BK Polyomavirus In Solid Organ Transplantation

Publication Date: April 1, 2019
Last Updated: March 14, 2022

RECOMMENDATIONS FOR BKPYV IN KIDNEY TRANSPLANTATION

Donor testing prior to kidney transplantation for genetic mark ers, BKPyV viruria, virus genotyping, or VLP/Vp1.specific.specific antibody levels is not recommended at the present time. (Low, Strong)
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Recipient testing prior to kidney transplantation for genetic markers, BKPyV VLP/Vp1‐specific antibody levels, or BKPyV (subtype)‐neutralizing antibody levels, or BKPyV‐specific T‐cell quantity or function is not recommended at the present time. (Low, Strong)
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Kidney transplant recipients should be screened for BKPyV DNAemia by QNAT to identify patients to be considered for preemptive treatment for PyVAN. (Moderate, Strong)
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Screening for BKPyV‐DNAemia by QNAT should be performed monthly until month 9, then every 3 months until 2 years posttransplant. (Moderate, Strong)
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Kidney transplant recipients should be tested for BKPyVDNAemia by QNAT when undergoing renal allograft biopsy for surveillance (Low, Strong)
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  • or for cause/indication
(Moderate, Strong)
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to inform histopathology studies.

Clinical virology laboratories providing screening and monitoring BKPyV‐DNAemia by QNAT in kidney transplant recipients should participate in proficiency testing by external quality assurance programs to provide information about assay performance. (Moderate, Strong)
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BKPyV-DNAemia should be confirmed within 3 weeks to be sus tained as plasma BKPyV loads >3 log10 c/mL (probable PyVAN), (Moderate, Strong)
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  • or to be increasing to plasma BKPyV loads of >4 log10 c/mL (presumptive PyVAN).
(High, Strong)
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In kidney transplant patients without increased risk of acute rejection and baseline renal function, renal allograft biopsy is not required prior to reducing immunosuppression. (Moderate, Strong)
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A minimum of two biopsy cores should be taken, preferentially containing also medullary tissues. (Moderate, Strong)
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The diagnosis of proven PyVAN should be sought by demonstrat ing cytopathic changes of tubular epithelial cells in the allograft tissue, and confirmed by immunohistochemistry or in situ hybrid ization (“proven PyVAN”). (High, Strong)
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The histological findings of proven PyVAN should be semi‐quantitatively assessed using the AST‐IDCOP 2013 as well as the Banff 2017 Study group proposal. (High, Strong)
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In kidney transplant patients with proven PyVAN and the absence of BKPyV-DNAemia in blood, urine, and graft tissue, JCPyV-associated nephropathy should be considered and specific QNAT be sought on urine, blood, and allograft tissue. (Moderate, Strong)
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For the diagnosis of acute rejection and concurrent PyVAN, the presence of endarteritis, fibrinoid vascular necrosis, glomerulitis, or C4d deposits along peritubular capillaries should be documented. (Low, Strong)
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In kidney transplant patients with sustained BKPyV‐DNAemia and biopsy‐proven acute rejection as evidenced by intimal arteritis or positive C4d stain (with or without proven PyVAN), antirejection therapy should be given first followed by reducing immunosuppression in a second step. (Low, Strong)
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The primary treatment of sustained BKPyV-DNAemia/probable PyVAN, presumptive PyVAN, or proven PyVAN in kidney trans plant patients without concurrent acute rejection is reducing maintenance immunosuppression. (Moderate, Strong)
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Tacrolimus trough levels are commonly targeted to <6 ng/mL, (Moderate, Strong)
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  • cyclosporine trough levels to <150 ng/mL,
(Moderate, Strong)
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  • mycophenolate mofetil/mycophenolic acid daily dose equivalents of less or equal than half of the daily maintenance dose,
(ModerateStrong)
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and sirolimus trough levels of <6 ng/mL. (Very Low, Weak)
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Additional strategies have been switching from tacrolimus to low-dose cyclosporine‐A, or switching from the calcineurin inhibitors to sirolimus, or switching from mycophenolic acid to low‐dose sirolimus, or from mycophenolic acid to leflunomide. (Very Low, Weak)
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In patients with sustained BKPyV-DNAemia/probable PyVAN, presumptive PyVAN, or proven PyVAN, despite adequately reduced immunosuppression, the use of adjunctive therapies may be considered. (Low, Weak)
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Return to routine maintenance immunosuppression after suc cessful clearance of BKPyV-DNAemia should be considered under careful monitoring plasma viral loads to counteract rejection. (Very Low, Weak)
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Acute rejection after reducing immunosuppression for BKPyV-DNAemia, presumptive, or proven PyVAN should be treated according to standard protocols. (Low, Weak)
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Retransplantation can be considered for patients after loss of a first kidney allograft due to PyVAN, but frequent screening for BKPyV replication is recommended. (Low, Strong)
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Recommendation Grading

Overview

Title

BK Polyomavirus In Solid Organ Transplantation

Authoring Organization

American Society of Transplantation

Publication Month/Year

April 1, 2019

Last Updated Month/Year

July 7, 2022

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

The present AST‐IDCOP guidelines update information on BK polyomavirus (BKPyV) infection, replication, and disease, which impact kidney transplantation (KT), but rarely non‐kidney solid organ transplantation (SOT)

Target Patient Population

Kidney transplantation patients

Inclusion Criteria

Female, Male, Adolescent, Adult, Older adult

Health Care Settings

Ambulatory, Hospital, Operating and recovery room, Outpatient

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Diagnosis, Prevention, Management, Treatment

Diseases/Conditions (MeSH)

D014180 - Transplantation, D016030 - Kidney Transplantation, D016377 - Organ Transplantation, D011120 - Polyomavirus, D027601 - Polyomavirus Infections, D001739 - BK Virus

Keywords

antiviral, prophylaxis, renal transplant, antimicrobial prophylaxis, nephropathy, solid organ transplant, polyoma, BK virus

Source Citation

Hirsch, HH, Randhawa, PS; on behalf of AST Infectious Diseases Community of Practice. BK polyomavirus in solid organ transplantation—Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant. 2019; 33:e13528.