Boonyapredee Maytee, Knight Kendral, Little Dustin
Nephrology, Adventist Health Partners, 333 Chestnut Street, Suite L06, Hinsdale, IL 60521.
Department of Internal Medicine, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889.
Mil Med. 2014 Jun;179(6):e699-702. doi: 10.7205/MILMED-D-13-00489.
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.
BK病毒肾病和细胞性排斥反应是肾移植受者移植肾功能障碍的常见原因。这两者在移植肾活检时可能难以区分，且可能同时存在。对于同时存在BK感染和排斥反应的患者，治疗起来很复杂，因为治疗前者需要降低免疫抑制，而治疗后者则需要增加免疫抑制，这两种理念相互冲突。作者介绍了一名57岁肾移植受者的病例，该患者在移植后8周因BK病毒血症（BKV）导致血清肌酐升高而接受移植肾活检。活检显示为班夫分类1b级急性细胞性排斥反应，没有足够证据诊断BK病毒相关性肾病。患者接受了静脉注射免疫球蛋白（IVIG）治疗，免疫抑制治疗没有其他变化。静脉注射免疫球蛋白后，血浆和尿液中的BK病毒呈指数级增加，移植肾功能进一步恶化。再次活检显示明显的BK病毒性肾病，只有在降低免疫抑制并开始使用来氟米特后，BKV和肌酐才下降。虽然病例系列研究表明IVIG在BK感染情况下可能有潜在作用，但需要进一步研究来确定这种方法的安全性和有效性。
