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Kidney Week

Abstract: PO2484

Recurrent Anemia due to Chronic Parvovirus B19 Infection in a Kidney Transplant Recipient: Can Everolimus Make a Difference?

Session Information

Category: Trainee Case Report

  • 1902 Transplantation: Clinical

Authors

  • Rodriguez-Espinosa, Diana, Hospital Clínic de Barcelona, Hospital Clinic de Barcelona, Barcelona, Barcelona, Spain
  • Esforzado, Nuria, Hospital Clínic de Barcelona, Hospital Clinic de Barcelona, Barcelona, Barcelona, Spain
  • Diekmann, Fritz, Hospital Clínic de Barcelona, Hospital Clinic de Barcelona, Barcelona, Barcelona, Spain
  • Revuelta, Ignacio, Hospital Clínic de Barcelona, Hospital Clinic de Barcelona, Barcelona, Barcelona, Spain
Introduction


Parvovirus B19 (PB19) is a common infection among transplant recipients. Usually, it is asymptomatic, but some patients may suffer severe infections, often presenting with recurrent flares despite standard treatment. Relapses are usually managed by reducing immunosuppressive treatment (IST), potentially increasing graft rejection risk.

Case Description


45-year-old woman with ESKD due to ADPKD, received a living-donor kidney transplant on May 2013. Maintenance IST consisted of mycophenolate mofetil (MMF), prednisone and tacrolimus. A month after transplantation, she presented with fever and anemia. A bone marrow aspirate revealed pure red blood cell aplasia (PRCA) which was attributed to PB19 after positive serum qualitative PCR. She was treated intravenous immunoglobulin (IVIG) at 2g/kg and MMF was stopped with good response. However 3 new relapses occurred (anemia and malaise with viral loads for PB19 over a million copies). A monthly prophylactic dose of IVIG was initiated to control the infection. In spite of this, episodes of anemia and a high PB19 viral load (over half a million copies) continued to happen at least 3 times per year. Finally, given the potential antiviral properties of mTOR inhibitors (mTORi), conversion from tacrolimus to everolimus was decided, Since November 2017 her maintenance IST consists of everolimus and prednisone alone, her last prophylactic IVIG was on December 2017, and since then she has been non-anemic with serum viral loads below 1000 copies, and without IVIG treatment.

Discussion

Incidence of symptomatic PB19 infection is highest during the 1st year after transplantation, like in the case presented. Standard therapy consists of IVIG. However, early KTR, often relapse after the IVIG effect wears off. In such cases, reduction of IST is needed to control the infection and avoid recurrences. There are multiple studies indicating that mTORi have antiviral properites although their effect on PB19 has not been specifically studied.
In conclusion, conversion from tacrolimus to an mTORi, could be an interesting approach in difficult-to-manage cases similar to ours, moderating the reduction of IST and minimizing the risk of rejection. Further studies are needed to establish this approach as “treatment of choice” in relapsing PB19 infection.