Challenges in Management of BK Virus Infections in HIV-Infected Renal Transplant Recipients

BK virus (BKV) poses a significant threat to kidney transplantation as it can lead to severe complications, including BK virus nephropathy (BKVN). Many transplant recipients harbor latent BKV, which can reactivate under immunosuppression, leading to viruria, viremia, and potential graft loss. The management of BKVN in human immunodeficiency virus (HIV)-positive patients is especially complex owing to the dual challenge of balancing immunosuppressive therapy and antiretroviral treatment, compounded by potential drug interactions. This study aimed to investigate the incidence, risk factors, and outcomes of BKVN in HIV-positive kidney transplant recipients, comparing these findings to findings in HIV-negative recipients.

The United Network for Organ Sharing database was used to identify kidney transplant recipients between August 2009 and February 2022, excluding those age <18 years, with prior transplants, or with unknown HIV status. Parametric and nonparametric tests were used to assess risk factors for BKVN in HIV-positive individuals.

Among 1909 HIV-positive kidney transplant recipients, 15 (0.8%) experienced graft loss due to BKVN, compared to 558 of 168,836 (0.3%) HIV-negative recipients. HIV-positive individuals had a higher risk of BKVN-related graft loss (P < .001). In the HIV-positive group, delayed graft function (DGF), greater HLA mismatch, older donor age, older recipient age, and a history of diabetes were significant risk factors for BKVN. The HIV-positive BKVN group had shorter graft survival compared to their HIV-negative counterparts (P = .044).

This study confirms that HIV-positive individuals are at greater risk of graft loss due to BKVN, with risk factors including DGF, greater HLA mismatch, older donor and recipient age, and a history of diabetes.