肾移植术后BK病毒相关性肾病的诊断与治疗

Diagnosis and treatment of BK virus-associated nephropathy after renal transplantation

目的探讨肾移植术后BKV相关性肾病(BK virus associated nephropathy,BKVAN)的诊断与治疗方法。方法针对62例血肌酐进行性升高的受者行血液及尿液BKV-DNA定量检测,阳性受者常规行移植肾穿刺活检以明确诊断。结果21例受者发现有BKV感染,20例受者停用吗替麦考酚酯(MMF)并用来氟米特替代,减少他克莫司用量,1例尿液(-)血液(+)受者以西罗莫司替代他克莫司并减少MMF用量。其中11例尿液(+)血液(-)受者中,4例受者尿液BKV-DNA转阴且血肌酐明显下降,4例受者尿液BKV-DNA载量有所下降且血肌酐维持稳定,1例受者因肺部感染合并肝肾功能衰竭导致死亡,1例受者尿液BKV-DNA较前下降但血肌酐较前上升,1例受者合并急性排斥反应及移植肾积水,血肌酐较前上升,BKV-DNA尚未复查;9例尿液(+)血液(+)受者中,6例尿液BKV-DNA载量下降并血液检测转阴且血肌酐明显下降,2例受者血液BKV载量有所下降,尿液BKV载量无变化且血肌酐维持稳定,1例受者血肌酐稳定,尚未复查;1例尿液(-)血液(+)受者因大幅度减少免疫抑制剂引起急性排斥反应,最终因治疗不及时导致移植肾功能丧失,恢复血液透析。结论通过降低免疫抑制强度对治疗BKVAN疗效确切,但需警惕因减少免疫抑制剂引起的急性排斥反应。

Objective To explore the diagnosis and treatment of BKV nephropathy after renal transplantation.Methods A total of 62 patients with progressive creatinine elevation were routinely examined by blood and urine BKV-DNA.And 21 patients with positive results underwent graft biopsies for confirming a diagnosis.Results Among 21 cases of BKV infection,20 cases received leflunomide in replacing mycophenolate mofetil(MMF)and a lower dose of tacrolimus.One case with urine(-)&blood(+)received sirolimus in replacing tacrolimus and a lower dose of MMF.Among 11 cases with urine(+)and blood(-),urinary BKV-DNA turned negative&creatinine decreased markedly(n=4),urinary BKV-DNA load decreased&creatinine stablized(n=4),death from pulmonary infection with hepatic&renal failure(n=1),urine BKV-DNA load decreased&creatine increased(n=1),BKV–DNA load was not re-examined in 1 case of acute rejection and hydronephrosis with elevated creatine;Among 9 cases with urine(+)&blood(+),blood BKV-DNA turned negative with urinary BKV-DNA load&creatine decreased(n=6),blood BKV-DNA load decreased&creatine stablized(n=2)and no re-examination with a stable level of creatine(n=1);One case with urine(-)&blood(+)was not timely treated and ultimately leading to graft loss after an onset of acute rejection.Conclusions BKV nephropathy may be effectively treated by decreasing immunosuppressive intensity.However,clinicians should stay on a high alert for acute rejection due to an excessive reduction of immunosuppressive agents.