A Heartbreaking Renal Transplantation: Is Norepinephrine the Culprit to Blame?

INTRODUCTION: Takotsubo cardiomyopathy (TCM), also known as "broken heart syndrome," "apical ballooning syndrome," and "stress-induced cardiomyopathy," was first described in Japanese patients in 1990 by Sato et al. TCM is an increasingly recognized syndrome characterized by transient and reversible systolic dysfunction of the apical and middle segments of the left ventricle. This syndrome resembles acute myocardial infarction in the absence of evident coronary artery occlusion. Herein, we present a case of a 51-year-old male who underwent his second deceased-donor renal transplantation for end-stage-renal-disease due to a work-related accident. Perioperatively, initiation of continuous infusion of noradrenaline was decided to achieve adequate graft perfusion due to persistently low blood pressure. On the second postoperative day, the patient experienced tachycardia and atypical angina-like chest pain. Electrocardiogram (ECG) showed signs of myocardial infarction and elevated troponin levels were observed. Urgent coronary angiography was normal and transthoracic echocardiography (TEE) was indicative for Takotsubo cardiomyopathy. DISCUSSION: Although, the precise pathophysiology of Takotsubo cardiomyopathy is still unknown, it seems that it is associated with excessive sympathetic stimulation, microvascular dysfunction, coronary artery vasospasm, and abnormal myocardial tissue metabolism. The development of patient's symptoms after the initiation of norepinephrine along with their immediate resolution after the discontinuation of the drug might suggest a causal relationship. This is the first time that TCM after renal transplantation is thought to be linked with the administration of exogenous catecholamines.

Exploring associations between anthropometric indices and graft function in patients receiving renal transplant.

BACKGROUND: The aim of the present study was to identify indicators of malnutrition, as obtained by anthropometric measurements, that might be potential predictors of transplant outcomes. METHODS: One hundred and three patients receiving a graft from a living or a deceased donor were included in this prospective study. Body mass index (BMI) based on pretransplant dry body weight, triceps skinfold, mid-arm muscle circumference and corrected mid-arm muscle area were measured. Post-transplant data on delayed graft function (DGF) and glomerular filtration rate (GFR) at discharge were collected until patient discharge. RESULTS: Delayed graft function developed in 36.9% of the patients. BMI was the only anthropometric variable associated with a higher likelihood of DGF (odds ratio = 1.25, 95% confidence interval = 1.07-1.47) after adjusting for age, gender, donor group, donor age and years of dialysis before transplantation. Obesity was associated with a higher frequency of DGF (83.3% versus 31.1%, P = 0.001) compared to normal weight. GFR at discharge was negatively associated with BMI [ß = -0.014 (0.005), P = 0.004], being overweight [ß = -0.151 (0.041), P < 0.001] and obesity [ß = -0.188 (0.053), P = 0.001], after adjusting for age, gender, donor group, donor age and years of dialysis, but was not associated with indices of muscle reserves. CONCLUSIONS: The likelihood of DGF was higher among obese patients, whereas GFR at discharge was negatively associated with being overweight and obesity.

Surgical Dead End in a Renal Transplant Recipient Associated With a Rare Thrombohemorrhagic Syndrome.

BACKGROUND: Primary breast angiosarcoma is an extremely rare malignancy. Association of this type of tumor with Kasabach-Merritt syndrome has only been reported in 3 cases in the past. To our knowledge, this is the first reported case of a solid-organ recipient. METHODS: A 53-year-old woman who underwent a deceased-donor renal transplantation 5 years previously presented with a 12-month history of a giant ulcerated lesion on her left breast. Biopsy of the overlying skin suggested primary angiosarcoma. Concurrently, the patient's bleeding from the site of the biopsy and hematology investigations indicated the presence of Kasabach-Merritt syndrome. RESULTS: The case was discussed in a multidisciplinary setting. The decision was to use anthracycline-based chemotherapy as up-front treatment to assess tumor response and gain a local benefit for a subsequent resection. After the completion of 1 cycle of chemotherapy, the patient died of cardiovascular insufficiency. Primary angiosarcoma of the breast occurs in the third to fourth decade and has been reported only in women. CONCLUSIONS: A high clinical suspicion and referral to a specialized center are necessary. Total mastectomy appears to be the only treatment conferring benefit; chemotherapy and radiation therapy are of little value.

Evolution of Renal Function in Renal Allograft Recipients Under Various Everolimus-Based Immunosuppressive Regimens.

BACKGROUND: Long-term allograft survival is a major challenge in kidney transplantation. This study sought to estimate the evolution of renal function in patients receiving different immunosuppressive regimens based on everolimus (EVR). METHODS: Ninety-nine renal allograft recipients were included in a 12-month open-label, noninterventional, prospective, single-center study. Patients were divided into 2 groups, de novo and late conversion to EVR. RESULTS: Group A included 40 patients under calcineurin inhibitor (CNI) plus EVR. Median time posttransplantation was 33.06 months (interquartile range 18.25 to 42.85). Mean estimated glomerular filtration rate (eGFR) the first month posttransplantation (using Modification of Diet in Renal Disease formula) was 54.89 ± 19.08 mL/min, and mean proteinuria was 0.54 ± 0.38 g/24 h. At the end of follow up, mean eGFR and mean proteinuria significantly improved (65.49 ± 20.79 mL/min; P = .011 and 0.157 ± 0.089 g/24 h; P = .002, respectively). Group B consisted of 59 patients; 49 of them initially received mycophenolic acid (MPA) plus CNI, and 10 had been on azathioprine plus CNI. Initial immunosuppression was switched to MPA plus EVR in 49 patients, CNI plus EVR in 4 patients, and EVR in 6 patients, in a median time of 37 months (interquartile range 14.75 to 112.5) posttransplantation. Main indications for conversion were malignancies and biopsy-proven chronic allograft injury. Mean eGFR 1 month posttransplantation and at the time of conversion were 50.79 ± 17.83 mL/min and 57.39 ± 19.17 mL/min, respectively (P = .014). After conversion, mean eGFR increased (66 ± 24.89 mL/min; P = .006). Mean proteinuria was 0.509 ± 0.530 g/24 h the first posttransplantation month, and it remained stable at 0.415 ± 0.431 g/24 h until study completion. Two acute rejection episodes occurred. At the end of follow-up, patient and death-censored graft survival were 97% and 100%, respectively. CONCLUSIONS: In kidney transplant recipients, EVR either de novo or after conversion with or without CNI is a safe and effective treatment that preserves renal function.

Incidence and management of Kaposi sarcoma in renal transplant recipients: the Greek experience.

OBJECTIVE: One of the most common malignancies in kidney transplant recipients is Kaposi sarcoma. The incidence of Kaposi sarcoma, which develops after renal transplantation, is 400-500 times higher than that in the general population. The aims of this study were to review the experience with Kaposi sarcoma in the highest-volume transplantation Unit in Greece and to analyze clinical characteristics and response to treatment, with respect to both the patients' survival and the renal graft function. MATERIALS AND METHODS: The records of 2008 renal graft recipients between March 1983 and December 2012 were retrospectively reviewed. Kaposi sarcoma was diagnosed based on clinical, laboratory, radiological, endoscopic, and histopathologic examinations. The disease was staged according to the classification of Al-Khader et al. RESULTS: The prevalence of Kaposi sarcoma was 1.2% in our renal transplant population. Of these, 1006 recipients underwent living-donor renal transplantation, whereas 1002 received their graft from deceased donors. Post-transplantation malignancy developed in 153 patients, among which, Kaposi sarcoma has been found in 24 cases. Of the 24 cases of Kaposi sarcoma, lesions were mainly cutaneous in 14 cases, visceral and cutaneous in 8, and concomitant visceral and lymph node involvement was observed in 2 patients. With regard to the final outcome, 20 patients (83.3%) showed remission of the disease, whereas 4 patients with visceral involvement (16.6%) did not respond to chemotherapy and discontinuation of immunosuppression and died. Moreover, 8 deaths occurred due to apparently unrelated causes. CONCLUSIONS: Kaposi sarcoma is an important part (15.7%) of all post-transplantation neoplasias in our series. Furthermore, our findings confirmed the previously described close association between human herpesvirus-8 and post-transplantation Kaposi sarcoma. Reduction of immunosuppression or discontinuation of calcineurin inhibitors results in remission of the disease in most of the cases. Prognosis in patients with Kaposi sarcoma limited to the skin is favorable, whereas visceral involvement is associated with high mortality.

Lithiasis of the renal allograft, a rare urological complication following renal transplantation: a single-center experience of 2,045 renal transplantations.

BACKGROUND AND PURPOSE: Urinary lithiasis represents an unusual urologic complication in renal transplantation, with an incidence of 0.17%-1.8%.We present our experience with renal graft lithiasis in our series of renal transplantations. MATERIAL AND METHODS: We reviewed the medical records for 2045 patients who underwent kidney transplantation from January 1983 to July 2013. Among the grafts, 9 patients were found to have allograft lithiasis. In 6 cases, the calculi were localized within the renal unit, and in 3 cases in the ureter. Two of the patients had relapsed after a few years from the first treatment. In both of them the stones were localized again in the ureter. RESULTS: In our series, incidence of graft lithiasis was 0.44% (n = 9). Three of the 9 patients (33.3%) were treated via percutaneous nephrolithotripsy (PCNL), 3 (33.3%) underwent extracorporeal shockwave lithotripsy (ESWL), 2 (22.2%) passed their stones spontaneously, and 1 (11.1%) underwent PCNL after 2 failed ESWL interventions. All patients are currently stone free but still remain under close urologic surveillance. CONCLUSIONS: Urinary stone formation can lead to significant morbidity and graft loss. The treatment options should be similar to those for patients in the general population. Long-term follow-up is substantial to determine the outcome and to prevent the recurrence.

Ovarian carcinosarcoma in a renal transplant recipient. A unique case of a rare tumor.

INTRODUCTION: De novo malignancies have become one of the leading causes of late mortality after renal transplantation, with their incidence being 2-15 fold higher than in general population. We present herein a unique case of ovarian carcinosarcoma in a renal transplant recipient. CASE REPORT: A 69-year-old female renal transplant recipient presented with progressive distension and vague abdominal pain. Clinical examination revealed a large abdominal mass. Magnetic resonance imaging scan verified the presence of the mass. An exploratory laparotomy was performed, identifying a giant tumor measuring 33 x 22 x 10 cm. Optimal debulking surgery was performed, the postoperative course was uneventful and she was discharged on the 8(th) postoperative day. The final diagnosis was ovarian carcinosarcoma. The patient received adjuvant chemotherapy and at 6-month follow-up, she was disease-free. CONCLUSION: Ovarian Carcinosarcoma is a rare and aggressive neoplasia, comprising 1-2 % of all ovarian tumors. Radical surgical approach, as well as appropriate chemotherapy are the cornerstone of treatment. In the presented case, where immunosuppression is involved, further evaluation should be made as far as immunosuppression dose reduction or switch is concerned.

Advanced donor age alone is not a risk factor for graft survival in kidney transplantation.

BACKGROUND: The use of kidneys from elderly deceased donors has substantially increased organ supply, although it is associated with worse graft function and survival rates. The risk of kidneys from elderly donors as well as expanded criteria donors (ECDs) on kidney transplant outcome was investigated. PATIENTS AND METHODS: Seventy-five kidney transplants from ECDs over a 5-year period were reviewed retrospectively. Old age and increased donor risk variables were analyzed separately in relation to graft function and survival. RESULTS: Sixty-four of 75 (85.3%) recipients had functioning grafts 5 years posttransplant. The overall actuarial graft survivals from 1 to 5 years were 87.5%, 68.1%, 57.3%, 55.4%, and 47.3%, respectively. Early graft function gave 47 (62.7%) kidneys remarkable actuarial survivals of 100.0%, 88.3%, 75.8%, 75.8%, and 68.4% at 1 to 5 years posttransplant, and 28 (37.3%) kidneys had delayed graft function with substantially decreased actuarial survival rates, ranging from 66.7% to 23.2%. Kidneys from elderly donors had considerable actuarial graft survival rates of 100.0%, 83.3%, 76.9%, 76.9%, and 67.0% from 1 to 5 years, respectively; these were the best graft survival rates compared with kidneys from the other donor categories. The other donor risk variables when associated with advanced age of any had an adverse effect on recipient graft function and survival, but no single risk variable alone, or a combination of any two, showed any statistically significant variability. CONCLUSION: Elderly kidney donors provided a substantial organ pool expansion without affecting patient and graft survival in many patients. ECDs can be utilized safely if adequate measures are taken.

Long-term post transplant alloantibody monitoring: a single center experience.

Between 2000 and 2010, 4241 sera from 597 renal transplant (RTx) recipients were monitored for DSA development. The patients were selected in the absence of immunological memory to donor HLA before RTx and were divided into two groups: the historic group, consisting of patients transplanted before December 1996 and the study group, consisting of those transplanted after December 1996. Ninety-two out of 597 (15.4%) patients developed de novo DSA post-RTx, while 196 had third party anti-HLA antibodies. DSA were more frequent in the historic group compared with the study group (P < 0.001). Anti-HLA class-III DSA predominated in both groups (84.6% vs. 69.7%) and were directed preferentially against donor HLA-DQ (65/92,70.6%). Recipients of class II-incompatible grafts developed DSA more frequently than those receiving class II-compatible grafts (P = 0.003). DSA production was not different between pre-sensitized and non-sensitized patients (P = 0.842). DSA class I (HR = 31.78), DSA class II (HR = 20.92), and non-DSA (HR = 5.94) were the only independent predictors for graft failure. In conclusion, this study shows the results of long-term post-transplant alloantibody monitoring, and confirm the strong association of DSA and graft loss. Protocols that remove anti-HLA antibodies from RTx recipients may benefit allograft survival.

Vascular complications in renal transplantation: a single-center experience in 1367 renal transplantations and review of the literature.

Renal transplantation is the treatment of choice for end-stage renal disease. Vascular complications in renal transplantation are not uncommon and may often lead to allograft loss. The most common vascular complications are transplant renal artery stenosis, transplant renal artery thrombosis, transplant renal vein thrombosis, biopsy-induced vascular injuries, pseudoaneurysm formation, and hematomas. Transplant renal artery and vein thrombosis have an early onset and a dramatic clinical manifestation and usually lead to allograft loss. In contrast, transplant renal artery stenosis has better treatment possibilities, whereas the rest do not occur so often. In our institution, 1367 renal transplantations were performed from September 1980 to April 2005. During this period, we encountered 38 major vascular complications leading to graft loss and 19 transplant renal artery stenoses with successful treatment in the majority of cases. According to these data, we can conclude that renal transplantation is a safe therapeutic procedure for renal failure.

Urological complications: analysis and management of 1525 consecutive renal transplantations.

Urological complications after renal transplantation increase morbidity, delay graft function, and occasionally lead to graft and/or patient loss. The aim of this study was to analyze the causes of and therapeutic approaches to urological complications in renal transplantation as they related to patient outcomes. A series of 1525 consecutive renal transplantations were performed over a 24-year period. Renal grafts were obtained in 814 cases from living-related and in 711 from cadaveric donors. A Lich-Gregoire ureterovesical reimplantation technique with minimal bladder wall dissection was employed in all cases. Ureteral stents were routinely used in cadaveric transplants and exceptionally among living-related grafts. Urological complications were classified according to the mechanism and site of urinary tract involvement: graft ureteropelvic junction obstruction/stenosis (A), ureteral obstruction/stenosis (B), ureterovesical anastomosis obstruction/stenosis (C), urinary leakage (D), and other (E). Overall, we encountered 96 urological complications (6.3%). Group C complications occurred in 29 cases (30.2%), followed by 27 cases (28.1%) for group B patients, 25 cases (26.0%) for group D, 12 cases (12.5%) for group A, and 3 cases (3.1%) for group E patients. Surgical intervention was required in 49 (51.0%) of all urological complications. The others (n = 47, 49.0%) were treated either conservatively or by minimally invasive procedures. A rapid diagnosis of urological complications, assisted by early posttransplant DTPA scans, routine ultrasonography, and especially prompt treatment, resulted in compensation of renal graft dysfunction in the vast majority (n = 90, 93.8%) of cases. Surgical techniques of graft retrieval and reimplantation are of utmost importance to minimize the incidence of urological complications.

Angioplasty and stenting of arterial stenosis affecting renal transplant function.

PURPOSE: To evaluate the efficacy of percutaneous angioplasty and stenting in cases of artery stenosis of the transplanted kidney or proximal iliac artery stenosis causing transplant dysfunction and/or increase of the arterial blood pressure. MATERIALS AND METHODS: Between January 1999 and June 2007, we evaluated 24 patients who had undergone renal transplantation and subsequently were diagnosed with refractory hypertension and transplant dysfunction for signs of possible renal transplant artery stenosis. Color Doppler ultrasonography and magnetic resonance angiography preceded the intrarterial angiographic investigation, with false-negative results in 18.2% and 13.6% of patients, respectively. In 2 of the 24 patients, angiography did not reveal arterial stenosis affecting the transplanted kidney. Two patients had severe ipsilateral iliac artery stenosis and the remaining 20 had transplant artery stenosis. Successful angioplasty and stenting were performed in these 22 patients. RESULTS: The method was technically feasible in 100%. The procedure-related morbidity was 0%. During the follow-up period (range: 3 to 104 months), two patients died with normal transplant function, two suffered transplant failure, and the remaining 18 still have normal transplant function and easily controlled hypertension. CONCLUSION: Percutaneous angioplasty and stenting in cases of arterial stenosis affecting the renal transplant function are safe and effective procedures. Even more, the strong clinical suspicion must lead to angiographic investigation regardless of the results of other imaging approaches.

Biopsy-related hemorrhage of renal allografts treated by percutaneous superselective segmental renal artery embolization.

INTRODUCTION: Biopsy-related vascular injuries in renal transplants are rare, but they can lead to dramatic clinical symptoms prompting immediate treatment. Transcatheter embolization is a minimally invasive technique used to treat some forms of arterial bleeding. This study evaluated the efficacy of this technique in iatrogenic biopsy-related vascular lesions in renal allografts. MATERIALS AND METHODS: Over the last eight years, six patients with severe renal hemorrhage were admitted to the angiography department of our hospital for evaluation and possible further treatment. All of them had a history of previous biopsy of a transplanted kidney. They all presented with clinical signs of hemodynamic instability. Angiographic investigation of the kidneys preceded further intervention in all cases. All underwent hyperselective embolization of the specific bleeding vessel with the use of microcoils and/or gelfoam particles. RESULTS: Successful embolization of the feeding artery could be performed in all patients. Superselective segmental renal artery embolization had a successful outcome concerning a steady renal function and a stable clinical course. No complications occurred. CONCLUSION: Transcatheter embolization is a safe and efficient endovascular technique to treat biopsy-related vascular injuries in renal transplants. Immediate clinical success and significant benefit in renal function can be obtained, and the longevity of the allograft after successful embolization mainly depends on the natural outcome.

Delayed renal graft function: the influence of immunosuppression.

INTRODUCTION: We evaluated the influence of different immunosuppressive regimens on delayed renal graft function and progression of renal function in the first year after transplantation. PATIENTS AND METHODS: Patients were divided into four groups according to the immunosuppressive regimen received: (1) rapamycin (Rap) + mycophenolate mofetil (MMF) + methylprednisolone (MP) + daclizumab (Dmab); (n = 44); (2) tacrolimus (Tac) + MMF + MP + Dmab (n = 39); (3) cyclosporine (CsA) + MMF + MP + basiliximab (Bmab); (n = 30); (4) antithymocyte globulin (ATG) + MMF + MP and CsA after ATG withdrawal (n = 40). Data were analyzed using ANOVA and linear regression. Delayed graft function was defined as the need for hemodialysis posttransplantation. RESULTS: There were no statistically significant differences between the four groups in terms of gender, time on dialysis before transplantation, histocompatibility, donor age, and cold ischemia time. However, age (49.8, 50.4, 49.8, and 43.5 years, P < .05), panel reactive antibodies (22%, 39%, 27%, 34%, P < .05) and time of delayed graft function (12, 7, 3, 6 days, P < .05) were significantly different between the four groups. The time of delayed graft function depended on the immunosuppressive regimen, as well as donor and recipient age (P < .05). The creatinine clearance demonstrated a statistically significant difference between the four groups in the first month after transplantation (45, 46, 61, 53 mL/min, P < .05), though no further difference was observed at the month 12th. CONCLUSIONS: The type of immunosuppressive therapy seems to substantially influence the time of recovery from delayed renal graft function, even though it does not seem to affect future graft function. Especially Rap, probably due to its potent antiproliferative effects, seems to prolong the length of graft recovery after renal transplantation.

Endovascular repair as first-choice treatment of iliac pseudoaneurysms following renal transplantation.

Pseudoaneurysms of the arterial anastomosis are rare complications of renal transplantation. We report three cases of patients with extrarenal pseudoaneurysms and describe their treatment by endovascular placement of covered stents. Two of these aneurysms were due to vascular infections by fungi. An 8-week antifungal therapy proved to be successful in preventing the risk of fungal infection of the graft material in both patients. All three of our grafts remained open 2 months to 3 years after their placement with no evidence of stenosis or infection.

Human herpesvirus type 8 genotypes in iatrogenic, classic and AIDS-associated Kaposi's sarcoma from Greece.

BACKGROUND: Kaposi's sarcoma-associated herpesvirus (KSHV)/human herpesvirus 8 (HHV-8) is consistently found in almost all observed Kaposi's sarcomas (KS), whether AIDS-associated, iatrogenic or classic. To our knowledge no data are available on the genetic polymorphism of HHV-8 from Greece. We report the study of 15 renal transplant recipients with KS, 5 with AIDS-associated KS, 11 with classic KS and 60 healthy individuals from Greece. MATERIALS AND METHODS: Polymerase chain reaction (PCR) was carried out on DNA extracted from peripheral-blood mononuclear cells (PBMC) or KS cutaneous biopsies, using specific primers for the HHV-8, KS330 fragment from ORF-26 (233 bp) and the highly variable region (VR1) from ORF-K1 (363 bp). RESULTS: HHV-8 DNA was detected in 30 out of 31 (97%) KS cases, regardless of their clinico-pathological subtype and in 10 out of 60 (16.7%) healthy individuals. Sequencing of the ORF26 fragment demonstrated that the 40 HHV-8 strains were of the A and C sub-types. Furthermore, sequencing of the ORF-K1 showed that these HHV-8 strains of Greek origin were of the A1, A4, C1 or C3 sub-type. CONCLUSION: Our findings imply a possible link of the C3 subtype of HHV-8 in renal transplant-related KS cases (iatrogenic KS) in Greece, a link of the A4 subtype in AIDS-associated KS cases and a potential involvement of the A1 subtype in Greek classic KS incidences, as HHV-8 strains among healthy individual tested belong to the C1, C3 or A1 subtypes.

Prolonged ureteral stenting in obstruction after renal transplantation: long-term results.

BACKGROUND: Renal transplantation is an effective treatment for end-stage renal disease. Ureteral stenosis is the most frequent urologic complication. We report our long-term follow-up results concerning endourologic treatment of ureteral obstruction after renal transplantation. METHODS: Between May 1997 and September 2000, 15 patients with renal transplant obstructive uropathy were managed with percutaneous nephrostomy and prolonged ureteral stenting. RESULTS: Percutaneous nephrostomies were performed successfully in all 15 kidneys. In 13 patients, antegrade ureteral stenting was attempted, which was successful in 11 patients (85%). After prolonged ureteral stenting (mean duration 15 months), the stent was removed in all patients, 90% of whom had no recurrence. During follow-up (36 to 71 months; mean 51), urea, creatinine, sodium, and potassium determinations and ultrasound scans were performed. Success was defined as a reduction in hydronephrosis. No major complications were observed. CONCLUSIONS: Modern endourologic procedures have replaced open reconstructive surgery in most patients with ureteral obstruction after renal transplantation, because they may offer a definitive treatment with low morbidity.

Metastatic melanoma within a transplanted kidney: a case report.

A 57-year-old woman recipient of a cadaveric renal allograft displayed metastatic melanoma within the transplant. The patient, who received imunnosuppressive therapy with cyclosporine, azathioprine, and prednisone, displayed normal renal function for 10 months posttransplantation. She was admitted due to multiple, large, rapidly growing skin nodules over the lower abdomen and to dyspnea. After a diagnostic evaluation, the renal graft was removed, revealing metastatic melanoma within the transplanted kidney and 2 focal points of melanoma within the skin lesions. The patient returned to hemodialysis, received chemotherapy and interferon A, but failed to respond and died 11 days after the nephrectomy.

Polyomavirus BK infection in Greek renal transplant recipients.

BK polyoma virus associated nephropathy is increasingly recognized as an important cause of allograft dysfunction among renal transplant recipients. Herein we present the cases of two renal transplant recipients who developed progressive functional deterioration suspicious for BK polyoma virus involvement. One patient had been treated with mycophenolate mofetil (MMF), cyclosporine (CsA), and prednisolone (P), and the second patient with tacrolimus (Tac), MMF, and (P). Using quantitative real-time polymerase chain reactions for BK virus DNA, we monitored the content of BK virus in the blood to evaluate disease progression. The high BK virus load initially detected in the blood samples from these patients decreased in the patient who received MMF, CsA, and P after the reduction of immunosuppression, but not in the patient who was treated with Tac, MMF and P. In contrast to previous reports, our patients had not received treatment with anti-lymphocyte globulin (ALG) or monoclonal anti-CD3 antibody (OKT3) after transplantation. It is concluded that even in the absence of vigorous antirejection treatment, immunosuppressive therapy based on Tac and MMF may carry the risk of BK virus-associated nephropathy. Because BK virus specific antiviral therapy is not available, its course may be monitored by measuring the viral load in blood.