Elsevier

Transplantation Proceedings

Volume 50, Issue 8, October 2018, Pages 2575-2578
Transplantation Proceedings

15th Congress of the Asian Society of Transplantation
Case report
High-Dose Intravenous Immunoglobulin Treatment of Polyomavirus Nephropathy Developing After T Cell–Mediated Rejection Treatment: A Case Report

https://doi.org/10.1016/j.transproceed.2018.01.021Get rights and content

Highlights

  • Optimal BK treatment methods have not been established, and controversy exists.

  • High-dose intravenous immunoglobulin therapy can lead to the successful treatment of BK virus infection after other treatments have failed.

Abstract

Background

Reactivation of BK polyomavirus causes destructive virus allograft nephropathy; however, treatment options are limited. Herein, we report a case in which a patient with T cell–mediated rejection was treated with steroid therapy. The patient subsequently developed BK viremia and was successfully treated by using intravenous immunoglobulin (IVIG) after failing to respond to conventional treatment.

Case Presentation

A 54-year-old man had been undergoing peritoneal dialysis for 3 years before kidney transplantation. He had an elevated serum creatinine level (2.26 mg/dL; normal range, 1.2–1.4 mg/dL) and reduced urine output 2 months after transplantation. Suspecting T cell–mediated rejection, steroid pulse therapy (methylprednisolone 250 mg twice daily) was performed for 3 days. Despite treatment, there was a recurrence of increased serum creatinine, and real-time quantitative polymerase chain reaction (serum samples) indicated BK viremia (>5.5 × 105 copies/mL). Results of a kidney biopsy revealed polyomavirus nephropathy (BK virus positive and C4d negative). Thus, the patient's tacrolimus dosage was reduced (from 2.75 mg twice daily to 2 mg once daily), he discontinued mycophenolate mofetil, and he was administered ciprofloxacin and leflunomide. However, the BK viremia showed no improvement, even after 3 months of treatment. Thus, he was administered high-dose IVIG (1 g/kg, 5 times over 5 weeks). The viremia load (blood specimen) decreased to 5197 copies/mL, and the patient's graft function stabilized. His serum creatinine decreased to 2.68 mg/dL. The patient is currently being followed up.

Conclusions

Optimal BK treatment methods have not been established, and IVIG treatment remains controversial. However, the present case provides an example of successful treatment using high-dose IVIG.

Section snippets

Case Presentation

A 54-year-old man with a history of hypertension, type 2 diabetes, and continuous ambulatory peritoneal dialysis for 3 years (before kidney transplantation) due to end-stage renal disease underwent kidney transplantation and left nephrectomy on April 22, 2016. He was admitted with an increased serum creatinine level of 2.26 mg/dL (normal range, 1.2–1.4 mg/dL) on June 11, 2016 (postoperative day 50). He had no urinary symptoms. Kidney ultrasound revealed normal echogenicity in the transplanted

Discussion

The present case provides an example of successful treatment using high-dose IVIG in a patient with TCMR and BKVN. There is currently a great deal of controversy about how to treat such cases.

The use of IVIG has a long history in the field of transplantation, and IVIG products are known to have powerful immunomodulatory effects on inflammatory and autoimmune diseases [7]. The rationale of IVIG use in the management of BKVN is based on the potential transfer of protective immunity. The activity

Conclusions

The present case demonstrates that high-dose IVIG therapy can lead to the successful treatment of BKVN after other treatments have failed.

References (9)

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Cited by (0)

The current study was supported by an Inha University Research Grant.

The first two authors contributed equally to this work.

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