#NephMadness 2018: Virally Infected Kidneys – Much More Than HIV and HCV!

Vikas Dharnidharka, MD

Dr. Dharnidharka is the Chief of the Pediatric Nephrology division and a Professor of Pediatrics at Washington University in St Louis. His research and clinical interests are both related to the infectious and malignancy complications of organ transplantation, especially BK virus nephropathy, Epstein-Barr virus, and post-transplant lymphoproliferative disorders (PTLD). Follow him @Vikas_R_D.

Competitors for the Transplantation Region

Pathogenic DSAs vs The Untransplantables

Kidney Donor Risk vs Virally Infected Kidneys

The Virally Infected Kidneys team includes two “frontcourt bigs” viruses, HIV, and hepatitis C, for which curative treatment options now exist, so both are now major players in the decision of which kidney to transplant, and to whom. But this team is much deeper. Many opportunistic viruses affect the transplant recipient while on immunosuppression.

In kidney transplantation, the major opportunistic viruses are cytomegalovirus (CMV), Epstein-Barr virus (EBV) and BK virus (BKV), dubbed the Big Three perimeter team players. These viruses don’t have the same name recognition as the two frontcourt bigs, but from the perimeter, their effects are as devastating. HIV and Hep C are only present in a small portion of the population, whereas large proportions of the population are infected by each of these perimeter viruses by young adult age. The Big Three manage to keep a pool of latent virus in the host life-long, away from immune surveillance. CMV and EBV live in reticuloendothelial cells and BK lives in uroepithelium. Each virus is transmitted with the kidney transplant; hence, virally infected kidneys aren’t just about HIV and Hep C.

More severe infections occur when transplanting a Big Three-infected kidney to an uninfected host (eg, children, who are much more likely to be seronegative to these viruses at time of transplant). CMV and EBV can cause life-threatening systemic disease or malignancy, but can also reduce allograft survival with subclinical infection. BKV nephropathy significantly reduces allograft survival. Only CMV has a proven effective prophylaxis or treatment (valganciclovir). Vaccines for EBV or BKV are still not near. So this team is really the two bigs and the perimeter three – a high-caliber starting five that deserves to go deep in the NephMadness tournament.

– Post written by Vikas Dharnidharka. Follow him @Vikas_R_D.

As with all content on the AJKD Blog, the opinions expressed are those of the author of each post, and are not necessarily shared or endorsed by the AJKD Blog, AJKD, the National Kidney Foundation, Elsevier, or any other entity unless explicitly stated.

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