David-Neto Elias, Agena Fabiana, Silva Ribeiro David Daisa, Paula Flavio Jota de, Camera Pierrotti Ligia Camera, Domingues Fink Maria Cristina, Fonseca de Azevedo Luiz Sergio
Renal Transplantation Service, Division of Urology, Hospital das Clínicas, Sao Paulo University School of Medicine, São Paulo, Brazil.
Division of Nephrology, Hospital das Clínicas, Sao Paulo University School of Medicine, São Paulo, Brazil.
Transpl Infect Dis. 2019 Apr;21(2):e13056. doi: 10.1111/tid.13056. Epub 2019 Mar 5.
Polyoma viremia is associated with damage to renal tubular and urothelial cells. This may imply that a certain level of viremia, even cleared thereafter, could be associated with long-term renal dysfunction.
We, retrospectively, analyzed 390 first renal transplants adult recipients (≥18 years) who were monitored for BK viremia in the first 12 months and evaluated estimated GFR (MDRD-4 equation) at 1 month and at the last follow-up (959 ± 392 days).
One hundred and ninety-nine patients (51%) developed at least one positive viremia: 105 (53%) low viremia (<10 copies/mL), 36 (18%) high viremia (4 × 10 > viremia ≥ 10 copies/mL) and 58 (15%) viremia (≥4 × 10 copies/mL) consistent with polyoma virus associated nephropathy (PyVAN). Out of these 58 patients, 24 (6%) developed bx-proven (SV40+) PyVAN and 34(8.7%) presumptive PyVAN (SV40-). Baseline characteristics, immunosuppression, KDRI, rejection episodes, etc., did not differ among groups but there were more deceased donors and ATG induction therapy in the high viremia group. At last follow-up, all patients in the low, high viremia and presumptive PyVAN (except 2) had cleared BK viremia. Bx-proven PyVAN led to 14 graft losses, 10 due to PyVAN. In the presumptive PyVAN there was only one graft loss registered as due to PyVAN. eGFR, at 1 month after KTx, did not differ among groups (51 ± 22 vs 48 ± 24 vs 45 ± 27 vs 43 ± 18 vs 46 ± 22 mL/min/1.73 m ), for no, low and high viremia as well for presumptive PyVAN and bx-proven PyVAN groups, respectively. At the last follow-up, eGFR did not differ between the no, low, and high viremia compared to baseline and to each other but was statistically lower in the presumptive and bx-proven PyVAN (38 ± 15 and 17 ± 7 mL/min/1.73 m ) either compared to baseline or to the other groups.
This study shows that low and high levels of BK viremia do not lead to GFR changes although very high viremia levels, compatible with presumptive or bx-proven PyVAN, even if cleared thereafter, lead to allograft damage and decreased GFR.
多瘤病毒血症与肾小管和尿路上皮细胞损伤相关。这可能意味着一定水平的病毒血症，即使随后清除，也可能与长期肾功能障碍有关。
我们回顾性分析了390例首次接受肾移植的成年受者（≥18岁），这些受者在最初12个月接受了BK病毒血症监测，并在1个月及最后一次随访（959±392天）时评估了估计肾小球滤过率（MDRD-4方程）。
199例患者（51%）发生至少一次病毒血症阳性：105例（53%）为低病毒血症（<10拷贝/mL），36例（18%）为高病毒血症（4×10>病毒血症≥10拷贝/mL），58例（15%）病毒血症（≥4×10拷贝/mL）符合多瘤病毒相关性肾病（PyVAN）。在这58例患者中，24例（6%）发生经活检证实（SV40+）的PyVAN，34例（8.7%）为疑似PyVAN（SV40-）。各组间的基线特征、免疫抑制、KDRI、排斥反应等无差异，但高病毒血症组的死亡供体和抗胸腺细胞球蛋白诱导治疗更多。在最后一次随访时，低、高病毒血症组和疑似PyVAN组（除2例）的所有患者均已清除BK病毒血症。经活检证实的PyVAN导致14例移植肾丢失，其中10例因PyVAN。在疑似PyVAN组中，仅登记有1例移植肾丢失归因于PyVAN。肾移植术后1个月时，各组间的估算肾小球滤过率无差异（分别为51±22、48±24、45±27、43±18、46±22 mL/min/1.73m²），分别对应无病毒血症、低病毒血症、高病毒血症以及疑似PyVAN组和经活检证实的PyVAN组。在最后一次随访时，无病毒血症、低病毒血症和高病毒血症组与基线相比以及相互之间的估算肾小球滤过率无差异，但疑似和经活检证实的PyVAN组的估算肾小球滤过率与基线相比或与其他组相比在统计学上更低（分别为38±15和17±7 mL/min/1.73m²）。
本研究表明，低水平和高水平的BK病毒血症不会导致肾小球滤过率改变，尽管与疑似或经活检证实的PyVAN相符的非常高的病毒血症水平，即使随后清除，也会导致移植肾损伤和肾小球滤过率降低。
