Cytomegalovirus and polyomavirus infection after renal transplantation

Czech version

Authors: Jana Machová; Tomáš Reischig
Authors‘ workplace: I. interní klinika LF UK a FN Plzeň
Published in: Vnitř Lék 2017; 63(7-8): 488-497
Category: Reviews

Overview

Viral infections are among the most common infectious complications affecting transplant recipients. Due to immunosuppressive therapy predominantly affecting cellular immunity and thus successfully reducing the incidence of acute rejection, there is a higher incidence of viral infections. Herpesviruses and polyomaviruses are ubiquitous pathogens which have the ability to persist in a state of latent infection. In addition to post-transplant reactivation, donor-induced primoinfection can also occur, leading to increased morbidity and contributing to decreased survival of patients. Moreover, there are long-term indirect effects, resulting in an impaired function of the transplanted organs and their premature loss. This article provides a brief overview of infections which have the greatest impact on transplant recipients, i.e. cytomegalovirus and BK polyomavirus, their diagnosis, prevention and treatment.

Key words:
BK virus – cytomegalovirus – ganciclovir – immunosuppressive therapy – JC virus – kidney transplantation – polyomavirus – polyomavirus-associated nephropathy – preemptive therapy – prophylaxis – valaciclovir

Sources

1. Krech U. Complement-fixing antibodies against cytomegalovirus in different parts of the world. Bulletin of the World Health Organization 1973; 49(1): 103.

2. Hibberd PL, Tolkoff-Rubin NE, Cosimi AB et al. Symptomatic cytomegalovirus disease in the cytomegalovirus antibody seropositive renal transplant recipient treated with OKT3. Transplantation 1992; 53(1): 68–72.

3. Sia IG, Wilson JA, Groettum CM et al. Cytomegalovirus (CMV) DNA load predicts relapsing CMV infection after solid organ transplantation. J Infect Dis 2000; 181(2): 717–720.

4. Manuel O, Husain S, Kumar D et al. Assessment of cytomegalovirus-specific cell-mediated immunity for the prediction of cytomegalovirus disease in high-risk solid-organ transplant recipients: a multicenter cohort study. Clin Infect Dis 2013; 56(6): 817–824. Dostupné z DOI: <http://dx.doi.org/10.1093/cid/cis993>.

5. Razonable RR, Humar A. [AST Infectious Diseases Community of Practice]. Cytomegalovirus in solid organ transplantation. Am J Transplant 2013;13(Suppl 4): 93–106. Dostupné z DOI: <http://dx.doi.org/10.1111/ajt.12103>.

6. Reusser P Human cytomegalovirus infection and disease after bone marrow and solid organ transplantation. Baillière‘s clinical infectious diseases 1996; 3(3): 357–371.

7. Khoury JA, Storch GA, Bohl D et al. Prophylactic versus preemptive oral valganciclovir for the management of cytomegalovirus infection in adult renal transplant recipients. Am J Transplant 2006; 6(9): 2134–2143.

8. Lowance D et al. Valacyclovir for the prevention of cytomegalovirus disease after renal transplantation. N Engl J Med 1999; 340(19): 1462–1470.

9. Reischig T, Hribova P, Jindra P et al. Long-term outcomes of pre-emptive valganciclovir compared with valacyclovir prophylaxis for prevention of cytomegalovirus in renal transplantation. J Am Soc Nephrol 2012; 23(9):1588–1597. Dostupné z DOI: <http://dx.doi.org/10.1681/ASN.2012010100>.

10. Humar A, Lebranchu Y, Vincenti F et al. The Efficacy and Safety of 200 Days Valganciclovir Cytomegalovirus Prophylaxis in High‐Risk Kidney Transplant Recipients. Am J Transplant 2010; 10(5): 1228–1237. Dostupné z DOI: <http://dx.doi.org/10.1111/j.1600–6143.2010.03074.x>.

11. Freeman RB Jr. The “indirect” effects of cytomegalovirus infection. Am J Transplant 2009; 9(11): 2453–2458. Dostupné z DOI: <http://dx.doi.org/10.1111/j.1600–6143.2009.02824.x>.

12. Reischig T. Cytomegalovirus-associated renal allograft rejection: new challenges for antiviral preventive strategies. Expert Rev Anti Infect Ther 2010; 8(8): 903–910.

13. Sagedal S, Hartmann A, Nordal KP et al. Impact of early cytomegalovirus infection and disease on long-term recipient and kidney graft survival. Kidney Int 2004; 66(1): 329–337.

14. Smith JM, Corey L, Bittner R et al. Subclinical viremia increases risk for chronic allograft injury in pediatric renal transplantation. J Am Soc Nephrol 2010; 21(9): 1579–1586. Dostupné z DOI: <http://dx.doi.org/10.1681/ASN.2009111188>.

15. Kotton CN, Kumar D, Caliendo AM et al. Updated international consensus guidelines on the management of cytomegalovirus in solid-organ transplantation. Transplantation 2013; 96(4): 333–360. Dostupné z DOI: <http://dx.doi.org/10.1097/TP.0b013e31829df29d>.

16. Ljungman P, Boeckh M, Hirsch HH et al. Definitions of cytomegalovirus infection and Disease in Transplant Patients for Use in Clinical Trials Clin Infect Dis 2017; 64(1): 87–91.

17. Preiksaitis JK, Hayden RT, Tong Y et al. Are we there yet? Impact of the 1st International Standard for cytomegalovirus DNA on the harmonization of results reported on plasma samples. Clin Infect Dis 2016; 63(5): 583–589. Dostupné z DOI: <http://dx.doi.org/10.1093/cid/ciw370>.

18. Sester M, Leboeuf C, Schmidt T et al. The “ABC” of Virus‐Specific T Cell Immunity in Solid Organ Transplantation. Am J Transplant 2016; 16(6): 1697–1706. Dostupné z DOI: <http://dx.doi.org/10.1111/ajt.13684>.

19. Reischig T, Jindra P, Svecová M et al. The impact of cytomegalovirus disease and asymptomatic infection on acute renal allograft rejection. J Clin Virol 2006; 36(2): 146–151.

20. Sagedal S, Nordal KP, Hartmann A et al. The impact of cytomegalovirus infection and disease on rejection episodes in renal allograft recipients. Am J Transplant 2002; 2(9): 850–856.

21. Reischig T, Jindra P, Hes O et al. Effect of cytomegalovirus viremia on subclinical rejection or interstitial fibrosis and tubular atrophy in protocol biopsy at 3 months in renal allograft recipients managed by preemptive therapy or antiviral prophylaxis. Transplantation 2009; 87(3): 436–444. Dostupné z DOI: <http://dx.doi.org/10.1097/TP.0b013e318192ded5>.

22. Pascher A, Proesch S, Pratschke J et al. Rat Cytomegalovirus Infection Interferes with Anti‐CD4 mAb‐(RIB 5/2) Mediated Tolerance and Induces Chronic Allograft Damage. Am J Transplant 2006; 6(9): 2035–2045.

23. Courivaud C, Bamoulid J, Chalopin JM et al. Cytomegalovirus exposure and cardiovascular disease in kidney transplant recipients. J Infect Dis 2013; 207(10): 1569–1575. Dostupné z DOI: <http://dx.doi.org/10.1093/infdis/jit064>.

24. Humar A, Gillingham K, Payne WD et al. Increased incidence of cardiac complications in kidney transplant recipients with cytomegalovirus disease. Transplantation 2000; 70(2): 310–313.

25. Walker RC, Marshall WF, Strickler JG et al. Pretransplantation assessment of the risk of lymphoproliferative disorder. Clin Infect Dis 1995; 20(5): 1346–1353.

26. Paya C, Humar A, Dominguez E et al. Efficacy and safety of valganciclovir vs. oral ganciclovir for prevention of cytomegalovirus disease in solid organ transplant recipients. Am J Transplant 2004; 4(4): 611–620.

27. Humar A, Limaye AP, Blumberg EA et al. Extended valganciclovir prophylaxis in D+/R− kidney transplant recipients is associated with long-term reduction in cytomegalovirus disease: two-year results of the IMPACT study. Transplantation 2010; 90(12): 1427–1431.

28. Reischig T, Kacer M, Jindra P et al. Randomized Trial of valganciclovir versus valacyclovir prophylaxis for prevention of cytomegalovirus in renal transplantation. Clin J Am Soc Nephrol 2015; 10(2):294–304. Dostupné z DOI: <http://dx.doi.org/10.2215/CJN.07020714>.

29. Reischig T, Jindra P, Mares J et al. Valacyclovir for cytomegalovirus prophylaxis reduces the risk of acute renal allograft rejection. Transplantation 2005; 79(3): 317–324.

30. Reischig T, Jindra P, Hes O et al. Valacyclovir prophylaxis versus preemptive valganciclovir therapy to prevent cytomegalovirus disease after renal transplantation. Am J Transplant 2008; 8(1): 69–77.

31. Hodson EM, Jones CA, Webster AC et al. Antiviral medications to prevent cytomegalovirus disease and early death in recipients of solid-organ transplants: a systematic review of randomised controlled trials. Lancet 2005; 365(9477): 2105–2115.

32. Kalil AC, Levitsky J, Lyden E et al. Meta-analysis: the efficacy of strategies to prevent organ disease by cytomegalovirus in solid organ transplant recipients. Ann Intern Med 2005; 143(12): 870–880.

33. Arthurs SK, Eid AJ, Pedersen RA et al. Delayed-onset primary cytomegalovirus disease and the risk of allograft failure and mortality after kidney transplantation. Clin Infect Dis 2008; 46(6): 840–846. Dostupné z DOI: <http://dx.doi.org/10.1086/528718>.

34. Reischig T. Advances in cytomegalovirus-preventive strategies in solid organ transplantation: defending pre-emptive therapy. Expert Rev Anti Infect Ther 2012; 10(1): 51–61. Dostupné z DOI: <http://dx.doi.org/10.1586/eri.11.156>.

35. Gerna G, Lilleri D, Fornara C et al. Monitoring of Human Cytomegalovirus‐Specific CD4+ and CD8+ T‐Cell Immunity in Patients Receiving Solid Organ Transplantation. Am J Transplant 2006; 6(10): 2356–2364.

36. Egli A, Binet I, Binggeli S et al. Cytomegalovirus-specific T-cell responses and viral replication in kidney transplant recipients. J Transl Med 2008; 6: 29. Dostupné z DOI: <http://dx.doi.org/10.1186/1479–5876–6–29>.

37. Mattes FM, Vargas A, Kopycinski J et al. Functional Impairment of Cytomegalovirus Specific CD8 T Cells Predicts High‐Level Replication After Renal Transplantation. Am J Transplant 2008; 8(5): 990–999. Dostupné z DOI: <http://dx.doi.org/10.1111/j.1600–6143.2008.02191.x>. Erratum in Am J Transplant 2011; 11(5): 1107.

38. Benmarzouk-Hidalgo OJ, Cisneros JM, Cordero E et al. Therapeutic effect of the acquisition of cytomegalovirus-specific immune response during preemptive treatment. Transplantation 2011; 91(8): 927–933. Dostupné z DOI: <http://dx.doi.org/10.1097/TP.0b013e3182115ba2>.

39. Nickel P, Bold G, Presber F et al. High levels of CMV-IE-1-specific memory T cells are associated with less alloimmunity and improved renal allograft function. Transpl Immunol 2009; 20(4): 238–242. Dostupné z DOI: <http://dx.doi.org/10.1016/j.trim.2008.11.002>.

40. Battiwalla M, Wu Y, Bajwa RP et al. Ganciclovir inhibits lymphocyte proliferation by impairing DNA synthesis. Biol Blood Marrow Transplant 2007; 13(7): 765–770.

41. Kliem V, Fricke L, Wollbrink T et al. Improvement in Long‐Term Renal Graft Survival due to CMV Prophylaxis with Oral Ganciclovir: Results of a Randomized Clinical Trial. Am J Transplant 2008; 8(5): 975–983. Dostupné z DOI: <http://dx.doi.org/10.1111/j.1600–6143.2007.02133.x>.

42. Witzke O, Hauser IA, Bartels M et al. Valganciclovir prophylaxis versus preemptive therapy in cytomegalovirus-positive renal allograft recipients: 1-year results of a randomized clinical trial. Transplantation 2012; 93(1): 61–68. Dostupné z DOI: <http://dx.doi.org/10.1097/TP.0b013e318238dab3>.

43. Spinner ML, Saab G, Casabar E et al. Impact of prophylactic versus preemptive valganciclovir on long-term renal allograft outcomes. Transplantation 2010; 90(4): 412–418. Dostupné z DOI: <http://dx.doi.org/10.1097/TP.0b013e3181e81afc>.

44. Florescu DF, Qiu F, Schmidt CM et al. A Direct and Indirect Comparison Meta-analysis on the Efficacy of Cytomegalovirus Preventive Strategies in Solid Organ Transplantation. Clin Infect Dis 2014; 58(6): 785–803. Dostupné z DOI: <http://dx.doi.org/10.1093/cid/cit945>.

45. Brennhan DC, Garlock KA, Lippmann BA et al. Control of cytomegalovirus-associated morbidity in renal transplant patients using intensive monitoring and either preemptive or deferred therapy. J Am Soc Nephrol 1997; 8(1): 118–125.

46. Åsberg A, Humar A, Rollag H et al. Oral valganciclovir is noninferior to intravenous ganciclovir for the treatment of cytomegalovirus disease in solid organ transplant recipients. Am J Transplant 2007; 7(9): 2106–2113.

47. Emery VC, Griffiths PD. Prediction of cytomegalovirus load and resistance patterns after antiviral chemotherapy. Proc Natl Acad Sci U.S.A. 2000; 97(14): 8039–8044.

48. McGavin JK, Goa KL. Ganciclovir: an update of its use in the prevention of cytomegalovirus infection and disease in transplant recipients. Drugs 2001; 61(8): 1153–1183.

49. Åsberg A, Humar A, Jardine AG et al. Long‐Term Outcomes of CMV Disease Treatment with Valganciclovir Versus IV Ganciclovir in Solid Organ Transplant Recipients. Am J Transplant 2009; 9(5): 1205–1213. Dostupné z DOI: <http://dx.doi.org/10.1111/j.1600–6143.2009.02617.x>.

50. Chou SW. Cytomegalovirus drug resistance and clinical implications. Transplant Infectious Disease 2001; 3(Suppl 2): S20-S24.

51. Eid AJ, Arthurs SK, Deziel PJ et al. Emergence of drug‐resistant cytomegalovirus in the era of valganciclovir prophylaxis: therapeutic implications and outcomes. Clin Transplant 2008; 22(2): 162–170. Dostupné z DOI: <http://dx.doi.org/10.1111/j.1399–0012.2007.00761.x>.

52. Lurain NS, Chou S. Antiviral drug resistance of human cytomegalovirus. Clin Microbiol Rev 2010; 23(4): 689–712. Dostupné z DOI: <http://dx.doi.org/10.1128/CMR.00009–10.>.

53. Ozaku KS, Câmara NO, Nogueira E et al. The use of sirolimus in ganciclovir‐resistant cytomegalovirus infections in renal transplant recipients. Clin Transplant 2007; 21(15): 675–680.

54. Ljungman P, Deliliers GL, Platzbecker U et al. Cidofovir for cytomegalovirus infection and disease in allogeneic stem cell transplant recipients. Blood 2001; 97(2): 388–392.

55. Egli A, Infanti L, Dumoulin A et al. Prevalence of polyomavirus BK and JC infection and replication in 400 healthy blood donors. J Infect Dis 2009; 199(6): 837–846.

56. Antonsson A, Green AC, Mallitt KA et al. Prevalence and stability of antibodies to the BK and JC polyomaviruses: a long-term longitudinal study of Australians. J Gen Virol 2010; 91(Pt 7): 1849–1853. Dostupné z DOI: <http://dx.doi.org/10.1099/vir.0.020115–0>.

57. Boldorini R, Veggiani C, Barco D et al. Kidney and urinary tract polyomavirus infection and distribution: molecular biology investigation of 10 consecutive autopsies. Arch Pathol Lab Med 2005; 129(1): 69–73.

58. Chesters PM, Heritage J, McCance DJ. Persistence of DNA sequences of BK virus and JC virus in normal human tissues and in diseased tissues. J Infect Dis 1983; 147(4): 676–684.

59. Schachtner T et al. The Loss of BKV‐specific Immunity From Pretransplantation to Posttransplantation Identifies Kidney Transplant Recipients at Increased Risk of BKV Replication. Am J Transplant 2015; 15(8): 2159–2169. Dostupné z DOI: <http://dx.doi.org/10.1111/ajt.13252>.

60. Hirch HH, Knowles W, Dickenmann M et al. Prospective study of polyomavirus type BK replication and nephropathy in renal-transplant recipients. N Engl J Med 2002; 347(7): 488–496.

61. Bohl DL, Brennan DC. BK virus nephropathy and kidney transplantation. Clin J Am Soc Nephrol 2007; 2(Suppl 1): S36-S46.

62. Ahuja M, Cohen EP, Dayer AM et al. Polyoma virus infection after renal transplantation: Use of Immunostaining as a Guide to Diagnosis. Transplantation 2001; 71(7): 896–899.

63. Mengel M, Marwedel M, Radermacher J et al. Incidence of polyomavirus‐nephropathy in renal allografts: influence of modern immunosuppressive drugs. Nephrol Dial Transplant 2003; 18(6): 1190–1196.

64. Hirsch HH, Steiger J. Polyomavirus Bk. Lancet Infect Dis 2003; 3(10): 611–623.

65. Hirsch HH, Snydman DR. BK virus: opportunity makes a pathogen. Clin Infect Dis 2005; 41(3): 354–360.

66. Hirch HH, Randhawa P. [AST Infectious Diseases Community of Practice]. BK polyomavirus in solid organ transplantation. Am J Transplant 2013; 13(Suppl 4): S179-S188. Dostupné z DOI: <http://dx.doi.org/10.1111/ajt.12110>.

67. Hirsch HH, Vincenti F, Friman S et al. Polyomavirus BK replication in de novo kidney transplant patients receiving tacrolimus or cyclosporine: a prospective, randomized, multicenter study. Am J Transplant 2013; 13(1): 136–145. Dostupné z DOI: <http://dx.doi.org/10.1111/j.1600–6143.2012.04320.x>.

68. Prince O, Savic S, Dickenmann M et al. Risk factors for polyoma virus nephropathy. Nephrol Dial Transplant 2009; 24(3): 1024–1033. Dostupné z DOI: <http://dx.doi.org/10.1093/ndt/gfn671>.

69. Drachenberg CB, Hirsch HH, Papadimitriou JC et al. Polyomavirus BK versus JC replication and nephropathy in renal transplant recipients: a prospective evaluation. Transplantation 2007; 84(3): 323–330.

70. Mengelle C, Kamar N, Mansuy JM et al. JC virus DNA in the peripheral blood of renal transplant patients: A 1‐year prospective follow‐up in France. J Med Virol 2011; 83(1): 132–136. Dostupné z DOI: <http://dx.doi.org/10.1002/jmv.21951>.

71. Cheng XS, Bohl DL, Storch GA et al. Inhibitory interactions between BK and JC virus among kidney transplant recipients. J Am Soc Nephrol 2011; 22(5): 825–831. Dostupné z DOI: <http://dx.doi.org/10.1681/ASN.2010080877>.

72. Hardinger KL, Koch MJ, Bohl DJ et al. BK‐Virus and the Impact of Pre‐Emptive Immunosuppression Reduction: 5‐Year Results. Am J Transplant 2010; 10(2): 407–415. Dostupné z DOI: <http://dx.doi.org/10.1111/j.1600–6143.2009.02952.x>.

73. Brennan DC, Agha I, Bohl DL et al. Incidence of BK with tacrolimus versus cyclosporine and impact of preemptive immunosuppression reduction. Am J Transplant 2005; 5(3): 582–594.

74. Elfadawy N, Flechner SM, Schold JD et al. Transient versus Persistent BK Viremia and Long-Term Outcomes after Kidney and Kidney–Pancreas Transplantation. Clin J Am Soc Nephrol 2014; 9(3): 553–561. Dostupné z DOI: <http://dx.doi.org/10.2215/CJN.08420813>.

75. Sawinski D, Forde KA, Trofe-Clark J et al. Persistent BK viremia does not increase intermediate-term graft loss but is associated with de novo donor-specific antibodies. J Am Soc Nephrol 2015; 26(4): 966–975. Dostupné z DOI: <http://dx.doi.org/10.1681/ASN.2014010119>.

76. Drachenberg CB, Papadimitriou JC, Hirsch HH et al. Histological patterns of polyomavirus nephropathy: correlation with graft outcome and viral load. Am J Transplant 2004; 4(12): 2082–2092.

77. Masutani K, Shapiro R, Basu A et al. The Banff 2009 Working Proposal for polyomavirus nephropathy: a critical evaluation of its utility as a determinant of clinical outcome. Am J Transplant 2012; 12(4) :907–918. Dostupné z DOI: <http://dx.doi.org/10.1111/j.1600–6143.2012.03993.x>.

78. Dadhania D, Snopkowski C, Ding R et al. Validation of noninvasive diagnosis of BK virus nephropathy and identification of prognostic biomarkers. Transplantation 2010; 90(2):189–197. Dostupné z DOI: <http://dx.doi.org/10.1097/TP.0b013e3181e2a932>.

79. Wunderink HF, van der Meijden E, van der Blij-de Brouwer CS et al. Pretransplantation Donor-Recipient Pair Seroreactivity Against BK Polyomavirus Predicts Viremia and Nephropathy After Kidney Transplantation. Am J Transplant 2017; 17(1):161–172. Dostupné z DOI: <http://dx.doi.org/10.1111/ajt.13880>.

80. Schachtner T, Müller K, Stein M et al. BK Virus‐Specific Immunity Kinetics: A Predictor of Recovery from Polyomavirus BK‐Associated Nephropathy. Am J Transplant 2011; 11(11): 2443–2452. Dostupné z DOI: <http://dx.doi.org/10.1111/j.1600–6143.2011.03693.x>.

81. Binggeli S, Egli A, Schaub S et al. Polyomavirus BK‐specific cellular immune response to VP1 and large T‐antigen in kidney transplant recipients. Am J Transplant 2007; 7(5): 1131–1139.

82. Schaub S, Hirsch HH, Dickenmann M et al. Reducing immunosuppression preserves allograft function in presumptive and definitive polyomavirus‐associated nephropathy. Am J Transplant 2010; 10(12): 2615–2623. Dostupné z DOI: <http://dx.doi.org/10.1111/j.1600–6143.2010.03310.x>.

83. Sood P, Senanayake S, Sujeet K et al. Management and outcome of BK viremia in renal transplant recipients: a prospective single-center study. Transplantation 2012; 94(8): 814–821. Dostupné z DOI: <http://dx.doi.org/10.1097/TP.0b013e31826690c6>.

84. Li YJ, Weng CH, Lai WC et al. A suppressive effect of cyclosporine A on replication and noncoding control region activation of polyomavirus BK virus. Transplantation 2010; 89(3): 299–306. Dostupné z DOI: <http://dx.doi.org/10.1097/TP.0b013e3181c9b51c>.

85. Acott PD, O’Regan PA, Lee SH et al. In vitro effect of cyclosporin A on primary and chronic BK polyoma virus infection in Vero E6 cells. Transpl Infect Dis 2008; 10(6): 385–390. Dostupné z DOI: <http://dx.doi.org/10.1111/j.1399–3062.2008.00330.x>.

86. Acott P, O’Regan PA, Crocker JF. Suppression of early and chronic BK polyoma virus replication by mycophenolic acid in Vero cells. Transpl Int 2009; 22(2): 225–231. Dostupné z DOI: <http://dx.doi.org/10.1111/j.1432–2277.2008.00766.x>.

87. Hirsch HH, Lu M, Wernli M. Polyomavirus Bk (bkv) Replication in Renal Tubular Epithelial Cells Is Inhibited by mtor Inhibitors, but Activated by Tacrolimus in a Pathway Involving the Fkbp12. Am J Transplant 2011; 11(1) :179. Dostupné z DOI: <http://dx.doi.org/10.1111/j.1600–6143.2010.03307.x>.

88. Lee BT, Gabardi S, Grafals M et al. Efficacy of levofloxacin in the treatment of BK viremia: a multicenter, double-blinded, randomized, placebo-controlled trial. Clin J Am Soc Nephrol 2014; 9(3): 583–589. Dostupné z DOI: <http://dx.doi.org/10.2215/CJN.04230413>.

89. Johnston O, Jaswal D, Gill JS et al. Treatment of polyomavirus infection in kidney transplant recipients: a systematic review. Transplantation 2010; 89(9): 1057–1070. Dostupné z DOI: <http://dx.doi.org/10.1097/TP.0b013e3181d0e15e>.

90. Menter T, Mayr M, Schaub S et al. Pathology of Resolving Polyomavirus‐Associated Nephropathy. Am J Transplant 2013; 13(6): 1474–1483. Dostupné z DOI: <http://dx.doi.org/10.1111/ajt.12218>.

91. Wiebe C, Gibson IW, Blydt-Hansen TD et al. Evolution and clinical pathologic correlations of de novo donor‐specific HLA antibody post kidney transplant. Am J Transplant 2012; 12(5): 1157–1167. Dostupné z DOI: <http://dx.doi.org/10.1111/j.1600–6143.2012.04013.x>.

92. Everly MJ, Rebellato LM, Haisch CE et al. Incidence and impact of de novo donor-specific alloantibody in primary renal allografts. Transplantation 2013; 95(3): 410–417. Dostupné z DOI: <http://dx.doi.org/10.1097/TP.0b013e31827d62e3>.

93. Mannon RB, Hoffmann SC, Kampen RL et al. Molecular evaluation of BK polyomavirus nephropathy. Am J Transplant 2005; 5(12): 2883–2893.