title: Increased BK viremia and progression to BK-virus nephropathy following high-dose intravenous immunoglobulin for acute cellular rejection.
abstract: BK virus nephropathy and cellular rejection are common causes of allograft dysfunction in renal transplant recipients. The two can be difficult to distinguish on allograft biopsy and can be present simultaneously. Management of the patient with coexistent BK infection and rejection is complicated by the conflicting ideals of decreasing immunosuppression to treat the former and increasing immunosuppression to treat the latter. The authors present the case of a 57-year-old renal transplant recipient who underwent allograft biopsy 8 weeks post-transplant for evaluation of increased serum creatinine in the setting of BK viremia (BKV). Biopsy revealed Banff classification 1b acute cellular rejection, with insufficient evidence to diagnose BK virus-associated nephropathy. The patient was administered intravenous immune globulin (IVIG), with no other changes in immunosuppressive therapy. Plasma and urine BK increased exponentially following IVIG administration, and allograft function further deteriorated. Repeat biopsy showed overt BK viral nephropathy, and BKV and creatinine decreased only after reduction in immunosuppression and initiation of leflunomide. Although case series have suggested a potential role for IVIG in the setting of BK infection, further study is needed to define the safety and efficacy of this approach.
authors.affiliation: Nephrology, Adventist Health Partners, 333 Chestnut Street, Suite L06, Hinsdale, IL 60521.
authors.forename: Maytee
authors.initials: M
authors.lastname: Boonyapredee
authors.affiliation: Department of Internal Medicine, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889.
authors.forename: Kendral
authors.initials: K
authors.lastname: Knight
authors.affiliation: Department of Nephrology, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889.
authors.forename: Dustin
authors.initials: D
authors.lastname: Little
mesh_terms: D001739:BK Virus; D017809:Fatal Outcome; D005260:Female; D006084:Graft Rejection / Q000188:drug therapy* / Q000276:immunology; D006801:Humans; D007111:Immunity, Cellular; D016756:Immunoglobulins, Intravenous / Q000008:administration & dosage* / Q000009:adverse effects; D007155:Immunologic Factors / Q000008:administration & dosage* / Q000009:adverse effects; D007166:Immunosuppressive Agents / Q000627:therapeutic use; D016030:Kidney Transplantation; D008875:Middle Aged; D009173:Mycophenolic Acid / Q000031:analogs & derivatives / Q000627:therapeutic use; D027601:Polyomavirus Infections / Q000139:chemically induced / Q000150:complications*; D051437:Renal Insufficiency / Q000821:virology*; D016559:Tacrolimus / Q000627:therapeutic use; D014412:Tumor Virus Infections / Q000139:chemically induced / Q000150:complications*; D014766:Viremia / Q000139:chemically induced / Q000150:complications*
chemical_list: D016756:Immunoglobulins, Intravenous; D007155:Immunologic Factors; D007166:Immunosuppressive Agents; D009173:Mycophenolic Acid; D016559:Tacrolimus