Management strategies for common viral infections in pediatric renal transplant recipients

Table 1 Pre-transplant screening and diagnostic work-up for kidney transplant recipients

CMV	CMV IgG serology in both donors and recipients
EBV	Screening by EBV serology in both donors and recipients
BKPyV	Not done at present
HSV	HSV antibodies in blood
VZV	Pretransplant screening for previous VZV infectio
Hepatitis B & C	HBV
	HBsAg and antibody to hepatitis B core antigen (antiHBc)
	HCV
	HCV antibody test
Respiratory viruses	Nasopharyngeal wash or bronchoalveolar lavage fluid (BAL) specimens (in the case of Adeno virus - stools or plasma), by conventional viral culture, PCR, or direct immunofluorescence

CMV: Cytomegalovirus; EBV: Epstein-Barr virus; BKPyV: Human BK polyomavirus; HSV: Herpes simplex viruses; VZV: Varicella zoster virus; HBV: Hepatitis B virus; HCV: Hepatitis C virus.

Table 2 Post-transplant screening and diagnostic work-up for kidney transplant recipients

CMV	Quantitative CMV viral load
	Diagnosis- presence of CMV DNA in whole blood or plasma
	Tissue biopsy
	Diagnosis- presence of CMV inclusion or immunostaining
	CMV serology
	Diagnosis- presence of CMV IgG post kidney transplantation in
	CMV R- patients
EBV	Quantitative EBV viral load
	Tissue biopsy
	EBV serology
BKPyV	Urine cytology
	Quantitative BK viral load in urine
	Quantitative BK viral load in plasma
	Allograft biopsy
HSV	Direct fluorescence antibody for HSV from vesicular lesions or PCR from CSF or visceral tissue samples
VZV	Direct fluorescence antibody for VZV from vesicular lesions or PCR from CSF or visceral tissue samples
Hepatitis B & C	HBV
	HBsAg and antibody to hepatitis B core antigen (antiHBc)
	HCV
	HCV antibody test
Respiratory viruses	Nasopharyngeal wash or bronchoalveolar lavage fluid (BAL) specimens, (in the case of Adeno virus - stools or plasma), by conventional viral culture, PCR, or direct immunofluorescence

CMV: Cytomegalovirus; EBV: Epstein-Barr virus; BKPyV: Human BK polyomavirus; HSV: Herpes simplex viruses; VZV: Varicella zoster virus; HBV: Hepatitis B virus; PCR: Polymerase chain reaction.

Table 3 Treatment of viral infections kidney transplant recipients

CMV	CMV load copy no < 500 - below quantifiable level - no action
	CMV load copy no 500-3000 - active CMV infection - repeat CMV in 1 week, consider treatment if clinically indicated
	CMV load copy no > 3000 - Active CMV infection - commence pre-emptive treatment
	Intravenous ganciclovir or oral valganciclovir
EBV	Immunosuppressive drug reduction
	Ganciclovir and valganciclovir have antiviral impact against EBV
BKPyV	Immunosuppressive drug reduction
	No specific antiviral therapy
HSV	Acyclovir
	Intravenous or oral
VZV	Intravenous acyclovir, while less severe infection can be treated with oral acyclovir
Hepatitis B & C	Immunosuppressive drug reduction
	Hepatitis B – Lamivudine
	Hepatitis C - IFN and ribavirin
Respiratory viruses	Reduce immunosuppressive drugs
	Supportive care and, in some cases, the use of antivirals

CMV: Cytomegalovirus, EBV: Epstein-Barr virus, BKPyV: Human BK polyomavirus, HSV: Herpes simplex viruses, VZV: Varicella zoster virus.

Table 4 Prevention of viral infections kidney transplant recipients

CMV	Valganciclovir
	Universal prophylaxis - Dose (mg) = (7 × BSA × eGFR) once a day
	Preemptive therapy - Dose (mg) = ( 7 × BSA × eGFR) bd
EBV	EBV viral load surveillance and preemptive therapy for EBV mismatched patients
BKPyV	BK viral load monitoring and early identification of BK viremia
HSV	Avoidance of visitors or health professionals who have HSV signs and symptoms
VZV	Avoidance of visitors or health professionals who have VZV signs and symptoms. Vaccination including family members
Hepatitis B & C	Hepatitis B vaccination and immunity verified with Hepatitis B surface antibody screening following completion of the vaccination series
Respiratory viruses	Avoidance of other individuals who have signs or symptoms of infection, hand hygiene, and use of droplet precautions for those suspected of having infection

CMV: Cytomegalovirus; EBV: Epstein-Barr virus; BKPyV: Human BK polyomavirus; HSV: Herpes simplex viruses; VZV: Varicella zoster virus.