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Polyomavirusinfektionen bei pädiatrischen Nierentransplantatempfängern

Neue Ergebnisse aus dem europäischen Kindertransplantationsregister CERTAIN

Polyomavirus infections in pediatric kidney transplant recipients

New results from the European pediatric renal transplantation registry CERTAIN

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Der Nephrologe Aims and scope

Zusammenfassung

Die nach Nierentransplantation (NTx) relevantesten humanen Polyomaviren sind das BK- (BKPyV) und das JC-Polyomavirus (JCPyV). Unter medikamentöser Immunsuppression können sie eine Transplantatnephropathie (PyVAN) durch eine virusinduzierte interstitielle Nephritis mit gravierenden Folgen bis hin zum Organverlust verursachen. In einer kürzlich publizierten epidemiologischen Studie des CERTAIN-Konsortiums beobachteten wir, dass eine BKPyV-Virämie bei etwa 39 % und eine biopsiegesicherte BKPyVAN bei nahezu 5 % der Kinder und Jugendlichen in den ersten 5 Jahren nach NTx auftritt. Risikofaktoren sind junges Empfängeralter, eine obstruktive Uropathie als primäre Nierenerkrankung sowie ein tacrolimusbasiertes immunsuppressives Regime und eine hohe Nettoimmunsuppression. Ein regelmäßiges, präsymptomatisches Screening der BKPyV-Last in Urin und Plasma über 5 Jahre nach NTx ist zur Frühdiagnostik notwendig, um bei hoher Viruslast die Immunsuppression frühzeitig reduzieren bzw. modifizieren zu können und so einen Organverlust zu vermeiden. Spezifisch wirksame antivirale Medikamente fehlen bislang. Eine JCPyV-Replikation im Urin ist häufig (21,6 %) nach pädiatrischer NTx, im Plasma seltener (12,1 %), führt aber nur in Einzelfällen zur Transplantatnephropathie. Ein generelles präsymptomatisches Screening auf JCPyV wird daher derzeit nicht empfohlen. Allerdings muss insbesondere bei Transplantatdysfunktion, fehlendem BKPyV-Nachweis im Plasma, aber SV40Ag(„simian virus 40 antigen“)-Positivität in der Transplantatnierenbiopsie eine JCPyVAN in Betracht gezogen werden. Diese neuen Ergebnisse zu Polyomavirusinfektionen bei pädiatrischen Nierentransplantatempfängern haben in die interdisziplinäre AWMF-Leitlinie Einzug gehalten.

Abstract

The two most relevant human polyomaviruses after renal transplantation (RTx) are the BK polyomavirus (BKPyV) and the JC polyomavirus (JCPyV). Under medicinal immunosuppressive treatment both can cause polyomavirus-induced interstitial nephritis and associated transplant nephropathy (PyVAN) with severe consequences, including organ loss. In a recently published large-scale epidemiological study of the CERTAIN research network with 313 pediatric patients from 16 European transplantation centers in 6 countries, it was observed that BKPyV viremia occurs in approximately 39% during the first 5 years after RTx and biopsy-proven BKPyVAN is diagnosed in almost 5% of the children and adolescents. Independent risk factors are young recipient age, obstructive uropathy as the primary renal disease as well as a tacrolimus-based immunosuppressive regimen and a high net state of immunosuppression. Regular presymptomatic monitoring of BKPyV viruria and viremia during the first 5 years after RTx is necessary for a timely reduction or modification of the immunosuppressive regimen in cases of significant viremia in order to avoid organ loss. So far, specific and effective antiviral drugs are still lacking. A JCPyV replication in urine (21.6%) is common after pediatric RTx, in plasma (12.1%) less common, but leads to transplant nephropathy in isolated cases only. A general presymptomatic JCPyV screening is therefore currently not recommended. Nevertheless, a JCPyVAN must be considered in cases of transplant dysfunction and lack of detection of BKPyV in plasma, but immunohistochemical detection of SV40Ag positivity in the kidney transplant biopsy. These new results on polyomavirus infections in pediatric renal transplant recipients have been included in the interdisciplinary Association of the Scientific Medical Societies in Germany guidelines (AWMF 093-002).

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  1. Zentrum für Kinder- und Jugendmedizin, Klinik Kinderheilkunde I (Schwerpunkte: Allgemeine Kinderheilkunde, Neuropädiatrie, Stoffwechsel, Gastroenterologie, Nephrologie), Universitätsklinikum Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Deutschland

    B. Höcker & B. Tönshoff

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B. Höcker und B. Tönshoff geben an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren.

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B. Tönshoff, Heidelberg

L.T. Weber, Köln

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Höcker, B., Tönshoff, B. Polyomavirusinfektionen bei pädiatrischen Nierentransplantatempfängern. Nephrologe 14, 199–205 (2019). https://doi.org/10.1007/s11560-019-0327-x

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  • DOI: https://doi.org/10.1007/s11560-019-0327-x

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