Clinical Characteristic and Outcomes of BK Virus Infection in Kidney Transplant Recipients Managed Using a Systematic Surveillance and Treatment Strategy.

BACKGROUND: BK virus (BKV)-associated nephropathy is a significant complication of kidney transplantation that progresses to graft dysfunction and graft loss. The aim of this study was to know the infection rate and progression of BKV according to our strategy. MATERIALS AND METHODS: This study included 302 patients who received kidney transplantation between August 2010 and October 2012. Patients were divided into 4 groups: no BK infection, BK viruria only, low BK viremia, and high BK viremia. RESULTS: In this study, 57 patients had BK viremia (18.9%), and 18 patients had BK nephropathy (5.9%) during a 2-year follow-up period. Age, sex, cytomegalovirus (CMV) viremia, existence of donor-specific antibodies, type of transplantation, and delayed graft function were not significantly different. Disappearance of BKV infection was better in the viruria and low viremia groups than in the high viremia group (P = .001), and duration of BK infection was longer in the high viremia group than the low viremia group (P = .002). CONCLUSION: All diagnosed cases of BKV nephropathy were in the high BK viremia group. For BK viruria and viremia, early detection of BK infection together with early intervention by reduced immunosuppressant is a useful strategy to maintain allograft function. Long-term follow up is required to identify the risk factors for BK infection and graft survival after kidney transplantation.

Alemtuzumab induction for retransplantation after primary transplant with alemtuzumab induction
.

BACKGROUND: Lymphocyte-depleting induction with alemtuzumab (ALEM) or rabbit antithymocyte-globulin (rATG) is commonly used at retransplantation. It is unknown which agent is preferable, particularly when ALEM was used at primary transplant. OBJECTIVE: Evaluate outcomes after ALEM at retransplant following primary transplant with ALEM induction (ALEM-ALEM) as compared to retransplant with rATG (ALEM-rATG). MATERIALS AND METHODS: Single-center, observational cohort study of adult patients receiving kidney or pancreas transplant between January 1, 2001 and December 12, 2016. RESULTS: 45 patients (16 ALEM-ALEM and 29 ALEM-rATG) met inclusion criteria. The ALEM-ALEM group had fewer days between transplants (621.0 ± 821.8 vs. 2,024.4 ± 1,285.8, p = 0.049), lower panel-reactive-antibodies (PRA) prior to transplant 2 (15.7 ± 31.5 vs. 53.2 ± 37.8; p = 0.0003), and more pancreas secondary transplants, although this was not statistically significant (ALEM-ALEM 37.5% vs. ALEM-rATG 10.3%, p = 0.05). The ALEM-ALEM group experienced a significantly higher rate of fungal infection (ALEM-ALEM 46.8% vs. ALEM-rATG 11.3%, p = 0.02). When adjusted in a multivariate model, this trend persisted (HR 3.97, CI 0.95 - 16.5, p = 0.05). A subgroup analysis of patients receiving a kidney for both transplant 1 and 2 to remove the possible confounding effect of pancreas allografts also found incidence of fungal infection at 1 year to be significantly higher in the ALEM-ALEM group (ALEM-ALEM 25% vs. ALEM-rATG 9.3%, p = 0.025). Rejection rates were not different between groups at 1 year (ALEM-ALEM 25% vs. ALEM-rATG 24.2%). Rates of cytomegalovirus (CMV) infection, BK polyomavirus infection, patient and graft survival were also similar. CONCLUSION: Patients with repeat courses of ALEM induction across multiple transplants may have a higher incidence of fungal infection. Future studies are needed to explore this risk, particularly in light of current drug manufacturer allocation practices and potential increased utilization by transplant centers.

A delicate balance between rejection and BK polyomavirus associated nephropathy; A retrospective cohort study in renal transplant recipients.

BACKGROUND: The immunosuppressive agents mycophenolate acid (MPA) and tacrolimus (Tac) are associated with a higher incidence of BK polyomavirus nephropathy (BKPyVAN). In this observational retrospective cohort study, the frequency of BK polyomavirus (BKPyV) complications over a 24-month period was studied. METHODS: 358 renal transplant recipients (RTR) treated with MPA, with either cyclosporine A (CsA) (CsAM group) or Tac (TacM group) and mostly prednisolone, were included. RESULTS: Incidence of BKPyV-viremia was not significantly different between the CsAM (n = 42/191) (22.0%) and the TacM (n = 36/167) (21.6%) group. Biopsy proven BKPyVAN occurred more often in the TacM group (6.6%) versus the CsAM group (2.1%) (p = 0.03). Longitudinal data analysis showed a significant earlier decline of viral load in plasma in the CsAM group compared to the TacM group (p = 0.005). The incidence of biopsy proven acute rejection (BPAR) was significantly higher in the CsAM (19.9%) compared to the TacM (10.8%) (p = 0.02) group. Graft loss, estimated glomerular filtration rate and mortality rate did not differ in both treatment groups. CONCLUSION: In conclusion, this study shows that immunosuppressive treatment with Tac and MPA compared to CsA and MPA is associated with a lower incidence of BPAR, but at the cost of an increased risk of developing BKPyVAN in the first two years post-transplant.

Polyomavirus-associated Prostatitis in Wistar Han Rats Following Immunosuppression in a Chronic Toxicity Study.

Chronic prostatitis characterized on light microscopic examination by moderate, multifocal, predominantly lymphocytic inflammation associated with epithelial atypia and intranuclear and cytoplasmic inclusion-like material was identified in the prostate gland of 2 Wistar Han rats administered an immunomodulatory test article in a 6-month chronic toxicity study. Transmission electron microscopy of the prostate glands identified 45-nm, nonenveloped, icosahedral virions arranged in paracrystalline array within the cell nuclei in 1 of the 2 rats. The size, shape, location, and array pattern were most consistent with a polyomavirus. The light and electron microscopic findings after immunosuppression in our case have a resemblance to a polyomavirus recently reported to affect prostate gland epithelium in a colony of immunocompromised X-linked severe combined immune deficiency rats. To the best of our knowledge, this is the first report of light and electronic microscopic lesions in the reproductive tract associated with polyomavirus following chronic immunosuppression in a widely used, wild-type Wistar Han rat.

BK and Other Polyomaviruses in Kidney Transplantation.

For more than 40 years, polyomaviruses (BK virus and JC virus) have been known to cause disease in human beings. Recently, 11 new polyomaviruses were discovered. However, the majority of these viruses are rare in renal transplant recipients and BK and JC viruses remain the most important polyomaviruses to impact this population. BK virus presents as BK virus nephropathy and has, in rare instances, been associated with hemorrhagic cystitis or ureteral strictures. JC virus can cause progressive multifocal leukoencephalopathy or nephropathy in this population as well, but is uncommon. Antiviral prophylactic and therapeutic interventions for these diseases are lacking to date, although reduction of immunosuppression has been associated with success in treating both BK virus nephropathy and JC virus-induced disease. Risk factors are not well defined and vary across studies. However, the cumulative degree of immunosuppression is regarded universally as an important contributor to BK virus replication. For these reasons, it is recommended to screen all renal transplant recipients prospectively for BK virus infection. Multicenter trials using standardized BK and JC virus screening methods are necessary to define risk factors better, and to determine the effect of prophylaxis and treatments for these polyomaviruses affecting renal transplant recipients.

BK Virus Nephropathy in Heart Transplant Recipients.

Polyomavirus-associated nephropathy (PVAN) has become an important cause of kidney failure in kidney transplant recipients. PVAN is reported to affect 1% to 7% of kidney transplant recipients, leading to premature transplant loss in approximately 30% to 50% of diagnosed cases. PVAN occurring in the native kidneys of solid-organ transplant recipients other than kidney only recently has been noted. We report 2 cases of PVAN in heart transplant recipients, which brings the total of reported cases to 7. We briefly review the literature on the hypothesized causes of PVAN in kidney transplant recipients and comment on whether these same mechanisms also may cause PVAN in other solid-organ transplant recipients. PVAN should be considered in the differential diagnosis when evaluating worsening kidney function. BK viremia surveillance studies of nonkidney solid-organ recipients should be conducted to provide data to assist the transplantation community in deciding whether regular monitoring of nonkidney transplant recipients for BK viremia is indicated.

First confirmed case of native polyomavirus BK nephropathy in a liver transplant recipient seven years post-transplant.

Renal dysfunction frequently occurs in liver transplant recipients and is associated with increased morbidity and mortality. BK virus is a human polyoma virus that reactivates during immunocompromised states and is a known cause of renal allograft dysfunction in renal transplant recipients. However, BK nephropathy of native kidneys is rare in non-renal transplant recipients. There is no published data linking BK virus and renal dysfunction in liver transplant recipients. We describe the first confirmed case of native polyomavirus BK nephropathy in a liver transplant recipient. BK nephropathy should be considered in the differential diagnosis of new renal failure in liver transplant recipients.

Increased BK viremia and progression to BK-virus nephropathy following high-dose intravenous immunoglobulin for acute cellular rejection.

BK virus nephropathy and cellular rejection are common causes of allograft dysfunction in renal transplant recipients. The two can be difficult to distinguish on allograft biopsy and can be present simultaneously. Management of the patient with coexistent BK infection and rejection is complicated by the conflicting ideals of decreasing immunosuppression to treat the former and increasing immunosuppression to treat the latter. The authors present the case of a 57-year-old renal transplant recipient who underwent allograft biopsy 8 weeks post-transplant for evaluation of increased serum creatinine in the setting of BK viremia (BKV). Biopsy revealed Banff classification 1b acute cellular rejection, with insufficient evidence to diagnose BK virus-associated nephropathy. The patient was administered intravenous immune globulin (IVIG), with no other changes in immunosuppressive therapy. Plasma and urine BK increased exponentially following IVIG administration, and allograft function further deteriorated. Repeat biopsy showed overt BK viral nephropathy, and BKV and creatinine decreased only after reduction in immunosuppression and initiation of leflunomide. Although case series have suggested a potential role for IVIG in the setting of BK infection, further study is needed to define the safety and efficacy of this approach.

The risk of progressive multifocal leukoencephalopathy under biological agents used in the treatment of chronic inflammatory diseases.

Biological agents such as monoclonal antibodies and soluble cytokine receptors have taken on an expanding role in the treatment of chronic immune mediated diseases. Progressive multifocal leukoencephalopathy (PML) is a rare central neurological disease caused by JC virus infection that has been described in the setting of conditions with severe impairment of immune surveillance, such as haematological malignancies, stem cell or solid organ transplantation and AIDS. This serious demyelinating disease has recently been described in patients receiving monoclonal antibodies for chronic inflammatory diseases such as multiple sclerosis, Crohn's disease, rheumatoid arthritis, systemic lupus erythematosus or psoriasis. We review here the disease of PML, the different biological agents used in chronic inflammatory diseases that are associated with an increased risk of PML (natalizumab, rituximab, efalizumab and alemtuzumab), and the potential mechanisms that may explain the development of PML. Based on current knowledge of the biology of the JC virus and on the mechanisms of action of these biological agents, we discuss currently available tools that may be helpful in evaluating the risk of PML in this patient population.

Immunosuppressive agents as risk factors for BK virus nephropathy: an overview and update.

IMPORTANCE OF THE FIELD: BK virus has emerged as an important cause of graft dysfunction and failure in renal transplant recipients. Risk factors for BK virus nephropathy (BKN) are not well established, but evidence suggests that it is the result of a complex interplay between multiple donor- and recipient-related factors. AREAS COVERED IN THIS REVIEW: The purpose of this article is to review the current understanding on the effect of various immunosuppressive agents on BK viral replication and the results of different reported immunosuppression reduction protocols. WHAT THE READER WILL GAIN: The intensity of overall immunosuppression has been accepted as a major risk factor for the development of BKN. We review the data regarding the contribution of different anti-rejection agents to the risk of BK virus-induced graft injury. TAKE HOME MESSAGE: Although reduction in immunosuppression on detection of BK viral replication appears to be the most successful means in preserving allograft function, data are emerging that support the stronger association of the disease with tacrolimus, in contrast to mycophenolate compounds. Therefore, initial dose reduction for tacrolimus may be more beneficial than this anti-metabolite preemptively or after diagnosis of BKN.

SV40 infection associated with rituximab treatment after kidney transplantation in nonhuman primates.

BACKGROUND: A regimen consisting of polyclonal anti-T-cell antibody, sirolimus (SRL), and donor bone marrow (DBM) infusion induces robust transplantation tolerance to skin allografts in mice. We investigated the effect of a similar regimen in a nonhuman primate (NHP) model. METHODS: Cynomolgus macaques (Macaca fascicularis) were transplanted with mismatched kidney allografts. Recipients were treated with 7 doses of antithymocyte globulin (Thymoglobulin, day 1 to 9), sirolimus, and DBM infusion (day 14). Anti-CD20 antibody, rituximab, was given on days 0 and 5. RESULTS: A regimen of Thymoglobulin, 30 days of SRL, and DBM infusion induced significantly greater prolongation of graft survival with a mean survival time of 88 days compared with the control regimen (no DBM) with an mean survival time of 53 days (P=0.022). Unlike the murine skin allograft model, all grafts were rejected within 111 days. A combination of Thymoglobulin, continuous SRL, and rituximab caused graft and systemic SV40 infection and failed to achieve further extension of graft survival. C4d deposition was observed in 50% of recipients as early as 18 days, suggesting antidonor antibody production. A transient, low-to-moderate degrees of multilineage chimerism was observed after DBM infusion. Treatment with Thymoglobulin resulted in profound depletion of CD4+ and CD8+ T cells, whereas addition of rituximab achieved prolonged (up to 3 months) depletion of CD20+ B cells. CONCLUSION: The Thymoglobulin, SRL, and DBM protocol is simple and produces long-term kidney allograft survival in NHP although additional treatment modalities may be necessary for induction of long-term tolerance.

Treatment of gammaherpesvirus-related neoplastic disorders in the immunosuppressed host.

Neoplastic disease is a frequent complication in patients with acquired immunodeficiency disease (AIDS) and other immunodeficiencies. Many such neoplasms are caused by either Epstein-Barr virus (EBV) or Kaposi's sarcoma-associated herpes virus (KSHV). The treatment of such patients can be challenging. At the same time, the viral origin of these tumors offers targets to develop pathogenesis-based therapies. Standard therapies for these diseases involve such approaches as treating the underlying immunodeficiency, cytotoxic chemotherapy, and immunologic antitumor therapy. Novel therapy approaches include specific immune therapy and anti-angiogenesis approaches, now under development.

Polyoma virus infection after renal transplantation. Use of immunostaining as a guide to diagnosis.

BACKGROUND: Polyoma virus infection is characterized by lymphocytic interstitial infiltrate in the kidney, and it mimics acute rejection. The purpose of this study is to estimate renal allograft outcome with this infection and characterize the lymphocytic infiltrates in polyoma virus-infected renal allografts. METHODS: Patients who had polyoma virus inclusions in renal allograft biopsies were identified. Other viral inclusions were excluded by immunohistochemistry. The lymphocytic infiltrates of six cases of polyoma virus infection were compared with six cases of definite acute rejection by immunostaining for T and B cells. RESULTS: There were 10 cases of polyoma virus infections in renal transplant recipients. Immunosuppressants consisted of mycophenolate mofetil with tacrolimus in eight cases and mycophenolate mofetil with cyclosporine in two. The median time of diagnosis of polyoma virus infection after transplantation was 9.5 months, and the time to graft failure after the diagnosis was 4 months. Reduced allograft survival was seen in patients who had polyoma virus infection. Immunostaining for T and B cells revealed marked increase in the B cells (CD20) in renal allografts with polyoma virus infection of 21% (range, 5-40%) compared with 6% (range, 0-10%) in those with acute rejection (P=0.039). Reduced cytotoxic T cells (TIA-1: median, 7%; range, 2-15%) were seen in polyoma virus-infected allografts compared with 24% (range, 15-30%) in those patients who had acute rejection (P=0.0159). CONCLUSION: Irreversible graft failure is more prevalent with polyoma virus infection. Enhanced immunosuppressants with mycophenolate mofetil with tacrolimus may play a role in the development of this infection. An increase in CD20 and a decrease in cytotoxic T cells in allografts is characteristic of polyoma virus infection.

Integration of proviral sequences, but not at the common integration sites of the FGF8 locus, in an androgen-dependent mouse mammary Shionogi carcinoma.

A retroviral insertional mutation, especially by mouse mammary tumor virus (MMTV), is a major cause of murine mammary tumorigenesis. Prompted by our previous finding that FGF8, an insertionally activated cellular oncogene, is highly expressed in androgen-dependent mouse mammary Shionogi carcinoma cells, we here investigated retroviral integration adjacent to the fgf8 locus in Shionogi carcinoma. In the genomic Southern blots for fgf8 and its 5'-upstream gene npm3, the hybridized fragments were identical to the host DD/Sio mice, the original Shionogi carcinoma 115 tumor, and a pair of cultured Shionogi carcinoma cell lines of SC-3 and SC-4, suggesting that no retroviral integration occurred around either loci. The genomic cloning for the fgf8 locus from SC-3 cells also confirmed no MMTV integration. In addition, npm3, which is usually coactivated with fgf8 by MMTV insertion,was not up-regulated by androgens in SC-3 cells. All these findings led us to conclude that no retroviral insertion was present at the common integration sites adjacent to the fgf8 locus in Shionogi carcinoma although we demonstrated in this study that multiple proviral sequences of MMTV, Moloney murine sarcoma virus and FBJ-murine sarcoma virus are integrated into SC-3 cells in association with their distinct promoter activity in SC-3 cells.

Immunotherapy for Epstein-Barr virus-associated cancers.

Epstein-Barr virus (EBV)-associated lymphoproliferative disease (EBV-LPD) is a frequently fatal complication of organ transplantation and human immunodeficiency virus (HIV) infection. We have studied the safety and efficacy of adoptively transferred, gene-marked virus-specific cytotoxic T lymphocytes (CTLs) as prophylaxis and treatment of EBV-LPD in recipients of T-cell-depleted allogeneic bone marrow. In 42 patients treated prophylactically, no toxicity was experienced. None of these patients developed EBV-LPD, in contrast with eight of 53 (15%) patients who did not receive prophylactic CTL. Three patients who had not received CTL developed aggressive disease and received CTL as treatment. Gene-marked CTL homed to tumor sites and selective accumulation of marker gene was detected in tumor tissues. Tumors regressed completely in two patients, but the third died of respiratory failure. Infused CTLs persisted for up to 3 years in vivo, they rapidly reconstituted EBV-specific immune responses to levels seen in normal individuals, and they reduced high viral titers by two to three logs. We are now using autologous EBV-specific CTL to treat patients with relapsed EBV-positive Hodgkin's disease and we are developing methods for the generation of antigen-specific lines. This approach could be applied to patients with HIV who develop EBV-LPD, using CTL derived early in the course of HIV infection.

Development of human papillomavirus-associated Buschke-Löwenstein penile carcinoma during cyclosporine therapy for generalized pustular psoriasis.

Buschke-Löwenstein-type giant penile condyloma developed in a human immunodeficiency virus-negative, 25-year-old man after 4 years of intermittent cyclosporine therapy (5 mg/kg/day) for pustular psoriasis. Microscopic examination showed multifocal areas of invasive squamous cell carcinoma. Dot blot analysis of amplified polymerase chain reaction products with primers directed at the L1 region demonstrated signals for several human papillomavirus genotypes, including human papillomavirus type 16, that correlated with different histologic patterns consisting of verrucous and bowenoid changes and invasive carcinoma. This case conforms to the enhanced risk of cutaneous carcinogenesis from either papillomavirus infection or chronic actinic damage that has become evident in patients with organ allografts and cyclosporine therapy.

Oral contraceptives and human papillomavirus infection in cervical intraepithelial neoplasia.

We report about 142 patients from whom colposcopically directed cervical punch biopsies were taken which showed condylomatous lesions with or without cervical intraepithelial neoplasia (CIN). Fifty-six (39.4%) of these women used oral contraceptives (OC) for at least two years before examination. We used DNA in situ hybridization on all biopsies for detection of human papillomavirus (HPV)-DNA. Among OC users a significant trend towards higher HPV infection rates in high grade CIN (odds ratio 2.9, P less than 0.05) was found, whereas non-users of oral contraceptives had the highest HPV infection rate in condylomatous lesions without CIN (odds ratio 0.5, P less than 0.05). Thus in OC users HPV infection was about 24 times more likely in CIN III as in condyloma, while among non-users the trend was the other way round (7-fold likelihood of HPV positivity in condyloma compared to CIN III). Other known risk factors for cervical carcinoma did not influence HPV infection rates in either group.

[New knowledge on the mechanism of action of oncogenes, carcinogens and anticarcinogens]. / Neue Erkenntnisse über den Mechanismus des Wirksamwerdens von Onkogenen, von Kokarzinogenen und von Antikarzinogenen.

In the development of a tumour a multistep process is existing, in which after activation of a cellular oncogen and after efficacy of a viral oncogenat first an avalanche-like increase of transforming, excluding the regulation of cell division proteins takes place. In many forms of tumours the transforming proteins possess the property of protein kinases and phosphorylize proteins situated in the area of the cell membrane. In some forms of tumours an enrichment in the area of the cell nucleus takes place. Secondarily, in the tumour cells frequently other oncogens are activated and an activation of further genes for the formation of growth factors or of proteins of the histocompatibility complex, respectively, occurs. Some transforming proteins themselves possess the properties of growth factors and of receptors, respectively, for the binding of such ones. Cocarcinogens activate the protein kinase C, e.g. the phorbol esters. Anticarcinogens influence the transcription, e.g. the vitamin A and the 1,25-dihydroxyvitamin D3. Vitamin A and analogous compounds increases the functional capacity of the immune defense.

Cyclosporine: a new and promising immunosuppressive agent.

Cyclosporine is an exciting new agent that has been heralded as a major advance in chemical immunosuppression for organ transplantation. The drug is a potent, reversible suppressant of both humoral and cellular immunity and does not cause myelosuppression. Its mechanism of action appears to be selective for lymphocytes and may interrupt the necessary cellular signals required for proliferation of alloreactive T-cells. In early clinical trials cyclosporine has been shown to ameliorate renal allograft survival. A major concern about its widespread clinical use has been the observed nephrotoxicity and possible development of lymphomas in treated patients. Adverse side effects may be minimized by pharmacologic monitoring of drug levels. Future questions include the ideal dosage schedule, necessity for additional immunosuppressive agents, distinction between nephrotoxicity and rejection, and the precise mode of absorption, accumulation, and metabolism of the drug. Cyclosporine may be considered the prototype of a new generation of immunosuppressive agents that open up new perspectives in the field of immunoregulation. The ability to synthesize the compound may permit future biochemical manipulations to increase the immunobiologic specificity and decrease the toxicity of the drug.