BK virus-associated nephropathy in a lung transplant patient: case report and literature review

Abstract

Background BK virus-associated nephropathy (BKVAN) is a relatively common cause of renal dysfunction in the first six months after renal transplantation. It arises from reactivation of the latent and usually harmless BK virus (BK virus) due to immunosuppression and other factors including some that are unique to renal transplantation such as allograft injury. BKVAN is much rarer in non-renal solid organ transplantation, where data regarding diagnosis and management are extremely limited. Case presentation We report a case of a 58-year-old man found to have worsening renal dysfunction nine months after bilateral sequential lung transplantation for chronic obstructive pulmonary disease (COPD). He had required methylprednisolone for acute allograft rejection but achieved good graft function. Urine microscopy and culture and renal ultrasound were normal. BK virus PCR was positive at high levels in urine and blood. Renal biopsy subsequently confirmed BKVAN. The patient progressed to end-stage renal failure requiring haemodialysis despite reduction in immunosuppression, including switching mycophenolate for everolimus, and the administration of intravenous immunoglobulin (IVIG). Conclusions This very rare case highlights the challenges presented by BK virus in the non-renal solid organ transplant population. Diagnosis can be difficult, especially given the heterogeneity with which BKV disease has been reported to present in such patients, and the optimal approach to management is unknown. Balancing reduction in immunosuppression against prevention of allograft rejection is delicate. Improved therapeutic options are clearly required.

Long-Term Infectious Complications of Kidney Transplantation

“…In immunocompromised hosts, the disease can progress from asymptomatic viruria to viremia and organ-invasive disease. It usually presents as BK polyomavirus-associated nephropathy in kidney transplant recipients (42). Asymptomatic viruria, detected on routine screening, is the earliest manifestation and is seen in 25%-40% of patients in the first year.…”

BK virus nephropathy in non‐renal solid organ transplant recipients: Are we looking hard enough?

“…Seven out of these eleven patients had diabetes mellitus that was being treated with medications. Our literature search revealed 24 previous reports of biopsy‐proven native BKV nephropathy in NRSOT patients bringing the total to 28 12‐35 Table 3 summarizes the renal outcome in these patients categorized by type of solid organ transplant. It can be seen that a majority of NRSOT patients with biopsy‐proven native kidney BKV nephropathy were reported to have developed CKD or ESRD.…”

“…Native kidney BKV associated disease in non‐renal solid organ transplant (NRSOT) recipients has been described in case reports and series over the years, but it has not been systematically studied 12‐35 . BKV nephropathy in the NRSOT recipient has the potential to lead to chronic kidney disease (CKD) or end‐stage renal disease (ESRD) with associated morbidity and mortality 36‐38 .…”

Current status of glucocorticoid usage in solid organ transplantation

“…There are case reports of BKVAN that resulted in native kidney failure in other types of SOT patients. A GC pulse for the treatment of acute allograft rejection has been reported in these patients before BKVAN[ 85 ]. Causality assessment needs more studies.…”