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A prospective and diagnostic marker for the development of nephropathy in renal transplant recipients
Polyomaviruses are small (45 nm, approximately 5,000 bp), DNA-containing viruses and include 3 closely related viruses of clinical significance: Simian virus 40 (SV-40), JC virus (JCV), and BK virus (BKV). SV-40 naturally infects rhesus monkeys but can infect humans, while BKV and JCV cause productive infection only in humans.(1,2) Acquisition of BKV begins in infancy. Serological evidence of infection by BKV is present in 37% of individuals by 5 years of age and over 80% of adolescents.
BKV is an important cause of interstitial nephritis and BKV-associated nephropathy (BKVAN) in recipients of kidney transplants. Up to 5% of renal allograft recipients can be affected at about 40 weeks (range 6-150) posttransplantation.(3) Quantitative PCR analysis of BKV DNA in the plasma is the most widely used blood test for the laboratory diagnosis of BKV-associated nephropathy. Importantly, the presence of BKV DNA in blood reflects the dynamics of the disease: the conversion of plasma from negative to positive for BKV DNA after transplantation, the presence of DNA in plasma in conjunction with the persistence of nephropathy, and its disappearance from plasma after the reduction of immunosuppressive therapy.(4-8) The presence of BKV DNA in plasma at levels > or =10,000 copies BKV DNA/mL may correlate with an increased risk of BKVAN with this assay. Furthermore, the trend of viral DNA quantitation (eg, increasing, decreasing) may be helpful in predicting the onset of BKVAN.
Increasing copy levels of BK virus (BKV) DNA in serial specimens may indicate possible BKV- associated nephropathy (BKVAN) in kidney transplant patients.
Viral loads >10,000 copies/mL in plasma may also indicate a risk for BKVAN.
This assay does not cross react with other polyomaviruses, including JC virus and Simian virus 40 (SV-40).
Serial monitoring of viral loads may be indicated to assess changing levels of BK virus (BKV) DNA.
Qualitative results are available as LCBKP / BK Virus, Molecular Detection, PCR, Plasma.
This test is not to be used to screen healthy patients. It is to be used for patients with a clinical history or risk factors for BKV disease. Depending on the population, varying percentages of patients may be found to be positive.
The following validation supports the use of this assay for clinical testing.
Accuracy/Diagnostic Sensitivity and Specificity:
Results from this real-time PCR assay on the LightCycler (LC PCR) were compared to a previous PCR assay (directed to VP2 region of the polyoma virus based on a published method) on 112 plasma specimens and 108 urine specimens. Using the previous method as the gold standard, the diagnostic sensitivity and specificity is 94% and 90% for plasma and 100% and 100% for urine, respectively. The discrepant specimens had low viral DNA copy numbers (<5,000 copies/mL), which is associated with greater variability of quantitative results.
Supplemental Data (Spiking Studies):
To supplement the above data, 30 negative plasma and urine specimens were spiked with BK virus (BKV)-positive control plasmid at the approximate limit of detection (LoD). The 30-spiked specimens were run in a blinded manner along with 57 plasma and 58 urine negative (nonspiked) specimens. 100% of the spiked specimens were positive and 100% of the nonspiked specimens were negative.
The lower LoD of this assay is 244 DNA target copies per mL in urine and plasma.
No PCR signal was obtained from the extracts of a variety of human viruses that can be found in urine or plasma, including cytomegalovirus, Epstein-Barr virus, human herpesvirus-6, enterovirus, adenovirus, and mumps virus.
Qualitative interassay and intra-assay precision were 100%. Quantitative values had a standard deviation of <0.25 log10 across the analytical measuring range.
The reference range of BKV in plasma is "None Detected." This test is not to be used to screen healthy patients. It is to be used for patients with a clinical history or risk factors for BKV-associated nephropathy.
Reportable Range (lower and upper limits of quantification, analytical measurement range):
Reportable range is from 5,000 to 50,000,000 copies/mL. The assay demonstrates acceptable linearity between these values.
1. Kazory A, Ducloux D: Renal transplantation and polyomavirus infection: recent clinical facts and controversies. Transplant Infect Dis 2003;5(2):65
2. Vilchez RA, Arrington AS, Butel JS: Polyomaviruses in kidney transplant recipients. Am J Transplantation 2002;2(5):481
3. Hirsch HH: Polyomavirus BK nephropathy: a (re-)emerging complication in renal transplantation. Am J Transplantation 2002;2(1):25-30
4. Randhawa PS, Demetris AJ: Nephropathy due to polyomavirus type BK. N Engl J Med 2000;342:1361-1363
5. Volker NT, Klimkait IF, Binet P, et al: Testing for polyomavirus type BK DNA in plasma to identify renal-allograft recipients with viral nephropathy. N Engl J Med 2000;342:1309-1315
6. Hariharan S: BK virus nephritis after renal transplantation. Kidney Int 2006;69:655-662
7. Blanckaert K, De Vriese AS: Current recommendations for diagnosis and management of polyoma BK virus nephropathy in renal transplant recipients. Nephrol Dial Transplant 2006;21(12):3364-3367
8. Viscount HB, Eid AJ, Espy MJ, et al: Polyomavirus polymerase chain reaction as a surrogate marker of polyomavirus-associated nephropathy. Transplantation 2007;84(3):340-345