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BK Virus

Hans H Hirsch

Transplantation & Clinical VirologyDepartment Biomedicine (Haus Petersplatz)

Division Infection DiagnosticsDepartment Biomedicine (Haus Petersplatz)University of Basel

Infectious Diseases & Hospital EpidemiologyUniversity Hospital Basel

Switzerland

Centre de ConfCentre de Conf öörencerence28 rue du Docteur Roux 28 rue du Docteur Roux -- 7501575015ParisParis22.04.201322.04.2013

� Circular double-stranded DNA of 5100 bp� 2 regulatory proteins, 3 structural proteins

– No classic antiviral target (viral polymerase, protease)

Polyomavirus (PyV)Polyomavirus (PyV)

early genes late genes

non-coding control region

Background

PolyomaviridaePolyomaviridae

Background

TSPyV

OraPyV1B

PyV

SqP

yV

MPyVHaPyV

LPyV

OraPyV2

MCPyV

APyVFPyV

CaPyV

CP

yV

GH

PyV

MP

tV

Bat

PyV

SLPy

V

SV40JCPyVSA12

BKPyV

HPyV7

HPyV6

KIP

yVW

UP

yV

Wukipolyomavirus Avipolyomavirus

Orthopolyomavirus0.2

Human Polyomavirus Infection and DiseaseHuman Polyomavirus Infection and Disease

� BKV– Nephropathy (PyVAN)– Hemorrhagic cystitis (PyVHC)

� JCV– Multifocal leukoencephalopathy (PyVML)

� MCPyV– Merkel cell carcinoma

� KIPyV– Bronchitis, pneumonia?

� WUPyV– Bronchitis, pneumonia?

� HPyV-6– Unknown, skin?

� HPyV-7– Unknown, skin?

� TS-PyV– Skin spiculae, alopecia

� HPyV-9– Unknown, lymphocytes?

� …

MCPyVImmunodeficientMerkel cellcarcinoma

PyVAN

PyVHCLacey et al 2007

IgG Seroprevalence

40-60%

40-60%

50-60%

60-70%

80-90%

60-70%

30-40%

TS-PyVSOTSkin spiculae,alopecia

10-80%

40% ?

Egli A, Infanti L, Dumoulin A, Buser A, Samaridis J, Stebler C, Gosert R, Hirsch HH (2009) Prevalence of Polyomavirus BK and JC Infection and Replication in 400 Healthy Blood Donors J Infect Dis 199 : 837-846Dalianis T, Hirsch HH (2013) Human Polyomavirus and Cancer Virology 437: 63 - 72Background

� BK-VP1 and JC-VP1 expression in baculovirus SF9– Virus-like particles (BK-VLP, JC-VLP)

� N= 400 (100 per age decade from 20 – 59yrs) � IgG Seroprevalence

– BKV 82%– JCV 58%

� Viruria– BKV 7% (9%)– JCV 19% (33%)

� No viremia

BKV and JCV Infection and Replication BKV and JCV Infection and Replication in Healthy Blood Donorsin Healthy Blood Donors

Egli A, Infanti L, Dumoulin A, Buser A, Samaridis J, Stebler C, Gosert R, Hirsch HH (2009) Prevalence of Polyomavirus BK and JC Infection and Replication in 400 Healthy Blood Donors J Infect Dis 199 : 837-846

Kardas P, Weissbach F, Samarides J, Hirsch HH (unpublished)

JC VP1 VLP

BK VP1 VLP

Background

Hirsch HH, Randhawa P and the American Society of Transplantation IDCOP (2013) AST Infectious Disease Community of Practice Guidelines: BK Polyomavirus Update 2012 Am J Transpl 13 (in press)

� Incidence rate 5% (1% - 12%) after kidney transplantation– Functional deficits in ~90%, graft loss in ~50% (range 10% - 90%)

� (Multi-)focal disease, proceeds through histology stages A, B, C� No effective antiviral drug� Treatment by improving immune control = reducing immunosuppression

Large T-antigenAgnoproteinDecoy cell

BK PolyomavirusBK Polyomavirus --associated Nephropathyassociated Nephropathy

Background

The Issues of BKV in Kidney TransplantsThe Issues of BKV in Kidney Transplants

The problem�Irreversible functional decline�Heterogeneous histological presentation

– Refractory interstitial nephritis

�Chronic allograft nephropathy (IF/TA)�Graft loss

The challenge�Widespread viral infection�Complementing risk factors�Lack of early diagnosis�Uncertain response to modulating immunosuppression�No effective antivirals�Uncertainty about retransplantation

Refractory RejectionRefractory Rejection

0

100

200

300

400

500

600

0 20 40 60 80 100 120

Weeks posttransplantation

Ser

um C

reat

inin

e -

- -

(um

ol/L

)

100

1000

10000

100000

1000000

10000000

Pla

sma

BK

VLo

ad -

-

(GE

q/m

L)

AZACsA

AR ARPANAR

PAN Allograftremoval

PANAR

AZAMMFPRE

TAC CsA

Steroids i.v.

Biopsy

Intensified Immunosuppression

Nickeleit V, Hirsch HH, Binet I, Gudat F, Prince O, Dalquen P, Thiel G, Mihatsch MJ (1999) Polyomavirus infection in renal allograft recipients: from latent infection to manifest disease J Am Soc Nephrol 10: 1080Hirsch & Steiger (2003) Polyomavirus BK Lancet Infect Dis 3: 611

Progressive Allograft FailureProgressive Allograft Failure

0

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0 20 40 60 80 100 120


Ser

um C

reat

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ol/L

)

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10000

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1000000

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Pla

sma

BK

VLo

ad -

-

(GE

q/m

L)

AZACsA

AR ARPANAR


PANAR

AZAMMFPRE

TAC CsA

Steroids i.v.

Biopsy


Chronic Allograft NephropathyChronic Allograft Nephropathy

0

100

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0 20 40 60 80 100 120


Ser

um C

reat

inin

e -

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ol/L

)

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Pla

sma

BK

VLo

ad -

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(GE

q/m

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AZACsA

AR ARPANAR


PANAR

AZAMMFPRE

TAC CsA

Steroids i.v.

Biopsydecoy cellsin urine

plasma BKVDNA positive

plasma BKVDNA negative


Heterogenous HistologyHeterogenous Histology

Courtesy of M.J. Mihatsch & H.Hopfer, Basel

Immunohistochemistry for SV40 large TImmunohistochemistry for SV40 large T --antigenantigen

Courtesy of M.J. Mihatsch & H.Hopfer, Basel

Purighalla et al. 1995 Am J Kid Dis 26: 671

PyVAN without PyVAN without →→→→→→→→ with significant inflammationwith significant inflammation

Gosert R, Rinaldo CH, Funk GA, Egli A, Ramos E, Drachenberg CB Hirsch HH (2008) Polyomavirus BK with rearranged Non-CodingControl Region emerge in vivo in Renal Transplant Patients and increase Viral Replication and Cytopathology J Exp Med 205: 841

BK PyVAN and Plasma BKV loadBK PyVAN and Plasma BKV load

100

1000

10000

100000

1000000

10000000

0

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400

500

600

0 20 40 60 80 100 120

Pla

sma

BK

VLo

ad -

-

(GE

q/m

L)

Ser

um C

reat

inin

e -

- -

(um

ol/L

)


AZA CsA

AR AR PyVAN

AR PyVAN

Allograft removal

PyVAN AR

AZA MMF PRE

TAC CsA

Steroids i.v.

Biopsy A B C


� BKV plasma viral half-life t 1/2 ~1-2h� Steady-state: High viral turnover ~99% per day� Renal tubular epithelial cell loss ~106 to ~107 /day� In silico model to predict viral cytopathology and clearance

BKV Dynamics after Transplant NephrectomyBKV Dynamics after Transplant Nephrectomy

BK

V lo

ad lo

g10

Funk GA, Gosert R, Comoli P, Ginevri F, Hirsch HH (2008) Polyomavirus BK Replication Dynamics in vivo and in silico to predict Cytopathology and Viral Clearance in Kidney Transplants Am J Transplant 8: 2368Funk GA, Steiger J, Hirsch HH (2006) Rapid dynamics of Polyomavirus BK in Renal Transplant Recipients J Infect Dis 193: 80

[S-Crea]

Weeks post transplant

Nephrectomy

PyVAN pathology and risk of graft lossPyVAN pathology and risk of graft loss

Graft function

Baseline

Slightly impaired

Significantly impaired,progressive failure

False-negativebiopsy, %

PyVANstages

A

B1B2B3

C

Risk ofgraft loss, %

<10

50

>80

10–30

Drachenberg et al. 2004 Am J Transplant 4:2082-92Drachenberg, Papadimitriou 2006 Transpl Inf Dis 8: 68

high-level

Viruria

Viruria

Viremia

NephropathyPyVAN

BKV Viruria and Viremia precedes BKV Viruria and Viremia precedes provenproven PyVANPyVAN

Hirsch HH, Knowles W, Dickenmann M, Passweg J, Klimkait T, Mihatsch MJ, Steiger J (2002) Prospective Study of Polyomavirus type BK Replication and Nephropathy in Renal Transplant Recipients N Engl J Med 2002; 347: 488

Screening for BKV replication

Viremia 78%

www.kdigo.org

1. Schold et al. Transpl Int 20092. Dharnidharka et al. Transplantation 20093. Hirsch et al. NEJM 20024. Bohl Am J Transplant 2007;2:S36–46;5. Brennan et al. Am J Transplant 2005;5:582–94

Risk factors for BKV replication and PyVANRisk factors for BKV replication and PyVAN

Non-modifiable risk factors

� Donor BKV seropositive / recipient BKV seronegative

� Older recipients (>65 years)

� Male Recipient

� Donor age (>65 years)

� HLA mismatches

� Acute rejection and therapy

� Pediatric recipient

� Re-transplantation

Modifiable risk factors

� Induction� Maintenance immunosuppression2

� Stents5

19

Donor Serostatus and Recipient BKV ViruriaDonor Serostatus and Recipient BKV Viruria

Bohl et al. 2005 Am J Transplant 5; 2213

Role of SteroidsRole of Steroids

Risk Factor P RR

Decoy Cells Acute rejection / Steroid Pulses 0.01 1.21

BKV Viremia Acute rejection / Steroid Pulses 0.01 1.28HLA Mismatches 0.04 1.78

PyVAN Acute rejection / Steroid Pulses 0.02 1.38

� Prospective single-center study of 78 kidney transplants in Basel� Multiple logistic regression analysis for independent risk factors

Hirsch HH et al. N Engl J Med 2002;347:488–96

Risk of BKV and ImmunosuppressionRisk of BKV and Immunosuppression

Adapted from Dharnidharka VR, et al. Transplantation 2009;87:1019–26

Induction: IL2 vs none

Induction: thymoglobulin vs none

CsA based vs tacrolimus based

Azathioprine based vs MMF based

No anti-metabolites vs MMF based

mTORi: yes vs no

Low risk

Adjusted hazard ratio

High risk

0.0 0.5 1.0 1.5 2.0 2.5

Retrospective analysis of BKV treatment within 24 m onths Retrospective analysis of BKV treatment within 24 m onths Organ Procurement and Transplantation Network data Organ Procurement and Transplantation Network data

from 34,937 primary kidney transplant recipients 20 04from 34,937 primary kidney transplant recipients 20 04––20062006

Risk Factors of BKV ViremiaRisk Factors of BKV Viremia

Hirsch HH, Vincenti F, Friman S, Tuncer M, Citterio F, Wiecek A, Scheuermann E, Klinger M, Pecovitz MD, Prestele H (2013)Polyomavirus BK Replication in De Novo Kidney Transplant Patients Receiving Tacrolimus or Cyclosporine: A Prospective, Randomized, Multicenter Study Am J Transplant 13: 136

1 2 3 6 120

5

10

15

20

BK

vire

mia

(%

)

p=0.048

p=0.004

Tacrolimus

Cyclosporin

p=0.494

p=0.279

p=0.095

Univariate

� International prospective multicenter study >600 de novo kidney transplant patients receiving basiliximab, mycophenolate, prednisone and randomized 1:1 to Cyclosporine (C2) vs Tacrolimus (C0)

� International prospective multicenter study >600 de novo kidney transplant patients randomized 1:1 to Cyclosporine vs Tacrolimus

DIRECT Study: Multivariate at 6 MonthsDIRECT Study: Multivariate at 6 Months

Viremia Month 6 OR 95% CI p-value

CNI (CsA vs. Tac) 0.60 (0.36, 0.99) 0.044

Age (per 10 years) 1.14 (0.94, 1.40) 0.187

Gender (male vs female) 1.03 (0.61, 1.74) 0.920

Race (white vs. other) 0.69 (0.35, 1.34) 0.272

History of DM (yes vs no) 1.32 (0.64, 2.72) 0.449

HLA mismatches (>4 vs <4) 1.21 (0.66, 2.21) 0.544

DGF (yes vs. No) 1.62 (0.79, 3.32) 0.192

Cumulative steroid dose (per 1 g) 1.19 (1.03, 1.38) 0.017


Risk Factors of BKV ViremiaRisk Factors of BKV Viremia


Steroids TacrolimusSteroids

TacrolimusMaleAge

1 2 3 6 120

5

10

15

20

BK

vire

mia

(%

)

p=0.048

p=0.004

Tacrolimus

Cyclosporin

p=0.494

p=0.279

p=0.095

Multivariate

Univariate

� International prospective multicenter study >600 de novo kidney transplant patients randomized 1:1 to Cyclosporine vs Tacrolimus

Alemtuzumab Induction in 666 Kidney TransplantsAlemtuzumab Induction in 666 Kidney Transplants

25

Theodoropoulos et al. (2013) Am J Transplant 13: 197

Risk Factors for BKPyVANRisk Factors for BKPyVAN

26


Graft Survival of 666 Kidney TransplantsGraft Survival of 666 Kidney Transplants

27


HighHigh --Risk Kidney Transplant PatientsRisk Kidney Transplant Patients

BK-PyVAN1-10%

High-levelBKV viruria

30-50%

BKV viremia10-20%

BKV seropositive

80 - 90%

BKV viremia clearance: 35/38 patients (92%)

Clinical rejection after clearance:

3/38 patients (8%)

Schaub S, Hirsch HH, Dickenmann M, Steiger J, Mihatsch MJ, Hopfer H, Mayr M (2010) Reducing immunosuppression preserves allograft function in presumptive and definitive polyomavirus-associated nephropathy Am J Transplant 10: 2615

AST Guidelines 2013AST Guidelines 2013

Hirsch HH & Randhawa P (2013) American Society of Transplantation Infectious Disease Community of Practice Guideline: BK Polyomavirus Update 2012 Am J Transplant 13: 179

BKV Viremia and SV40 + HistologyBKV Viremia and SV40 + Histology

Menter T, Mayr M, Schaub S, Mihatsch MJ, Hirsch HH, Hopfer H (2013) Pathology of resolving polyomavirusAssociated nephropathy Am J Transplant 13: in press

Clearance of BKV viremiaClearance of BKV viremia

DefinitivePyVAN(n=13)

PresumptivePyVAN(n=17)

Low BKV viremia(n=18) P value

Clearance of BKV viremia, n (%) 12 (92) 15 (88) 8 (100) 0.60

Months from first BKV viremia to BKV clearance

8.8(2.8–18.5)

4.6(1.2–23.3)

2.9(0.9–4.6)

0.001

Reduction of immunosuppressionto achieve BKV clearance, n (%)

Step 1 2 (17) 8 (53) 8 (100) 0.001

Step 2 6 (50) 7 (47)

Step 3 4 (33) ‒

Schaub S, Hirsch HH, Dickenmann M, Steiger J, Mihatsch MJ, Hopfer H, Mayr M (2010) Reducing immunosuppression preserves allograft function in presumptive and definitive polyomavirus-associated nephropathy Am J Transplant 10: 2615

Challenges persistChallenges persist ……

� Standardizing BKV load measurement– WHO Standard for calibrating in international units– Establishing BKV load as clinical endpoint (“10’000 copies”?)

• Sood et al. (Abstract 1103); Eyileten et al. (Abstract 1093) ATC 2012

� PyVAN histological diagnosis– Quality control Randhawa et al. (Abstract 1096) ATC 2012

– 10th Banff proposal on staging (fibrosis vs inflammation)• Matsutani et al. (Abstract 287) ATC 2012

� Role of BKV-specific immunity as surrogate marker– BKV-specific T-cells and antibody responses

• Hariharan et al. (Abstract 284) ATC 2012

• Dziubianau et al. (Abstract 288) ATC 2012

� Differentiating PyVAN and acute rejection� Diagnosis and treatment of advanced PyVAN

– Antivirals?

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BKV-LT

group 1(inc/hi)

group 2(dec)

Mean (SD) 52(±109) 104 (±128) 102 (± 110) 337 (±343)Median (range) 22 (0-524) 72 (8-465) 53 (0-392) 285 (45-1432)

P=0.001

BKV-VP1

group 1(inc/hi)

group 2(dec)

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BKV-VP1

group 1(inc/hi)

group 2(dec)

Clearing BKV viremia parallels increasing BKVClearing BKV viremia parallels increasing BKV --specific Tspecific T --cells in bloodcells in blood

RisingBKV viremia

ClearingBKV viremia

RisingBKV viremia

ClearingBKV viremia

Key Results 4

Binggeli S, Egli A, Schaub S, Binet I, Mayr M, Steiger J, Hirsch HH (2007) Polyomavirus BK-Specific Cellular Immune Response to VP1 and Large T-Antigen in Kidney Transplant Recipients Am J Transplant 7: 1131

Large T antigen-spec. T-cells VP1- spec. T-cells

BKVBKV --specific Tspecific T --cells in blood cells in blood afterafter declining viremiadeclining viremia(= not predicting)(= not predicting)

Schachter et al. 2012 Am J Transplant 11: 2443Schachter et al. (Abstract 289) ATC 2012 Interferon-g induced protein 10 (IP10) in Serum.

LT-specific T-cells

VP1-specific T-cells

VP1-specific IgM

BKV viral load

Clearing BKV viremia is linked to selfClearing BKV viremia is linked to self --limiting acute limiting acute interstitial nephritisinterstitial nephritis


Residualinflammation

“Plasma-cellRich” infiltrate

InterstitialInflammatoryinfiltrate

Clearing BKV viremia, graft function, and HLAClearing BKV viremia, graft function, and HLA --DRDR


PyVAN Course PyVAN Course versus versus Acute RejectionAcute Rejection

� Urine mRNA profile and functional outcome – BKV VP-1 mRNA, proteinase inhibitor-9; granzyme B– Declining function (DF) PyVAN: 3A, 2B, 3C– Stable PyVAN: 6A, 2B, 2C

Dadhania et al (2010) Transplantation 90: 189

SummarySummary

� BKV replication as surrogate marker of progressive risk– High-level viruria → viremia

� Nephropathy staging A →B1,B2,B3→C and risk of graft failure� Screening kidney transplant patients for BKV replication

– Basel consensus 2005, KDIGO 2009, AST-IDCOP 2009, 2013 � Risk factors

– Imbalance between donor BKV load/replication and recipient BKV-specific immune control

– Tacrolimus and steroids have dual role by activating BKV replication and impairing specific T-cell activation

� Treatment by reducing immunosuppression� Interstitial inflammation difficult to interpret

– Baseline or stable renal function, < 3 months after BKV viremia clearance

– Declining renal function, >3 months after BKV viremia clearance

Thank you !Thank you !

Transplantation & Clinical VirologyTobias Bethge

Alexis DumoulinVroni DelZenero

Michela CioniAndrea GlaserRainer GosertDenise KranzPiotr Kardas

Celine LeboeufJulia Manzetti

Min-Ji LuNicole Pina

Jacqueline SamaridesGunhild Unterstab

Marion Wernli

Past membersAdrian EgliGeorg Funk

Helen HachemiNina KhannaSabrina Köhli

David Leuenberger

Nephrology USBJürg Steiger

Stefan SchaubMichael Dickenmann

Michael Mayr

Pathology USBMichael Mihatsch

Helmut Hopfer

Istituto Gaslini Genua, ItalyFabrizio Ginevri

University Hospital North NorwayChristine H. Rinaldo

Karen Sörensen

UMTC Baltimore, Md, USACinthia Drachenberg

Emilio Ramos

San Matteo Pavia, ItalyPatrizia Comoli

Karolinska Institutet StockholmTina Dalianis

University of HelsinkiIrmeli Lautenschlager

Illka HelanteräDBM

Giulio SpagnoliPaul Zaja

Pascal Lorentz

Swiss Transplant Cohort StudyBiocenter Proteomics Facility Timo Glatter