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Rostaing L, Jouve T, Terrec F, Malvezzi P, Noble J. Adverse Drug Events after Kidney Transplantation. J Pers Med 2023; 13:1706. [PMID: 38138933 PMCID: PMC10744736 DOI: 10.3390/jpm13121706] [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: 11/12/2023] [Revised: 12/04/2023] [Accepted: 12/09/2023] [Indexed: 12/24/2023] Open
Abstract
Introduction: Kidney transplantation stands out as the optimal treatment for patients with end-stage kidney disease, provided they meet specific criteria for a secure outcome. With the exception of identical twin donor-recipient pairs, lifelong immunosuppression becomes imperative. Unfortunately, immunosuppressant drugs, particularly calcineurin inhibitors like tacrolimus, bring about adverse effects, including nephrotoxicity, diabetes mellitus, hypertension, infections, malignancy, leukopenia, anemia, thrombocytopenia, mouth ulcers, dyslipidemia, and wound complications. Since achieving tolerance is not feasible, patients are compelled to adhere to lifelong immunosuppressive therapies, often involving calcineurin inhibitors, alongside mycophenolic acid or mTOR inhibitors, with or without steroids. Area covered: Notably, these drugs, especially calcineurin inhibitors, possess narrow therapeutic windows, resulting in numerous drug-related side effects. This review focuses on the prevalent immunosuppressive drug-related side effects encountered in kidney transplant recipients, namely nephrotoxicity, post-transplant diabetes mellitus, leukopenia, anemia, dyslipidemia, mouth ulcers, hypertension, and viral reactivations (cytomegalovirus and BK virus). Additionally, other post-kidney-transplantation drugs such as valganciclovir may also contribute to adverse events such as leukopenia. For each side effect, we propose preventive measures and outline appropriate treatment strategies.
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Affiliation(s)
- Lionel Rostaing
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, University Hospital Grenoble, 38043 Grenoble, France; (T.J.); (F.T.); (P.M.); (J.N.)
- Institute for Advanced Biosciences (IAB), INSERM U 1209, CNRS UMR 5309, Université Grenoble Alpes, 38043 Grenoble, France
- Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
| | - Thomas Jouve
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, University Hospital Grenoble, 38043 Grenoble, France; (T.J.); (F.T.); (P.M.); (J.N.)
- Institute for Advanced Biosciences (IAB), INSERM U 1209, CNRS UMR 5309, Université Grenoble Alpes, 38043 Grenoble, France
| | - Florian Terrec
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, University Hospital Grenoble, 38043 Grenoble, France; (T.J.); (F.T.); (P.M.); (J.N.)
| | - Paolo Malvezzi
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, University Hospital Grenoble, 38043 Grenoble, France; (T.J.); (F.T.); (P.M.); (J.N.)
| | - Johan Noble
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, University Hospital Grenoble, 38043 Grenoble, France; (T.J.); (F.T.); (P.M.); (J.N.)
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Breyer I, Dodin B, Djamali A, Jorgenson MR, Garg N, Aziz F, Mohamed MA, Mandelbrot DA, Parajuli S. Risk factors and outcomes of BK viremia among deceased donor kidney transplant recipients based on donor characteristics. Transpl Infect Dis 2021; 24:e13768. [PMID: 34825437 DOI: 10.1111/tid.13768] [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: 09/21/2021] [Revised: 10/22/2021] [Accepted: 11/17/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION BK polyomavirus (BKV) is a common infection among kidney transplant recipients (KTR). Risk factors and outcomes based on donor characteristics remain largely unknown. METHODS In this study, we aimed to analyze the impact of donor factors through a paired kidney analysis. We included 289 pairs of adult deceased donor transplants (578 KTRs total); each pair had received kidneys from the same donor. Recipient pairs were divided into three groups: "no BK group" if neither KTR developed BK viremia (n = 336), "discordant" if the only one did (n = 176), and "concordant" if both did (n = 66). Acute rejection (AR), graft failure, and BK nephropathy (BKN) were outcomes of interest. RESULTS Donors in the concordant group were younger, had lower kidney donor profile index (KDPI), and were less likely to be donor after circulatory death (DCD). In multivariate analyses, KTRs who had a donor with a higher body mass index (BMI) (hazard ratio (HR): 0.97; 95% confidence interval (CI): 0.95-0.99; p = .009) were less likely to develop BKV. Concordance was not associated with AR (HR: 0.83; 95% CI: 0.51-1.34; p = .45), graft failure (HR: 1.77; 95% CI: 0.42-7.50; p = .43), or BKN (HR: 1.02; 95% CI: 0.51-2.03; p = .96). DISCUSSION Our study suggests lower donor BMI is associated with BKV infection, and concordance or discordance between paired kidney recipients is not associated with poor outcomes.
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Affiliation(s)
- Isabel Breyer
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Ban Dodin
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Arjang Djamali
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Margaret R Jorgenson
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Neetika Garg
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Fahad Aziz
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Maha A Mohamed
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Didier A Mandelbrot
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Sandesh Parajuli
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
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Terrec F, Jouve T, Malvezzi P, Janbon B, Naciri Bennani H, Rostaing L, Noble J. Belatacept Use after Kidney Transplantation and Its Effects on Risk of Infection and COVID-19 Vaccine Response. J Clin Med 2021; 10:jcm10215159. [PMID: 34768680 PMCID: PMC8585113 DOI: 10.3390/jcm10215159] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 10/26/2021] [Accepted: 11/02/2021] [Indexed: 02/07/2023] Open
Abstract
Introduction: Belatacept is a common immunosuppressive therapy used after kidney transplantation (KT) to avoid calcineurin-inhibitor (CNI) use and its related toxicities. It is unclear whether its use exposes KT recipients (KTx) to a greater risk of infection or a poorer response to vaccines. Areas covered: We reviewed PubMed and the Cochrane database. We then summarized the mechanisms and impacts of belatacept use on the risk of infection, particularly opportunistic, in two settings, i.e., de novo KTx and conversion from CNIs. We also focused on COVID-19 infection risk and response to SARS-CoV-2 vaccination in patients whose maintenance immunosuppression relies on belatacept. Expert opinion: When belatacept is used de novo, or after drug conversion the safety profile regarding the risk of infection remains good. However, there is an increased risk of opportunistic infections, mainly CMV disease and Pneumocystis pneumonia, particularly in those with a low eGFR, in older people, in those receiving steroid-based therapy, or those that have an early conversion from CNI to belatacept (i.e., <six months post-transplantation). Thus, we recommend, if possible, delaying conversion from CNI to belatacept until at least six months post-transplantation. Optimal timing seems to be eight months post-transplantation. In addition, KTx receiving belatacept respond poorly to SARS-CoV-2 vaccination.
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Affiliation(s)
- Florian Terrec
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, Centre Hospitalier Universitaire Grenoble Alpes (CHU), Université Grenoble Alpes, 38043 Grenoble, France; (F.T.); (T.J.); (P.M.); (B.J.); (H.N.B.); (J.N.)
| | - Thomas Jouve
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, Centre Hospitalier Universitaire Grenoble Alpes (CHU), Université Grenoble Alpes, 38043 Grenoble, France; (F.T.); (T.J.); (P.M.); (B.J.); (H.N.B.); (J.N.)
- School of Medicine, Université Grenoble Alpes, 38043 Grenoble, France
| | - Paolo Malvezzi
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, Centre Hospitalier Universitaire Grenoble Alpes (CHU), Université Grenoble Alpes, 38043 Grenoble, France; (F.T.); (T.J.); (P.M.); (B.J.); (H.N.B.); (J.N.)
| | - Bénédicte Janbon
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, Centre Hospitalier Universitaire Grenoble Alpes (CHU), Université Grenoble Alpes, 38043 Grenoble, France; (F.T.); (T.J.); (P.M.); (B.J.); (H.N.B.); (J.N.)
| | - Hamza Naciri Bennani
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, Centre Hospitalier Universitaire Grenoble Alpes (CHU), Université Grenoble Alpes, 38043 Grenoble, France; (F.T.); (T.J.); (P.M.); (B.J.); (H.N.B.); (J.N.)
| | - Lionel Rostaing
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, Centre Hospitalier Universitaire Grenoble Alpes (CHU), Université Grenoble Alpes, 38043 Grenoble, France; (F.T.); (T.J.); (P.M.); (B.J.); (H.N.B.); (J.N.)
- School of Medicine, Université Grenoble Alpes, 38043 Grenoble, France
- Correspondence: ; Tel.: +33-4-76-76-54-60
| | - Johan Noble
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, Centre Hospitalier Universitaire Grenoble Alpes (CHU), Université Grenoble Alpes, 38043 Grenoble, France; (F.T.); (T.J.); (P.M.); (B.J.); (H.N.B.); (J.N.)
- School of Medicine, Université Grenoble Alpes, 38043 Grenoble, France
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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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Keller N, Duquennoy S, Conrad A, Fafi-Kremer S, Morelon E, Bouvier N, Moulin B, Hurault De Ligny B, Caillard S. Clinical utility of leflunomide for BK polyomavirus associated nephropathy in kidney transplant recipients: A multicenter retrospective study. Transpl Infect Dis 2019; 21:e13058. [PMID: 30730102 DOI: 10.1111/tid.13058] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Revised: 01/25/2019] [Accepted: 01/27/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND BK polyomavirus associated nephropathy (BKPyVAN) is a significant clinical issue in kidney transplant (KT) recipients. No specific therapy is currently available, although treatment with leflunomide may be part of the therapeutic strategy. Here, we sought to examine the impact of leflunomide on the evolution of BKPyVAN. METHODS This was an observational retrospective study conducted in 3 French transplant centers. KT recipients who developed BKPyVAN and received leflunomide after failure of other treatment approaches were deemed eligible. Graft function, viral clearance, patient survival, rejection rates, treatment tolerability, and immunosuppression levels served as the main outcome measures. RESULTS A total of 55 patients were included. Treatment with leflunomide was started after a mean of 1.4 ± 4.1months after BKPyVAN diagnosis. Between the introduction of leflunomide and the end of follow-up, creatinine levels increased by 31 ± 118% (P = 0.04), whereas viremia decreased by 79 ± 37% (P < 0.001). Blood viral clearance was observed in 76% of the study patients. Rejection episodes occurred in 33% of the participants. Eleven patients lost their graft (9 of which because of BKPyVAN). Ten patients developed adverse effects and 3 discontinued leflunomide. CONCLUSION We cannot conclude about the exact place of leflunomide in the therapeutic strategy of BKPyVAN. It may be a part of the therapy to promote BK polyomavirus clearance in cases of BKPyVAN who fail to improve after immunosuppression lowering alone. Unfortunately, a significant decline in renal function and high rejection rates remain major clinical challenges.
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Affiliation(s)
- Nicolas Keller
- Nephrology and Transplantation Department, Universitary Hospital, Strasbourg, France
| | - Simon Duquennoy
- Nephrology-Dialysis-Transplantation Department, Universitary Hospital, Caen, France
| | - Anne Conrad
- Nephrology-Transplantation and Immunology Department, Hôpital Edouard-Herriot, Universitary Hospital, Lyon, France
| | - Samira Fafi-Kremer
- Virology Laboratory, Strasbourg University Hospital, Strasbourg, France.,INSERM UMR_S 1109, ImmunoRhumatologie Moléculaire, Fédération Hospitalo-Universitaire OMICARE, Fédération de Médecine Translationnelle de Strasbourg, Institut d'Immunologie et d'Hématologie, Strasbourg Cedex, France
| | - Emmanuel Morelon
- Nephrology-Transplantation and Immunology Department, Hôpital Edouard-Herriot, Universitary Hospital, Lyon, France
| | - Nicolas Bouvier
- Nephrology-Dialysis-Transplantation Department, Universitary Hospital, Caen, France
| | - Bruno Moulin
- Nephrology and Transplantation Department, Universitary Hospital, Strasbourg, France.,INSERM UMR_S 1109, ImmunoRhumatologie Moléculaire, Fédération Hospitalo-Universitaire OMICARE, Fédération de Médecine Translationnelle de Strasbourg, Institut d'Immunologie et d'Hématologie, Strasbourg Cedex, France
| | | | - Sophie Caillard
- Nephrology and Transplantation Department, Universitary Hospital, Strasbourg, France.,INSERM UMR_S 1109, ImmunoRhumatologie Moléculaire, Fédération Hospitalo-Universitaire OMICARE, Fédération de Médecine Translationnelle de Strasbourg, Institut d'Immunologie et d'Hématologie, Strasbourg Cedex, France
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6
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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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Abstract
BK polyomavirus (BKV) causes frequent infections during childhood and establishes persistent infections within renal tubular cells and the uroepithelium, with minimal clinical implications. However, reactivation of BKV in immunocompromised individuals following renal or hematopoietic stem cell transplantation may cause serious complications, including BKV-associated nephropathy (BKVAN), ureteric stenosis, or hemorrhagic cystitis. Implementation of more potent immunosuppression and increased posttransplant surveillance has resulted in a higher incidence of BKVAN. Antiviral immunity plays a crucial role in controlling BKV replication, and our increasing knowledge about host-virus interactions has led to the development of improved diagnostic tools and clinical management strategies. Currently, there are no effective antiviral agents for BKV infection, and the mainstay of managing reactivation is reduction of immunosuppression. Development of immune-based therapies to combat BKV may provide new and exciting opportunities for the successful treatment of BKV-associated complications.
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8
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El Ansary M, Abd Elhamid S, Saadi G, Ismail W, Ibrahim N, Bahaa El-Din N, Alhsyek S. Prevalence of polyoma BK virus infection among living-donor renal transplant recipients. Transpl Infect Dis 2016; 18:529-37. [PMID: 27226063 DOI: 10.1111/tid.12557] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 02/25/2016] [Accepted: 03/17/2016] [Indexed: 02/05/2023]
Abstract
BACKGROUND Polyomavirus nephropathy (PVN) mainly caused by BK polyomavirus (BKPyV) remains the most common productive viral infection of the kidney in immunosuppressed patients. The diagnosis of PVN is based on the detection of BK viruria and BK viremia in conjunction with histological findings in the graft biopsy. METHODS Our study was aimed to estimate the prevalence of productive BKPyV infection among renal transplant patients within the first year post-transplant and identify those at risk of developing PVN. Our cross-sectional study was conducted on 134 kidney transplant patients. Evidence of BKPyV replication was assessed by viral quantification of blood and urine samples of studied patients using a quantitative real-time polymerase chain reaction (Q-PCR)PCR), detection of decoy cells in urine cytology smears, histological examination of graft biopsies from Q-PCR BKPyV-positive patients, and immunohistochemical staining by simian virus 40 (SV40) antibody. RESULTS Significant BKPyV infection was prevalent in 8% (n = 11) of our patients, with a peak of BKPyV infection about 8 months post transplant. BKPyV viral load by Q-PCR assay in these patients varied from 1350 to 20,000,000 (1.35 × 10(3) to 2 × 10(7) ) copies/mL for urine samples and 935 to 18,920 (9.35 × 10(2) to 1.89 × 10(4) ) copies/mL for blood samples. All the 11 patients were positive for decoy cells but only 3 developed PVN based on histology and positive SV40 staining. BKPyV infection was more prevalent in older patients. All patients responded to reduction in their immunosuppressive regimens, apart from 2 patients who required replacement of calcineurin inhibitors-based regimen with mammalian target of ramapycin inhibitors with an overall good response. CONCLUSION Protocol screening programs based on detection of viral replication by viruria, viremia, and decoy cells in urine are necessary to shed light on patients with high virus replication and hence increased risk of developing PVN, and to allow early diagnosis and intervention.
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Affiliation(s)
- M El Ansary
- Department of Clinical Pathology, Kasr El-Aini, Cairo University, Cairo, Egypt
| | - S Abd Elhamid
- Department of Clinical Pathology, Kasr El-Aini, Cairo University, Cairo, Egypt
| | - G Saadi
- Department of Internal Medicine & Nephrology, Kasr El-Aini, Cairo University, Cairo, Egypt
| | - W Ismail
- Department of Pathology, Faculty of Medicine, BeniSuef University, BeniSuef, Egypt
| | - N Ibrahim
- Department of Clinical Pathology, Kasr El-Aini, Cairo University, Cairo, Egypt
| | - N Bahaa El-Din
- Department of Clinical Pathology, Kasr El-Aini, Cairo University, Cairo, Egypt
| | - S Alhsyek
- Department of Biochemistry, Faculty of Science, Trebles University, Trebles, Libya
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9
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The association between polyomavirus BK strains and BKV viruria in liver transplant recipients. Sci Rep 2016; 6:28491. [PMID: 27338010 PMCID: PMC4919687 DOI: 10.1038/srep28491] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Accepted: 06/03/2016] [Indexed: 12/30/2022] Open
Abstract
BK virus (BKV) is a polyomavirus that cause of allograft dysfunction among kidney transplant recipients. The role of BKV infection in non-renal solid organ transplant recipients is not well understood neither for the relationship between various BKV strains with occurrence of BKV viral viruria. This study aimed to understand the prevalence of BKV infection and identified of BKV various strains in the urine of liver transplant recipients. There was not significant difference of renal outcome between high BKV viruria and low BKV viruria in the liver transplant recipients. The WW-non-coding control region (NCCR) BKV detected in urine was associated with higher urinary BKV load, whereas the Dunlop-NCCR BKV was detected in the urine of low urinary BKV load. An in vitro cultivation system demonstrated that WW-BKV strain exhibiting the higher viral DNA replication efficiency and higher BKV load. Altogether, this is the first study to demonstrate the impact of BKV strains on the occurrence of BK viruria in the liver transplant recipients.
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10
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Gonzalez S, Escobar-Serna DP, Suarez O, Benavides X, Escobar-Serna JF, Lozano E. BK Virus Nephropathy in Kidney Transplantation: An Approach Proposal and Update on Risk Factors, Diagnosis, and Treatment. Transplant Proc 2016; 47:1777-85. [PMID: 26293050 DOI: 10.1016/j.transproceed.2015.05.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2015] [Revised: 04/30/2015] [Accepted: 05/14/2015] [Indexed: 12/16/2022]
Abstract
BK virus belongs to Polyomaviridae family; it causes 95% of nephropathy cases related to polyomavirus, with the other 5% caused by JC virus. Nephropathy jeopardizes graft function, causing a premature failure of the graft in 1%-10% of patients with kidney transplants. Nowadays, antiviral effective treatment is unknown, which is why blood and urine screening of renal transplantation patients has become the most important recommendation to guide the decrease of immunosuppression, and the only proven method to decrease poor outcomes. Different interventions, such as cidofovir, leflunomide, fluoroquinolones, and intravenous immunoglobulin, have been attempted with no improvement at all. This review aims to summarize the most relevant features of BK virus, historical issues, transmission mechanisms, risk factors, and therapeutic interventions.
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Affiliation(s)
- S Gonzalez
- Organ and Tissues Transplant Group, Surgery Department, Medical School, National University of Colombia, Bogotá, Colombia.
| | - D P Escobar-Serna
- Organ and Tissues Transplant Group, Surgery Department, Medical School, National University of Colombia, Bogotá, Colombia
| | - O Suarez
- Organ and Tissues Transplant Group, Surgery Department, Medical School, National University of Colombia, Bogotá, Colombia
| | - X Benavides
- Organ and Tissues Transplant Group, Surgery Department, Medical School, National University of Colombia, Bogotá, Colombia
| | - J F Escobar-Serna
- Internal Medicine and Critical Care, Universidad de Antioquia, Medellín, Colombia
| | - E Lozano
- Organ and Tissues Transplant Group, Surgery Department, Medical School, National University of Colombia, Bogotá, Colombia; Hospital Universitario San Ignacio, Bogotá, Colombia
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12
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Kim H, Yang W, Han D, Park S. Clinical Courses of Renal Transplant Recipients with High BK Viremia. Transplant Proc 2013; 45:2975-9. [DOI: 10.1016/j.transproceed.2013.08.033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Risk Factors for BK Virus–Associated Hemorrhagic Cystitis in Allogeneic Stem Cell Transplant Recipients. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2013. [DOI: 10.1097/ipc.0b013e318278f89a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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14
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Mengelle C, Mansuy JM, Sauné K, Barthe C, Boineau J, Izopet J. A new highly automated extraction system for quantitative real-time PCRs from whole blood samples: Routine monitoring of opportunistic infections in immunosuppressed patients. J Clin Virol 2012; 53:314-9. [DOI: 10.1016/j.jcv.2012.01.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2011] [Revised: 01/03/2012] [Accepted: 01/05/2012] [Indexed: 10/14/2022]
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15
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Krisl JC, Taber DJ, Pilch N, Chavin K, Bratton C, Thomas B, McGillicuddy J, Baliga P. Leflunomide efficacy and pharmacodynamics for the treatment of BK viral infection. Clin J Am Soc Nephrol 2012; 7:1003-9. [PMID: 22461534 DOI: 10.2215/cjn.12531211] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES BK virus is an infection in kidney transplantation patients jeopardizing graft survival. Unfortunately, there is no consensus on treatment of BK viremia and nephropathy. Leflunomide has been studied for the treatment of BK viremia and nephropathy, but there are limited data on the utility of leflunomide therapeutic drug monitoring. This study aimed to determine if a pharmacodynamic relationship exists between BK viral load reduction and leflunomide metabolite, A77 1726, serum concentrations. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This study was a retrospective, single-center, longitudinal analysis of patients identified with BK viremia with or without nephropathy. Patients were grouped according to whether they received leflunomide. All BK viral PCR and A77 1726 concentrations were analyzed to determine pharmacodynamics, and were correlated with clinical outcomes. RESULTS Of 76 patients identified, 52 received leflunomide therapy and 24 did not. Patients who received leflunomide were further analyzed according to A77 1726 concentrations and BK clearance; there was no difference in BK clearance. There was a lack of correlation between A77 1726 concentrations and log change in BK viral PCR concentration. Multivariate analysis demonstrated that mycophenolate mofetil discontinuation, BK viremia without nephropathy, and mean BK viral load were significantly associated with BK viral clearance; leflunomide use lacked this association. CONCLUSIONS Pharmacodynamic analysis revealed no association between A77 1726 concentrations and BK viral PCR reductions. Multivariate analysis demonstrated that leflunomide therapy was not associated with BK viral clearance. Randomized studies are needed to determine the utility of leflunomide for BK viremia and nephropathy.
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Affiliation(s)
- Jill C Krisl
- Department of Pharmacy Services, Medical University of South Carolina, Charleston, South Carolina, USA.
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16
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Nishimura K, Uchida K, Yuzawa K, Fukuda Y, Ichikawa Y, Akioka K, Fujisawa M, Sugitani A, Ito S, Nakatani T, Horimi T, Yoshimura N. Excellent Results With High-Dose Mizoribine Combined With Cyclosporine, Corticosteroid, and Basiliximab in Renal Transplant Recipients: Multicenter Study in Japan. Transplant Proc 2012; 44:147-9. [DOI: 10.1016/j.transproceed.2011.11.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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17
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Renoult E, Coutlée F, Pâquet M, St Louis G, Girardin C, Fortin MC, Cardinal H, Lévesque R, Schürch W, Latour M, Barama A, Hébert MJ. Evaluation of a Preemptive Strategy for BK Polyomavirus-Associated Nephropathy Based on Prospective Monitoring of BK Viremia: A Kidney Transplantation Center Experience. Transplant Proc 2010; 42:4083-7. [DOI: 10.1016/j.transproceed.2010.09.024] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2010] [Accepted: 09/09/2010] [Indexed: 10/18/2022]
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18
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Mengelle C, Kamar N, Mansuy JM, Sandres-Sauné K, Legrand-Abravanel F, Miédougé M, Rostaing L, Izopet J. JC virus DNA in the peripheral blood of renal transplant patients: A 1-year prospective follow-up in France. J Med Virol 2010; 83:132-6. [DOI: 10.1002/jmv.21951] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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19
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Treatment of polyomavirus infection in kidney transplant recipients: a systematic review. Transplantation 2010; 89:1057-70. [PMID: 20090569 DOI: 10.1097/tp.0b013e3181d0e15e] [Citation(s) in RCA: 169] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND.: Polyomavirus-associated nephropathy (PVAN) is an important cause of kidney graft loss but there is no consensus on its management. This study aimed to systematically document all published treatments for PVAN to determine the most effective therapy. METHODS.: A computerized search in MEDLINE, EMBASE, and Cochrane databases (1950-2008) was performed. References from review articles and published abstracts from the American Transplant Congress (2005-2008) were also included. Study selection criteria included (a) population: adult (>18 years) kidney-only, primary or repeat renal transplant recipients; (b) setting: polyoma viruria, viremia or biopsy-proven PVAN or both; and (c) treatment: immunosuppression reduction alone or with adjuvant agents. The primary outcome was graft failure rate, and secondary outcomes included acute rejection rate, elimination of viruria and viremia, graft function, patient survival, and adverse events. RESULTS.: Of 555 identified citations, 40 studies examining the effect of immunosuppression reduction alone or in combination with cidofovir, leflunomide, intravenous immunoglobulin, or ciprofloxacin were included for appraisal. Pooled results found a death-censored graft loss rate of 8/100 patient-years for immunosuppression reduction alone and 8 and 13/100 patient-years for the addition of cidofovir or leflunomide, respectively. CONCLUSIONS.: There does not seem to be a graft survival benefit of adding cidofovir or leflunomide to immunosuppression reduction for the management of PVAN. However, the evidence base is poor and highlights the urgent need for adequately powered randomized trials to define the optimal treatment of this important condition.
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20
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A suppressive effect of cyclosporine A on replication and noncoding control region activation of polyomavirus BK virus. Transplantation 2010; 89:299-306. [PMID: 20145520 DOI: 10.1097/tp.0b013e3181c9b51c] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND The effect of cyclosporine A (CsA) on polyomavirus BK virus (BKV) replication remains unclear. The aim of this in vitro study was to investigate the effect of CsA on BKV replication in human uroepithelial cells. METHODS After infection of a human renal proximal tubular cell line, HK-2 with BKV, BKV viral load in the presence of CsA was assessed by real-time polymerase chain reaction. The BKV large T-antigen (LTag) expression was measured by Western blot analysis. The BKV early promoter activity was determined by measuring luciferase activity of the BKV noncoding control region luciferase reporter. The BKV LTag expression in a human bladder carcinoma cell line, T24, was assessed by immunofluorescence. RESULTS The results demonstrated that the increased levels of BKV LTag and viral protein 1 transcripts measured by real-time polymerase chain reaction were suppressed by CsA in a dose-dependent manner (0.5-4 microg/mL). Western blot analysis also showed that CsA inhibited BKV LTag expression. In addition, the activity of the BKV early promoter, which was enhanced by BKV LTag overexpression, was abrogated by CsA. Finally, the suppressive effect of CsA on BKV replication was also shown in T24 cells as CsA reduced immunofluorescent staining of BKV LTag in these cells. CONCLUSION This in vitro study indicates that CsA suppresses BKV replication in human proximal renal tubular cells and uroepithelial cells of the urinary bladder and inhibits the BKV-LTag-regulated increase in early promoter activity.
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Araya CE, Garin EH, Neiberger RE, Dharnidharka VR. Leflunomide therapy for BK virus allograft nephropathy in pediatric and young adult kidney transplant recipients. Pediatr Transplant 2010; 14:145-50. [PMID: 19344337 DOI: 10.1111/j.1399-3046.2009.01183.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BKVAN affects about 5% of kidney transplant recipients and may lead to graft failure. Treatment for BKVAN is challenging. Leflunomide, an immunosuppressant with antiviral activity in vitro was used successfully in some adult patients but there are no reports of its use in pediatric patients. We present our experience with three kidney transplant recipients with BKVAN who received leflunomide. Three male patients aged 9, 12, and 20 yr developed BKVAN at 9, 12, and 2 months after a kidney transplant. Immunosuppression was reduced and cidofovir was administered in all patients 2-3 wk apart. Due to inability to travel to receive cidofovir in one, lack of reduction in BK viral load in the second, and rising serum creatinine despite cidofovir in the third patient, we discontinued cidofovir and initiated leflunomide. Teriflunomide target trough levels were 30-60 microg/mL. The patients received leflunomide for 27, 26, and 24 months, respectively. BK viral load decreased below 1000 DNA copies/mL in one and was undetectable in two patients after beginning leflunomide. All patients tolerated leflunomide without side effects. Leflunomide use in a select group of patients is well tolerated and may provide an alternative for treatment of BKVAN in pediatric patients.
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Affiliation(s)
- Carlos E Araya
- Division of Pediatric Nephrology, Department of Pediatrics, University of Florida College of Medicine, Gainesville, FL 32610-0296, USA.
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22
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Bechert CJ, Schnadig VJ, Payne DA, Dong J. Monitoring of BK viral load in renal allograft recipients by real-time PCR assays. Am J Clin Pathol 2010; 133:242-50. [PMID: 20093233 DOI: 10.1309/ajcp63vdfckcruul] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
BK virus (BKV) is a nonenveloped, double-stranded DNA virus of the polyomavirus family that primarily affects immunocompromised people. BKV may cause nephropathy in renal transplant recipients receiving immunosuppressive therapy, resulting in renal dysfunction and, possibly, graft loss. Monitoring of BK viral load in urine and blood has been used as a surrogate marker of BKV nephropathy (BKVN). Although real-time polymerase chain reaction (PCR) is the method of choice, currently there is no US Food and Drug Administration-approved or standardized BK viral load assay. Different PCR assays vary significantly in sample types, DNA extraction method, PCR primers and probes, and reference materials used to generate a standard curve. These differences can affect the accuracy, specificity, and dynamic ranges of various real-time PCR assays. These analytic differences cause difficulty in comparing test results, making it impossible to establish universal standardized cutoff values that correlate with clinical manifestations of BKVN. In this review, we summarize real-time PCR assays used for managing BKVN.
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Marcén R. Immunosuppressive drugs in kidney transplantation: impact on patient survival, and incidence of cardiovascular disease, malignancy and infection. Drugs 2009; 69:2227-43. [PMID: 19852526 DOI: 10.2165/11319260-000000000-00000] [Citation(s) in RCA: 215] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Renal transplant recipients have increased mortality rates when compared with the general population. The new immunosuppressive drugs have improved short-term patient survival up to 95% at 1-2 years, but these data have to be confirmed in long-term follow-up. Furthermore, no particular regimen has proved to be superior over others with regard to patient survival. Cardiovascular diseases are the most common cause of mortality in renal transplant recipients and while no immunosuppressive drug has been directly associated with cardiovascular events, immunosuppressive drugs have different impacts on traditional risk factors. Corticosteroids and ciclosporin are the agents with the most negative impact on weight gain, blood pressure and lipids. Tacrolimus increases the risk of new-onset diabetes mellitus. Sirolimus and everolimus have the most impact on risk factors for post-transplant hyperlipidaemia. Modifications in immunosuppression could improve the cardiovascular profile but there is little evidence regarding the beneficial effects of these changes on patient outcomes. Malignancies are also an increasing cause of mortality, overtaking cardiovascular disease in some series. Induction therapy, azathioprine and calcineurin inhibitors (CNIs) are probably the immunosuppressive agents most linked with post-transplant malignancies. Mycophenolate mofetil (MMF) has no negative impact on the incidence of malignancies. Target of rapamycin (mTOR) inhibitors have antioncogenic properties and they are associated with a lower incidence of malignancies. In addition, these agents have been recommended for use to decrease the dose or withdrawal of CNIs in patients with malignancies. Infections are still an important cause of morbidity and mortality in renal transplant recipients. Some immunosuppressive agents such as MMF increase the incidence of cytomegalovirus infection and the need for prophylactic measures in risk recipients. The use of potent immunosuppressive therapy has resulted in the appearance of BK virus nephropathy, which progresses to graft failure in a high percentage of patients. Although first associated with tacrolimus and MMF immunosuppression, recent data suggest that BK nephropathy appears with any kind of triple therapy. In conclusion, reducing risk factors for patient death should be a major target to improve outcomes after renal transplantation. Effort should be made to control cardiovascular diseases, malignancies and infections with improved use of immunosuppressive drugs. Preliminary results with belatacept suggest its safety and efficacy, and open new perspectives in the immunosuppression of de novo renal transplant recipients.
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Affiliation(s)
- Roberto Marcén
- Department of Nephrology, Ramón y Cajal Hospital, Alcalá de Henares University, Madrid, Spain.
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Abstract
The immunomodulatory drug leflunomide is frequently used for treating polyomavirus-associated nephropathy, yet its antiviral mechanism is unclear. We characterized the effects of the active leflunomide metabolite A771726 (LEF-A) on the polyomavirus BK (BKV) life cycle in human renal tubular epithelial cells. LEF-A at 10 microg/ml reduced the extracellular BKV load by 90% (IC(90)) but with significant host cytostatic effects. BKV genome replication, late protein expression, and virion assembly and release were inhibited with visible disruption of the nuclear replication architecture. Both host cell and antiviral effects were largely reversed by uridine addition, implicating nonspecific pyrimidine depletion as the major anti-BKV mechanism of leflunomide.
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25
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Abstract
The immunomodulatory drug leflunomide is frequently used for treating polyomavirus-associated nephropathy, yet its antiviral mechanism is unclear. We characterized the effects of the active leflunomide metabolite A771726 (LEF-A) on the polyomavirus BK (BKV) life cycle in human renal tubular epithelial cells. LEF-A at 10 microg/ml reduced the extracellular BKV load by 90% (IC(90)) but with significant host cytostatic effects. BKV genome replication, late protein expression, and virion assembly and release were inhibited with visible disruption of the nuclear replication architecture. Both host cell and antiviral effects were largely reversed by uridine addition, implicating nonspecific pyrimidine depletion as the major anti-BKV mechanism of leflunomide.
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26
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Li YJ, Chen YC, Lai PC, Fang JT, Yang CW, Chiang YJ, Chu SH, Wu MJ, Tian YC. A direct association of polyomavirus BK viruria with deterioration of renal allograft function in renal transplant patients. Clin Transplant 2009; 23:505-10. [DOI: 10.1111/j.1399-0012.2009.00982.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Prince O, Savic S, Dickenmann M, Steiger J, Bubendorf L, Mihatsch MJ. Risk factors for polyoma virus nephropathy. Nephrol Dial Transplant 2008; 24:1024-33. [PMID: 19073658 PMCID: PMC2644630 DOI: 10.1093/ndt/gfn671] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Polyoma virus-associated nephropathy (PVN) is a common cause of renal transplant failure. The risk factors for the development of PVN have not yet been studied in large cohorts of patients for periods of 20 years. METHODS We collected clinical, renal biopsy and urinary cytology data from all patients with renal transplantations performed at the University Hospital of Basel from 1985 to 2005. All patients with a renal biopsy and urine cytology were included (n = 880). Renal transplants were divided into three groups, according to evidence of polyoma virus (PV) infection (decoy cells in the urine) and biopsy-proven PVN: Renal transplants without evidence of a PV infection (n = 751). Renal transplants with PV reactivation, e.g. decoy cell (DC) found by urinary cytology, but without PVN (n = 90). Renal transplants with PVN (n = 39). RESULTS The prevalence of biopsy-proven PVN in this cohort of patients was 3.3%. Immunosuppression with mycophenolate and/or tacrolimus, ATGAM, male gender of the recipient and a higher number of transplant rejection episodes were factors significantly associated with PVN development. CONCLUSIONS The most important risk factors for the development of PVN are acute rejection and ATGAM used as induction therapy as well as tacrolimus and mycophenolate as maintenance therapy. Therefore, we conclude that patients with tacrolimus and mycophenolate maintenance therapy should be carefully monitored for the development of PVN.
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Affiliation(s)
- Olivier Prince
- Geriatric Medicine, University Hospital Basel, Switzerland
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28
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Wu JK, Harris MT. Use of leflunomide in the treatment of polyomavirus BK-associated nephropathy. Ann Pharmacother 2008; 42:1679-85. [PMID: 18957628 DOI: 10.1345/aph.1l180] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To review the available literature describing the use of leflunomide for the treatment of polyomavirus BK-associated nephropathy (BKVAN) in renal transplant recipients. DATA SOURCES Relevant literature was obtained through MEDLINE (1950-May 2008) and Science Citation Index Expanded (1900-May 2008) by using search terms leflunomide, Arava, polyomavirus, polyoma, BK virus, and transplant. Additional articles were identified through a manual search of the reference lists of the articles obtained. STUDY SELECTION AND DATA EXTRACTION All articles that were written in English and discussed leflunomide use for BKVAN in renal transplant recipients were evaluated. Case reports and in vitro studies were included in this review. DATA SYNTHESIS BKVAN has emerged as a problematic infectious complication with limited treatment options in renal transplant recipients. Leflunomide, used off-label for refractory BKVAN, is postulated to possess both antiviral and immunosuppressive properties. Two in vitro culture studies, 5 case reports/series, 2 retrospective cohort studies, and 3 prospective observational trials that described leflunomide use in BKVAN were identified. Available literature suggests that leflunomide at target blood concentrations of around 40 mg/L, in addition to immunosuppressive reduction, reduces BK viremia/viruria and graft failure, with few dose-limiting adverse events. It is highly recommended that routine complete blood cell counts, hepatic function panels, and drug concentrations be monitored to detect toxicity. CONCLUSIONS Leflunomide appears to be promising as adjunctive treatment of BKVAN in renal transplant patients. Due to the lack of controlled randomized trials, however, use of leflunomide as first-line treatment cannot be routinely recommended.
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Affiliation(s)
- Judy K Wu
- Department of Pharmacy, Duke University Hospital, Durham, NC 27710, USA.
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Sung H, Choi BH, Pyo YJ, Kim MN, Han DJ. Quantitation of BK virus DNA for diagnosis of BK virus-associated nephropathy in renal transplant recipients. J Korean Med Sci 2008; 23:814-8. [PMID: 18955787 PMCID: PMC2580024 DOI: 10.3346/jkms.2008.23.5.814] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Quantitative measurement of BK virus DNA (Q-BKDNA) has been used for the early diagnosis and monitoring of BK virus-associated nephropathy (BKVAN). This study was designed to determine the BKDNA cutoff for the diagnosis of BKVAN. Between June 2005 and February 2007, 64 renal transplant recipients taken renal biopsies due to renal impairment submitted plasma and urine for Q-BKDNA. Eight BKVAN patients (12.5%) had median viral loads of 6.0 log10 copies/mL in plasma and 7.3 log10 copies/mL in urine. Among 56 non-BKVAN patients, 45 were negative for Q-BKDNA; 4 were positive in plasma with a median viral load of 4.8 log10 copies/ mL, and 10 were positive in urine with a median viral load of 4.8 log10 copies/mL. Receiver operating characteristic curve analysis showed that a cutoff of 4.5 log10 copies/mL in plasma and a cutoff of 5.9 log10 copies/mL in urine had a sensitivity of 100% and a specificity of 96.4%, respectively. A combined cutoffs of 4 log10 copies/ mL in plasma and 6 log10 copies/mL in urine had better performance with a sensitivity of 100% and a specificity of 98.2% than each cutoff of urine or plasma. QBKDNA with the combined cutoffs could reliably diagnose BKVAN in renal transplant recipients.
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Affiliation(s)
- Heungsup Sung
- Department of Laboratory Medicine, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea
| | - Byung Hoo Choi
- Department of Laboratory Medicine, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea
| | - Yeon Jung Pyo
- Department of Laboratory Medicine, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea
| | - Mi-Na Kim
- Department of Laboratory Medicine, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea
| | - Duck Jong Han
- Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea
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Epidemiology of BK virus in renal allograft recipients: independent risk factors for BK virus replication. Transplantation 2008; 86:521-8. [PMID: 18724220 DOI: 10.1097/tp.0b013e31817c6447] [Citation(s) in RCA: 98] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Identification of risk factors for BK virus (BKV) replication may improve transplant outcome. We investigated the impact of immunosuppressive drugs on the prevalence of BKV replication in recipients of human renal allografts. METHODS One hundred twenty renal allograft recipients were studied prospectively at 1, 3, and 6 months posttransplantation to identify risk factors for BKV replication. BKV replication was quantified by measurement of urinary cell BKV VP1 mRNA levels using BKV specific primers and TaqMan probe in a real-time quantitative polymerase chain reaction assay. Levels of urinary cell mRNA for granzyme B, CD103, and transforming growth factor-beta1 were measured to ascertain whether BKV replication is associated with an inflammatory signature. RESULTS The prevalence of BKV replication increased over time and was highest at 6 months compared with 1 or 3 months posttransplantation (P<0.001). A logistic regression model analysis demonstrated that steroid maintenance therapy (odds ratio: 8.3, P=0.003) and induction with rabbit anti-human thymocyte globulin (odds ratio: 5.8, P=0.008) were independent risk factors for BKV replication. Neither mycophenolate mofetil dose nor tacrolimus dose or trough levels were different between those with or without BKV replication. The development of acute rejection or antirejection treatment with methylprednisolone did not increase the risk of BKV replication. BKV replication was associated with heightened levels of urinary cell mRNA for granzyme B (P<0.002), CD103 (P<0.005) but not for transforming growth factor-beta1 (P>0.05). CONCLUSIONS Steroid maintenance therapy and induction with antithymocyte globulin are independent risk factors for BKV replication in renal allograft recipients treated with tacrolimus and mycophenolate mofetil.
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Sessa A, Esposito A, Giliberti A, Bergallo M, Costa C, Rossano R, Lettieri E, Capuano M. BKV Reactivation in Renal Transplant Recipients: Diagnostic and Therapeutic Strategy—Case Reports. Transplant Proc 2008; 40:2055-8. [DOI: 10.1016/j.transproceed.2008.05.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Dall A, Hariharan S. BK virus nephritis after renal transplantation. Clin J Am Soc Nephrol 2008; 3 Suppl 2:S68-75. [PMID: 18309005 DOI: 10.2215/cjn.02770707] [Citation(s) in RCA: 106] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BK virus nephritis is an increasing problem and is posing a threat to improving renal transplant graft survival. The pathogenesis of this condition remains to be investigated. Higher prevalence of BK virus infection in recent years has been correlated with declining acute rejection rates and the use of potent immunosuppressive agents. Patients with this infection usually have asymptomatic viremia and/or nephritis with or without worsening of renal function. The diagnosis of this disease is based on detecting the virus or its effects in urine, blood, and renal tissue. In the past, approximately 30 to 60% of patients with BK virus nephritis developed graft failure. In recent years, the combination of early detection, prompt diagnosis, and therapies including preventive measures have resulted in better outcomes.
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Affiliation(s)
- Aaron Dall
- Division of Nephrology, Medical College of Wisconsin, 9200 West Wisconsin Avenue, Milwaukee, WI 53226, USA
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Mischitelli M, Bellizzi A, Anzivino E, Fioriti D, Boldorini R, Miglio U, Chiarini F, Di Monaco F, Pietropaolo V. Complications post renal transplantation: literature focus on BK virus nephropathy and diagnostic tools actually available. Virol J 2008; 5:38. [PMID: 18315864 PMCID: PMC2268664 DOI: 10.1186/1743-422x-5-38] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2008] [Accepted: 03/03/2008] [Indexed: 12/11/2022] Open
Abstract
Clinical diagnosis of kidney transplants related illnesses is not a simple task. Several studies were conducted to define diseases and complications after renal transplantation, but there are no comprehensive guidelines about diagnostic tools for their prevention and detection. The Authors of this review looked for the medical literature and pertinent publications in particular to understand the role of Human Polyomavirus BK (BKV) in renal failure and to recognize analytical techniques for BK virus associated nephropathy (BKVAN) detection.
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Affiliation(s)
- Monica Mischitelli
- Department of Public Health Sciences, La Sapienza University, Rome, Italy.
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34
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Prevention and Treatment of Infection in Kidney Transplant Recipients. THERAPY IN NEPHROLOGY & HYPERTENSION 2008. [PMCID: PMC7152127 DOI: 10.1016/b978-141605484-9.50092-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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35
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Giessing M, Muller D, Winkelmann B, Roigas J, Loening SA. Kidney transplantation in children and adolescents. Transplant Proc 2007; 39:2197-201. [PMID: 17889136 DOI: 10.1016/j.transproceed.2007.07.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Worldwide, specific pediatric allocation schemes successfully try to minimize waiting time for children with end-stage renal disease (ESRD). The article is a review of current issues in pediatric kidney transplantation. The procedure is the treatment of choice for children and adolescents with ESRD, with 1- and 3-year graft survival rates of 95% and 90% and recipient survival after 5 and 10 years of 95% and 90%. Preoperative surgery is often necessary to minimize negative effects of congenital anomalies. No minimum age exists for pediatric transplantation, but most often the recipient body weight is ideally above 10 to 15 kg. Technical concepts should include extravesical anastomosis, stenting of the ureter, and potentially intraperitoneal placement of the graft. Immunosuppression has constantly improved. The aim is a tailored regimen to reduce side effects and improve compliance, which necessitates intense counseling of the child and the parents prior to, during, and after transplantation as many adolescents lose their graft due to noncompliance. Intense follow-up must also exclude infections, especially with herpes and polyoma viruses. For the future, age matching may be only one promising concept to improve results. As only a small number of children require the procedure in each country, multinational studies should be initiated to optimize outcomes in children and adolescents.
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Affiliation(s)
- M Giessing
- Charité University Hospital, Department of Urology (Campus Mitte), Berlin, Germany.
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