Polyomavirus-associated nephropathy (PVAN) is a frequent cause of kidney transplant failure. We determined the risk factors for biopsy-proven PVAN among 1027 recent kidney transplant recipients by univariate and multivariate analyses. The rate of PVAN was determined over an univariate and multivariate analysis over an average of 30 months of follow-up of patients receiving predominantly living donor grafts with antibody induction and sequential surveillance biopsies to detect subclinical graft disease. Seventy-four transplant recipients were diagnosed with PVAN with the finding made on surveillance biopsy in 40 patients. These 40 cases did not differ from the 34 non-surveillance cases with respect to baseline clinical characteristics or initial histological features. Older recipient age and female donor gender were independent risks associated with PVAN. Factors not linked to PVAN risk included the use and type of induction agent, use of tacrolimus vs sirolimus, the number of human lympocyte antigen (HLA) mismatches, or the frequency of acute rejection. We conclude that PVAN preferentially affects older age patients and allografts from female donors but is unrelated to immunological risk, choice of immunosuppression, or rejection history.

Polyomavirus-associated nephropathy (PVAN) is managed by reduced immunosuppression with or without antiviral therapy. Data from 55 patients with biopsy-proven PVAN were analyzed for adverse outcomes and influence of baseline variables and interventions. During 20+/-11 months follow-up, the frequencies of graft loss, major and any functional decline were 15%, 24% and 38%, respectively. Repeat biopsies were performed in 45 patients with persistent PVAN in 47%. Low-dose cidofovir, IVIG and cyclosporine conversion were used in 55%, 20% and 55% of patients. No single intervention was associated with improved outcome. Of the variables examined, only degree of interstitial fibrosis at diagnosis was associated with kidney function decline. In contrast, donor source, interstitial fibrosis, proportion of BKV positive tubules and plasma viral load at diagnosis were all associated with failure of histological viral clearance. This retrospective, nonrandomized analysis suggests that: (i) Graft loss within 2 years of PVAN diagnosis is now uncommon, but ongoing functional decline and persistent infection occur frequently. (ii) Low-dose cidofovir, IVIG and conversion to cyclosporine do not abrogate adverse outcomes following diagnosis. (iii) Fibrosis at the time of diagnosis predicts subsequent functional decline. Further elucidation of the natural history of PVAN and its response to individual interventions will require prospective clinical trials.