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Human Polyomavirus 9 Infection in Kidney Transplant Patients Els Van Der Meijden, Herman F

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Human Polyomavirus 9 Infection in Kidney Transplant Patients Els Van Der Meijden, Herman F Human Polyomavirus 9 Infection in Kidney Transplant Patients Els van der Meijden, Herman F. Wunderink, Caroline S. van der Blij-de Brouwer, Hans L. Zaaijer, Joris I. Rotmans, Jan Nico Bouwes Bavinck, and Mariet C.W. Feltkamp Several human polyomaviruses of unknown preva- For kidney transplant patients, BKPyV infection is con- lence and pathogenicity have been identified, including hu- sidered the most common viral complication and causes man polyomavirus 9 (HPyV9). To determine rates of HPyV9 nephropathy and graft loss in 1%–10% of cases if left un- infection among immunosuppressed patients, we screened treated (8). It is not known what determines the severity serum samples from 101 kidney transplant patients in the of BKPyV infection and whether co-infection is involved Netherlands for HPyV9 DNA and seroreactivity. A total of in the pathogenesis. 21 patients had positive results for HPyV9 DNA; positiv- ity rates peaked at 3 months after transplantation, but the Since 2007, at least 10 novel HPyVs have been discov- highest viral loads were measured just after transplantation. ered (9–20); of these, Merkel cell polyomavirus (MCPyV) During 18 months of follow-up, HPyV9 seroprevalence in- and trichodysplasia spinulosa–associated polyomavirus creased from 33% to 46% among transplant patients; sero- (TSPyV) have been shown to be associated with disease prevalence remained stable at ≈30% in a control group of (11,19,21,22). Human polyomavirus 9 (HPyV9), so far healthy blood donors in whom no HPyV9 DNA was detect- without a disease association, was identified in 2011 from a ed. Further analysis revealed an association between de- serum sample from a kidney transplant patient (17). Over- tection of HPyV9 and detection of BK polyomavirus but not all seroprevalence of HPyV9 has been determined to be of cytomegalovirus. Our data indicate that HPyV9 infection 25% to 50% (23–26). is frequent in kidney transplant patients, but the nature of Because HPyV9 was originally isolated from a kid- infection—endogenous or donor-derived—and pathogenic ney transplant recipient (17), we aimed to systematically potential of this virus remain unknown. study the presence of HPyV9 infection in kidney transplant patients and investigate a possible association with the he Polyomaviridae constitute a family of small DNA known nephropathogenic BKPyV. We analyzed a cohort Tviruses that infect a variety of hosts. BK polyomavirus of 101 transplant patients who received either a kidney (BKPyV) and JC polyomavirus (JCPyV), discovered in transplant or a simultaneous kidney–pancreas transplant 1971 (1,2), are well-known examples of human polyoma- for the appearance of markers for HPyV9 infection dur- viruses (HPyVs) that cause severe disease in immunocom- ing the 18 months after transplantation. We assessed the promised patients. Serologic data have revealed that most presence of HPyV9 DNA and IgG seroresponses in serum polyomaviruses are ubiquitous (3–6). In case of JCPyV samples. The HPyV9 findings in the transplant cohort were and BKPyV, primary infection occurs early in life, with- compared with those obtained for an age- and sex-matched out apparent symptoms, and persists throughout life as la- cohort of healthy blood donors. Co-infection with BKPyV tent infection in the kidneys, accompanied by occasional was investigated by comparing observed HPyV9 and BK- virus shedding in urine (7). When immunity is decreased, PyV viremia levels in the transplant cohort. For compara- these viruses can reactivate with detectable viremia and tive purposes, we also tested for cytomegalovirus (CMV), manifestation of disease, which poses a threat to, among which, like polyomaviruses, frequently reactivates during others, patients who receive solid-organ transplants. immunosuppressive drug use after transplantation. Author affiliations: Leiden University Medical Center, Leiden, the Materials and Methods Netherlands (E. van der Meijden, H.F. Wunderink, C.S. van der Blij-de Brouwer, J.I. Rotmans, J.N. Bouwes Bavinck, M.C.W. Study Population Feltkamp); and Sanquin Blood Supply Foundation, Amsterdam, the The cohort study consisted of 101 patients who re- Netherlands (H.L. Zaaijer) ceived kidney (n = 83) or kidney–pancreas (n = 18) trans- DOI: http://dx.doi.org/10.3201/eid2006.140055 plants during 2002–2004 at Leiden University Medical Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 20, No. 6, June 2014 991 RESEARCH Center (LUMC), Leiden, the Netherlands (Table 1). This Viral DNA Detection and Quantification study population is part of a larger prospective European Total nucleic acids were extracted from 200 µL serum multicenter study designed to investigate the role of human by using the MagNA Pure LC Total Nucleic Acid Isolation papillomavirus infection in the development of skin cancer Kit–High Performance and MagNA Pure LC Instrument in solid-organ transplant patients (27). The study adhered (Roche Diagnostics, Indianapolis, IN, USA). To monitor to the Declaration of Helsinki Principles, and the medi- the quality of DNA extraction and potential PCR inhibi- cal ethical committee of the LUMC approved of the study tion, we added low concentrations of phocine herpesvirus design (Medical Ethical Committee no. P02.111). Partici- (28) to the lysis buffer. DNA was eluted in a final volume pants gave written informed consent. of 100 mL elution buffer, of which 10 mL was used as in- All patients received induction with interleukin-2 re- put for real-time quantitative PCR (qPCR). ceptor blocker daclizumab (100 mg/d) on the day of trans- Primers and Taqman probes were designed by using plantation and 10 days after transplantation or basiliximab Beacon Designer software (Premier Biosoft, Palo Alto, (40 mg at days 0 and 4), followed by triple therapy with CA, USA). For HPyV9, we used the following prim- prednisone, tacrolimus, or cyclosporine and mycopheno- ers and probe, located in the viral protein (VP) 1 gene late mofetil. For kidney transplant patients, the dose of the amplifying a product of 109 nt: sense primer 5′- CCT- calcineurin inhibitor (tacrolimus or cyclosporine) was ta- GTAAGCTCTCTCCTTA-3′, antisense primer 5′- CCT- pered at 6 weeks after transplantation, whereas for kidney– GATAAATTCTGACTTCTTC-3′, and probe FAM-5′- pancreas transplant patients, the calcineurin inhibitor was CTTGTTCTCTGGTCTTATGCCTCA-3′-BHQ-1. For reduced at 3 months after transplantation. BKPyV, we used the following primers and probe, located The time points of serum sample collection and the in the VP1 gene amplifying a product of 90 nt: sense prim- number of samples collected per time point are summarized er 5′-GAAAAGGAGAGAGTGTCCAGGG-3′, antisense in Table 2 and shown in relation to the date of transplanta- primer 5′-GAACTTCTACTCCTCCTTTTATTAGT-3′, tion. The baseline samples were obtained in the days im- and probe FAM-5′-CCAAAAAGCCAAAGGAACCC- mediately after transplantation (time point 0, T0). To col- 3′-BHQ1. lect the subsequent samples, patients were asked to visit the The BKPyV qPCR and phocine herpesvirus PCR LUMC outpatient clinic for follow-up sample collection at were duplexed for DNA quality and potential PCR inhibi- the preferred time points of 3, 6, 9, 12, and 18 months after tion monitoring. Furthermore, the BKPyV qPCR was val- transplantation (T3–T18). A total of 58 patients provided a idated to detect BKPyV genotypes I–IV. qPCR reactions sample at all 6 time points: 31, 6, 4, and 2 patients provided were performed in a total volume of 50 μL, containing 25 5, 4, 3, or 1 samples, respectively. μL HotStart Taq mastermix (QIAGEN, Hilden, Germany), Stored pretransplantation serum samples, if available, 0.5 µmol/L of each primer, 0.35 µmol/L BKPyV probe or were retrieved and tested for HPyV9 DNA (n = 65; Table 0.4 µmol/L HPyV9 probe, and 3.5 mmol/L MgCl2. Re- 2) and antibodies (n = 45, 40 of which were also included actions were performed by using a CFX96 real-time de- in pretransplantation DNA testing). The average dates of tection system (Bio-Rad, Hercules, CA, USA) with the obtaining samples for DNA and antibody testing were 8 following cycle conditions: 15 min at 95°C followed by and 2 days before transplantation, respectively. 45 cycles of amplification (30 s at 95°C; 30 s at 60°C for To obtain a healthy control population, we analyzed HPyV9 qPCR and 55°C for BKPyV qPCR; 30 s at 72°C). anonymized samples from 87 random unpaid blood donors For quantification, a standard of pGEX 5×3 HPyV9 VP1 (Table 2). For each donor, 2 follow-up serum samples were plasmid (Genscript, Piscataway, NJ, USA) and of a quan- studied, collected 1 year apart (T0 and T12). The donors tified BKPyV-positive urine sample were used. Analyti- were matched for age and sex with the transplant patient cal sensitivity of the HPyV9 and BKPyV qPCRs was ≈10 study population (Table 1). copies/mL. CMV load was measured as described (29) Table 1. Characteristics of patients and controls for study of human polyomavirus 9 prevalence among kidney transplant patients, the Netherlands* Transplant patient type Characteristic All Kidney Kidney–pancreas p value Blood donors Patients and controls 101 83 (82) 18 (18) 87 Mean age, y (range) 47 (21–74) 48 (21–74) 43 (30–54) 0.129† 52 (29–68) Sex F 34 (34) 27 (33) 7 (39) 0.605‡ 31 (36) M 67 (66) 56 (67) 11(61) 56 (64) *Values are no. (%) except as indicated. †Comparison of kidney and kidney–pancreas patient groups; Student t test. ‡Comparison of kidney and kidney–pancreas patient groups; 2 test. 992 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 20, No. 6, June 2014 HPyV9 in Kidney Transplant Patients Table 2. Detection of human polyomavirus 9 DNA and viral loads in kidney transplant patients and blood donors, the Netherlands* Mean time after transplantation or No. No. (%) HPyV9 Mean viral load, Population first sample collection, mo (range) samples DNA positive copies/mL (range) Transplantation patients 101 21 (20.8)† 157 (25–530)‡ Transplant type Kidney 83 17 (20.5)† 135 (25–530)‡ Kidney and pancreas 18 4 (22.2)† 250 (89–472)‡ No.
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