The KHA-CARI Guidelines – Caring for Australasians with Renal Impairment KHA-CARI Adaptation of KDIGO Clinical Practice Guideline for the Care of Kidney Transplant

GUIDELINES a. We suggest screening high risk kidney transplant recipients for BK polyoma virus (BKV) with quantitative plasma NAT. The frequency of screening is not clear however the risk is higher in the early post transplant period. (2C) The frequency of screening suggested by KDIGO is a reasonable option as follows: i. monthly for the first 3–6 months after transplantation (2D); ii. then every 3 months until the end of the first post-transplant year (2D); iii. whenever there is an unexplained rise in serum creatinine (2D); and iv. after treatment for acute rejection. (2D). b. We suggest reducing immunosuppressive medications when BKV plasma nucleic acid testing (NAT) is persistently greater than 10,000 copies/ml (107 copies/L) unless there is a contra-indication. (2D) c. We suggest performing a renal biopsy in the event of a deterioration in renal allograft function in order to establish the presence of BK nephropathy or other pathology. (2C) An audit of BKV screening frequency and management should be considered by individual units, as should an audit of the use of biopsies in instances of deterioration of allograft function. The results of the audits should be reviewed against patient and graft outcomes. BACKGROUND The following background has been based on that provided in the KDIGO guideline and edited to reflect review conducted for the adaptation. (BK polyoma virus (BKV) is a member of the polyoma family of viruses. BKV can cause nephropathy, which is diagnosed by kidney biopsy. Reduction of immunosuppression is defined as a decrease in the amount and intensity of immunosuppressive medication. Nucleic acid testing (NAT) is defined as one or more molecular methods used to identify the presence of DNA or RNA (e.g. polymerase chain reaction). These guidelines are adapted from the KDIGO guidelines with changes largely related to the comparatively low incidence of BK nephropathy in Australia and New Zealand compared to some international centres. The use of NAT (PCR) to detect BKV in plasma provides a sensitive method for identifying BKV infection and determining KTRs who are at increased risk for BKV nephropathy. Early identification of BKV infection may allow measures to be taken that may prevent BKV nephropathy. When NAT is not available, microscopic evaluation of urine for the presence of decoy cells is an acceptable, albeit nonspecific, alternative screening method for BKV disease and the risk for BKV nephropathy. Fifty percent of patients who develop BK viremia do so by 3 …