title: Polyomavirus-associated nephropathy: a comparison of 2 different strategies for immunosuppression reduction.
abstract: Polyomavirus-associated nephropathy (PVAN) is an increasing cause of renal allograft dysfunction, but the optimal management of immunosuppression for these patients is unclear. We examined the clinical course of 58 patients with biopsy-proven PVAN diagnosed from 1997 to 2008 at Johns Hopkins Medical Institutions. Immunosuppression management was analyzed as 2 different immunosuppression reduction strategies, the first centered on eliminating a single immunosuppressive drug and reducing the doses of all other immunosuppressive drugs (Strategy A, n = 40), compared with the second, centered on reducing the doses of all immunosuppressive drugs and eliminating none (Strategy B, n = 18). Primary outcome was graft failure, defined as a 50% reduction in estimated glomerular filtration rate, or the need for dialysis within 2 years of PVAN diagnosis. Graft failure developed in 17 (29%) patients during follow-up. In unadjusted and adjusted Cox models, both strategies of immunosuppression reduction had similar efficacy in preventing graft failure (hazard ratio [HR], 0.61; 95% confidence interval, 0.18-2.06; p = 0.43). Rejection after PVAN occurred in 24 of 58 patients and was associated with a 3-fold higher risk of graft failure (HR, 2.99; p = 0.005). Ancillary therapies (cidofovir or leflunomide) were associated with a trend toward faster clearance of viremia (p = 0.65) but were not predictive of outcome.In conclusion, the 2 strategies of immunosuppression reduction had similar efficacy in preventing graft failure. Post-PVAN rejection leads to graft failure. Early repeat allograft biopsy should be considered in the management of PVAN with persistent graft dysfunction.
authors.affiliation: From Department of Medicine (DG, SP, TS), Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Medicine (GNN), St.Luke's-Roosevelt Hospital Center, New York, New York; Department of Pathology (CH), Medical College of Wisconsin, Milwaukee, Wisconsin; and Welch Center for Prevention, Epidemiology and Clinical Research (TS), Johns Hopkins Medical Institutions, Baltimore, Maryland.
authors.forename: Duvuru
authors.initials: D
authors.lastname: Geetha
authors.forename: Shyam
authors.initials: S
authors.lastname: Parkhie
authors.forename: Girish N
authors.initials: GN
authors.lastname: Nadkarni
authors.forename: Chun
authors.initials: C
authors.lastname: He
authors.forename: Tariq
authors.initials: T
authors.lastname: Shafi
mesh_terms: D000998:Antiviral Agents / Q000008:administration & dosage*; D004305:Dose-Response Relationship, Drug; D005260:Female; D005500:Follow-Up Studies; D006084:Graft Rejection / Q000517:prevention & control*; D006801:Humans; D007165:Immunosuppression Therapy / Q000379:methods*; D007166:Immunosuppressive Agents / Q000008:administration & dosage*; D007674:Kidney Diseases / Q000188:drug therapy* / Q000209:etiology; D016030:Kidney Transplantation / Q000009:adverse effects*; D008297:Male; D008875:Middle Aged; D027601:Polyomavirus Infections / Q000150:complications / Q000188:drug therapy*; D012189:Retrospective Studies; D012307:Risk Factors; D016896:Treatment Outcome
chemical_list: D000998:Antiviral Agents; D007166:Immunosuppressive Agents