Purpose: BKV infection is associated with a progressive decline in renal function in renal transplant recipients with a significant incidence of graft loss (30-40%) in the setting of BKV allograft nephropathy (BKVAN). BK viremia serves as a quantifiable surrogate marker of the course of infection and has to be aggressively managed to preempt the development of BKVAN.
Methods: An intensive post-transplant screening protocol, early diagnosis and reduction in immunosuppression with/without the use of antiviral therapy – Leflunomide (LF) with/without low dose Cidofovir (CIDF) [0.25-0.40 mg/kg] has been utilized to preempt the development of BKVAN. CIDF was used instead of LF in the setting of initial high serum viral titers & when use of LF had no significant effect on serum viral titers. Demographics, immunosuppressive therapy with immune monitoring, viral PCR assays, allograft biopsies, clinical course, renal function & graft outcome were studied.
Results: Retrospective data (2006-date) – 57 patients with BKV infection (viruria ± viremia) diagnosed in 431 consecutive renal transplants. Median time to diagnosis – 120 days (range 21-1460 days). 41/57 patients (72%) had BK viremia, median viral load 10,100 copies (range 300->39 million copies). Allograft biopsies – performed in 27 patients (7 positive for BKVAN).
Group 1 (Viruria only): 16 patients: 15 patients (median viral load 39 million, range 800-> 100 billion) cleared with reduction in immunosuppression (R-IM) and 1 cleared with R-IM+LF.
Group 2 (Viruria + Viremia): 41 patients: 19 cleared with R-IM, 9 with R-IM+LF. One graft lost to BKVAN. 1 patient – being treated with R-IM+LF with significant reduction in viremia.
CIDF group: 11 patients (4 have BKVAN) – 4 cleared viremia (mean 13 doses), 5 patients have had significant reduction in viremia with ongoing treatment (mean 16.4 doses) and 2 patients have just initiated treatment.
The mean serum creatinine for patients in Group 2 – 1.3 (range 0.6-2.2). There have been only 2 graft losses: 1 due to BKVAN (early in study, no antiviral Rx) & the other to chronic antibody mediated rejection.
Conclusions: Early clearance of BK viremia significantly reduces the potential for graft loss. We advocate this approach together with use of low dose Cidofovir which is well tolerated with clearance of BK and stabilization of renal function.
To cite this abstract in AMA style:Varma C, Cipollina G, Le M, Gupta M, Kotru A. BK Virus (BKV) Infection in Renal Transplantation: Excellent Outcomes with a Protocol of Intensive Post-Transplant Screening with Reduction in Immunosuppression & Treatment with Leflunomide and/or Low Dose Cidofovir [abstract]. Am J Transplant. 2013; 13 (suppl 5). https://atcmeetingabstracts.com/abstract/bk-virus-bkv-infection-in-renal-transplantation-excellent-outcomes-with-a-protocol-of-intensive-post-transplant-screening-with-reduction-in-immunosuppression-treatment-with-leflunomide-andor/. Accessed December 1, 2020.
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