Safa Kassem, Heher Eliot, Gilligan Hannah, Williams Winfred, Tolkoff-Rubin Nina, Wojciechowski David
Massachusetts General Hospital, Boston, MA.
Clin Transpl. 2015;31:257-263.
BK virus (BKV) is a common infection encountered after kidney transplantation. BKV is associated with a spectrum of manifestations, starting with sub-clinical viruria, followed by viremia and BKV-associated nephropathy. Standard of care includes routine post-transplant screening for BK viruria and/or viremia. Both the Kidney Disease Improving Global Outcomes and the American Society of Transplantation Infectious Diseases Community of Practice have published screening recommendations. Although they vary slightly, they both highlight the importance of early detection with serial screening. Once BK viremia is detected, the standard management approach includes a reduction of immunosuppression. Guidelines differ slightly about the sequence of the immunosuppression reduction, but the end result is the same: lowering the overall immunosuppressive burden in the patient with BKV infection. At the Massachusetts General Hospital, from 2007 to 2009, there was no BKV screening protocol in place. The rate of screening during this time period increased from 62% to 81%. A total of 29 of the 243 patients were diagnosed with BK viremia (11.9%), with 23 identified as a result of screening and 6 as a result of testing for graft dysfunction. We developed a BKV screening protocol consisting of BKV polymerase chain reaction testing in blood starting 2 months after kidney transplantation and every 2 months thereafter, continuing through month 24 regardless of the allograft function. Additional screening for 6 more months is performed in patients who receive anti-lymphocyte globulin for the treatment of acute rejection. Finally, all patients with otherwise unexplained allograft dysfunction are screened. Currently, work is being done investigating the use of mammalian target of rapamycin inhibitors to treat BKV infection. Trials are also ongoing evaluating cell-based therapies for BKV. Research to develop a vaccine or a direct-acting antiviral agent is in critical need and an area of research that should be given high priority.
BK病毒（BKV）是肾移植后常见的感染源。BKV与一系列临床表现相关，始于亚临床病毒尿，随后是病毒血症和BKV相关性肾病。护理标准包括移植后常规筛查BK病毒尿和/或病毒血症。改善全球肾脏病预后组织和美国移植传染病学会实践社区均已发布筛查建议。尽管两者略有不同，但都强调了通过系列筛查进行早期检测的重要性。一旦检测到BK病毒血症，标准的管理方法包括减少免疫抑制。关于免疫抑制减少的顺序，指南略有不同，但最终结果是相同的：降低BKV感染患者的总体免疫抑制负担。在麻省总医院，2007年至2009年期间没有BKV筛查方案。在此期间，筛查率从62%提高到了81%。243名患者中有29名被诊断为BK病毒血症（11.9%），其中23名是筛查发现的，6名是因移植功能障碍检测发现的。我们制定了一项BKV筛查方案，包括肾移植后2个月开始每2个月进行一次血液中的BKV聚合酶链反应检测，持续至第24个月，无论同种异体移植功能如何。接受抗淋巴细胞球蛋白治疗急性排斥反应的患者还需额外筛查6个月。最后，对所有原因不明的移植功能障碍患者进行筛查。目前，正在开展研究调查使用雷帕霉素靶蛋白抑制剂治疗BKV感染。也在进行评估基于细胞的BKV治疗方法的试验。开发疫苗或直接作用抗病毒药物的研究迫切需要，应作为高度优先的研究领域。
