Management of BK virus-associated haemorrhagic cystitis in allogeneic stem cell transplant recipients

Abstract

BK virus (BKV)-related haemorrhagic cystitis (HC) is an important cause of morbidity following allogeneic haematopoietic stem cell transplantation (HSCT). The various risk factors include high-level BKV viruria and/or viremia, myeloablative conditioning, acute graft versus host disease (GVHD), cytomegalovirus viremia, and unrelated or HLA-mismatched donor. The presence of high plasma BK viral load and cytopenias have been implicated as important predictors for protracted disease course. These patients frequently require hospitalisation which may extend for several weeks. Supportive measures in the form of analgesics, intravenous hydration, bladder irrigation, and transfusion support remain the mainstay of management. Various drugs have been used with limited success in this setting. These include antiviral drugs, fluoroquinolones, leflunomide, growth factors, clotting factors, estrogens, and prostaglandins. The role of adoptive cellular immunotherapy has also been explored but lacks clinical validation. The strategies aimed at expediting urothelial repair like hyperbaric oxygen therapy (HBOT), intravesical fibrin glue and platelet-rich plasma (PRP) are emerging. Some patients with severe disease do require surgical intervention to relieve urinary obstruction. The frequent co-occurrence of acute GVHD and CMV disease further complicates the management in such patients. There is an unmet need for effective and evidence-based options for the prevention and management of this disease. Due to lack of robust data supported by randomised trials, the acceptability of the available guidelines to simplify the treatment is expected to be low. Despite the availability of various treatment options, the management of BKV-related HC in day-to-day practice continues to be a challenge. The aim of this article is to put forward an up-to-date review of the preventive and therapeutic strategies for BKV-related HC.

BKV Related Hemorrhagic Cystitis—An Insight into Risk Factors and Later Complications—An Analysis on Behalf of Polish Adult Leukemia Group

“…The BK virus (BKV)-associated hemorrhagic cystitis (BK-PyVHC) is a well-recognized complication and a common cause of morbidity in patients undergoing hematopoietic cell transplantation (HCT) [1]. Besides increasing the morbidity of HCT recipients, BKV prolongs hospital stay, increases the risk of death, and escalates healthcare costs [2].…”

Pentosan polysulfate for the treatment of hemorrhagic cystitis after allogeneic hematopoietic cell transplant

“…4 Leflunomide and intravesicular cidofovir have a role in treating BK virus-induced HC but their benefit is unproven and toxicities can be substantial. [5][6][7] In contrast, PPS is a well-tolerated oral medication that could potentially lessen the need for invasive procedures or more toxic medications in the management of HC.…”

“…Symptom improvement can also be seen with the withdrawal of immunosuppression; however, this is not always feasible, especially early in the transplant course. [5][6][7] Pentosan polysulfate (PPS) is a heparin-like, sulfated polysaccharide that is indicated for the relief of bladder pain or discomfort associated with interstitial cystitis (IC). 8,9 The drug is thought to act by repairing the glycosaminoglycan layer lining the bladder, which acts as a protective barrier to prevent solute permeability and contact with cell membranes.…”

Infectious disease in hematopoietic stem cell transplantation

“…), the status of iron homeostasis, and functional hyposplenism, can also significantly add to the morbidity and mortality associated with acquired infections. 4…”

“…), the status of iron homeostasis, and functional hyposplenism, can also significantly add to the morbidity and mortality associated with acquired infections. 4 Transplant related factors that can contribute to infections are: (A) type of transplant, (B) type of stem cell graft, (C) type of conditioning regimen used, (D) immunosuppression regimen used, and (E) donor type, with the degree of mismatch of human leukocyte antigen mismatch between donor and recipient.…”