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Tabachnikov O, Skorecki K, Kruzel-Davila E. APOL1 nephropathy - a population genetics success story. Curr Opin Nephrol Hypertens 2024; 33:447-455. [PMID: 38415700 PMCID: PMC11139250 DOI: 10.1097/mnh.0000000000000977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/29/2024]
Abstract
PURPOSE OF REVIEW More than a decade ago, apolipoprotein L1 ( APOL1 ) risk alleles designated G1 and G2, were discovered to be causally associated with markedly increased risk for progressive kidney disease in individuals of recent African ancestry. Gratifying progress has been made during the intervening years, extending to the development and clinical testing of genomically precise small molecule therapy accompanied by emergence of RNA medicine platforms and clinical testing within just over a decade. RECENT FINDINGS Given the plethora of excellent prior review articles, we will focus on new findings regarding unresolved questions relating mechanism of cell injury with mode of inheritance, regulation and modulation of APOL1 activity, modifiers and triggers for APOL1 kidney risk penetrance, the pleiotropic spectrum of APOL1 related disease beyond the kidney - all within the context of relevance to therapeutic advances. SUMMARY Notwithstanding remaining controversies and uncertainties, promising genomically precise therapies targeted at APOL1 mRNA using antisense oligonucleotides (ASO), inhibitors of APOL1 expression, and small molecules that specifically bind and inhibit APOL1 cation flux are emerging, many already at the clinical trial stage. These therapies hold great promise for mitigating APOL1 kidney injury and possibly other systemic phenotypes as well. A challenge will be to develop guidelines for appropriate use in susceptible individuals who will derive the greatest benefit.
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Affiliation(s)
- Orly Tabachnikov
- Department of Nephrology, Rambam Healthcare Campus, Haifa, Israel
| | - Karl Skorecki
- Department of Nephrology, Rambam Healthcare Campus, Haifa, Israel
- Departments of Genetics and Developmental Biology and Rappaport Faculty of Medicine and Research Institute, Technion—Israel Institute of Technology, Haifa, Israel
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
| | - Etty Kruzel-Davila
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
- Department of Nephrology, Galilee Medical Center, Nahariya, Israel
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Lv Y, Liu X. Hemorrhagic cystitis induced by JC polyomavirus infection following COVID-19: a case report. BMC Urol 2024; 24:87. [PMID: 38627797 PMCID: PMC11020351 DOI: 10.1186/s12894-024-01464-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 03/24/2024] [Indexed: 04/19/2024] Open
Abstract
JC polyomavirus (JCPyV) is a human polyomavirus that can establish lifelong persistent infection in the majority of adults. It is typically asymptomatic in immunocompetent individuals. However, there is a risk of developing progressive multifocal leukoencephalopathy (PML) in immunocompromised or immunosuppressed patients. Though JCPyV commonly resides in the kidney-urinary tract, its involvement in urinary system diseases is extremely rare. Here, we reported a case of a 60-year-old male patient with coronavirus disease 2019 (COVID-19) infection who developed hemorrhagic cystitis after receiving treatment with nirmatrelvir 300 mg/ritonavir 100 mg quaque die (QD). Subsequent metagenomic next-generation sequencing (mNGS) confirmed the infection to be caused by JCPyV type 2. Then, human immunoglobulin (PH4) for intravenous injection at a dose of 25 g QD was administered to the patient. Three days later, the hematuria resolved. This case illustrates that in the setting of compromised host immune function, JCPyV is not limited to causing central nervous system diseases but can also exhibit pathogenicity in the urinary system. Moreover, mNGS technology facilitates rapid diagnosis of infectious etiology by clinical practitioners, contributing to precise treatment for patients.
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Affiliation(s)
- Yuanjie Lv
- Department of Infection, Hospital of Traditional Chinese Medicine, Xinchang County, No.188 Shijiu Feng Road, Qixing Street, Shaoxing, 312500, China.
| | - Xiaoping Liu
- Department of Infection, Hospital of Traditional Chinese Medicine, Xinchang County, No.188 Shijiu Feng Road, Qixing Street, Shaoxing, 312500, China
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Querido S, Ormonde C, Adragão T, Weigert A. JCV viruria associates with suboptimal recovery of kidney function three years after living kidney donation. J Bras Nefrol 2022; 44:368-375. [PMID: 35138324 PMCID: PMC9518630 DOI: 10.1590/2175-8239-jbn-2021-0148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 11/10/2021] [Indexed: 11/22/2022] Open
Abstract
ABSTRACT Introduction: Few studies have investigated pre-donation factors that could affect renal recovery after living kidney donation (LKD). We retrospectively investigated the role of John Cunningham virus (JCV) infection and other pre-donation factors on the magnitude of kidney function decline after LKD. Methods: Urine JCV viral loads, glomerular filtration rate, and blood pressure were evaluated in 60 consecutive LK donors before donation. Suboptimal compensatory hypertrophy was defined as an eGFR <60% of the pre-donation eGFR. Results: LKD (40% JCV infected) were followed for 3.2±1.6 years. No association was found between age, gender, and baseline hypertension with 1st, 2nd, 3rd, and 4th years post-donation eGFR <60% of the pre-donation eGFR. Mean eGFR recovery at the 3rd year after donation was lower in JCV infected donors vs non-infected donors (61.8% vs 71.0%, p=0.006). Conclusion: We hypothesized that JCV could shift glomeruli into a hyperfiltration state before nephrectomy, modulating the magnitude of compensatory hypertrophy after donation. Conversely, JCV might curtail the ability of the remaining kidney to promote hyperfiltration. Longer follow up is needed to determine whether JCV viruria ultimately leads to lower eGFR over time or if it is a protective factor for the remaining kidney.
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Outcomes of Living Kidney Donor Candidates and Living Kidney Recipient Candidates with JC Polyomavirus and BK Polyomavirus Viruria. Int J Nephrol 2021; 2021:8010144. [PMID: 34457361 PMCID: PMC8397544 DOI: 10.1155/2021/8010144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 08/13/2021] [Indexed: 12/26/2022] Open
Abstract
Introduction Recent data have emerged about a protective association between JCV viruria and chronic kidney disease (CKD). Material and Methods. Single-center retrospective cohort study; 230 living kidney donors (LKD) candidates and 59 potential living kidney receptors (LKR) were enrolled. Plasma and urinary JCV and BKV viral loads were measured in all LKD candidates and in nonanuric LKR candidates. Twenty-six living kidney transplant surgeries were performed. LKR were followed in order to evaluate BKV and JCV viremia and urinary viral shedding after KT. Results In LKD candidates, JCV viruria was negatively associated with proteinuria of >200 mg/24 hours (JC viruric LKD: 12.5% vs JCV nonviruric LKD: 26.7%, p=0.021, OR:0.393; 95% CI: 0.181–0.854). In a multivariate analysis, LKD candidates with JCV viruria had a lower risk of proteinuria of >200 mg/24 hours (p=0.009, OR: 0.342, 95% CI: 0.153–0.764), in a model adjusted for age, gender, presence of hypertension, and eGFR <80 mL/min. Prevalence of JCV viruria was higher in LKD candidates when compared with LKR candidates (40.0% vs 1.7%, p < 0.001). Among the 26 LKR, 14 (53.8%) KT patients evolved with JCV viruria; 71.4% received a graft from a JCV viruric donor. Conclusion Our data corroborate the recent findings of an eventual protective association between JCV viruria and kidney disease, and we extrapolated this concept to a South European population.
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Kruzel-Davila E, Sankofi BM, Kubi Amos-Abanyie E, Ghansah A, Nyarko A, Agyemang S, Awandare GA, Szwarcwort-Cohen M, Reiner-Benaim A, Hijazi B, Ulasi I, Raji YR, Boima V, Osafo C, May Adabayeri V, Matekole M, Olanrewaju TO, Ajayi S, Mamven M, Antwi S, Ademola AD, Plange-Rhule J, Arogundade F, Akyaw PA, Winkler CA, Salako BL, Ojo A, Skorecki K, Adu D. HIV Viremia Is Associated With APOL1 Variants and Reduced JC-Viruria. Front Med (Lausanne) 2021; 8:718300. [PMID: 34513880 PMCID: PMC8429812 DOI: 10.3389/fmed.2021.718300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 08/05/2021] [Indexed: 11/23/2022] Open
Abstract
Variants in the Apolipoprotein L1 (APOL1) gene (G1-rs60910145, rs73885319, G2-rs71785313) are common in Africans and in individuals of recent African ancestry and are associated with an increased risk of non-diabetic chronic kidney disease (CKD) and in particular of HIV associated nephropathy (HIVAN). In light of the significantly increased risk of HIVAN in carriers of two APOL1 risk alleles, a role in HIV infectivity has been postulated in the mechanism of APOL1 associated kidney disease. Herein, we aim to explore the association between HIV viremia and APOL1 genotype. In addition, we investigated interaction between BK and JC viruria, CKD and HIV viremia. A total of 199 persons living with HIV/AIDS (comprising 82 CKD cases and 117 controls) from among the participants in the ongoing Human Heredity and Health in Africa (H3Africa) Kidney Disease Research Network case control study have been recruited. The two APOL1 renal risk alleles (RRA) genotypes were associated with a higher risk of CKD (OR 12.6, 95% CI 3.89-40.8, p < 0.0001). Even a single APOL1 RRA was associated with CKD risk (OR 4.42, 95% CI 1.49-13.15, p = 0.007). The 2 APOL1 RRA genotypes were associated with an increased probability of having HIV viremia (OR 2.37 95% CI 1.0-5.63, p = 0.05). HIV viremia was associated with increased CKD risk (OR 7.45, 95% CI 1.66-33.35, P = 0.009) and with a significant reduction of JC virus urine shedding (OR 0.35, 95% CI 0.12-0.98, p = 0.046). In contrast to prior studies, JC viruria was not associated with CKD but was restricted in patients with HIV viremia, regardless of CKD status. These findings suggest a role of APOL1 variants in HIV infectivity and emphasize that JC viruria can serve as biomarker for innate immune system activation.
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Affiliation(s)
- Etty Kruzel-Davila
- Rappaport Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel
- Nephrology Department, Rambam Health Care Campus, Haifa, Israel
| | - Barbara Mensah Sankofi
- College of Health Sciences, Noguchi Memorial Institute for Medical Research, University of Ghana, Accra, Ghana
- West African Centre for Cell Biology of Infectious Pathogens, College of Basic and Applied Sciences, University of Ghana, Accra, Ghana
| | - Ernestine Kubi Amos-Abanyie
- College of Health Sciences, Noguchi Memorial Institute for Medical Research, University of Ghana, Accra, Ghana
| | - Anita Ghansah
- College of Health Sciences, Noguchi Memorial Institute for Medical Research, University of Ghana, Accra, Ghana
| | - Alexander Nyarko
- College of Health Sciences, Noguchi Memorial Institute for Medical Research, University of Ghana, Accra, Ghana
| | - Seth Agyemang
- West African Centre for Cell Biology of Infectious Pathogens, College of Basic and Applied Sciences, University of Ghana, Accra, Ghana
- University of Ghana Medical School, College of Health Sciences, University of Ghana, Accra, Ghana
| | - Gordon A. Awandare
- West African Centre for Cell Biology of Infectious Pathogens, College of Basic and Applied Sciences, University of Ghana, Accra, Ghana
| | | | | | - Basem Hijazi
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
| | - Ifeoma Ulasi
- Department of Medicine, College of Health Sciences University of Nigeria, Enugu, Nigeria
| | | | - Vincent Boima
- University of Ghana Medical School, College of Health Sciences, University of Ghana, Accra, Ghana
| | - Charlotte Osafo
- University of Ghana Medical School, College of Health Sciences, University of Ghana, Accra, Ghana
| | - Victoria May Adabayeri
- University of Ghana Medical School, College of Health Sciences, University of Ghana, Accra, Ghana
| | - Michael Matekole
- University of Ghana Medical School, College of Health Sciences, University of Ghana, Accra, Ghana
| | - Timothy O. Olanrewaju
- Department of Medicine, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Samuel Ajayi
- Department of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Manmak Mamven
- Department of Medicine, University of Abuja, Abuja, Nigeria
| | - Sampson Antwi
- Department of Medicine, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | | | - Jacob Plange-Rhule
- Department of Medicine, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | | | - Priscilla Abena Akyaw
- College of Health Sciences, Noguchi Memorial Institute for Medical Research, University of Ghana, Accra, Ghana
| | - Cheryl A. Winkler
- Department of Medicine, Frederick National Laboratory for Cancer Research (NIH), Frederick, MD, United States
| | | | - Akinlolu Ojo
- School of Medicine, University of Kansas Medical Center, Kansas City, KS, United States
| | - Karl Skorecki
- Rappaport Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel
- Rambam Health Care Campus, Haifa, Israel
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
| | - Dwomoa Adu
- University of Ghana Medical School, College of Health Sciences, University of Ghana, Accra, Ghana
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Mormando R, Wolfe AJ, Putonti C. Discriminating between JCPyV and BKPyV in Urinary Virome Data Sets. Viruses 2021; 13:v13061041. [PMID: 34072839 PMCID: PMC8230216 DOI: 10.3390/v13061041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 05/15/2021] [Accepted: 05/27/2021] [Indexed: 11/21/2022] Open
Abstract
Polyomaviruses are abundant in the human body. The polyomaviruses JC virus (JCPyV) and BK virus (BKPyV) are common viruses in the human urinary tract. Prior studies have estimated that JCPyV infects between 20 and 80% of adults and that BKPyV infects between 65 and 90% of individuals by age 10. However, these two viruses encode for the same six genes and share 75% nucleotide sequence identity across their genomes. While prior urinary virome studies have repeatedly reported the presence of JCPyV, we were interested in seeing how JCPyV prevalence compares to BKPyV. We retrieved all publicly available shotgun metagenomic sequencing reads from urinary microbiome and virome studies (n = 165). While one third of the data sets produced hits to JCPyV, upon further investigation were we able to determine that the majority of these were in fact BKPyV. This distinction was made by specifically mining for JCPyV and BKPyV and considering uniform coverage across the genome. This approach provides confidence in taxon calls, even between closely related viruses with significant sequence similarity.
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Affiliation(s)
- Rita Mormando
- Bioinformatics Program, Loyola University Chicago, Chicago, IL 60660, USA;
| | - Alan J. Wolfe
- Department of Microbiology and Immunology, Stitch School of Medicine, Loyola University Chicago, Maywood, IL 60153, USA;
| | - Catherine Putonti
- Bioinformatics Program, Loyola University Chicago, Chicago, IL 60660, USA;
- Department of Microbiology and Immunology, Stitch School of Medicine, Loyola University Chicago, Maywood, IL 60153, USA;
- Department of Biology, Loyola University Chicago, Chicago, IL 60660, USA
- Correspondence:
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Freedman BI, Kopp JB, Sampson MG, Susztak K. APOL1 at 10 years: progress and next steps. Kidney Int 2021; 99:1296-1302. [PMID: 33794228 DOI: 10.1016/j.kint.2021.03.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 02/17/2021] [Accepted: 02/25/2021] [Indexed: 12/29/2022]
Abstract
APOL1 kidney risk variants (RVs) were identified in 2010 as major drivers of glomerular, tubulointerstitial, and renal microvascular disease in individuals with sub-Saharan African ancestry. In December 2020, the "APOL1 at Ten" conference summarized the first decade of progress and discussed controversies and uncertainties that remain to be addressed. Topics included trypanosome infection and its role in the evolution of APOL1 kidney RVs, clinical phenotypes in APOL1-associated nephropathy, relationships between APOL1 RVs and background haplotypes on cell injury and molecular mechanisms initiating disease, the role of clinical APOL1 genotyping, and development of novel therapies for kidney disease. Future goals were defined, including improved characterization of various APOL1 RV phenotypes in patients and experimental preclinical models; further dissection of APOL1-mediated pathways to cellular injury and dysfunction in kidney (and other) cells; clarification of gene-gene and gene-environment interactions; and evaluation of the role for existing and novel therapies.
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Affiliation(s)
- Barry I Freedman
- Section on Nephrology, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Jeffrey B Kopp
- Kidney Disease Section, National Institute of Diabetes and Digestive and Kidney Disease, National Institutes of Health, Bethesda, Maryland, USA
| | - Matthew G Sampson
- Division of Pediatric Nephrology, Boston Children's Hospital, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA; Broad Institute, Cambridge, Massachusetts, USA
| | - Katalin Susztak
- Renal Electrolyte and Hypertension Division, Department of Medicine, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA; Department of Genetics, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA; Institute for Diabetes, Obesity and Metabolism, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA.
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Diagnostic accuracy of semiquantitative point of care urine albumin to creatinine ratio and urine dipstick analysis in a primary care resource limited setting in South Africa. BMC Nephrol 2021; 22:103. [PMID: 33743616 PMCID: PMC7981803 DOI: 10.1186/s12882-021-02290-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 03/02/2021] [Indexed: 11/21/2022] Open
Abstract
Background The prevalence of chronic kidney disease (CKD) is predicted to rise over the next few decades. In resource-limited settings access to central laboratory services is limited. Point-of-care (POC) urine dipstick testing offers the potential to detect markers of kidney damage (albuminuria) as well as markers of other disease processes. We evaluated the diagnostic accuracy of the semi-quantitative albumin-creatinine ratio (ACR) Sysmex UC-1000 POC urine dipstick system as well as the extent of other abnormal dipstick findings in urine. Methods 700 participants from a rural area in South Africa were screened for albuminuria. A spot urine sample was used to measure POC and central laboratory ACR. We determined the sensitivity, specificity, positive predictive value and negative predictive value of the POC ACR, and recorded dipstick parameters. Results The prevalence of albuminuria was 11.6% (95%CI; 9.3–14.2). Those with albuminuria had higher mean diastolic (82 vs 79 mmHg, p = 0.019) and systolic (133 vs 128 mmHg, p = 0.002) blood pressures and a higher proportion of diabetes mellitus (17.6 vs 4.9%, p < 0.001). The sensitivity of the POC ACR system was 0.79, specificity 0.84, positive predictive value 0.39 and negative predictive value 0.97. The sensitivity improved to 0.80, 0.85, 0.85 and 0.89 in those with elevated blood pressure, diabetes mellitus, HIV positive status, and those 65 years and older, respectively. Abnormalities other than albuminuria were detected in 240 (34.3%) of the samples; 88 (12.6%) were positive for haematuria, 113 (16.1%) for leucocytes, 66 (9.4%) for nitrites and 27 (3.9%) for glycosuria. Conclusion Our study shows that POC ACR has good negative predictive value and could be used to rule out albuminuria when screening for CKD. Additionally, a high proportion of participants had other urine abnormalities detected with dipsticks which may reflect kidney disease or co-morbid untreated genitourinary pathology such as urinary tract infections or endemic schistosomiasis with important implications for CKD. Supplementary Information The online version contains supplementary material available at 10.1186/s12882-021-02290-5.
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Nqebelele NU, Dickens C, Dix-Peek T, Duarte R, Naicker S. JC Virus and APOL1 Risk Alleles in Black South Africans With Hypertension-Attributed CKD. Kidney Int Rep 2019; 4:939-945. [PMID: 31317116 PMCID: PMC6611950 DOI: 10.1016/j.ekir.2019.05.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 05/10/2019] [Accepted: 05/13/2019] [Indexed: 01/13/2023] Open
Abstract
Introduction The polyomaviruses, John Cunningham (JC) and BK, infect humans, with primary infection occurring in childhood. First-degree relatives of African American individuals with nondiabetic chronic kidney disease (CKD) who had 2 apolipoprotein L1 (APOL1) risk variants had a lower prevalence of kidney disease in the presence of JC viruria. This study determined the prevalence of polyomavirus infections and their effects, in the presence APOL1 risk alleles, on CKD. Methods Sixty-four black South African individuals with hypertension-attributed CKD with an estimated glomerular filtration rate (eGFR) ≤60 ml/min per 1.73 m2, 44 first-degree relatives, and 56 unrelated controls were included. Viral DNA was extracted from urine and genomic DNA from blood using the Maxwell automated platform. Viral-load quantification was determined using Genesig polyomavirus kits. Genotyping of the APOL1 G1 and G2 variants was by polymerase chain reaction-restriction fragment length polymorphism. Results The prevalence of JC viruria was significantly higher in controls (36%) and first-degree relatives (20%) than in patients with CKD (3%, P < 0.001). Although patients with CKD and their first-degree relatives had similar socioeconomic status scores, we found a lower prevalence of JC viruria in patients with CKD compared with their first-degree relatives, who had normal kidney function. The absence of John Cunningham virus (JCV), DNA was a strong predictor of CKD (odds ratio [OR] 43.43; 95% confidence interval [CI] 7.39-255.20; P < 0.001). Conclusion There was a strong association between the absence of JC viruria and CKD. Studies with a larger sample are essential to determine the renoprotective effects of JCV and its interactions with APOL1.
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Affiliation(s)
- Nolubabalo U Nqebelele
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Caroline Dickens
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Therese Dix-Peek
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Raquel Duarte
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Saraladevi Naicker
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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