Prevention and management of BK virus-induced (polyomavirus-induced) nephropathy in kidney transplantation
- Ajit P Limaye, MD, FACP, FIDSA
Ajit P Limaye, MD, FACP, FIDSA
- Professor of Medicine
- University of Washington
- Daniel C Brennan, MD, FACP
Daniel C Brennan, MD, FACP
- Editor-in-Chief — Nephrology
- Section Editor — Renal Transplantation
- Professor of Medicine
- Washington University School of Medicine
- Section Editor
- Barbara Murphy, MB, BAO, BCh, FRCPI
Barbara Murphy, MB, BAO, BCh, FRCPI
- Section Editor — Renal Transplantation
- Professor of Medicine
- Mount Sinai School of Medicine
Polyomaviruses are ubiquitous, small, nonenveloped, double-stranded DNA viruses that infect a variety of animals (including monkeys, humans, rabbits, rodents, and birds) but tend to be species specific. The polyomaviruses are highly seroprevalent in humans but only cause clinical disease among immunocompromised patients.
Multiple human polyomaviruses have been identified. BK virus (BKV) and JC virus are the two most common polyoma viruses associated with human disease and the only two associated with nephropathy (BKVN).
The major diseases caused by BKV are tubulointerstitial nephritis and ureteral stenosis in renal transplant recipients and hemorrhagic cystitis in bone marrow transplant recipients. BKV causes clinical disease of the genitourinary tract due in part to its tropism for genitourinary epithelium. JC virus causes a small proportion of polyomavirus nephropathy (<5 percent) among kidney transplant recipients and is typically associated with a milder clinical course.
BKVN reportedly occurs in up to 10 percent of kidney allograft recipients . Overall, the reported incidence of allograft failure ranges from 15 to 50 percent of affected individuals [2-5]. Approaches to prevention and management of BKVN in kidney transplant recipients are presented here. The clinical manifestations and diagnosis of this disorder and general overviews of these viruses are discussed separately. (See "Overview of JC polyomavirus, BK polyomavirus, and other polyomavirus infections" and "Virology, epidemiology, and pathogenesis of JC polyomavirus, BK polyomavirus, and other human polyomaviruses" and "Clinical manifestations and diagnosis of BK virus-induced (polyomavirus-induced) nephropathy in kidney transplantation".)
SCREENING AND PREVENTION
BKV infections progress through well-characterized stages [6-9]. Initially, BKV DNA is detected in the urine, followed by detection in the plasma, and, finally, in the kidney (ie, BKVN) (figure 1). (See "Clinical manifestations and diagnosis of BK virus-induced (polyomavirus-induced) nephropathy in kidney transplantation".)
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- SCREENING AND PREVENTION
- Approach to screening
- Decreased immunosuppression
- Antiviral agents
- - Intravenous immune globulin
- - Leflunomide
- - Cidofovir
- - Brincidofovir (formerly CMX001)
- - Quinolone antibiotics
- - Retinoic acid
- MONITORING RESPONSE TO TREATMENT
- KIDNEY RETRANSPLANTATION
- SUMMARY AND RECOMMENDATIONS