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Abu Jawdeh BG, Smith ML, Hudson MR, Mour GK, Budhiraja P, Rosenthal JL. Case report: JC polyomavirus nephropathy in simultaneous heart-kidney transplantation: the role of viral-specific in situ hybridization staining. Front Med (Lausanne) 2023; 10:1282827. [PMID: 37928458 PMCID: PMC10622943 DOI: 10.3389/fmed.2023.1282827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 09/27/2023] [Indexed: 11/07/2023] Open
Abstract
Introduction JC polyomavirus (JCPyV) is a ubiquitous virus that can be latent in the brain and the kidney. It is the etiologic agent responsible for progressive multifocal leukoencephalopathy, a fatal, demyelinating disease of the central nervous system, and rarely causes polyomavirus nephropathy in immunocompromised kidney transplant recipients. Case description We present the first case of JCPyV nephropathy in a simultaneous heart-kidney transplant patient, where viral-specific in situ hybridization staining of the kidney tissue was utilized to confirm the diagnosis. The patient was diagnosed 6 years after simultaneous heart-kidney transplantation and was treated with immunosuppression reduction and intravenous immunoglobulin. Discussion JCPyV nephropathy should be considered in the differential diagnosis of kidney allograft injury, particularly, with suggestive light microscopy histologic features in the absence of BK polyomavirus viremia and/or viruria. In addition to obtaining JCPyV PCR in the blood, in situ hybridization staining may have a utility in confirming the diagnosis. To date, we lack effective JCPyV-specific therapies, and prompt initiation of immunosuppression reduction remains the mainstay of treatment.
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Affiliation(s)
| | - Maxwell L. Smith
- Division of Anatomic Pathology, Mayo Clinic Arizona, Phoenix, AZ, United States
| | | | - Girish K. Mour
- Division of Nephrology, Mayo Clinic Arizona, Phoenix, AZ, United States
| | - Pooja Budhiraja
- Division of Nephrology, Mayo Clinic Arizona, Phoenix, AZ, United States
| | - Julie L. Rosenthal
- Division of Cardiovascular Diseases, Mayo Clinic Arizona, Phoenix, AZ, United States
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Fachin A, De Carlo C, Maestro A, Zanon D, Barbi E, Maximova N. Rapid Resolution of Life-Threatening Hypertriglyceridemia after Evinacumab Administration in a Pediatric HSCT Recipient: A Case Report. Pharmaceuticals (Basel) 2023; 16:1069. [PMID: 37630982 PMCID: PMC10457918 DOI: 10.3390/ph16081069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 07/21/2023] [Accepted: 07/22/2023] [Indexed: 08/27/2023] Open
Abstract
Evinacumab, a human monoclonal antibody against angiopoietin-like protein 3 (ANGPTL3), has recently been approved by the U.S. Food and Drug Administration as an add-on therapy for homozygous familial hypercholesterolemia (HoFH) in patients of 12 years and older. Its role as a triglyceride-lowering drug is also emerging in the literature. However, it has not been approved for this indication yet, neither in the adult nor in the pediatric population. We describe the case of a 10-year-old boy who underwent an allogeneic hematopoietic stem cell transplant for acute lymphoblastic leukemia complicated by chronic graft-versus-host disease (GVHD) and presented life-threatening refractory hypertriglyceridemia due to the concomitant use of ruxolitinib and sirolimus. After the failure of the insulin treatment and due to the technical impossibility of performing lipid apheresis, the child underwent evinacumab treatment, obtaining a dramatic rapid reduction in triglyceride and cholesterol levels. This is the first report of a pediatric patient younger than 12 years in Europe receiving evinacumab to treat severe hypertriglyceridemia. The therapy with angiopoietin-like proteins inhibitors has been effective, safe, and well-tolerated in our patient, suggesting that evinacumab may be used in the pediatric population when other therapeutic strategies are ineffective or contraindicated.
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Affiliation(s)
- Alice Fachin
- Department of Medicine, Surgery and Health Sciences, University of Trieste, 34127 Trieste, Italy; (A.F.); (E.B.)
| | - Chiara De Carlo
- Department of Medicine, Surgery and Health Sciences, University of Udine, 33100 Udine, Italy;
| | - Alessandra Maestro
- Institute for Maternal and Child Health—IRCCS Burlo Garofolo, 34137 Trieste, Italy; (A.M.); (D.Z.)
| | - Davide Zanon
- Institute for Maternal and Child Health—IRCCS Burlo Garofolo, 34137 Trieste, Italy; (A.M.); (D.Z.)
| | - Egidio Barbi
- Department of Medicine, Surgery and Health Sciences, University of Trieste, 34127 Trieste, Italy; (A.F.); (E.B.)
- Institute for Maternal and Child Health—IRCCS Burlo Garofolo, 34137 Trieste, Italy; (A.M.); (D.Z.)
| | - Natalia Maximova
- Institute for Maternal and Child Health—IRCCS Burlo Garofolo, 34137 Trieste, Italy; (A.M.); (D.Z.)
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Kurašová E, Štěpán J, Krejčí K, Mrázek F, Sauer P, Janečková J, Tichý T. Current Status, Prevention and Treatment of BK Virus Nephropathy. Acta Medica (Hradec Kralove) 2022; 65:119-124. [PMID: 36942701 DOI: 10.14712/18059694.2023.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
All renal transplant recipients should undergo a regular screening for BK viral (BKV) viremia. Gradual reduction of immunosuppression is recommended in patients with persistent plasma BKV viremia for 3 weeks after the first detection, reflecting the presence of probable or suspected BKV-associated nephropathy. Reduction of immunosuppression is also a primary intervention in biopsy proven nephropathy associated with BKV (BKVN). Thus, allograft biopsy is not required to treat patients with BKV viremia with stabilized graft function. There is a lack of proper randomised clinical trials recommending treatment in the form of switching from tacrolimus to cyclosporin-A, from mycophenolate to mTOR inhibitors or leflunomide, or the additive use of intravenous immunoglobulins, leflunomide or cidofovir. Fluoroquinolones are not recommended for prophylaxis or therapy. There are on-going studies to evaluate the possibility of using a multi-epitope anti-BKV vaccine, administration of BKV-specific T cell immunotherapy, BKV-specific human monoclonal antibody and RNA antisense oligonucleotides. Retransplantation after allograft loss due to BKVN can be successful if BKV viremia is definitively removed, regardless of allograft nephrectomy.
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Affiliation(s)
- Ester Kurašová
- University Hospital Olomouc and Palacký University Olomouc, Faculty of Medicine and Dentistry, Department of Internal Medicine III - Nephrology, Rheumatology and Endocrinology, Olomouc, Czech Republic.
| | - Jakub Štěpán
- University Hospital Olomouc and Palacký University Olomouc, Faculty of Medicine and Dentistry, Department of Internal Medicine III - Nephrology, Rheumatology and Endocrinology, Olomouc, Czech Republic
| | - Karel Krejčí
- University Hospital Olomouc and Palacký University Olomouc, Faculty of Medicine and Dentistry, Department of Internal Medicine III - Nephrology, Rheumatology and Endocrinology, Olomouc, Czech Republic
| | - František Mrázek
- University Hospital Olomouc and Palacký University Olomouc, Faculty of Medicine and Dentistry, Department of Immunology, Olomouc, Czech Republic
| | - Pavel Sauer
- University Hospital Olomouc and Palacký University Olomouc, Faculty of Medicine and Dentistry, Department of Microbiology, Olomouc, Czech Republic
| | - Jana Janečková
- University Hospital Olomouc and Palacký University Olomouc, Faculty of Medicine and Dentistry, Department of Surgery II, Olomouc, Czech Republic
| | - Tomáš Tichý
- University Hospital Olomouc and Palacký University Olomouc, Faculty of Medicine and Dentistry, Department of Clinical and Molecular Pathology, Olomouc, Czech Republic
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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] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Kharel A, Djamali A, Jorgenson MR, Alzoubi B, Swanson KJ, Garg N, Aziz F, Mohamed MA, Mandelbrot DA, Parajuli S. Risk factors for progression from low level BK dnaemia to unfavorable outcomes after BK management via immunosuppressive reduction. Transpl Infect Dis 2021; 23:e13561. [PMID: 33400361 DOI: 10.1111/tid.13561] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 12/23/2020] [Accepted: 12/29/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUNDS Effective management of BK viremia (BKPyV-DNAemia) in kidney transplant recipients (KTRs) involves regular monitoring and adjustment of immunosuppression. With this strategy, the majority of patients will clear BK or have ongoing, but non-significant, low-level BKPyV-DNAemia. However, despite adjustments, some will develop more severe sequelae of BK including BKPyV-DNAemia >5 log10 copies/mL and BK nephropathy, and others may develop de novo DSA (dnDSA) or acute rejection (AR). METHODS This was a single-center study of KTRs transplanted at the University of Wisconsin-Madison between 01/01/2015 and 12/31/2017. In this study, we sought to elucidate characteristics associated with the progression of BKPyV-DNAemia to unfavorable outcomes after decreasing immunosuppressive medications for the management of BK viremia as described in consensus guidelines. RESULTS A total of 224 KTRs fulfilled our selection criteria; 118 (53%) resolved or had persistent low DNAemia, 64 (28%) had severe BK/nephropathy, and 42 (19%) developed dnDSA or AR. In multivariable analysis, female gender (HR: 2.05; 95% CI: 1.08-3.90; P = .02); previous rejection (HR: 2.90; 95% CI: 1.04-8.12; P = .04), and early infection (HR: 0.81; 95% CI: 0.72-0.90; P < .001) were associated with the development of severe BK/nephropathy. Conversely, non-depleting induction at transplant (HR: 2.06; 95% CI: 1.03-4.11; P = .03), HLA mismatches >3 (HR: 2.27; HR: 1.01-5.06; P = .04), and delayed graft function (HR: 4.14; 95% CI: 1.12-15.28; P = .03) were associated with development of dnDSA and/or rejection. CONCLUSION Our study suggests that almost half of KTRs with BKPyV-DNAemia managed by our immunosuppressant adjustment protocol progress unfavorably. Identification of these risk factors could assist the frontline clinician in creating an individualized immunosuppressive modification plan potentially mitigating negative outcomes.
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Affiliation(s)
- Abish Kharel
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Arjang Djamali
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Margaret R Jorgenson
- Department of Pharmacy, University of Wisconsin Hospital and Clinics, Madison, WI, USA
| | - Beyann Alzoubi
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Kurtis J Swanson
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Neetika Garg
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Fahad Aziz
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Maha A Mohamed
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Didier A Mandelbrot
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Sandesh Parajuli
- Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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Rodriguez-Cubillo B, de la Higuera MAM, Lucena R, Franci EV, Hurtado M, Romero NC, Moreno AR, Valencia D, Velo M, Fornie IS, Sanchez-Fructuoso AI. Should cyclosporine be useful in renal transplant recipients affected by SARS-CoV-2? Am J Transplant 2020; 20:3173-3181. [PMID: 32529737 PMCID: PMC7307110 DOI: 10.1111/ajt.16141] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 05/26/2020] [Accepted: 06/08/2020] [Indexed: 01/25/2023]
Abstract
Minimization of immunosuppression and administration of antiretrovirals have been recommended for kidney transplant recipients (KTRs) with coronavirus disease 2019 (COVID-19). However, outcomes remain poor. Given the likely benefit of cyclosporine because of its antiviral and immunomodulatory effect, we have been using it as a strategy in KTRs diagnosed with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We studied 29 kidney transplant recipients (KTRs) who were admitted to our institution with COVID-19 between March 15and April, 24, 2020. Mycophenolate and/or mammalian target of rapamycin inhibitors (mTORi) were discontinued in all patients. Two therapeutic strategies were compared: Group 1, minimization of calcineurin inhibitors (N = 6); and Group 2, cyclosporine-based therapy (N = 23), with 15 patients switched from tacrolimus. Hydroxychloroquine was considered in both strategies but antivirals in none. Six patients died after respiratory distress (20.6%). Five required mechanical ventilation (17.2%), and 3 could be weaned. Nineteen patients had an uneventful recovery (65.5%). In group 1, 3 of 6 patients died (50%) and 1 of 6 required invasive mechanical ventilation (16.7%). In group 2, 3 of 23 patients died (12.5%). Renal function did not deteriorate and signs of rejection were not observed in any patient on the second treatment regime. In conclusion, immunosuppressant treatment based on cyclosporine could be safe and effective for KTRs diagnosed with COVID-19.
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Affiliation(s)
- Beatriz Rodriguez-Cubillo
- Nephrology Department, Hospital Clinico San Carlos, Madrid, Spain
- Correspondence Beatriz Rodriguez-Cubillo
| | | | - Rafael Lucena
- Nephrology Department, Hospital Clinico San Carlos, Madrid, Spain
| | - Elena V. Franci
- Nephrology Department, Hospital Clinico San Carlos, Madrid, Spain
| | - Maria Hurtado
- Nephrology Department, Hospital Clinico San Carlos, Madrid, Spain
| | | | | | - Daniela Valencia
- Nephrology Department, Hospital Clinico San Carlos, Madrid, Spain
| | - Mercedes Velo
- Nephrology Department, Hospital Clinico San Carlos, Madrid, Spain
| | - Iñigo S. Fornie
- Internal Medicine Department, Hospital Clinico San Carlos, Madrid, Spain
| | - Ana I. Sanchez-Fructuoso
- Nephrology Department, Hospital Clinico San Carlos, University of Medicine Complutense de Madrid, Madrid, Spain
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Matsumura S, Kato T, Taniguchi A, Kawamura M, Nakazawa S, Namba-Hamano T, Abe T, Nonomura N, Imamura R. Clinical Efficacy of Intravenous Immunoglobulin for BK Polyomavirus-Associated Nephropathy After Living Kidney Transplantation. Ther Clin Risk Manag 2020; 16:947-952. [PMID: 33116544 PMCID: PMC7549878 DOI: 10.2147/tcrm.s273388] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 09/07/2020] [Indexed: 12/19/2022] Open
Abstract
Purpose BK polyomavirus (BKPyV)-associated nephropathy (BKPyVAN) is one of the most difficult infections to be treated after kidney transplantation. Although patients with BKPyVAN usually received a reduction of immunosuppressive agents, the majority of these patients undergo the loss of the graft kidney without any effective treatment afterward. Therefore, development of more effective therapy for BKPyVAN is eagerly expected. Patients and Methods Among patients who underwent a kidney transplantation between January 2016 and April 2019 at our hospital, there were five cases of BKPyVAN. After the initial diagnosis, all patients discontinued administration of mycophenolate mofetil (MMF), which was not enough to diminish decoy cells in urine cytology test. Therefore, all patients received additional intravenous immunoglobulin (IVIG) (100 mg/kg/day) therapy for five days and were evaluated for the therapeutic effect of IVIG with immunohistochemical examination using re-biopsy samples of the graft kidney. Results After IVIG therapy, 2 cases showed negative decoy cells in urine and 3 cases showed a drastic decrease of plasma BK virus load. Importantly, simian virus (SV) 40 large T antigens diminished after IVIG administration in all cases, which degraded polyomavirus nephropathy classification. Conclusion Although it is difficult to treat BKPyVAN after kidney transplant, IVIG therapy was considered to a promising treatment to improve severity of BKPyVAN especially in cases that dose reduction of immunosuppressive agents was ineffective.
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Affiliation(s)
- Soichi Matsumura
- Department of Urology, Osaka University Graduate School of Medicine, Osaka 565-0871, Japan
| | - Taigo Kato
- Department of Urology, Osaka University Graduate School of Medicine, Osaka 565-0871, Japan.,Department of Urological Immuno-Oncology, Osaka University Graduate School of Medicine, Osaka 565-0871, Japan
| | - Ayumu Taniguchi
- Department of Urology, Osaka University Graduate School of Medicine, Osaka 565-0871, Japan
| | - Masataka Kawamura
- Department of Urology, Osaka University Graduate School of Medicine, Osaka 565-0871, Japan
| | - Shigeaki Nakazawa
- Department of Urology, Osaka University Graduate School of Medicine, Osaka 565-0871, Japan
| | - Tomoko Namba-Hamano
- Department of Nephrology, Osaka University Graduate School of Medicine, Osaka 565-0871, Japan
| | - Toyofumi Abe
- Department of Urology, Osaka University Graduate School of Medicine, Osaka 565-0871, Japan
| | - Norio Nonomura
- Department of Urology, Osaka University Graduate School of Medicine, Osaka 565-0871, Japan
| | - Ryoichi Imamura
- Department of Urology, Osaka University Graduate School of Medicine, Osaka 565-0871, Japan
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Sharma R, Zachariah M. BK Virus Nephropathy: Prevalence, Impact and Management Strategies. Int J Nephrol Renovasc Dis 2020; 13:187-192. [PMID: 32821148 PMCID: PMC7423353 DOI: 10.2147/ijnrd.s236556] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 07/29/2020] [Indexed: 12/25/2022] Open
Abstract
BK virus reactivation as a result of therapeutic immunosuppression following renal transplant can result in BK polyomavirus nephropathy and renal allograft loss. This is a complex and challenging clinical problem with a range of management options and practices reported in literature. The current standard for early diagnosis and treatment is surveillance by measuring viral DNA in blood using qPCR. Immunosuppression reduction is the cornerstone of effective management but is associated with a risk of acute rejection following treatment.
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Affiliation(s)
- Rajeev Sharma
- School of Medicine, University of Nevada Las Vegas, Las Vegas, NV, USA.,Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
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