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A case of polyomavirus-associated nephropathy presenting late after transplantation

Nature Clinical Practice Nephrology volume 4, pages 283–287 (2008)Cite this article

Abstract

Background A 36-year-old white female, who had received a deceased-donor kidney transplant for end-stage renal disease secondary to reflux nephropathy 8 years previously, was referred to a transplant clinic for evaluation following an increase in her serum creatinine level from 123.8 µmol/l to 185.6 µmol/l (1.4 mg/dl to 2.1 mg/dl) over the preceding 9 months. Her immunosuppression regimen included mycophenolate mofetil, ciclosporin and prednisone, with ciclosporin trough levels ranging from 100 ng/ml to 150 ng/ml, as detected by fluorescence polarization immunoassay, over the preceding year. The following possible causes of subacute renal failure were ruled out: post-obstructive nephropathy, altered hemodynamics (hypotension and renal artery stenosis), and toxicity from medications other than calcineurin inhibitors. Potential etiologies such as acute T-cell-mediated rejection, acute and chronic antibody-mediated rejection, polyomavirus-associated nephropathy, and calcineurin inhibitor nephrotoxicity were considered.

Investigations Physical examination, urine and blood analysis, analysis of human leukocyte antigen antibodies by flow cytometry (Luminex®, Luminex Corporation, Austin, TX), ultrasound of the transplanted kidney, polymerase chain reaction assay for the detection of BK virus in the serum, and biopsy of the transplanted kidney with staining for simian virus 40 antigen.

Diagnosis Polyomavirus-associated nephropathy with advanced nephrosclerosis and moderate to marked hyaline arteriolosclerosis.

Management Reduction of immunosuppression by discontinuation of mycophenolate mofetil, dose reduction of ciclosporin, and initiation of leflunomide.

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Figure 1: Light microscopy of the patient's kidney biopsy sample.
Figure 2: Trend in the patient's serum creatinine level before diagnosis and following treatment of the BK virus nephropathy, together with serial serum BK viral load determined by polymerase chain reaction.

References

  1. Drachenberg CB et al. (2007) Polyomavirus BK versus JC replication and nephropathy in renal transplant recipients: a prospective evaluation. Transplantation 84: 323–330

    Article  Google Scholar 

  2. Nickeleit V et al. (2003) Polyomavirus nephropathy: morphology, pathophysiology, and clinical management. Curr Opin Nephrol Hypertens 12: 599–605

    Article  Google Scholar 

  3. Drachenberg CB et al. (2004) Histological patterns of polyomavirus nephropathy: correlation with graft outcome and viral load. Am J Transplant 4: 2082–2092

    Article  Google Scholar 

  4. Nickeleit V et al. (1999) Polyomavirus infection of renal allograft recipients: from latent infection to manifest disease. J Am Soc Nephrol 10: 1080–1089

    CAS  PubMed  Google Scholar 

  5. Hirsch HH et al. (2002) Prospective study of polyomavirus type BK replication and nephropathy in renal-transplant recipients. N Engl J Med 347: 488–496

    Article  Google Scholar 

  6. Brennan DC et al. (2005) Incidence of BK with tacrolimus versus cyclosporine and impact of preemptive immunosuppression reduction. Am J Transplant 5: 582–594

    Article  CAS  Google Scholar 

  7. Hirsch HH et al. (2005) Polyomavirus-associated nephropathy in renal transplantation: interdisciplinary analyses and recommendations. Transplantation 79: 1277–1286

    Article  Google Scholar 

  8. Kiberd BA (2005) Screening to prevent polyoma virus nephropathy: a medical decision analysis. Am J Transplant 5: 2410–2416

    Article  Google Scholar 

  9. Randhawa P et al. (2005) Monitoring for polyomavirus BK and JC in urine: comparison of quantitative polymerase chain reaction with urine cytology. Transplantation 79: 984–986

    Article  CAS  Google Scholar 

  10. Wadei HM et al. (2006) Kidney transplant function and histological clearance of virus following diagnosis of polyomavirus-associated nephropathy (PVAN). Am J Transplant 6: 1025–1032

    Article  CAS  Google Scholar 

  11. Josephson MA et al. (2006) Treatment of renal allograft polyoma BK virus infection with leflunomide. Transplantation 81: 704–710

    Article  CAS  Google Scholar 

  12. Vats A et al. (2003) Quantitative viral load monitoring and cidofovir therapy for the management of BK virus-associated nephropathy in children and adults. Transplantation 75: 105–112

    Article  CAS  Google Scholar 

  13. Farasati NA et al. (2005) Effect of leflunomide and cidofovir on replication of BK virus in an in vitro culture system. Transplantation 79: 116–118

    Article  CAS  Google Scholar 

  14. Leung AY et al. (2005) Ciprofloxacin decreased polyoma BK virus load in patients who underwent allogeneic hematopoietic stem cell transplantation. Clin Infect Dis 40: 528–537

    Article  CAS  Google Scholar 

  15. Sener A et al. (2006) Intravenous immunoglobulin as a treatment for BK virus associated nephropathy: one-year follow-up of renal allograft recipients. Transplantation 81: 117–120

    Article  CAS  Google Scholar 

  16. Ramos E et al. (2004) Retransplantation in patients with graft loss caused by polyoma virus nephropathy. Transplantation 77: 131–133

    Article  Google Scholar 

Download references

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Authors and Affiliations

  1. S Bansal is a Nephrology Fellow and MS Lucia is an Associate Professor of Pathology and the Chief of Genitourinary and Renal Pathology, at the University of Colorado at Denver Health Sciences Center, and A Wiseman is an Associate Professor of Medicine at the University of Colorado at Denver Health Sciences Center and the Clinical Director of the Kidney Transplant Program at the University of Colorado Hospital, Denver, CO, USA.,

    Shweta Bansal, M Scott Lucia & Alexander Wiseman

Authors
  1. Shweta Bansal
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  2. M Scott Lucia
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  3. Alexander Wiseman
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Correspondence to Alexander Wiseman.

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The authors declare no competing financial interests.

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Bansal, S., Lucia, M. & Wiseman, A. A case of polyomavirus-associated nephropathy presenting late after transplantation. Nat Rev Nephrol 4, 283–287 (2008). https://doi.org/10.1038/ncpneph0784

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