What is bk viremia

If you decide the patient has BK virus associated diseases what therapies should you initiate immediately? BK virus proliferation is well controlled by the host cellular immune response.

Therefore, currently, the best treatment is reduction in immunosuppression to restore the host cellular immune response. The best treatment is to reduce immunosuppression.

However, this may lead to graft rejection in a renal transplant patient. Pre-emptive screening for BK virus in blood and urine after renal transplant are implemented to detect any signs of BK proliferation. Cidofovir is an antiviral drug used for cytomegalovirus CMV showed inhibition of BK virus activity in vitro. There are case reports of treating PVAN with cidofovir; however, no randomized or controlled studies have been performed, and efficacy is yet to be determined.

Leflunomide is an immunosuppressive drug approved for use in rheumatoid arthritis. Although used by clinicians and described in case reports, there are no randomized or controlled studies to prove benefit. Ciprofloxacin is an antibacterial in the fluoroquinolone class. There are case reports describing benefits when used alone or in combination with immunosuppression reduction; however, there are no randomized or controlled studies to prove benefit.

Intravenous infusion of pooled immunoglobulins could decrease BK viral load in the plasma, as demonstrated in a small study of kidney transplant recipients. Randomized controlled studies are needed to determine efficacy. Best treatment is to reduce immunosuppression. Control of bleeding and supportive care, including bladder irrigation, analgesia, hyperhydration, and transfusion, are needed.

Fluoroquinolones showed in vitro inhibition of BK virus replication. There are case reports of efficacy in treating hemorrhagic cystitis in hematopoietic stem cell transplant patients. However, there are no randomized or controlled studies. Recently, a small retrospective study showed prevention of hemorrhagic cystitis when used as prophylaxis in hematopoietic stem cell transplant patients.

Cidofovir showed inhibition of BK virus activity in vitro. This has been used by clinicians both intravenously and as bladder instillation. However, small nonrandomized studies showed decreased BK viral load in the urine in less than one-half of the patients.

Although leflunomide is used by clinicians and described in case reports, there are no randomized or controlled studies to prove benefit. There are now several case reports and one retrospective study on the use of hyperbaric oxygen for treatment of BK virus associated disease. Mechanism of this treatment in a viral infection is unclear. True benefit will still need to be better studied. Since BK cellular immune response can control viral replication, cellular mediated therapy in development may prove to be useful.

Bleeding and renal failure can be reversed with supportive care and surgical measures. If immune reconstitution is feasible to better control BK virus proliferation, then chances are better for complete recovery. In rare instances, patients can die from BK virus associated diseases. Better prognosis for graft survival is correlated with the histological findings of mild viral cytopathic changes with minimal inflammatory infiltrates or fibrosis.

A robust BK virus specific cellular immune response is correlated with a decrease in both BK viruria and viremia. A rise of BK serology is associated with viral reactivation. This rise in antibodies does not prevent disease.

BK virus associated diseases can be responsible for the decline in renal function, even without any symptoms. Treatment for CMV or adenovirus should be initiated. The only way to distinguish between them is by urine PCR. Reduction of immunosuppression is the mainstay of BKVN treatment. Discontinuation of the anti-metabolite such as MMF is the most common approach, but a recent study [ 63 ] suggests that both tacrolimus and cyclosporine can inhibit anti-BK T-cell responses in vitro , challenging this practice.

Other treatment alternatives can include use of leflunomide, cidofovir, ciprofloxacin, rapamycin or intravenous immunoglobulin Table 5. Objective data regarding BK treatment are limited; a meta-analysis [ 64 ] of all published approaches to BK treatment found only 3 randomized controlled trials, 9 cohort studies and 29 case series. Regardless of the treatment strategy employed, rapid viral reduction has been associated with stable or improving glomerular filtration rate GFR [ 65 ].

Screening with subsequent immunosuppression reduction was shown to be effective in preventing allograft loss in single-center studies. Schaub et al. A longer term follow-up is equally encouraging. Hardinger et al. In their study, patients with BKV or BKVN treated with immunosuppression reduction had no difference in patient or allograft survival compared with those without. Patients maintained on tacrolimus-containing regimens were shown to have lower acute rejection rates and higher eGFRs despite BK.

In their meta-analysis, Johnston et al. One single-center trial [ 62 ] of 21 patients compared immunosuppression reduction alone versus addition of cidofovir and found better allograft survival with cidofovir use but no difference in BK clearance. Many other studies [ 66 , 67 ] have failed to find a benefit with cidofovir use, and the risk of renal side effects is significant. At this time, we do not recommend the use of cidofovir or leflunomide as adjuvant therapy for BKVN.

FK is a derivative of the active metabolite of leflunomide and inhibits pyrimidine biosynthesis to prevent lymphocyte proliferation. FK did decrease BKV and BK viruria in patients treated with it, but acute rejection rates and incidence of allograft loss in the FK treatment group were much higher than in the immunosuppression reduction group [ 69 ].

No further studies using FK are planned at this time. NCT is a randomized trial comparing the efficacy of reduction of immunosuppression versus substitution of tacrolimus for sirolimus for the treatment of BKV or BKVN.

NCT is an open-label trial using a combination of leflunomide and orotic acid in patients with high levels of BK viruria. Retransplantation after allograft loss due to BKVN is a reasonable option. Of the retransplants, only one kidney was lost due to recurrent BKVN. One- and 3-year allograft survival in the retransplanted patients was excellent at Although kidney transplant loss due to BKVN should not be a barrier to retransplantation, pretransplant clearance of BK viral load is necessary.

Transplant nephrectomy in patients with failed graft due to BKVN has not been found protective after retransplantation. BK infection is a relatively common and early posttransplant complication after kidney transplantation.

Careful screening can prevent allograft loss and should be employed. Translational laboratory-based assays are being developed that may provide additional information regarding patient clinical course in the future. The mainstay of treatment remains careful reduction of immunosuppression and close monitoring for the development of acute rejection.

Prospective studies a with longer follow-up are still needed to evaluate different treatment strategies while assessing the possibility of chronic allograft dysfunction due to systematic reduction of immunosuppression.

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Sign In. Advanced Search. Search Menu. Article Navigation. Close mobile search navigation Article Navigation. Volume Article Contents Abstract. BK virus infection: an update on diagnosis and treatment. Deirdre Sawinski , Deirdre Sawinski. Renal, Electrolyte, and Hypertension Division.

Correspondence and offprint requests to: Simin Goral; E-mail: gorals uphs. Oxford Academic. Simin Goral. Select Format Select format. Permissions Icon Permissions.

Abstract BK virus, first isolated in , is a significant risk factor for renal transplant dysfunction and allograft loss. BK virus , diagnosis , kidney , transplantation , treatment. Table 1. Open in new tab. Table 2. Summary of proposed risk factors for BK virus infection. Table 3. Summary of BKV screening methods.

Screening method. Open in new tab Download slide. Table 4. Summary of BK histology grading systems. BKVN stage. University of Maryland [ 46 ]. Polyomavirus Interdisciplinary work group [ 47 ]. American Society of Transplantation [ 21 ]. Banff working proposal [ 45 ]. Table 5. Immunosuppression adjustment strategy. Adverse events. Immunosuppression reduction Hirsch et al. New human papovavirus BK isolated from urine after renal transplantation.

Google Scholar Crossref. Search ADS. Human polyoma virus-associated interstitial nephritis in the allograft kidney. Rare subtypes of BK virus are viable and frequently detected in renal transplant recipients with BK virus-associated nephropathy. Subtypes of BK virus prevalent in Japan and variation in their transcriptional control region.

Prospective study of polyomavirus type BK replication and nephropathy in renal transplant recipients. Incidence of BK with tacrolimus versus cyclosporine and impact of preemptive immunosuppression reduction.

Prospective monitoring of BK virus replication in renal transplant recipients. Monthly screening for BK viremia is an effective strategy to prevent BK virus nephropathy in renal transplant recipients. Prospective monitoring of BK virus reactivation in renal transplant recipients in North India. Management and outcome of BK viremia in renal transplant Recipients: a prospective single center study.

Polyomavirus BK replication in denovo kidney transplant patients receiving tacrolimus or cyclosporine: a prospective, randomized, multicenter study. BK virus nephropathy in a heart transplant recipients: case report and review of the literature. Prevalence of BK virus replication among recipients of solid organ transplants. Polyomavirus Nephropathy: a current perspective and clinical considerations. It can damage your new kidney and cause your body to reject it. Your healthcare provider will check for signs of the virus in your system.

They will check both before and after receiving your kidney transplant. Symptoms may include:. Having any of these symptoms could be a sign of infection. This can affect the success of your kidney transplant. It is important to tell your healthcare provider if you notice any signs of infection. Your healthcare provider will decide how often to check you for BK virus and other infections. This helps make sure your transplant is not at risk.

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