhagen, 2100 Copenhagen, Denmark; (D.B.R.); (D.L.M.); (S.R.H.)
| | - Dina L. Møller
- Viro-Immunology Research Unit, Department of Infectious Diseases 8632, Rigshospitalet, University of Copenhagen, 2100 Copenhagen, Denmark; (D.B.R.); (D.L.M.); (S.R.H.)
| | - Sebastian R. Hamm
- Viro-Immunology Research Unit, Department of Infectious Diseases 8632, Rigshospitalet, University of Copenhagen, 2100 Copenhagen, Denmark; (D.B.R.); (D.L.M.); (S.R.H.)
| | - Álvaro H. Borges
- Department of Infectious Disease Immunology, Statens Serum Institut, 2300 Copenhagen, Denmark;
- Centre of Excellence for Health, Immunity and Infections (CHIP), Rigshospitalet, University of Copenhagen, 2100 Copenhagen, Denmark
| | - Alex C. Y. Nielsen
- Department of Clinical Microbiology, Rigshospitalet, University of Copenhagen, 2100 Copenhagen, Denmark; (A.C.Y.N.); (N.S.K.)
| | - Nikolai S. Kirkby
- Department of Clinical Microbiology, Rigshospitalet, University of Copenhagen, 2100 Copenhagen, Denmark; (A.C.Y.N.); (N.S.K.)
| | - Søren S. Sørensen
- Department of Nephrology, Rigshospitalet, University of Copenhagen, 2100 Copenhagen, Denmark;
- Department of Clinical Medicine, Rigshospitalet, University of Copenhagen, 2100 Copenhagen, Denmark
| | - Susanne D. Nielsen
- Viro-Immunology Research Unit, Department of Infectious Diseases 8632, Rigshospitalet, University of Copenhagen, 2100 Copenhagen, Denmark; (D.B.R.); (D.L.M.); (S.R.H.)
- Department of Clinical Medicine, Rigshospitalet, University of Copenhagen, 2100 Copenhagen, Denmark
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Escalante EJ, Rodríguez JG, Salas JDC, Castañeda Z, Conde MLM. Clinical Course, Nosocomial, and Opportunistic Infections Among Kidney Transplant Recipients with COVID-19: A Retrospective Single Center Study. Transplant Proc 2023; 55:1829-1842. [PMID: 37302863 PMCID: PMC10201330 DOI: 10.1016/j.transproceed.2023.05.009] [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: 04/19/2023] [Accepted: 05/16/2023] [Indexed: 06/13/2023]
Abstract
BACKGROUND We report the results of an observational study, analyzing the clinical course of kidney transplant patients hospitalized for COVID-19 and comparing it with a control to determine if outcomes, nosocomial, and opportunistic infections were different between groups. METHODS An observational, retrospective, case-control, single-center study, including a group of kidney transplant adults diagnosed with COVID-19, from March 2020 to April 2022. Transplant patients hospitalized for COVID-19 comprised the cases. The control group consisted of non-transplanted adults, without immunosuppressive treatment, hospitalized for COVID-19, and matched by age, sex, and month at diagnosis of COVID-19. Study variables were collected, including demographic/clinical, epidemiologic, clinical/biological at diagnosis, evolutive, and outcome variables. RESULTS Fifty-eight kidney transplant recipients were included. Thirty required hospital admission. Ninety controls were included. Transplant recipients had a higher frequency of intensive care unit (ICU) admission, ventilatory support, and death. The relative risk for death was 2.45. When adjusted by baseline estimated glomerular filtration rate (eGFR) and comorbidity, only the risk for opportunistic infection remained high. Variables independently associated with death were dyslipidemia, eGFR at admission, MULBSTA score, and ventilatory support. Pneumonia by Klebsiella oxytoca was the most frequent nosocomial infection. Pulmonary aspergillosis was the most frequent opportunistic infection overall. Pneumocystosis and cytomegalovirus colitis were more frequent among transplant patients. The relative risk for opportunistic infection in this group was 1.88. Baseline eGFR, serum interleukin 6 level, and coinfection were independently associated with it. CONCLUSIONS Evolutive course of COVID-19 requiring hospitalization in renal transplant recipients was primarily determined by comorbidity and baseline kidney function. At equal comorbidity and renal function, there were no differences in mortality, ICU admission, nosocomial infection, and hospital stay. However, the risk for opportunistic infection remained high.
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Affiliation(s)
- Elias Jatem Escalante
- Servicio de Nefrología, Hospital Universitari Arnau de Vilanova, Lleida, Catalonia, Spain.
| | | | | | - Zaira Castañeda
- Servicio de Nefrología, Hospital Universitari Arnau de Vilanova, Lleida, Catalonia, Spain
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Characteristics, risk factors and outcome of BKV nephropathy in kidney transplant recipients: a case-control study. BMC Infect Dis 2023; 23:74. [PMID: 36747162 PMCID: PMC9903532 DOI: 10.1186/s12879-023-08043-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 01/30/2023] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Following kidney transplantation, BK virus associated nephropathy (BKVN) occurs in 1 to 10% of kidney transplant recipients (KTR) and represents a major cause of graft loss. We aim at identifying factors associated with biopsy proven BKVN among KTR. METHODS We conducted a retrospective case-control study including all KTR with a biopsy-proven diagnosis of BKVN between 2005 and 2019. Clinical characteristics and outcome were described. For each case, one control KTR without BKV infection was identified and matched by age, transplant date, and donor status. Factors associated with BKVN diagnosis were identified using exact conditional logistic regression. Comparative survival was described using Kaplan-Meier estimator. RESULTS Sixty-four cases of BKVN were identified among 1737 new kidney transplantation (3.7% prevalence). Clinical characteristics did not differ between groups, except for a higher c-PRA among cases. BKVN occurred in a median time of 11 (5-14.5) months after KT, and was associated with a significantly impaired graft function at diagnosis. Following BKVN, 61 (95%) of the patients had immunosuppression reduction, which led to BKV DNAemia resolution in 49% of cases. In multivariate analysis, factors associated with BKVN diagnosis were lymphopenia < 500/mm3 and a prednisone dose > 7.5 mg/day. Median duration of follow-up was 40 months for both groups. BKVN was associated with a significantly increased risk of graft rejection (P = 0.02) and return to dialysis (P = 0.01). CONCLUSIONS BKVN remains a severe complication in KTR and is associated with an increased risk for acute rejection and return to dialysis. Lymphopenia below 500/mm3 and corticosteroid maintenance therapy are significantly associated with biopsy-proven BKVN diagnosis.
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Torres R, Montero C, Escobar C, Reina M, Acevedo A, Yomayusa N, Gayón D, Pérez J. Early Detection Strategy of BK Polyomavirus Nephropathy in Patients undergoing Renal Transplant: A Single-Center Retrospective Study. TRANSPLANTATION REPORTS 2021. [DOI: 10.1016/j.tpr.2021.100077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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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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7
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Shatizadeh Malekshahi S, Soleimanjahi H, Dorostkar F, Salimi V, Farahmand M. Survey of BK Virus in Renal Transplant Recipients in Iran: A Systematic Review and Meta-Analysis. Intervirology 2020; 64:1-9. [PMID: 33333504 DOI: 10.1159/000512132] [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: 09/25/2019] [Accepted: 09/22/2020] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION BK virus (BKV) infection in renal transplant (RT) recipients can cause hemorrhagic cystitis, transient renal dysfunction, and BKV nephropathy (BKVN). The prevalence and significance of BKV in RT recipients remain to be clarified in the Iranian population. The purpose of this review is to summarize the overall prevalence of BKV infection in RT recipients from previously published studies in Iran. METHODS We systematically reviewed articles through a comprehensive search of the main electronic and Persian national databases up to November 2019. RESULTS The overall pooled prevalence of BKV infection among the Iranian population was 23% (95% CI; 15-33%). Comparing these studies revealed that the prevalence of BKV in plasma samples ranges from 3 to 40%, in renal biopsies 1-13%, and in urine samples 10-49%. Due to substantial heterogeneity among reported studies (I2 = 93%, p < 0.01), random-effect meta-analysis was performed. BKV infection rate was slightly higher in women than men (16%, p = 0.04 vs. 14%, p < 0.01, respectively). The majority of the studies employed real-time PCR (24%, I2 = 93, p < 0.01) and analyzed plasma samples alone or in combination with other types of specimens. BKV prevalence from 5 cities among the Iranian population showed a higher prevalence rate in Guilan. CONCLUSION Our analysis provides a preliminary estimate of the epidemiology of BKV infection in RT recipients in Iran. These results arouse a need for more epidemiological studies of BKV infection in different unanalyzed regions in Iran. Early detection of BKV in RT recipients helps timely nephropathy diagnosis and prevents graft loss.
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Affiliation(s)
| | - Hoorieh Soleimanjahi
- Department of Virology, Faculty of Medical Sciences, Tarbiat Modares University, Teheran, Iran
| | - Fariba Dorostkar
- Virology Department, School of Public Health, Tehran University of Medical Sciences, Teheran, Iran
| | - Vahid Salimi
- Virology Department, School of Public Health, Tehran University of Medical Sciences, Teheran, Iran
| | - Mohammad Farahmand
- Virology Department, School of Public Health, Tehran University of Medical Sciences, Teheran, Iran,
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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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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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Lee S, Lee KW, Kim SJ, Park JB. Clinical Characteristic and Outcomes of BK Virus Infection in Kidney Transplant Recipients Managed Using a Systematic Surveillance and Treatment Strategy. Transplant Proc 2020; 52:1749-1756. [DOI: 10.1016/j.transproceed.2020.01.158] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Accepted: 01/22/2020] [Indexed: 02/07/2023]
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Everolimus for BKV nephropathy in kidney transplant recipients: a prospective, controlled study. J Nephrol 2020; 34:531-538. [PMID: 32533451 DOI: 10.1007/s40620-020-00777-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 06/06/2020] [Indexed: 12/18/2022]
Abstract
There is no specific therapy for polyoma BK virus nephropathy (BKVN) in kidney transplant recipients, a condition associated with poor outcomes. Everolimus showed promising antiviral effects, but data from prospective studies are limited. Therefore, we converted ten consecutive kidney transplant recipients with biopsy-proven BKVN from standard exposure Calcineurin inhibitors and Mycophenolate to Everolimus and reduced exposure Calcineurin inhibitors. Ten patients not administered Everolimus, on reduced exposure Calcineurin inhibitor and halved MPA doses served as controls. All kidney transplant recipients continued steroid therapy. Each patient underwent kidney graft biopsy, BKV replication by PCR, and de novo DSA determination. During a 3-year follow-up no graft loss occurred in kidney transplant recipients on Everolimus but it was observed in 5/10 controls (P = 0.032). eGFR improved on Everolimus and worsened in controls (between group difference + 25.6 ml/min/1.73 m2, 95% CI 10.5-40.7, P = 0.002). BKV replication declined in the Everolimus group alone (from 6.4 ± 0.8 to 3.6 ± 1.6 Log 10 genomic copies, P = 0.0001), and we found a significant inverse relationship between eGFR and BKV genomic copy changes (P = 0.022). Average Calcineurin inhibitors trough levels did not differ between the two study groups during follow-up. By multivariable Cox regression analysis, Everolimus treatment resulted the only significant predictor of survival free of a combined endpoint of graft loss and 57% eGFR reduction (P = 0.02). Kidney transplant recipients on Everolimus had a higher survival free of adverse graft outcome (log-rank test, P = 0.009). In conclusion an Everolimus-based immunosuppressive protocol with minimization of Calcineurin inhibitors and antimetabolite discontinuation effectively treated BKVN in kidney transplant recipients.
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Camilleri B, Pararajasingam R, Buttigieg J, Halawa A. Immunosuppression strategies in elderly renal transplant recipients. Transplant Rev (Orlando) 2020; 34:100529. [DOI: 10.1016/j.trre.2020.100529] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 11/09/2019] [Accepted: 12/18/2019] [Indexed: 01/23/2023]
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Renal transplantation in the elderly: Outcomes and recommendations. Transplant Rev (Orlando) 2020; 34:100530. [DOI: 10.1016/j.trre.2020.100530] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 11/09/2019] [Accepted: 12/18/2019] [Indexed: 12/20/2022]
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14
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Ahlenstiel-Grunow T, Pape L. Immunosuppression, BK polyomavirus infections, and BK polyomavirus-specific T cells after pediatric kidney transplantation. Pediatr Nephrol 2020; 35:625-631. [PMID: 31858227 DOI: 10.1007/s00467-019-04408-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 10/02/2019] [Accepted: 10/29/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND After kidney transplantation, immunosuppressive therapy increases risk of BK polyomavirus-associated nephropathy (BKPyVAN). Outcomes of BKPyV viremia are various and prognostic markers are missing. The impact of different immunosuppressive regimens on BKPyV infections is currently under discussion. METHODS We analyzed immunosuppressive therapy and BKPyV-specific cellular immunity to distinguish patients at risk of BKPyVAN from those with self-limiting viremia for purposes of risk-stratified BKPyV management. In a retrospective analysis, 46 pediatric kidney recipients with BKPyV viremia were analyzed with regard to duration of BKPyV viremia and immunosuppressive therapy; in addition, in 37/46 patients, BKPyV-specific CD4 and CD8 T cells were measured. RESULTS Nine patients showed persistent BKPyV viremia and BKPyVAN, and required therapeutic intervention, while 37 patients had asymptomatic, self-limiting viremia. At onset of viremia, 78% of patients with persistent viremia and BKPyVAN were treated with tacrolimus, whereas tacrolimus therapy was significantly less frequent in patients with self-limiting viremia (14%). The majority of patients with transient, self-limiting viremia received cyclosporine A (81%) and/or mTOR inhibitors (81%). Patients with persistent BKPyV viremia and BKPyVAN showed lack of BKPyV-specific CD4 and CD8 T cells (6/6), whereas the majority of patients with self-limiting viremia (27/31) had detectable BKPyV-specific CD4 and/or CD8 T cells ≥ 0.5 cells/μl (p < 0.001). CONCLUSIONS These results indicate that tacrolimus enhances risk of BKPyVAN with need of therapeutic intervention, whereas under cyclosporine A and mTOR inhibitors, the majority of pediatric kidney recipients showed self-limiting viremia. In patients at risk of BKPyV infections, combination of cyclosporine A and mTOR inhibitor may be advantageous.
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Affiliation(s)
- Thurid Ahlenstiel-Grunow
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany.
| | - Lars Pape
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany
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15
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Alfano G, Fontana F, Guaraldi G, Cappelli G, Mussini C. Successful treatment of BK virus associated-nephropathy in a human immunodeficiency virus-positive kidney transplant recipient. Int J STD AIDS 2020; 31:387-391. [PMID: 32075537 DOI: 10.1177/0956462419900853] [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] [Indexed: 11/17/2022]
Abstract
BK virus (BKV) is an opportunistic pathogen in those with impaired immunity. Viral replication is generally asymptomatic but is able to induce cytopathic alterations in renal cells. If BKV infection is left untreated, it leads to BKV-associated nephropathy (BKVAN) and graft loss. There is scarce experience in the management of BKV infection in kidney transplant recipients living with HIV. We report the successful treatment of BKVAN in an HIV-positive kidney transplant recipient who experienced BKV replication in the immediate post-transplantation period. A change in therapy from calcineurin inhibitor to sirolimus, steroid withdrawal and a short course of an immunomodulatory agent (leflunomide) controlled BKV viremia in the absence of drug side-effects or impairment of graft function.
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Affiliation(s)
- Gaetano Alfano
- Nephrology Dialysis and Transplant Unit, University Hospital of Modena, Modena, Italy.,Surgical, Medical and Dental Department of Morphological Sciences, Section of Nephrology, University of Modena and Reggio Emilia, Modena, Italy
| | - Francesco Fontana
- Nephrology Dialysis and Transplant Unit, University Hospital of Modena, Modena, Italy
| | - Giovanni Guaraldi
- Clinic of Infectious Diseases, University of Modena and Reggio Emilia, University Hospital of Modena, Modena, Italy
| | - Gianni Cappelli
- Nephrology Dialysis and Transplant Unit, University Hospital of Modena, Modena, Italy.,Surgical, Medical and Dental Department of Morphological Sciences, Section of Nephrology, University of Modena and Reggio Emilia, Modena, Italy
| | - Cristina Mussini
- Clinic of Infectious Diseases, University of Modena and Reggio Emilia, University Hospital of Modena, Modena, Italy
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16
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Chan BD, Wong G, Jiang Q, Lee MML, Wong WY, Chen F, Wong WT, Zhu L, Wong FKM, Tai WCS. Longitudinal study of BK Polyomavirus outcomes, risk factors, and kinetics in renal transplantation patients. Microb Pathog 2020; 142:104036. [PMID: 32017958 DOI: 10.1016/j.micpath.2020.104036] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 01/31/2020] [Accepted: 01/31/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND In the immunocompromised conditions following renal transplantation, BK virus can reactivate and cause BK virus associated nephropathy (BKVN). Increased BK viral loads and extended duration of infection have been linked to development of BKVN. The aim of this study was to observe the incidence of BKV infection and BKVN, and kinetics of infection and disease in renal transplantation recipients. METHODS From 2014 to 2018, we conducted a longitudinal cohort observational study of 139 renal transplantation patients treated at a single clinic. Quantitative PCR assay was conducted to assess longitudinal BK viral loads. Analysis of patient clinical characteristics was performed to determine risk factors for BKV infection and associated disease. RESULTS Of our cohort, 29 (20.9%) patients developed high BK viremia, and 7 (5.0%) developed biopsy-confirmed BKVN. Clinical parameters associated with diabetes (FBS, HbA1c) and hyperlipidemia (TG, TC, LDL-C) were found to be correlated with development of high BK viremia or BKVN. In 3 of 4 patients receiving intravenous immunoglobulin (IVIG) treatment, BK viral loads were reduced by at least 1 log within 2-3 months of administration. Significant differences were measured in BK viral loads and kidney function between BK viremic patients and BKVN patients by 3-9 months post-transplantation. CONCLUSIONS We identified diabetes and hyperlipidemia as potential risk factors for development of high BK viremia and/or BKVN. IVIG was seen to be effective in reducing viral titers. The period 3-9 months post-transplantation was identified as important for development of BKVN from high BK viremia.
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Affiliation(s)
- Brandon Dow Chan
- Department of Applied Biology & Chemical Technology, The Hong Kong Polytechnic University, Hung Hom, Hong Kong S.A.R, China
| | - Gabriella Wong
- Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
| | - Qing Jiang
- School of Statistics, Beijing Normal University, Beijing, China
| | - Magnolia Muk-Lan Lee
- Department of Applied Biology & Chemical Technology, The Hong Kong Polytechnic University, Hung Hom, Hong Kong S.A.R, China
| | - Wing-Yan Wong
- Department of Applied Biology & Chemical Technology, The Hong Kong Polytechnic University, Hung Hom, Hong Kong S.A.R, China
| | - Feifei Chen
- School of Statistics, Renmin University of China, Beijing, China
| | - Wing-Tak Wong
- Department of Applied Biology & Chemical Technology, The Hong Kong Polytechnic University, Hung Hom, Hong Kong S.A.R, China; State Key Laboratory of Chinese Medicine and Molecular Pharmacology (Incubation), The Hong Kong Polytechnic University Shenzhen Research Institute, Shenzhen, China
| | - Lixing Zhu
- Department of Mathematics, The Hong Kong Baptist University, Kowloon Tong, Hong Kong S.A.R, China
| | | | - William Chi-Shing Tai
- Department of Applied Biology & Chemical Technology, The Hong Kong Polytechnic University, Hung Hom, Hong Kong S.A.R, China; State Key Laboratory of Chinese Medicine and Molecular Pharmacology (Incubation), The Hong Kong Polytechnic University Shenzhen Research Institute, Shenzhen, China.
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Moktefi A, Kofman T, Sakhi H, Matignon M, Grimbert P. Simultaneous cytomegalovirus glomerulitis and BK virus nephropathy leading to kidney allograft loss. Pathology 2019; 51:641-644. [PMID: 31470994 DOI: 10.1016/j.pathol.2019.05.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 04/24/2019] [Accepted: 05/10/2019] [Indexed: 11/17/2022]
Affiliation(s)
- Anissa Moktefi
- APHP (Assistance Publique-Hôpitaux de Paris), Pathology Department, Groupe Hospitalier Henri-Mondor/Albert Chenevier, Créteil, France; Université Paris-Est-Créteil, (UPEC), DHU (Département Hospitalo-Universitaire), VIC (Virus-Immunité-Cancer), IMRB (Institut Mondor de Recherche Biomédicale), Equipe 21, INSERM U 955, Créteil, France.
| | - Tomek Kofman
- AP-HP (Assistance Publique-Hôpitaux de Paris), Nephrology and Renal Transplantation Department, Institut Francilien de Recherche en Néphrologie et Transplantation (IFRNT), Groupe Hospitalier Henri-Mondor/Albert-Chenevier, Créteil, France
| | - Hamza Sakhi
- Université Paris-Est-Créteil, (UPEC), DHU (Département Hospitalo-Universitaire), VIC (Virus-Immunité-Cancer), IMRB (Institut Mondor de Recherche Biomédicale), Equipe 21, INSERM U 955, Créteil, France; AP-HP (Assistance Publique-Hôpitaux de Paris), Nephrology and Renal Transplantation Department, Institut Francilien de Recherche en Néphrologie et Transplantation (IFRNT), Groupe Hospitalier Henri-Mondor/Albert-Chenevier, Créteil, France
| | - Marie Matignon
- Université Paris-Est-Créteil, (UPEC), DHU (Département Hospitalo-Universitaire), VIC (Virus-Immunité-Cancer), IMRB (Institut Mondor de Recherche Biomédicale), Equipe 21, INSERM U 955, Créteil, France; AP-HP (Assistance Publique-Hôpitaux de Paris), Nephrology and Renal Transplantation Department, Institut Francilien de Recherche en Néphrologie et Transplantation (IFRNT), Groupe Hospitalier Henri-Mondor/Albert-Chenevier, Créteil, France
| | - Philippe Grimbert
- Université Paris-Est-Créteil, (UPEC), DHU (Département Hospitalo-Universitaire), VIC (Virus-Immunité-Cancer), IMRB (Institut Mondor de Recherche Biomédicale), Equipe 21, INSERM U 955, Créteil, France; AP-HP (Assistance Publique-Hôpitaux de Paris), Nephrology and Renal Transplantation Department, Institut Francilien de Recherche en Néphrologie et Transplantation (IFRNT), Groupe Hospitalier Henri-Mondor/Albert-Chenevier, Créteil, France
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18
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Malik O, Saleh S, Suleiman B, Ashqar B, Maibam A, Yaseen M, Elrefaei A, Hines A, Cornea V, El-Husseini A, Mei X, Gedaly R, Castellanos AL, Waid T. Prevalence, Risk Factors, Treatment, and Overall Impact of BK Viremia on Kidney Transplantation. Transplant Proc 2019; 51:1801-1809. [DOI: 10.1016/j.transproceed.2019.03.035] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 03/13/2019] [Indexed: 02/07/2023]
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19
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Zareei N, Miri HR, Karimi MH, Afshari A, Geramizadeh B, Roozbeh J, Yaghobi R. Increasing of the interferon-γ gene expression during polyomavirus BK infection in kidney transplant patients. Microb Pathog 2019; 129:187-194. [DOI: 10.1016/j.micpath.2019.02.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Revised: 01/09/2019] [Accepted: 02/11/2019] [Indexed: 01/17/2023]
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20
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Favi E, Puliatti C, Sivaprakasam R, Ferraresso M, Ambrogi F, Delbue S, Gervasi F, Salzillo I, Raison N, Cacciola R. Incidence, risk factors, and outcome of BK polyomavirus infection after kidney transplantation. World J Clin Cases 2019; 7:270-290. [PMID: 30746369 PMCID: PMC6369392 DOI: 10.12998/wjcc.v7.i3.270] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Revised: 12/08/2018] [Accepted: 12/12/2018] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Polyomavirus-associated nephropathy is a leading cause of kidney allograft failure. Therapeutic options are limited and prompt reduction of the net state of immunosuppression represents the mainstay of treatment. More recent application of aggressive screening and management protocols for BK-virus infection after renal transplantation has shown encouraging results. Nevertheless, long-term outcome for patients with BK-viremia and nephropathy remains obscure. Risk factors for BK-virus infection are also unclear.
AIM To investigate incidence, risk factors, and outcome of BK-virus infection after kidney transplantation.
METHODS This single-centre observational study with a median follow up of 57 (31-80) mo comprises 629 consecutive adult patients who underwent kidney transplantation between 2007 and 2013. Data were prospectively recorded and annually reviewed until 2016. Recipients were periodically screened for BK-virus by plasma quantitative polymerized chain reaction. Patients with BK viral load ≥ 1000 copies/mL were diagnosed BK-viremia and underwent histological assessment to rule out nephropathy. In case of BK-viremia, immunosuppression was minimized according to a prespecified protocol. The following outcomes were evaluated: patient survival, overall graft survival, graft failure considering death as a competing risk, 30-d-event-censored graft failure, response to treatment, rejection, renal function, urologic complications, opportunistic infections, new-onset diabetes after transplantation, and malignancies. We used a multivariable model to analyse risk factors for BK-viremia and nephropathy.
RESULTS BK-viremia was detected in 9.5% recipients. Initial viral load was high (≥ 10000 copies/mL) in 66.7% and low (< 10000 copies/mL) in 33.3% of these patients. Polyomavirus-associated nephropathy was diagnosed in 6.5% of the study population. Patients with high initial viral load were more likely to experience sustained viremia (95% vs 25%, P < 0.00001), nephropathy (92.5% vs 15%, P < 0.00001), and polyomavirus-related graft loss (27.5% vs 0%, P = 0.0108) than recipients with low initial viral load. Comparison between recipients with or without BK-viremia showed that the proportion of patients with Afro-Caribbean ethnicity (33.3% vs 16.5%, P = 0.0024), panel-reactive antibody ≥ 50% (30% vs 14.6%, P = 0.0047), human leukocyte antigen (HLA) mismatching > 4 (26.7% vs 13.4%, P = 0.0110), and rejection within thirty days of transplant (21.7% vs 9.5%; P = 0.0073) was higher in the viremic group. Five-year patient and overall graft survival rates for patients with or without BK-viremia were similar. However, viremic recipients showed higher 5-year crude cumulative (22.5% vs 12.2%, P = 0.0270) and 30-d-event-censored (22.5% vs 7.1%, P = 0.001) incidences of graft failure than control. In the viremic group we also observed higher proportions of recipients with 5-year estimated glomerular filtration rate < 30 mL/min than the group without viremia: 45% vs 27% (P = 0.0064). Urologic complications were comparable between the two groups. Response to treatment was complete in 55%, partial in 26.7%, and absent in 18.3% patients. The nephropathy group showed higher 5-year crude cumulative and 30-d-event-censored incidences of graft failure than control: 29.1% vs 12.1% (P = 0.008) and 29.1% vs 7.2% (P < 0.001), respectively. Our multivariable model demonstrated that Afro-Caribbean ethnicity, panel-reactive antibody > 50%, HLA mismatching > 4, and rejection were independent risk factors for BK-virus viremia whereas cytomegalovirus prophylaxis was protective.
CONCLUSION Current treatment of BK-virus infection offers sub-optimal results. Initial viremia is a valuable parameter to detect patients at increased risk of nephropathy. Panel-reactive antibody > 50% and Afro-Caribbean ethnicity are independent predictors of BK-virus infection whereas cytomegalovirus prophylaxis has a protective effect.
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Affiliation(s)
- Evaldo Favi
- Renal Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan 20122, Italy
| | - Carmelo Puliatti
- Renal Transplantation, Barts Health NHS Trust, Royal London Hospital, London E1 1BB, United Kingdom
| | - Rajesh Sivaprakasam
- Renal Transplantation, Barts Health NHS Trust, Royal London Hospital, London E1 1BB, United Kingdom
| | - Mariano Ferraresso
- Renal Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan 20122, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan 20122, Italy
| | - Federico Ambrogi
- Department of Clinical Sciences and Community Health, University of Milan, Milan 20122, Italy
| | - Serena Delbue
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan 20100, Italy
| | - Federico Gervasi
- Department of Clinical Sciences and Community Health, University of Milan, Milan 20122, Italy
| | - Ilaria Salzillo
- Renal Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan 20122, Italy
| | - Nicholas Raison
- MRC Centre for Transplantation, King’s College London, London WC2R 2LS, United Kingdom
| | - Roberto Cacciola
- Renal Transplantation, Barts Health NHS Trust, Royal London Hospital, London E1 1BB, United Kingdom
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21
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Demey B, Tinez C, François C, Helle F, Choukroun G, Duverlie G, Castelain S, Brochot E. Risk factors for BK virus viremia and nephropathy after kidney transplantation: A systematic review. J Clin Virol 2018; 109:6-12. [PMID: 30343190 DOI: 10.1016/j.jcv.2018.10.002] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Revised: 09/13/2018] [Accepted: 10/08/2018] [Indexed: 01/15/2023]
Abstract
In the last 20 years, the management of BK polyomavirus (BKPyV) reactivation in kidney transplant patients has become a true challenge for the transplant community. The only treatment option is based on the early identification of at-risk patients. The number of reported risk factors for BKPyV reactivation has increased markedly in the literature last years, although they are sometimes in an unclear or contradictory manner. Our purpose is to provide a systematic review and meta-analysis of risk factors for BKPyV viremia and nephropathy described in multivariate analyses. The PubMed database was searched for prospective or prospectively-based observational studies on risk factors for BKPyV viremia and/or nephropathy. Our qualitative assessment of risk factors was based on the odds ratios and hazard ratios calculated in multivariate regression analyses. Of the 241 publications screened, 34 were included in the qualitative analysis. In all, 144 and 19 distinct factors were analyzed for BKPyV viremia and for BKPyV nephropathy, respectively. Our evaluation highlighted eight risk factors for BKPyV viremia: a tacrolimus regimen, a deceased donor, a male recipient, a history of previous transplant, age at transplantation, ureteral stent use, delayed graft function, and acute rejection episodes increased the risk of BKV viremia to varying extents. Tacrolimus and acute rejection episodes were also associated with a higher incidence of BKPyV nephropathy. BKPyV reactivation is a serious complication after renal transplantation. With a view to combating this problem, existing data should be published in full, and new prospective international multicenter studies should be performed.
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Affiliation(s)
- Baptiste Demey
- Department of Virology, Amiens University Medical Center, Amiens, France; AGIR Research Unit, EA 4294, Jules Verne University of Picardie, Amiens, France
| | - Claire Tinez
- Department of Virology, Amiens University Medical Center, Amiens, France; AGIR Research Unit, EA 4294, Jules Verne University of Picardie, Amiens, France
| | - Catherine François
- Department of Virology, Amiens University Medical Center, Amiens, France; AGIR Research Unit, EA 4294, Jules Verne University of Picardie, Amiens, France
| | - François Helle
- AGIR Research Unit, EA 4294, Jules Verne University of Picardie, Amiens, France
| | - Gabriel Choukroun
- Department of Nephrology, Amiens University Medical Center, Amiens, France
| | - Gilles Duverlie
- Department of Virology, Amiens University Medical Center, Amiens, France; AGIR Research Unit, EA 4294, Jules Verne University of Picardie, Amiens, France
| | - Sandrine Castelain
- Department of Virology, Amiens University Medical Center, Amiens, France; AGIR Research Unit, EA 4294, Jules Verne University of Picardie, Amiens, France
| | - Etienne Brochot
- Department of Virology, Amiens University Medical Center, Amiens, France; AGIR Research Unit, EA 4294, Jules Verne University of Picardie, Amiens, France.
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22
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The Role of mTOR Inhibitors in the Management of Viral Infections: A Review of Current Literature. Transplantation 2018; 102:S50-S59. [PMID: 29369973 DOI: 10.1097/tp.0000000000001777] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Viruses are the leading cause of infections after solid organ transplant. The antiviral properties of mammalian target of rapamycin inhibitors (mTORis) have been ascribed to a variety of mechanisms and historical data have supported their use over other immunosuppressants for a myriad of viruses. Herein, we summarize the most current data to highlight the role of mTORis in the management of viral infections after solid organ transplant. The mTORis play a clear role in the management of cytomegalovirus, and have data supporting their potential use for BK virus and human herpesvirus 8-related Kaposi sarcoma. No data definitively supports mTORis for use in Epstein-Barr virus-mediated posttransplant lymphoproliferative disorder or hepatitis C virus viral replication. Although theoretically an advantageous therapy for hepatitis C virus-related liver allograft fibrosis and human immunodeficiency virus, mTORi use specifically for these indications is less attractive with modern treatments currently available. Data surrounding mTORi efficacy in preventing rejection, and their toxicity profile must be balanced with their potential antiviral effects in combination with patient-specific factors.
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23
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Korth J, Anastasiou OE, Verheyen J, Dickow J, Sertznig H, Frericks N, Bleekmann B, Kribben A, Brinkhoff A, Wilde B, Sutter K, Dittmer U, Ciesek S, Witzke O, Widera M. Impact of immune suppressive agents on the BK-Polyomavirus non coding control region. Antiviral Res 2018; 159:68-76. [PMID: 30268912 DOI: 10.1016/j.antiviral.2018.09.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Revised: 04/23/2018] [Accepted: 09/26/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND Reactivation of the BK-Polyomavirus (BKPyV) can cause a polyomavirus associated nephropathy in approx. 10% of kidney transplant recipients. In these cases, current therapy is based on the reduction of immunosuppression. Since BKPyV-transcription is driven by the Non-Coding-Control-Region (NCCR) we were interested whether NCCR-activity is affected by immunosuppressive agents. METHODS Plasma samples from 45 BKPyV-positive patients after renal transplantation were subjected to PCR-analysis. NCCR-amplicons were cloned into a plasmid that allows the quantification of early and late NCCR-activity by tdTomato and eGFP expression, respectively. HEK293T-cells were transfected with the reporter-plasmids, treated with immunosuppressive agents, and subjected to FACS-analysis. In addition, H727-cells were infected with patient derived BKPyV, treated with mTOR-inhibitors, and NCCR activity was analysed using qRT-PCR. RESULTS While tacrolimus and cyclosporine-A did not affect NCCR-promoter-activity, treatment with mTOR1-inhibitor rapamycin resulted in the reduction of early, but not late-NCCR-promoter-activity. Treatment with dual mTOR1/2 inhibitors (INK128 or pp242) led to significant inhibition of early, however, concomitantly enhanced late-promoter-activity. In BKPyV infected cells both rapamycin and INK128 reduced early expression, however, INK128 resulted in higher late-mRNA levels when compared to rapamycin treatment. CONCLUSIONS Our results demonstrate that mTOR1-inhibitors are able to reduce early-expression of wildtype and rearranged NCCRs, which might contribute to previously described inhibition of BKPyV-replication. Dual mTOR1/2-inhibitors, however, additionally might shift viral early into late-expression promoting synthesis of viral structural proteins and particle production.
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Affiliation(s)
- Johannes Korth
- Department of Nephrology, University of Duisburg-Essen, University Hospital Essen, Hufelandstr. 55, 45147, Essen, Germany; Institute for Virology, University of Duisburg-Essen, University Hospital Essen, Virchowstr. 179, 45147, Essen, Germany
| | - Olympia E Anastasiou
- Institute for Virology, University of Duisburg-Essen, University Hospital Essen, Virchowstr. 179, 45147, Essen, Germany; Department of Gastroenterology, University of Duisburg-Essen, University Hospital Essen, Hufelandstr. 55, 45147, Essen, Germany
| | - Jens Verheyen
- Institute for Virology, University of Duisburg-Essen, University Hospital Essen, Virchowstr. 179, 45147, Essen, Germany
| | - Julia Dickow
- Institute for Virology, University of Duisburg-Essen, University Hospital Essen, Virchowstr. 179, 45147, Essen, Germany
| | - Helene Sertznig
- Institute for Virology, University of Duisburg-Essen, University Hospital Essen, Virchowstr. 179, 45147, Essen, Germany
| | - Nicola Frericks
- Institute for Virology, University of Duisburg-Essen, University Hospital Essen, Virchowstr. 179, 45147, Essen, Germany
| | - Barbara Bleekmann
- Institute for Virology, University of Duisburg-Essen, University Hospital Essen, Virchowstr. 179, 45147, Essen, Germany
| | - Andreas Kribben
- Department of Nephrology, University of Duisburg-Essen, University Hospital Essen, Hufelandstr. 55, 45147, Essen, Germany
| | - Alexandra Brinkhoff
- Department of Nephrology, University of Duisburg-Essen, University Hospital Essen, Hufelandstr. 55, 45147, Essen, Germany
| | - Benjamin Wilde
- Department of Nephrology, University of Duisburg-Essen, University Hospital Essen, Hufelandstr. 55, 45147, Essen, Germany
| | - Kathrin Sutter
- Institute for Virology, University of Duisburg-Essen, University Hospital Essen, Virchowstr. 179, 45147, Essen, Germany
| | - Ulf Dittmer
- Institute for Virology, University of Duisburg-Essen, University Hospital Essen, Virchowstr. 179, 45147, Essen, Germany
| | - Sandra Ciesek
- Institute for Virology, University of Duisburg-Essen, University Hospital Essen, Virchowstr. 179, 45147, Essen, Germany
| | - Oliver Witzke
- Department of Infectious Diseases, University of Duisburg-Essen, University Hospital Essen, Hufelandstr. 55, 45147, Essen, Germany
| | - Marek Widera
- Institute for Virology, University of Duisburg-Essen, University Hospital Essen, Virchowstr. 179, 45147, Essen, Germany.
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Grellier J, Hirsch HH, Mengelle C, Esposito L, Hebral AL, Bellière J, Weissbach F, Izopet J, Del Bello A, Kamar N. Impact of donor BK polyomavirus replication on recipient infections in living donor transplantation. Transpl Infect Dis 2018; 20:e12917. [PMID: 29800505 DOI: 10.1111/tid.12917] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 04/02/2018] [Accepted: 04/16/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Multiple risk factors for BK polyomavirus (BKPyV) replication after kidney transplantation have been described. Here, we investigated the impact of living donors' urinary BKPyV shedding and recipients' BKPyV antibody status pre-transplant on BKPyV replication during the first year post-transplantation. METHODS We assessed a cohort of living kidney donors and their paired recipients (n = 121). All donors were tested before transplantation, and recipients were tested before and after transplantation for BKPyV viruria and viremia. BKPyV-specific serology was assessed in all recipients at transplantation. RESULTS Ten of 121 donors (8.3%) had urinary BKPyV shedding pre-transplant, none had viremia. Overall, 33 (27.3%) recipients developed viruria after transplantation: 7 had received a kidney from a donor with BK viruria (7/10 positive donors) and 26 had received a kidney from a donor without BK viruria (26/111 negative donors; P = .0015). Fifteen (12.4%) recipients developed BK viremia after transplantation: 3 received a kidney from a donor with viruria (3/10 positive donors, 30%) and 12 received a kidney from a donor without viruria (12/111 negative donors, 11%; P = .08). One patient developed proven nephropathy. Ninety-one percent of recipients were seropositive for BKPyV. No relationship between recipients' sero-reactivity at transplantation and post-transplant BKPyV replication was observed. Pre-transplant donor urinary shedding was an independent risk factor for post-transplant BKPyV replication. CONCLUSION Screening living kidney donors for BKPyV can identify recipients at higher risk for BKPyV replication after transplantation who may benefit from intensified post-transplant screening and treatment strategies.
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Affiliation(s)
- Jimmy Grellier
- Department of Nephrology and Organ Transplantation, CHU Rangueil, Toulouse, France
| | - Hans H Hirsch
- Transplantation and Clinical Virology, Department of Biomedicine (Haus Petersplatz), University of Basel, Basel, Switzerland
| | | | - Laure Esposito
- Department of Nephrology and Organ Transplantation, CHU Rangueil, Toulouse, France
| | - Anne Laure Hebral
- Department of Nephrology and Organ Transplantation, CHU Rangueil, Toulouse, France
| | - Julie Bellière
- Department of Nephrology and Organ Transplantation, CHU Rangueil, Toulouse, France.,Université Paul Sabatier, Toulouse, France
| | - Fabian Weissbach
- Transplantation and Clinical Virology, Department of Biomedicine (Haus Petersplatz), University of Basel, Basel, Switzerland
| | - Jacques Izopet
- Laboratory of Virology, CHU Purpan, Toulouse, France.,Université Paul Sabatier, Toulouse, France.,INSERM U1043, IFR-BMT, CHU Purpan, Toulouse, France
| | - Arnaud Del Bello
- Department of Nephrology and Organ Transplantation, CHU Rangueil, Toulouse, France
| | - Nassim Kamar
- Department of Nephrology and Organ Transplantation, CHU Rangueil, Toulouse, France.,Université Paul Sabatier, Toulouse, France.,INSERM U1043, IFR-BMT, CHU Purpan, Toulouse, France
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25
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Korth J, Widera M, Dolff S, Guberina H, Bienholz A, Brinkhoff A, Anastasiou OE, Kribben A, Dittmer U, Verheyen J, Wilde B, Witzke O. Impact of low-level BK polyomavirus viremia on intermediate-term renal allograft function. Transpl Infect Dis 2018; 20. [PMID: 29156086 DOI: 10.1111/tid.12817] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 07/10/2017] [Accepted: 08/13/2017] [Indexed: 12/29/2022]
Abstract
BACKGROUND BK polyomavirus (BKPyV)-associated nephropathy (PyVAN) is a significant cause of premature renal transplant failure. High-level BKPyV viremia is predictive for PyVAN; however, low-level BKPyV viremia does not necessarily exclude the presence of PyVAN. As data are limited regarding whether or not low-level BKPyV viremia has an effect on intermediate-term graft outcome, this study analyzes the impact of low-level BKPyV viremia on intermediate-term graft function and outcome compared with high-level viremia and non-viremic patients. METHODS All renal transplant patients received follow-up examinations at the Department of Nephrology, University Hospital Essen. Patients were screened for BKPyV viremia and stratified into three groups according to their maximum BKPyV load in serum (low-level viremia, high-level viremia, and no viremia). RESULTS In 142 of 213 (67%) patients, BKPyV was never detected in serum; 42 of 213 (20%) patients were found positive for low-level viremia (≤104 copies/mL); and 29 of 213 (13%) patients showed high-level viremia (>104 copies/mL). No significant differences regarding transplant function and graft failure were observed between patients without BKPyV viremia (delta estimated glomerular filtration rate [eGFR] +0.1 mL/min [month 1 vs last visit at month 44]) and patients with low-level BKPyV viremia (delta eGFR -1.7 mL/min). In patients with high-level viremia, transplant function was significantly restricted (delta eGFR -6.5 mL/min) compared with low-level viremia until the last visit at 44 ± 9.7 months after transplantation. Although the graft function and graft loss were worse in the high-level viremia group compared with no viremia (eGFR 37 vs 45 mL/min), the difference was not significant. CONCLUSIONS High-level viremia was associated with impaired graft function. In contrast, low-level BKPyV viremia had no significant impact on intermediate-term graft function.
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Affiliation(s)
- Johannes Korth
- Department of Nephrology, University Hospital Essen, University Duisburg-Essen, Essen, Germany.,Institute of Virology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Marek Widera
- Institute of Virology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Sebastian Dolff
- Department of Infectious Diseases, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Hana Guberina
- Department of Infectious Diseases, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Anja Bienholz
- Department of Nephrology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Alexandra Brinkhoff
- Department of Nephrology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Olympia Evdoxia Anastasiou
- Institute of Virology, University Hospital Essen, University Duisburg-Essen, Essen, Germany.,Department of Gastroenterology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Andreas Kribben
- Department of Nephrology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Ulf Dittmer
- Institute of Virology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Jens Verheyen
- Institute of Virology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Benjamin Wilde
- Department of Nephrology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Oliver Witzke
- Department of Infectious Diseases, University Hospital Essen, University Duisburg-Essen, Essen, Germany
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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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Mycophenolate Mofetil Withdrawal With Conversion to Everolimus to Treat BK Virus Infection in Kidney Transplant Recipients. Transplant Proc 2017; 49:1773-1778. [DOI: 10.1016/j.transproceed.2017.06.030] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 06/01/2017] [Indexed: 01/05/2023]
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28
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van Doesum WB, Gard L, Bemelman FJ, de Fijter JW, Homan van der Heide JJ, Niesters HG, van Son WJ, Stegeman CA, Groen H, Riezebos-Brilman A, Sanders JSF. Incidence and outcome of BK polyomavirus infection in a multicenter randomized controlled trial with renal transplant patients receiving cyclosporine-, mycophenolate sodium-, or everolimus-based low-dose immunosuppressive therapy. Transpl Infect Dis 2017; 19. [DOI: 10.1111/tid.12687] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Revised: 12/02/2016] [Accepted: 12/04/2016] [Indexed: 02/06/2023]
Affiliation(s)
- Willem B. van Doesum
- Department of Internal Medicine; Division of Nephrology; University Medical Center Groningen; University of Groningen; Groningen The Netherlands
| | - Lilli Gard
- Department of Clinical Virology; University Medical Center Groningen; University of Groningen; Groningen The Netherlands
| | - Frederike J. Bemelman
- Renal Transplant Unit; Academic Medical Center; University of Amsterdam; Amsterdam The Netherlands
| | - Johan W. de Fijter
- Renal Transplant Unit; Department of Nephrology; Leiden University Medical Center; Leiden The Netherlands
| | | | - Hubert G. Niesters
- Department of Clinical Virology; University Medical Center Groningen; University of Groningen; Groningen The Netherlands
| | - Willem J. van Son
- Department of Internal Medicine; Division of Nephrology; University Medical Center Groningen; University of Groningen; Groningen The Netherlands
| | - Coen A. Stegeman
- Department of Internal Medicine; Division of Nephrology; University Medical Center Groningen; University of Groningen; Groningen The Netherlands
| | - Henk Groen
- Department of Epidemiology; University Medical Center Groningen; University of Groningen; Groningen The Netherlands
| | - Annelies Riezebos-Brilman
- Department of Clinical Virology; University Medical Center Groningen; University of Groningen; Groningen The Netherlands
| | - Jan Stephan F. Sanders
- Department of Internal Medicine; Division of Nephrology; University Medical Center Groningen; University of Groningen; Groningen The Netherlands
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29
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Jaw J, Hill P, Goodman D. Combination of Leflunomide and Everolimus for treatment of BK virus nephropathy. Nephrology (Carlton) 2017; 22:326-329. [PMID: 28247521 DOI: 10.1111/nep.12948] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Revised: 10/09/2016] [Accepted: 10/11/2016] [Indexed: 12/21/2022]
Abstract
BK nephropathy (BKN) is a common cause of graft dysfunction following kidney transplantation. Minimization of immunosuppressive therapy remains the first line of therapy, but this may lead to rejection and graft loss. In some cases, despite lowering immunosuppression, BK infection can persist, leading to chronic damage and kidney failure. Currently, there is no specific anti-BK viral therapy. Recent in vitro experiments have demonstrated a reduction in BK viral replication when infected cells are treated with the combination of Leflunomide and Everolimus. This study aims to explore the effect of this drugs combination on viral clearance and graft function in patients with persistent disease despite reduction in immunosuppression. We treated three patients with combination Leflunomide and Everolimus. Data on medical history, biochemical parameters and viral loads were collected. Significant improvement in viral loads was observed in two cases with resolution of viremia in another (Table 1). Two recipients had preserved allograft function. The remaining graft was lost because of combination of obstruction and BKN. No adverse reactions such as bone marrow toxicity were observed. Combination of Leflunomide and Everolimus is safe and should be considered as a rescue therapy in treatment of BKN, especially in those who fail to clear this infection despite reduction of immunosuppressive therapy.
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Affiliation(s)
- Juli Jaw
- Department of Nephrology, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Prue Hill
- Department of Anatomical Pathology, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - David Goodman
- Department of Nephrology, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
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30
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Pascual J, Royuela A, Fernández AM, Herrero I, Delgado JF, Solé A, Guirado L, Serrano T, de la Torre-Cisneros J, Moreno A, Cordero E, Gallego R, Lumbreras C, Aguado JM. Role of mTOR inhibitors for the control of viral infection in solid organ transplant recipients. Transpl Infect Dis 2016; 18:819-831. [PMID: 27600985 DOI: 10.1111/tid.12601] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Revised: 05/25/2016] [Accepted: 06/24/2016] [Indexed: 12/11/2022]
Abstract
Appropriate post-transplant immunosuppressive regimens that avoid acute rejection, while reducing risk of viral reactivation, have been sought, but remain a chimera. Recent evidence suggesting potential regulatory and antiviral effects of mammalian target of rapamycin inhibitors (mTORi) is of great interest. Although the concept of an immunosuppressive drug with antiviral properties is not new, little effort has been made to put the evidence together to assess the management of immunosuppressive therapy in the presence of a viral infection. This review was developed to gather the evidence on antiviral activity of the mTORi against the viruses that most commonly reactivate in adult solid organ recipients: cytomegalovirus (CMV), polyomavirus, Epstein-Barr virus (EBV), human herpesvirus 8 (HHV8), and hepatitis C virus (HCV). A rapid review methodology and evaluation of quality and consistency of evidence based on the GRADE system was used. The existing literature was variable in nature, although indicating a potential advantage of mTORi in CMV, polyomavirus, and HHV8 infection, and a most doubtful relation with EBV and HCV infection. Several recommendations about the management of these infections are presented that can change certain current patterns of immunosuppression and help to improve the prognosis of the direct and indirect effects of viral infection in solid organ recipients.
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Affiliation(s)
- Julio Pascual
- Department of Nephrology, Hospital del Mar, Barcelona, Spain.,Institut Mar for Medical Research, Barcelona, Spain.,REDINREN Spanish Network for Renal Research RD12/0021, Barcelona, Spain
| | - Ana Royuela
- Clinical Biostatistics Unit, Puerta de Hierro University Hospital, Instituto de Investigacion Puerta de Hierro (IDIPHIM), Madrid, Spain
| | - Ana M Fernández
- REDINREN Spanish Network for Renal Research RD12/0021, Barcelona, Spain.,Department of Nephrology, Hospital Ramón y Cajal, IRICYS, Madrid, Spain
| | - Ignacio Herrero
- Liver Unit, Clínica Universidad de Navarra, CIBERehd, IdiSNA, Pamplona, Spain
| | - Juan F Delgado
- Department of Cardiology, Institute of Investigation 1+12, Universidad Complutense de Madrid, University Hospital 12 de Octubre, Madrid, Spain
| | - Amparo Solé
- Lung Transplant Unit, Hospital Universitario y Politecnico la FE, Universidad de Valencia, Valencia, Spain
| | - Lluis Guirado
- REDINREN Spanish Network for Renal Research RD12/0021, Barcelona, Spain.,Department of Nephrology, Fundació Puigvert, Barcelona, Spain
| | - Trinidad Serrano
- Liver Unit, University Hospital Lozano Blesa, Zaragoza, IIS Aragon, Spain
| | | | - Asunción Moreno
- Infectious Diseases Service, Hospital Clinic-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Elisa Cordero
- Department of Infectious Diseases, Microbiology and Preventive Medicine, Institute of Biomedicine of Seville (IBiS), Hospital Universitario Virgen del Rocío, CSIC, University of Seville, Seville, Spain
| | - Roberto Gallego
- Department of Nephrology, Hospital Universitario de Gran Canaria Dr Negrin, Gran Canaria, Spain
| | - Carlos Lumbreras
- Unit of Infectious Diseases, Institute of Investigation 1+12, Universidad Complutense de Madrid, University Hospital 12 de Octubre, Madrid, Spain
| | - José M Aguado
- Unit of Infectious Diseases, Institute of Investigation 1+12, Universidad Complutense de Madrid, University Hospital 12 de Octubre, Madrid, Spain
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31
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Vigil D, Konstantinov NK, Barry M, Harford AM, Servilla KS, Kim YH, Sun Y, Ganta K, Tzamaloukas AH. BK nephropathy in the native kidneys of patients with organ transplants: Clinical spectrum of BK infection. World J Transplant 2016; 6:472-504. [PMID: 27683628 PMCID: PMC5036119 DOI: 10.5500/wjt.v6.i3.472] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 08/25/2016] [Accepted: 09/08/2016] [Indexed: 02/05/2023] Open
Abstract
Nephropathy secondary to BK virus, a member of the Papoviridae family of viruses, has been recognized for some time as an important cause of allograft dysfunction in renal transplant recipients. In recent times, BK nephropathy (BKN) of the native kidneys has being increasingly recognized as a cause of chronic kidney disease in patients with solid organ transplants, bone marrow transplants and in patients with other clinical entities associated with immunosuppression. In such patients renal dysfunction is often attributed to other factors including nephrotoxicity of medications used to prevent rejection of the transplanted organs. Renal biopsy is required for the diagnosis of BKN. Quantitation of the BK viral load in blood and urine are surrogate diagnostic methods. The treatment of BKN is based on reduction of the immunosuppressive medications. Several compounds have shown antiviral activity, but have not consistently shown to have beneficial effects in BKN. In addition to BKN, BK viral infection can cause severe urinary bladder cystitis, ureteritis and urinary tract obstruction as well as manifestations in other organ systems including the central nervous system, the respiratory system, the gastrointestinal system and the hematopoietic system. BK viral infection has also been implicated in tumorigenesis. The spectrum of clinical manifestations from BK infection and infection from other members of the Papoviridae family is widening. Prevention and treatment of BK infection and infections from other Papovaviruses are subjects of intense research.
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32
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Safa K, Chandran S, Wojciechowski D. Pharmacologic targeting of regulatory T cells for solid organ transplantation: current and future prospects. Drugs 2016; 75:1843-52. [PMID: 26493288 DOI: 10.1007/s40265-015-0487-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The last three decades have witnessed significant advances in the development of immunosuppressive medications used in kidney transplantation leading to a remarkable gain in short-term graft function and outcomes. Despite these major breakthroughs, improvements in long-term outcomes lag behind due to a stalemate between drug-related nephrotoxicity and chronic rejection typically due to donor-specific antibodies. Regulatory T cells (Tregs) have been shown to modulate the alloimmune response and can exert suppressive activity preventing allograft rejection in kidney transplantation. Currently available immunosuppressive agents impact Tregs in the alloimmune milieu with some of these interactions being deleterious to the allograft while others may be beneficial. Variable effects are seen with common antibody induction agents such that basiliximab, an IL-2 receptor blocker, decreases Tregs while lymphocyte depleting agents such as antithymocyte globulin increase Tregs. Calcineurin inhibitors, a mainstay of maintenance immunosuppression since the mid-1980s, seem to suppress Tregs while mammalian targets of rapamycin (less commonly used in maintenance regimens) expand Tregs. The purpose of this review is to provide an overview of Treg biology in transplantation, identify in more detail the interactions between commonly used immunosuppressive agents and Tregs in kidney transplantation and lastly describe future directions in the use of Tregs themselves as therapy for tolerance induction.
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Affiliation(s)
- Kassem Safa
- Division of Nephrology and Transplant Center, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA, USA
| | - Sindhu Chandran
- Division of Nephrology, Department of Medicine, University of California San Francisco Medical center, San Francisco, CA, USA
| | - David Wojciechowski
- Division of Nephrology and Transplant Center, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA, USA.
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33
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McKenna GJ. Is It Time to Use De Novo mTOR Inhibitors Posttransplant? CURRENT TRANSPLANTATION REPORTS 2016. [DOI: 10.1007/s40472-016-0111-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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34
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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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35
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Conversion to mTOR-inhibitors with calcineurin inhibitor elimination or minimization reduces urinary polyomavirus BK load in kidney transplant recipients. J Formos Med Assoc 2016; 115:539-46. [PMID: 26994751 DOI: 10.1016/j.jfma.2016.01.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Revised: 01/05/2016] [Accepted: 01/20/2016] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND/PURPOSE Polyomavirus BK (BKV) reactivation causes allograft dysfunction in some kidney transplant recipients. The use of mammalian target of rapamycin (mTOR) inhibitor-based immunotherapy is associated with a lower incidence of polyomavirus-associated nephropathy compared with other immunosuppressants. This retrospective study assessed whether conversion to mTOR inhibitor-based immunotherapy directly reduced urinary BKV load. METHODS A total of 63 kidney recipients were divided into mTOR inhibitor-conversion (21 patients) and nonconversion (42 patients) groups. Urinary BKV loads were determined before and at least 6 months after the conversion. RESULTS The results demonstrated that urinary BKV titer was significantly reduced in the conversion group (3.94 ± 0.43 copies (log)/mL to 2.49 ± 0.19 copies (log)/mL) and remained unaltered in the nonconversion group (3.19 ± 0.20 copies (log)/mL to 2.90 ± 0.20 copies (log)/mL). In addition, the percentage of patients with reduced urinary BKV load was significantly higher in the conversion group (76.2% vs. 42.9%). The estimated glomerular filtration rate after 24 months mTOR inhibitor conversion was significantly increased compared with that in the nonconversion group. Conversion to mTOR-inhibitor-based immunotherapy was the only factor associated with an increase in estimated glomerular filtration rate. CONCLUSION This study reveals an association of conversion to mTOR-inhibitor-based immunotherapy with the reduction of urinary BKV load.
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36
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Polyomavirus large T antigen is prevalent in urothelial carcinoma post–kidney transplant. Hum Pathol 2016; 48:122-31. [DOI: 10.1016/j.humpath.2015.09.021] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Revised: 09/03/2015] [Accepted: 09/18/2015] [Indexed: 01/08/2023]
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37
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Ventura-Aguiar P, Campistol JM, Diekmann F. Safety of mTOR inhibitors in adult solid organ transplantation. Expert Opin Drug Saf 2016; 15:303-19. [PMID: 26667069 DOI: 10.1517/14740338.2016.1132698] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Mammalian target of rapamycin (mTOR) inhibitors (sirolimus and everolimus) are a class of immunosuppressive drugs approved for solid organ transplantation (SOT). By inhibiting the ubiquitous mTOR pathway, they present a peculiar safety profile. The increased incidence of serious adverse events in early studies halted the enthusiasm as a kidney sparing alternative to calcineurin inhibitors (CNI). AREAS COVERED Herein we review mTOR inhibitors safety profile for adult organ transplantation, ranging from acute side effects, such as lymphoceles, delayed wound healing, or cytopenias, to long-term ones which increase morbidity and mortality, such as cancer risk and metabolic profile. Infection, proteinuria, and cutaneous safety profiles are also addressed. EXPERT OPINION In the authors' opinion, mTOR inhibitors are a safe alternative to standard immunosuppression therapy with CNI and mycophenolate/azathioprine. Mild adverse events can be easily managed with an increased awareness and close monitoring of trough levels. Most serious side effects are dose- and organ-dependent. In kidney and heart transplantation mTOR inhibitors may be safely used as either low-dose de novo or through early-conversion. In the liver, conversion 4 weeks post-transplantation may reduce long-term chronic kidney disease secondary to calcineurin nephrotoxicity, without increasing hepatic artery/portal vein thrombosis.
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Affiliation(s)
- Pedro Ventura-Aguiar
- a Department of Nephrology and Renal Transplantation , Hospital Clínic , Villarroel, 170, E-08036 Barcelona , Spain
| | - Josep Maria Campistol
- a Department of Nephrology and Renal Transplantation , Hospital Clínic , Villarroel, 170, E-08036 Barcelona , Spain.,b August Pi i Sunyer Biomedical Research Institute (IDIBAPS) , University of Barcelona , Barcelona , Spain
| | - Fritz Diekmann
- a Department of Nephrology and Renal Transplantation , Hospital Clínic , Villarroel, 170, E-08036 Barcelona , Spain
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Jouve T, Rostaing L, Malvezzi P. Place of mTOR inhibitors in management of BKV infection after kidney transplantation. J Nephropathol 2015; 5:1-7. [PMID: 27047803 PMCID: PMC4790181 DOI: 10.15171/jnp.2016.01] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Accepted: 12/14/2015] [Indexed: 12/12/2022] Open
Abstract
CONTEXT BK virus (BKV) viremia and BKV-associated nephropathy (BKVAN) have become a serious nuisance to kidney transplant (KT) patients since the mid-nineties, when the incidence of this disease has increased significantly. EVIDENCE ACQUISITION Directory of open access journals (DOAJ), EMBASE, Google Scholar, PubMed, EBSCO, and Web of Science have been searched. RESULTS Many hypothesis have been made as to why this phenomenon has developed; it is of general opinion that a more potent immunosuppression is at the core of the problem. The use of the association of tacrolimus (TAC) with mycophenolic acid (MPA) has gained momentum in the same years as the increase in BKV viremia incidence making it seem to be the most likely culprit. m-TOR inhibitors (m-TORIs) have been shown to have antiviral properties in vitro and this fact has encouraged different transplant teams to use these agents when confronted with BKV infection (viremia or nephropathy). However, the results are mitigated. There had been conflicting results for example when converting from TAC-to sirolimus-based immunosuppression in the setting of established BKVAN. CONCLUSIONS In order to prevent BKV infection we have to minimize to some extent immunosuppression, but it is not always possible, e.g. in high immunological risk patients. Conversely, we could use m-TORIs associated with low-dose calcineurin inhibitors (CNIs). This could be actually the key to a safe immunosuppression regimen both from the immunological stand point and from the viral one.
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Affiliation(s)
- Thomas Jouve
- Clinique Universitaire de Néphrologie, CHU Grenoble, France ; Université Grenoble Alpes, Grenoble, France
| | - Lionel Rostaing
- Clinique Universitaire de Néphrologie, CHU Grenoble, France ; Université Grenoble Alpes, Grenoble, France ; Department of Nephrology and Organ Transplantation, CHU Rangueil, Université Paul Sabatier, Toulouse, France ; INSERM U563, IFR-BMT, CHU Purpan, Toulouse, France
| | - Paolo Malvezzi
- Clinique Universitaire de Néphrologie, CHU Grenoble, France
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Malvezzi P, Rostaing L. The safety of calcineurin inhibitors for kidney-transplant patients. Expert Opin Drug Saf 2015; 14:1531-46. [DOI: 10.1517/14740338.2015.1083974] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Abstract
Purpose of review Polyomavirus nephropathy (PVN) mainly caused by BK virus (BKV) remains the most common productive viral infection of the kidney. Over the past decade, clinical interest often focused on BK viremia and viruria as the diagnostic mainstays of patient management. The purpose of this review is to discuss viral nephropathy in the context of BK viremia and viruria and new strategies to optimize diagnostic accuracy and patient management. The emerging roles of polyomaviruses in oncogenesis, salivary gland disease, and post-bone marrow transplantation as well as novel Polyomavirus strains are highlighted. Recent findings Areas of investigation include proposals by the Banff working group on the classification of PVN and studies on PVN progression and resolution, including the role cellular immune responses may play during reconstitution injury. New noninvasive strategies to optimize the diagnosis of PVN, that is, the urinary ‘polyomavirus-haufen’ test and mRNA expression levels for BKV in the urine, hold great promise to accurately identify patients with viral nephropathy. Tools are now available to separate ‘presumptive’ from ‘definitive’ disease in various patient cohorts including individuals post-bone marrow transplantation. Recent observations also point to a currently underrecognized role of polyomaviruses in oncogenesis post-transplantation and salivary gland disease in patients with HIV-AIDS. Summary This review summarizes recent studies on PVN and the significance of the BKV strain in disease. Current paradigms for patient management post-(renal) transplantation are discussed in the setting of new observations. Issues that still require clarification and further validation are highlighted.
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Dekeyser M, François H, Beaudreuil S, Durrbach A. Polyomavirus-Specific Cellular Immunity: From BK-Virus-Specific Cellular Immunity to BK-Virus-Associated Nephropathy? Front Immunol 2015; 6:307. [PMID: 26136745 PMCID: PMC4468917 DOI: 10.3389/fimmu.2015.00307] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 05/29/2015] [Indexed: 12/29/2022] Open
Abstract
In renal transplantation, BK-virus (BKV)-associated nephropathy has emerged as a major complication, with a prevalence of 1-10% and graft loss in >50% of cases. BKV is a member of the polyomavirus family and rarely induces apparent clinical disease in the general population. However, replication of polyomaviruses, associated with significant organ disease, is observed in patients with acquired immunosuppression. Monitoring of specific immunity combined with viral load could be used to individually assess the risk of viral reactivation and virus control. We review the current knowledge on BKV-specific cellular immunity and, more specifically, in immunocompromised patients. In the future, immune-based therapies could allow us to treat and prevent BKV-associated nephropathy.
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Affiliation(s)
- Manon Dekeyser
- Nephrology Department, IFRNT, Bicêtre Hospital , Le Kremlin Bicêtre , France ; UMRS1197, INSERM , Villejuif , France ; University Paris South , Orsay , France
| | - Hélène François
- Nephrology Department, IFRNT, Bicêtre Hospital , Le Kremlin Bicêtre , France ; UMRS1197, INSERM , Villejuif , France ; University Paris South , Orsay , France
| | - Séverine Beaudreuil
- Nephrology Department, IFRNT, Bicêtre Hospital , Le Kremlin Bicêtre , France ; UMRS1197, INSERM , Villejuif , France ; University Paris South , Orsay , France
| | - Antoine Durrbach
- Nephrology Department, IFRNT, Bicêtre Hospital , Le Kremlin Bicêtre , France ; UMRS1197, INSERM , Villejuif , France ; University Paris South , Orsay , France
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Wu D, Zhang MC, Chen JS, Li X, Cheng DR, Xie KN, Ji SM, Liu ZH, Wen JQ. BK Virus-Associated Nephropathy with Plasma Cell-Rich Infiltrates Treated by Bortezomib-Based Regimen. EXP CLIN TRANSPLANT 2015; 13:603-6. [PMID: 25748726 DOI: 10.6002/ect.2014.0225] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BK virus infection accompanied with plasma cell-rich infiltrates is a dilemma in renal transplant recipients. One young female patient diagnosed as BK virus-associated nephropathy with plasma cell-rich infiltrates at 16 months after renal transplant was treated with bortezomib and a sequential immuno-suppressive protocol of tacrolimus combined with leflunomide. After a short period of reduction, her serum creatinine increased slowly with stable BK viruria. The patient underwent repeat biopsy. The histologic changes showed a decrease in plasma cells and CD20+ cells in the allograft, but the other mononuclear cells showed no difference from the first biopsy. The immunosuppressive protocol was converted to tacrolimus combined with enteric-coated mycophenolate sodium. Her serum creatinine decreased gradually during 6 months of follow-up. We speculate that bortezomib can be used in BK virus-associated nephropathy accompanied with plasma cell-rich infiltrates, and this effect might be mediated through a decrease of plasma cells and CD20+ cells in the allograft. The dosage and time of therapy need to be explored in the future; additional studies of large samples are needed.
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Affiliation(s)
- Di Wu
- From the National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, Jiangsu Province; and the Department of Urology, Xuancheng People's Hospital, Xuancheng, Anhui Province, China
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Aksenova M, Tsetlina V, Gutovskaya E, Mitrofanova A, Balashov D, Maschan A. BK virus nephropathy in a pediatric patient after hematopoietic stem cell transplantation. Pediatr Transplant 2015; 19:E29-32. [PMID: 25484248 DOI: 10.1111/petr.12411] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/17/2014] [Indexed: 12/17/2022]
Abstract
We report the case of a seven-yr-old Caucasian girl who presented with progressive deterioration of renal function 13 months after HSCT for myelodysplastic syndrome. BK virus nephropathy was suspected and confirmed. After reduction of immunosuppression and treatment with IVIG, leflunomide, ciprofloxacin, and cidofovir, clearance of BK virus from blood was achieved, and further progression or renal failure was prevented. We believe that BK virus nephropathy should be considered in cases of renal function deterioration in all immunocompromised patients.
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Affiliation(s)
- M Aksenova
- Nephrology Department, Research and Clinical Institute for Pediatrics, the Pirogov Russian National Research Medical University, Moscow, Russia; Department of Clinical Diagnostics, the Rogachev Federal Research Center for Pediatric Hematology, Oncology and Immunology, Moscow, Russia
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Jacobi J, Rebhan D, Heller K, Velden J, Hilgers KF, Wullich B, Eckardt KU, Amann KU. Donor acute kidney injury and short-term graft outcome in renal transplantation. Clin Transplant 2014; 28:1131-41. [PMID: 25053244 DOI: 10.1111/ctr.12425] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND With increased waiting times for kidney transplantation, marginal organs from expanded criteria donors (ECD) are increasingly offered for allocation. In addition to ECD status, donors may have suffered from acute kidney injury (AKI) prior to organ procurement. METHODS In this retrospective cohort study, we studied short-term allograft function in 517 kidney transplants performed between the years 2008-2014. Recipients of allografts from deceased organ donors were categorized as standard criteria donors (SCD) or ECD with or without AKI defined by RIFLE criteria. RESULTS Of 382 deceased donations, 174 (45.5%) were classified as ECD and 63 (16.5%) fulfilled AKI criteria. Donor creatinine on hospital admission was similar, whereas creatinine before organ procurement differed (p < 0.001). Despite these differences, serum creatinine and eGFR at discharge and after one yr showed only minor differences between kidneys with or without AKI. In multivariate linear regression analyses, donor AKI was not a predictor of one-yr allograft function. CONCLUSIONS Given the poor prognosis of dialysis patients and the increase in waiting time, kidneys from SCD and ECD donors with AKI should be allocated for transplantation. In case of ECD donors with AKI, recipients should be informed about the possibility of permanent non-function or early graft loss.
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Affiliation(s)
- Johannes Jacobi
- Department of Nephrology and Hypertension, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
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