JC VIRUS DNA IN THE PERIPHERAL BLOOD OF RENAL TRANSPLANT PATIENTS: A ONE-YEAR PROSPECTIVE FOLLOW-UP IN FRANCE Catherine Mengelle, Nassim Kamar, Jean Michel Mansuy, Karine Sandres-Sauné, Florence Legrand-Abravanel, Marcel Miédougé, Lionel Rostaing, Jacques Izopet
To cite this version:
Catherine Mengelle, Nassim Kamar, Jean Michel Mansuy, Karine Sandres-Sauné, Florence Legrand- Abravanel, et al.. JC VIRUS DNA IN THE PERIPHERAL BLOOD OF RENAL TRANSPLANT PATIENTS: A ONE-YEAR PROSPECTIVE FOLLOW-UP IN FRANCE. Journal of Medical Virol- ogy, Wiley-Blackwell, 2010, 83 (1), pp.132. 10.1002/jmv.21951. hal-00599775
HAL Id: hal-00599775 https://hal.archives-ouvertes.fr/hal-00599775 Submitted on 11 Jun 2011
HAL is a multi-disciplinary open access L’archive ouverte pluridisciplinaire HAL, est archive for the deposit and dissemination of sci- destinée au dépôt et à la diffusion de documents entific research documents, whether they are pub- scientifiques de niveau recherche, publiés ou non, lished or not. The documents may come from émanant des établissements d’enseignement et de teaching and research institutions in France or recherche français ou étrangers, des laboratoires abroad, or from public or private research centers. publics ou privés. Journal of Medical Virology
JC VIRUS DNA IN THE PERIPHERAL BLOOD OF RENAL TRANSPLANT PATIENTS: A ONE-YEAR PROSPECTIVE FOLLOW-UP IN FRANCE For Peer Review
Journal: Journal of Medical Virology
Manuscript ID: JMV-09-1320.R2
Wiley - Manuscript type: Research Article
Date Submitted by the 04-Aug-2010 Author:
Complete List of Authors: Mengelle, Catherine; University hospital, Virology KAMAR, Nassim; CHU Rangueil, Nephrology, Dialysis, and Multi- Organ Transplantation; Inserm U563 MANSUY, Jean Michel; University hospital, Virology Sauné, Karine; University hospital, Virology; Inserm U563 Abravanel, Florence; University hospital, Virology; Inserm U563 Miédougé, Marcel; University Hospital, Virology Rostaing, Lionel; CHU Rangueil, Nephrology, Dialysis, and Multi- Organ Transplantation; Inserm U563 Izopet, Jacques; University Hospital, Virology; Inserm U563
Polyomavirus, solid-organ transplantation, immunosuppressive Keywords: treatment, nephropathy, progressive multifocal leuko- encephalopathy
John Wiley & Sons Page 1 of 17 Journal of Medical Virology
1 2 3 4 BKV - 4 3.9 5.2 5.6 5.4 5.7 3.8 2.5 5 1 - - - - 3.5 3.5 5.7 - - 6 JCV 7 8 9 BKV 4 4.3 4.7 5.5 3.6 3.8 3.1 10 2 - 3.1 2.5 2.5 0.6 - - 11 JCV 12 13 For Peer Review 14 BKV 3.4 6.7 3.1 3.9 2.5 3.5 2.8 2 3.1 2 - 15 ------5.7 - - 16 3 JCV 17 P 18 a BKV ------3.6 ------19 t 20 4 JCV ------1.9 ------21 i 22 e EBV 3.4 - - - - - 3.3 - 2.1 2.8 - 2.8 2.9 - 3.5 3.3 23 n 24 t 25 s 5 JCV 4.5 - - - 26 EBV 4.1 3.1 - - 27 28 29 30 - - - 2.8 4.1 - 2.5 2.5 2.5 2.1 2.1 2.5 3.6 2 .5 2.5 2.1 4.1 3.6 - 3.6 6 JCV 31 - 3.7 4.2 - 2.6 - - 4.6 - 4.1 - 3.9 ------3.5 - 32 CMV
33 34 - - - - 3.4 - - 3.4 ------35 7 JCV 36 37 EBV 2.9 - - - - 3.4 - 3.9 - 2.8 3.5 3.3 - 3.5 2.1 4.5 3.1 4.2 - - - - 38 39 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 40 Months 41 42 43 44 45 John Wiley & Sons 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 Journal of Medical Virology Page 2 of 17
1 2 3 4 5 6 Fig.1: Follow up of patients with JCV-DNA positive in whole blood. 7 Horizontal bars represent months of follow-up. 8 Red horizontal bars are those patients treated with rituximab 9 Virus loads are expressed as log 10 copies/mL. 10 Red stars represent detection of Decoy cells. 11 12 13 For Peer Review 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 John Wiley & Sons 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 Page 3 of 17 Journal of Medical Virology
1 2 3 1 JC VIRUS DNA IN THE PERIPHERAL BLOOD OF RENAL TRANSPLANT 4 5 6 2 PATIENTS: A ONE-YEAR PROSPECTIVE FOLLOW-UP IN FRANCE 7 8 3 9 10 4 C Mengelle 0,*, N Kamar, 1,2 , J M Mansuy 0, K Sandres Sauné 0,3, F Legrand Abravanel 0,3, M 11 12 0 1,2 0,3 13 5 Miédougé , L Rostaing , J Izopet 14 0 15 6 Department of Virology, University Hospital, CH Toulouse, 330 Ave. de Grande Bretagne, TSA 16 17 7 40031, 31059 Toulouse Cedex 9, France 18 8 1 Nephrology, Dialysis, and Multiorgan Transplant Unit, University Hospital, CH Toulouse, 1 av. 19 20 9 J. Poulhes, TSA 50032,For 31059 Toulouse Peer Cedex 9, Review France 21 22 10 2 : INSERM U858, IFR 31, 1 av. Jean Poulhès, TSA 50032, 31059 Toulouse Cedex 9, France 23 24 3 25 11 : INSERM U563, IFR 30, 330 Ave. de Grande Bretagne, TSA 40031, 31059 Toulouse Cedex 9, 26 12 France. 27 28 13 29 30 14 * Correspondance to: 31 32 33 15 Catherine Mengelle 34 35 16 Department of Virology 36 37 17 Federative institute of Biology 38 39 40 18 330 Avenue de Grande Bretagne 41 42 19 TSA 40031 43 44 20 31059 Toulouse Cedex 09 45 46 47 21 France 48 49 22 Phone : 33 5 676 90 419 50 51 23 Fax : 33 5 676 90 425 52 53 54 24 E mail : mengelle.c@chu toulouse.fr 55 56 25 57 58 26 Shortened title : JCV infection in renal transplantation 59 60
1 John Wiley & Sons Journal of Medical Virology Page 4 of 17
1 2 3 27 Abstract 4 5 6 28 There is little information on JC virus (JCV) infection in renal transplant patients. A long term 7 8 29 prospective follow up study was conducted to assess the incidence of JCV DNA in the blood of 9 10 30 103 adult renal transplant patients enrolled prospectively between 1 January and 31 December, 11 12 13 31 2006. Patients were monitored until April, 2008. JCV DNA was quantified by a real time 14 15 32 polymerase chain reaction in whole blood samples collected regularly for at least one year post 16 17 33 transplant. 18 19 34 JCV was detected in seven patients (6.8 %) (31/1487 whole blood samples) at a median time of 20 For Peer Review 21 22 35 139 days post transplant. The median JC virus load of the first positive DNA blood sample was 23 24 36 3.4 log 10 copies/mL (1.9 – 5.7 log 10 copies/mL). Induction therapy were either anti CD25 25 26 37 monoclonal antibodies ( n=5) or antithymocyte globulins ( n=2). Post transplant 27 28 29 38 immunosuppressive treatment included steroids with tacrolimus/mycophenolate mofetil (MMF) 30 31 39 (n=2), or ciclosporin/MMF ( n=1), or belatacept/MMF ( n=4). Two patients were also treated 32 33 40 with rituximab. All seven patients infected with JCV had other viral infections(s): BK virus (3), 34 35 36 41 Epstein Barr virus (2), Cytomegalovirus (1) or both BK virus and Epstein Barr virus (1). Three 37 38 42 patients had BKV associated nephropathy and decoy cells shedding. JCV infection was not 39 40 43 associated with acute rejection episodes or nephropathy, regardless of the virus load. No patient 41 42 43 44 developed progressive multifocal leukoencephalopathy during follow up. 44 45 45 Thus the incidence of JCV infection in renal transplant patients was low and not associated with 46 47 46 any specific clinical manifestations. JCV replication must still be diagnosed and differentiated 48 49 50 47 from BK virus infection because of its non aggressive course. 51 52 48 53 54 49 Key words: Polyomavirus, nephropathy, progressive multifocal leukoencephalopathy, solid organ 55 56 57 50 transplantation, immunosuppressive treatment 58 59 60
2 John Wiley & Sons Page 5 of 17 Journal of Medical Virology
1 2 3 51 Introduction 4 5 6 52 JC virus (JCV) is a member of the Polyomaviridae , which include other human viruses such as BK 7 8 53 virus, KI [Allander et al., 2007], WU [Gaynor et al., 2007] and SV40. JC and BK virus infections 9 10 54 are frequent and occur early in childhood. Seropositivity increases with age; BKV reaches a 11 12 13 55 seroprevalence of 91% in children aged 5 9 years, while seroprevalence of JCV reaches only 50% 14 15 56 by the age of 60 69 years [Knowles et al., 2003]. The transmission routes are not yet clear but are 16 17 57 thought to be via the respiratory tract, although oral fecal transmission is also possible. 18 19 58 Both viruses remain latent in the kidney, in B lymphocytes [Lafon et al., 1998; Monaco et al., 20 For Peer Review 21 22 59 1996] and in the central nervous system after primary infection, but they may be reactivated at 23 24 60 any time. JCV excretion in the urine can reach 46 % in immunocompetent patients, and the virus 25 26 61 usually remains asymptomatic [Pagani et al., 2003; Rossi et al., 2007]. However, reactivation of 27 28 29 62 either virus in immunosuppressed patients can cause several clinical syndromes. JCV can become 30 31 63 reactivated in patients infected with HIV, transplant recipients and patients with cancer, and may 32 33 64 produce progressive multifocal leukoencephalopathy, a fatal neurological demyelinating disease 34 35 36 65 [Hou and Major, 2000]. Polyomavirus associated nephropathy in renal transplant patients is 37 38 66 mostly due to BKV, but recent studies have shown that JCV infection may also be involved 39 40 67 [Drachenberg et al., 2007]. 41 42 43 68 Little is known at present on the incidence of JCV infection and its clinical consequences in these 44 45 69 patients. 46 47 70 This prospective long term follow up study assessed the incidence of JCV shedding in whole 48 49 50 71 blood samples from renal transplant recipients. The results were correlated with 51 52 72 immunosuppressive treatment and the virological parameters of the patients who excreted JC 53 54 73 virus. 55 56 57 74 58 59 60
3 John Wiley & Sons Journal of Medical Virology Page 6 of 17
1 2 3 75 Materials and methods 4 5 6 76 Patients 7 8 77 Adult renal transplant recipients under the care of Toulouse University Hospital were enrolled 9 10 78 prospectively from 1 January to 31 December, 2006 and were monitored until April, 2008. 11 12 13 79 Any induction therapy was based on antithymocyte globulins or anti CD25 monoclonal 14 15 80 antibodies. All patients were treated with steroids for post transplant immunosuppression. They 16 17 81 were also given tacrolimus/mycophenolate mofetil (MMF), or cyclosporin A/MMF, 18 19 82 belatacept/MMF, or cyclosporin/everolimus. Renal biopsies were taken when acute rejection was 20 For Peer Review 21 22 83 suspected. The patients were given three injections of methylprednisolone if acute rejection was 23 24 84 confirmed. Antithymocyte globulins were given to cases of steroid resistant acute rejection. 25 26 85 Finally, patients with humoral acute rejection were treated by plasmapheresis and rituximab. 27 28 29 86 Recipients were given prophylaxis for human cytomegalovirus (HCMV). Seropositive recipients 30 31 87 who had received a transplant from a seropositive or a seronegative donor, and high risk patients 32 33 88 (a seronegative recipient with a seropositive donor) were given valganciclovir prophylaxis (900 34 35 36 89 mg/d if their creatinine clearance was > 60 ml/min, and 450 mg/d if their creatinine clearance 37 38 90 was < 60 ml/min) during the first 3 to 4 months post transplantation. 39 40 91 Virological monitoring 41 42 43 92 All renal transplant recipients were tested prospectively for JCV excretion. Whole blood samples 44 45 93 were collected into potassium EDTA tubes from the time of transplantation to at least one year 46 47 94 post transplant. 48 49 50 95 Methods 51 52 96 Measurement of blood JCV DNA 53 54 97 JC virus DNA was extracted automatically from whole blood and detected by quantitative real 55 56 57 98 time PCR. The DNA was extracted from 200 L samples using a MagNA Pure™ instrument 58 59 99 (Roche Diagnostics, Meylan, France) and the MagNA Pure LC DNA Isolation Kit I® according 60
4 John Wiley & Sons Page 7 of 17 Journal of Medical Virology
1 2 3 100 to the manufacturer’s instructions. JCV DNA was detected using a Light Cycler™ system 4 5 6 101 (Roche). 7 8 102 The primers were located in the region coding for the agnoprotein: HMJC: 5’ ATA CAg TgC 9 10 103 TTT gCC TgA ACC 3’ and HMJC6: 5’ CAA CTg AgC AAT AgC ACT ACC 3’. The fluorogenic 11 12 13 104 probe was HSMSJC3: 6FAM 5’ACT ggA gCT CCg ggg gCT gTA 3’TAMRA. Real time PCR was 14 15 105 carried out using Fast Start DNA Master hybridization probes (Roche Diagnostics, Meylan, 16 17 106 France). The use of specific primers and probes insures no cross reactivity with BKV. Extracted 18 19 107 DNA (5 L) was added to the PCR mixture containing 2 mmol/L MgCl , 0.500 mol/L of each 20 For Peer Review 2 21 22 108 primer, and 0.100 mol/L of probe. The PCR conditions were initial denaturation for one cycle 23 24 109 of 2 min at 50°C followed by 2 min at 95°C, followed by 45 cycles of 20 s at 95°C and 60 s at 58 25 26 110 °C. Cooling was realised 30 s at 40 °C. The reaction, data acquisition, and analyses were all 27 28 29 111 performed on a Light Cycler instrument. The PCR was checked for contamination using a 30
31 112 negative sample. JCV DNA load in whole blood is expressed as log 10 genome copy number per 32 33 113 mL. Coupled with the MagNA Pure™ extraction, the detection limit was 500 copies genome per 34 35 36 114 mL (i.e. 2.7 log 10 copies/mL). 37 38 115 Patients were also tested for other opportunistic viral infections: cytomegalovirus (CMV), 39 40 116 Epstein Barr virus (EBV), and BK virus (BKV) were quantified in whole blood and urine 41 42 43 117 samples (BKV). 44 45 118 HCMV DNA, EBV DNA, and BKV DNA were extracted automatically from whole blood with 46 47 119 the MagNA Pure® instrument. HCMV DNA was quantified on a Light Cycler 1.0 ™ (Roche), as 48 49 50 120 described previously [Mengelle et al., 2003]. EBV DNA was quantified using a Light Cycler EBV 51 52 121 Quantification Kit® (Roche), according to the manufacturer’s instructions [Gulley et al., 2006; 53 54 122 Hill et al., 2006; Kozic et al., 2006]. BKV DNA was quantified on a Light Cycler 2.0™ (Roche), 55 56 57 123 as described previously [Basse et al., 2007]. 58 59 124 Serological markers 60
5 John Wiley & Sons Journal of Medical Virology Page 8 of 17
1 2 3 125 Hepatitis B antigens were tested using the Ag HBs Architect (Abbott, Abbott Park, Illinois, 4 5 6 126 USA), and anti HCV antibodies were tested using the anti HCV Architect (Abbott). HBV DNA 7 8 127 and HCV RNA were quantified using the COBAS Ampliprep COBAS Taqman96™ (CAP 9 10 128 CTM) system (Roche). 11 12 13 129 Anti HCMV IgG and IgM were assayed using the Liaison CMV IgG and Liaison CMV IgM 14 15 130 assays according to the manufacturer's instructions (DiaSorin, Saluggie, Italy) Anti VCA IgG and 16 17 131 anti EBNA antibodies were tested using the Liaison VCA IgG and Liaison EBNA IgG. Anti 18 19 132 VCA IgM antibodies were detected with the Liaison EBV IgM assays according to the 20 For Peer Review 21 22 133 manufacturer's instructions (DiaSorin). 23 24 134 Statistical analyses 25 26 135 StatView 5.0 was used for all statistical analyses. The results are shown as means or medians. 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
6 John Wiley & Sons Page 9 of 17 Journal of Medical Virology
1 2 3 136 Results 4 5 6 137 A total of 103 renal transplantations (68 men) were performed at the Toulouse University 7 8 138 Hospital between 1 January and 31 December, 2006. The mean age of the patients was 49.8 years 9 10 139 (range: 24 77 years). Patients were enrolled for at least one year post transplant. A total of 1487 11 12 13 140 whole blood samples were collected, and the median frequency of sampling was 12 (2 32) per 14 15 141 patient. 16 17 142 JCV was detected in 31 whole blood samples from seven of the 103 transplant patients (6.8%), 18 19 143 two women and five men. Their mean age was 44 (23 70) years. Six patients had undergone a 20 For Peer Review 21 22 144 first transplantation and one patient had undergone a second transplantation. The underlying 23 24 145 diagnoses were polycystic kidney disease (n=2), thrombotic microangiopathy (n=1), focal 25 26 146 segmental glomerulosclerosis (n=1), interstitial nephropathy (n=1), IgA nephropathy (n=1), and 27 28 29 147 an undetermined cause. 30 31 148 Induction therapies were anti CD25 monoclonal antibodies ( n=5) or antithymocyte globulins 32 33 149 (n=2). Their post transplant immunosuppressive therapy included steroids with tacrolimus/MMF 34 35 36 150 (n=2), or ciclosporin/MMF ( n=1), or belatacept/MMF ( n=4). Two patients were given 37 38 151 rituximab; one for a posttransplant focal segmental glomerulosclerosis relapse (375 mg/m² 39 40 152 twice), and the other for an acute humoral rejection (375 mg/m²/week for 4 weeks). 41 42 43 153 No patient had hepatitis B surface antigens or anti HCV antibodies. All patients were negative 44 45 154 for serum HBV DNA and HCV RNA. Five patients were anti HCMV seropositive, and all were 46 47 155 anti EBV positive at the time of transplantation. 48 49 50 156 The first positive JCV DNA sample was detected at a median time of 139 days post transplant 51 52 157 (43 250). The median JC virus load of the first positive DNA blood sample was 3.4 log 10 53 54 158 copies/mL (1.9 – 5.7 log 10 copies/mL). JCV DNA was detected in only one blood sample taken 55 56 57 159 from three patients: at 43, 180, 225 days post–transplant and the virus loads were 4.5, 5.7 and 1.9 58 59 160 log 10 copies/mL. The patient whose virus load was 5.7 log 10 copies/mL was treated with 60 161 rituximab.
7 John Wiley & Sons Journal of Medical Virology Page 10 of 17
1 2 3 162 JCV DNAemia was persistent in the other four (median 66 days, range 21 447). JCV DNA was 4 5 6 163 detected five times over 49 days in the one patient in this group who was treated with rituximab, 7 8 164 and the virus loads were very low (3.1, 2.5, 2.5, 0.6 and 2.5 log 10 copies/mL). 9 10 165 All patients had other viral infection(s): BKV (3), EBV (2), CMV (1) and BK+EBV (1). EBV 11 12 13 166 infection occurred soon after transplantation: 27, 29, and 43 days, whereas the other infections 14 15 167 occurred later: BK at 51, 115, 127, and 223 days post transplant, and CMV at 194 days post 16 17 168 transplant (in a HCMV seropositive patient). Fig. 1 summarizes the virological data for those 18 19 169 patients in whom JCV was detected. 20 For Peer Review 21 22 170 The urine of three patients contained decoy cells. The blood samples of these patients also 23 24 171 contained BKV DNA: the first quantified BKV virus loads were 2.8, 4 and 4 log 10 copies/mL, 25 26 172 and the urine BKV virus loads were 6.94, 10.83, and 10.89 log copies/mL. First BKV DNA was 27 10 28 29 173 detected at a median time of 121 days post transplant (51 223), and was prior to or at the same 30 31 174 time as JCV DNAemia. All three patients had a biopsy confirmed polyomavirus associated 32 33 175 nephropathy and had experienced acute rejection before BKV replication. The acute rejection 34 35 36 176 episodes had been treated with steroid injections alone (1), steroid injections and polyclonal 37 38 177 antibodies (1), and steroid injections, muromonab CD3, and rituximab (1). Pathological analysis 39 40 178 of a kidney biopsy taken from the fourth patient with BKV replication showed no features of 41 42 43 179 polyomavirus associated nephropathy. 44 45 180 The median CD3 count was 733/mm 3 (178– 1717) and the median CD4 count was 470/mm 3 46 47 181 (78 1184) at the time of first JCV DNAemia, and the median creatinine was 1.39 mg/dL (1.12 48 49 50 182 2.93). The median microalbuminuria was 94 mg/mL (25 244), the median hematuria was 9 51 52 183 cells/mm 3 (0 28), and the median leukocyturia was 3 cells/mm 3 (0 80). 53 54 55 56 57 58 59 60
8 John Wiley & Sons Page 11 of 17 Journal of Medical Virology
1 2 3 184 Discussion 4 5 6 185 Although BKV is known to be associated with polyomavirus associated nephropathy in renal 7 8 186 transplant recipients, little is known on the consequence of a JCV infection. In this study, the 9 10 187 incidence of JCV infection was determined in a long term follow up of renal transplant patients. 11 12 13 188 The incidence was similar to that found by Razonable et al., [2005], who detected JCV DNA in 14 15 189 the blood of 7.6% of renal transplant patients during the first year post transplant. The incidence 16 17 190 of JCV is similar to that of BKV DNAemia that was reported previously for the renal transplant 18 19 191 patients at Toulouse University Hospital [Basse et al., 2007]. Some authors have not detected JCV 20 For Peer Review 21 22 192 DNA in the blood of renal transplant and liver transplant patients [Randhawa et al., 2005], 23 24 193 whereas others have reported rare, transient and low viremia [Drachenberg et al., 2007]. In this 25 26 194 study, whole blood samples rather than plasma or leukocyte specimens were used to quantify 27 28 29 195 JCV DNA. Whole blood samples might increase the sensitivity of JCV detection, as has been 30 31 196 described for other viruses [Basse et al., 2007; Drachenberg et al., 2007; Fafi Kremer et al., 2004; 32 33 197 Garrigue et al., 2006; Gouarin et al., 2004], and could explain why current results differ from 34 35 36 198 those of other studies. 37 38 199 Urine samples were not tested regularly for JCV. BKV viruria is rare in immunocompetent 39 40 200 patient and is clearly associated with disruptions of cellular immunity, as demonstrated in bone 41 42 43 201 marrow transplant recipients [Doerries, 2006] and in patients infected with HIV [Hirsch and 44 45 202 Steiger, 2003]. In contrast, JCV is found commonly in the urine of immunocompetent patients: 46 47 203 JCV remains latent in the renal parenchyma after primary infection, and may be excreted in non 48 49 50 204 immunosuppressed individuals. It is found frequently in the urine of elderly persons in particular 51 52 205 [Chang et al., 2002; Kitamura et al., 1997]. This was why urine samples were not tested regularly; 53 54 206 positive results would have had to be been interpreted cautiously. 55 56 57 207 The association of JCV and polyomavirus associated nephropathy has been documented in 58 59 208 isolated cases [Kazory et al., 2003; Randhawa et al., 2005; Wen et al., 2004]. Only the blood of 60 209 patients with polyomavirus associated nephropathy contained JCV DNA, even at low
9 John Wiley & Sons Journal of Medical Virology Page 12 of 17
1 2 3 210 concentrations [Drachenberg et al., 2007]. Such an association was not observed in the current 4 5 6 211 study, none of the patients whose blood contained JCV DNA suffered from any polyomavirus 7 8 212 associated nephropathy whatever the virus load. Only three patients had decoy cells at the time of 9 10 213 JCV excretion: they were all infected with BKV with a very high virus loads in whole blood and 11 12 13 214 urine, indicating BKV associated nephropathy, as shown by others [Randhawa et al., 2005; 14 15 215 Viscount et al., 2007]. 16 17 216 None of the patients had any neurological symptoms and no cases of multifocal leuko 18 19 217 encephalopathy were diagnosed during follow up. Several cases of multifocal 20 For Peer Review 21 22 218 leukoencephalopathy have been reported recently in haematological [Pelosini et al., 2008] and 23 24 219 bone marrow transplant patients [Goldberg et al., 2002] treated with rituximab. Kamar et al. 25 26 220 [2009] reported that the incidence of JCV DNAemia in 73 rituximab treated solid organ 27 28 29 221 transplant patients was 5.5%, but no neurological disorder was found during long term follow 30 31 222 up. In the present study, only two of the seven JCV infected patients were treated with rituximab, 32 33 223 these results are very similar to those of the previous study. Overall, the JC virus loads were not 34 35 36 224 correlated with any clinical manifestations. 37 38 225 Frequent mixed infections with other opportunistic virus were detected in whole blood sample. 39 40 226 In particular, mixed BKV and JCV infections were observed in whole blood samples of four 41 42 43 227 patients. Three patients had biopsy confirmed BKV nephropathy, but no significant relationship 44 45 228 could be established between mixed infection and clinical manifestations since these 46 47 229 opportunistic infections were detected prior to or at the same time as JCV. This high incidence of 48 49 50 230 mixed infections, which reflects heavy immunosuppression, has not been described previously 51 52 231 [Drachenberg et al., 2007; Randhawa et al., 2005; Watcharananan et al.], although 53 54 232 immunosuppressive therapy was as potent as in this study: i.e., kidney transplant patients induced 55 56 57 233 with anti CD52 antibodies (alemtuzumab) followed by tacrolimus monotherapy. 58 59 234 60
10 John Wiley & Sons Page 13 of 17 Journal of Medical Virology
1 2 3 235 In conclusion, the present monocentric study shows that JCV infections are relatively uncommon 4 5 6 236 in renal transplant recipients. They were not associated with acute renal rejection, or with the 7 8 237 presence of decoy cells in the JCV DNAemia positive patients, suggesting that the course of JCV 9 10 238 infection is lower and less aggressive than of BKV. No association between JCV infection and 11 12 13 239 neurological manifestations was also detected. Overall, these results are comparable to those of 14 15 240 Razonable et al., [2005], who found episodes of subclinical JCV DNA in the blood of solid organ 16 17 241 transplant patients. 18 19 242 However, JCV infection should be surveyed regularly in transplant recipients as the presence of 20 For Peer Review 21 22 243 JCV DNA in the blood may differentiate between JCV and BKV infections. Therefore, detection 23 24 244 of JCV indicates over immunosuppressed patients who may benefit from reduction of 25 26 245 immunosuppressive treatment. 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
11 John Wiley & Sons Journal of Medical Virology Page 14 of 17
1 2 3 246 References 4 5 6 247 Allander T, Andreasson K, Gupta S, Bjerkner A, Bogdanovic G, Persson MA, Dalianis T, 7 8 248 Ramqvist T, Andersson B. 2007. Identification of a third human polyomavirus. J Virol 9 10 249 81(8):4130 4136. 11 12 13 250 Basse G, Mengelle C, Kamar N, Guitard J, Ribes D, Esposito L, Rostaing L. 2007. Prospective 14 15 251 evaluation of BK virus DNAemia in renal transplant patients and their transplant 16 17 252 outcome. Transplant Proc 39(1):84 87. 18 19 253 Chang H, Wang M, Tsai RT, Lin HS, Huan JS, Wang WC, Chang D. 2002. High incidence of JC 20 For Peer Review 21 22 254 viruria in JC seropositive older individuals. J Neurovirol 8(5):447 451. 23 24 255 Doerries K. 2006. Human polyomavirus JC and BK persistent infection. Adv Exp Med Biol 25 26 256 577:102 116. 27 28 29 257 Drachenberg CB, Hirsch HH, Papadimitriou JC, Gosert R, Wali RK, Munivenkatappa R, 30 31 258 Nogueira J, Cangro CB, Haririan A, Mendley S, Ramos E. 2007. Polyomavirus BK versus 32 33 259 JC replication and nephropathy in renal transplant recipients: a prospective evaluation. 34 35 36 260 Transplantation 84(3):323 330. 37 38 261 Fafi Kremer S, Brengel Pesce K, Bargues G, Bourgeat MJ, Genoulaz O, Seigneurin JM, Morand 39 40 262 P. 2004. Assessment of automated DNA extraction coupled with real time PCR for 41 42 43 263 measuring Epstein Barr virus load in whole blood, peripheral mononuclear cells and 44 45 264 plasma. J Clin Virol 30(2):157 164. 46 47 265 Garrigue I, Boucher S, Couzi L, Caumont A, Dromer C, Neau Cransac M, Tabrizi R, Schrive 48 49 50 266 MH, Fleury H, Lafon ME. 2006. Whole blood real time quantitative PCR for 51 52 267 cytomegalovirus infection follow up in transplant recipients. J Clin Virol 36(1):72 75. 53 54 268 Gaynor AM, Nissen MD, Whiley DM, Mackay IM, Lambert SB, Wu G, Brennan DC, Storch 55 56 57 269 GA, Sloots TP, Wang D. 2007. Identification of a novel polyomavirus from patients with 58 59 270 acute respiratory tract infections. PLoS Pathog 3(5):e64. 60
12 John Wiley & Sons Page 15 of 17 Journal of Medical Virology
1 2 3 271 Goldberg SL, Pecora AL, Alter RS, Kroll MS, Rowley SD, Waintraub SE, Imrit K, Preti RA. 4 5 6 272 2002. Unusual viral infections (progressive multifocal leukoencephalopathy and 7 8 273 cytomegalovirus disease) after high dose chemotherapy with autologous blood stem cell 9 10 274 rescue and peritransplantation rituximab. Blood 99(4):1486 1488. 11 12 13 275 Gouarin S, Vabret A, Gault E, Petitjean J, Regeasse A, Hurault de Ligny B, Freymuth F. 2004. 14 15 276 Quantitative analysis of HCMV DNA load in whole blood of renal transplant patients 16 17 277 using real time PCR assay. J Clin Virol 29(3):194 201. 18 19 278 Gulley ML, Fan H, Elmore SH. 2006. Validation of Roche LightCycler Epstein Barr virus 20 For Peer Review 21 22 279 quantification reagents in a clinical laboratory setting. J Mol Diagn 8(5):589 597. 23 24 280 Hill CE, Harris SB, Culler EE, Zimring JC, Nolte FS, Caliendo AM. 2006. Performance 25 26 281 characteristics of two real time PCR assays for the quantification of Epstein Barr virus 27 28 29 282 DNA. Am J Clin Pathol 125(5):665 671. 30 31 283 Hirsch HH, Steiger J. 2003. Polyomavirus BK. Lancet Infect Dis 3(10):611 623. 32 33 284 Hou J, Major EO. 2000. Progressive multifocal leukoencephalopathy: JC virus induced 34 35 36 285 demyelination in the immune compromised host. J Neurovirol 6 Suppl 2:S98 S100. 37 38 286 Kamar N, Mengelle C, Rostaing L. 2008. Incidence of JC virus replication after rituximab therapy 39 40 287 in solid organ transplant patients. Am J Transplant 9 (1):244 245. 41 42 43 288 Kazory A, Ducloux D, Chalopin JM, Angonin R, Fontaniere B, Moret H. 2003. The first case of 44 45 289 JC virus allograft nephropathy. Transplantation 76(11):1653 1655. 46 47 290 Kitamura T, Sugimoto C, Kato A, Ebihara H, Suzuki M, Taguchi F, Kawabe K, Yogo Y. 1997. 48 49 50 291 Persistent JC virus (JCV) infection is demonstrated by continuous shedding of the same 51 52 292 JCV strains. J Clin Microbiol 35(5):1255 1257. 53 54 293 Knowles WA, Pipkin P, Andrews N, Vyse A, Minor P, Brown DW, Miller E. 2003. Population 55 56 57 294 based study of antibody to the human polyomaviruses BKV and JCV and the simian 58 59 295 polyomavirus SV40. J Med Virol 71(1):115 123. 60
13 John Wiley & Sons Journal of Medical Virology Page 16 of 17
1 2 3 296 Kozic S, Vince A, Bes JI, Rode OD, Lepej SZ, Poljak M, Bozic M, Kessler HH. 2006. Evaluation 4 5 6 297 of a commercial real time PCR assay for quantitation of Epstein Barr virus DNA in 7 8 298 different groups of patients. J Virol Methods 135(2):263 268. 9 10 299 Lafon ME, Dutronc H, Dubois V, Pellegrin I, Barbeau P, Ragnaud JM, Pellegrin JL, Fleury HJ. 11 12 13 300 1998. JC virus remains latent in peripheral blood B lymphocytes but replicates actively in 14 15 301 urine from AIDS patients. J Infect Dis 177(6):1502 1505. 16 17 302 Mengelle C, Sandres Saune K, Pasquier C, Rostaing L, Mansuy JM, Marty M, Da Silva I, Attal M, 18 19 303 Massip P, Izopet J. 2003. Automated extraction and quantification of human 20 For Peer Review 21 22 304 cytomegalovirus DNA in whole blood by real time PCR assay. J Clin Microbiol 23 24 305 41(8):3840 3845. 25 26 306 Monaco MC, Atwood WJ, Gravell M, Tornatore CS, Major EO. 1996. JC virus infection of 27 28 29 307 hematopoietic progenitor cells, primary B lymphocytes, and tonsillar stromal cells: 30 31 308 implications for viral latency. J Virol 70(10):7004 7012. 32 33 309 Pagani E, Delbue S, Mancuso R, Borghi E, Tarantini L, Ferrante P. 2003. Molecular analysis of 34 35 36 310 JC virus genotypes circulating among the Italian healthy population. J Neurovirol 37 38 311 9(5):559 566. 39 40 312 Pelosini M, Focosi D, Rita F, Galimberti S, Caracciolo F, Benedetti E, Papineschi F, Petrini M. 41 42 43 313 2008. Progressive multifocal leukoencephalopathy: report of three cases in HIV negative 44 45 314 hematological patients and review of literature. Ann Hematol 87(5):405 412. 46 47 315 Randhawa P, Uhrmacher J, Pasculle W, Vats A, Shapiro R, Eghtsead B, Weck K. 2005. A 48 49 50 316 comparative study of BK and JC virus infections in organ transplant recipients. J Med 51 52 317 Virol 77(2):238 243. 53 54 318 Razonable RR, Brown RA, Humar A, Covington E, Alecock E, Paya CV. 2005. A longitudinal 55 56 57 319 molecular surveillance study of human polyomavirus viremia in heart, kidney, liver, and 58 59 320 pancreas transplant patients. J Infect Dis 192(8):1349 1354. 60
14 John Wiley & Sons Page 17 of 17 Journal of Medical Virology
1 2 3 321 Rossi A, Delbue S, Mazziotti R, Valli M, Borghi E, Mancuso R, Calvo MG, Ferrante P. 2007. 4 5 6 322 Presence, quantitation and characterization of JC virus in the urine of Italian 7 8 323 immunocompetent subjects. J Med Virol 79(4):408 412. 9 10 324 Viscount HB, Eid AJ, Espy MJ, Griffin MD, Thomsen KM, Harmsen WS, Razonable RR, Smith 11 12 13 325 TF. 2007. Polyomavirus polymerase chain reaction as a surrogate marker of 14 15 326 polyomavirus associated nephropathy. Transplantation 84(3):340 345. 16 17 327 Watcharananan SP, Kiertiburanakul S, Piyatuctsanawong W, Anurathapan U, Sungkanuparph S, 18 19 328 Pakakasama S, Chantratita W, Hongeng S. Cytomegalovirus, adenovirus, and 20 For Peer Review 21 22 329 polyomavirus co infection among pediatric recipients of allogeneic stem cell 23 24 330 transplantation: characteristics and outcome. Pediatric transplantation 14(5):675 681. 25 26 331 Wen MC, Wang CL, Wang M, Cheng CH, Wu MJ, Chen CH, Shu KH, Chang D. 2004. 27 28 29 332 Association of JC virus with tubulointerstitial nephritis in a renal allograft recipient. J Med 30 31 333 Virol 72(4):675 678. 32 33 334 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60
15 John Wiley & Sons