1. Evaluation and Management of BK Virus-Associated Nephropathy Following Allogeneic Hematopoietic Cell Transplantation 
Mihir Raval, Alison Gulbis, Catherine Bollard, Ann Leen, Roy Chemaly, Elizabeth Shpall, Amit Lahoti, Partow Kebriaei 
Biology of Blood and Marrow Transplantation 
Volume 17, Issue 11, Pages (November 2011)
DOI: /j.bbmt
Copyright © 2011 American Society for Blood and Marrow Transplantation Terms and Conditions

2. Figure 1
Immunohistochemistry images of renal biopsy. SV-40T stain was positive, suggesting BK virus involvement of the tubulointerstitium (A). Nuclear enlargement and smudge chromatin suggest viral inclusion (B). The presence of tubular casts for IgA is a nonspecific finding associated with tubulitis and interstitial lymphoplasmacytic infiltrates (C).
Biology of Blood and Marrow Transplantation  , DOI: ( /j.bbmt )
Copyright © 2011 American Society for Blood and Marrow Transplantation Terms and Conditions

3. Figure 2
Serum creatinine measurements beginning 100 days following transplantation in patient diagnosed with BK-associated hemorrhagic cystitis and nephropathy following a double cord blood transplant. The patient developed BK viruria, with >5 × 108 virus copies/mL urine, associated with hemorrhagic cystitis, 39 days post-HCT. At 105 days post-HCT, there was a rise in creatinine up to 3.6 mg/dL that was noted to be because of bilateral hydronephrosis, diagnosed by renal ultrasound, in the setting of persistent BK viruria, with improvement in creatinine following placement of bilateral percutaneous nephropathy tubes. Immunosuppression was also discontinued at this time. The presence of renal failure prohibited the use of cidofovir, so leflunomide was initiated on day +263, and over the course of 3 weeks, the creatinine decreased from 6.7 mg/dL to 3.5 mg/dL, with a 75% reduction in BK viruria from >5 × 108 to 1.25 × 108 copies of virus/mL urine. At approximately 1 year posttransplantation, 6.86 × 105 copies of virus/mL of urine was noted after taking leflunomide for approximately 15 weeks. However, the patient subsequently developed another rise in her creatinine concurrent with the development of a pseudomonas urinary tract infection. The patient remains on leflunomide at 20 mg daily, with no liver or bone marrow toxicities noted.
Biology of Blood and Marrow Transplantation  , DOI: ( /j.bbmt )
Copyright © 2011 American Society for Blood and Marrow Transplantation Terms and Conditions

4. Figure 3
Summary of ELISPOT responses as measured by SFC/105 peripheral blood mononuclear cells (PBMC) against the BK virus antigens LT and VP1. Pretransplantation, the patient was noted to have 10 SFC/2 × 105 PBMC against the VP1 antigen and 40 SFC/2 × 105 PBMC against the LT antigen. BK-virus reactive T cells remain undetectable at 360 days posttransplantation. The previously described ELISPOT assay was used to determine the frequency of virus-specific IFN-γ-secreting T cells.38 Briefly, PBMCs were isolated by ficoll gradient and plated at 2 × 105 cells/well. We measured the viral-specific activity of responder cells after direct stimulation with pepmixes spanning Hexon and Penton (Adv), IE1 and pp65 (CMV), VP1 and Large T (BK), MP1 and NP1 (Influenza), N and F (RSV), and EBNA1, EBNA3a, EBNA3b, EBNA3c, LMP1, LMP2, and BZLF1 (EBV). All pepmixes, which are overlapping peptide libraries (15mers overlapping by 11 amino acids) were purchased from JPT Technologies (Berlin, Germany). Each culture condition was run in triplicate. After 20 hours of incubation, plates were developed as previously described [38], dried overnight at room temperature in the dark, then sent to Zellet Consulting (New York, New York) for quantification. The frequency of T cells specific to each antigen was expressed as specific SFC per input cell numbers.
Biology of Blood and Marrow Transplantation  , DOI: ( /j.bbmt )
Copyright © 2011 American Society for Blood and Marrow Transplantation Terms and Conditions