title: Contrasting patterns of viral load response in transplant recipients with BK polyomavirus DNAemia on leflunomide therapy.
abstract: BACKGROUND
  Reduction in immunosuppression is considered the therapy of proven benefit for BKV infection in renal transplantation, but the use of leflunomide has also been reported. It was observed at this center that the patterns of viral load response while on leflunomide appear to fall into two distinct types.
  
  
  METHODS
  Medical records of 22 kidney and kidney-pancreas recipients at a single center who received leflunomide therapy for BKV DNAemia were reviewed. Information was collected on demographics, BKV viral loads, other antiviral therapy, immunosuppressive drug levels and doses, adverse effects, and graft and patient outcomes.
  
  
  RESULTS
  Eighteen of 22 cleared BKV viremia, and 12 of 22 had preserved allograft function; only two graft losses occurred in the screening era among leflunomide-treated patients. Two patterns of viral load reduction were observed, termed the "smooth" and the "zigzag" pattern, which differed in mean time to clear of BKV DNA (2.9 vs. 19.5 months, p = 0.0073). Graft preservation was correlated with lower serum creatinine (SCr) at the start of leflunomide therapy.
  
  
  CONCLUSIONS
  Long courses and "zigzag" fluctuations in viral load can occur in patients who eventually clear BKV on leflunomide with preserved allograft function. Intermittent increases in viral load do not necessarily portend therapeutic failure. Although the utility of leflunomide is still debated in the transplant community, this information may be useful to clinicians who choose to use it in selected patients.
authors.affiliation: Department of Infectious Disease, Medicine Institute, Cleveland, OH, USA.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Cuellar-Rodriguez
authors.forename: Brian
authors.initials: B
authors.lastname: Stephany
authors.forename: Emilio
authors.initials: E
authors.lastname: Poggio
authors.forename: Sherif B
authors.initials: SB
authors.lastname: Mossad
authors.forename: David
authors.initials: D
authors.lastname: Goldfarb
authors.forename: Michelle
authors.initials: M
authors.lastname: Lard
authors.forename: Medhat
authors.initials: M
authors.lastname: Askar
authors.forename: Richard
authors.initials: R
authors.lastname: Fatica
authors.forename: Titte
authors.initials: T
authors.lastname: Srinivas
authors.forename: William
authors.initials: W
authors.lastname: Braun
authors.forename: Daniel
authors.initials: D
authors.lastname: Shoskes
authors.forename: Stuart
authors.initials: S
authors.lastname: Flechner
authors.forename: Steven K
authors.initials: SK
authors.lastname: Schmitt
authors.forename: Rabin
authors.initials: R
authors.lastname: Shrestha
authors.forename: Robin K
authors.initials: RK
authors.lastname: Avery
mesh_terms: D001739:BK Virus / Q000187:drug effects* / Q000276:immunology; D004279:DNA, Viral / Q000097:blood*; D005260:Female; D006084:Graft Rejection / Q000276:immunology; D006801:Humans; D007166:Immunosuppressive Agents / Q000627:therapeutic use; D007555:Isoxazoles / Q000627:therapeutic use*; D016030:Kidney Transplantation; D000077339:Leflunomide; D008297:Male; D027601:Polyomavirus Infections / Q000188:drug therapy / Q000276:immunology* / Q000821:virology; D014412:Tumor Virus Infections / Q000188:drug therapy / Q000276:immunology* / Q000821:virology; D019562:Viral Load / Q000276:immunology*; D014766:Viremia / Q000276:immunology
chemical_list: D004279:DNA, Viral; D007166:Immunosuppressive Agents; D007555:Isoxazoles; D000077339:Leflunomide