TABLE 6.

Practice guidance suggestions for reducing immunosuppression

General management approach

• We suggest first confirming that all immunosuppressive drug doses and concentrations are within the institutional target range (weak, C)

• We recommend that BKPyV-DNAemia should be monitored every 2–4 wk until clearance (strong, B) or stabilizing at plasma viral loads <1000 c/mL (or equivalent) (weak, C)

• For rare patients on the lowest acceptable immunosuppression with detectable BKPyV-DNAemia below <1000 c/mL, we suggest follow-up of BKPyV-DNAemia and serum creatinine concentration every 3 mo (weak, D)

Strategy 1: Antimetabolite is reduced first

I. Reduction of the dose of antimetabolite by at least 50%

• We suggest further immunosuppression reduction if BKPyV-DNAemia does not decrease by 10-fold at 4 wk or does not clear below lower limit of detection (weak, C), as follows:

II. Discontinuation of the antimetabolite and tapering of corticosteroid dose to 5–10 mg/d of prednisone or equivalent, if applicable

• We suggest adding prednisone (or equivalent) 5–10 mg/d for patients who are not on corticosteroids to avoid CNI monotherapy (weak, C)

III. If further decrease in immunosuppression is necessary, we suggest a stepwise reduction of the CNI dose (tacrolimus trough target 5 ng/mL; cyclosporine trough target 100 ng/mL; weak, C)

• The target concentrations for further reduction are not well defined and need to be individualized. Expert opinion and case reports discuss tacrolimus target trough concentrations of 3 ng/mL and cyclosporine target trough concentrations 75 ng/mL followed by tacrolimus target trough of 1.5 ng/mL; cyclosporine target trough of 50 ng/mL (no recommendation—statement only)

Strategy 2: CNI is reduced first

I. Reduction of the dose of CNI by 25%–50% in 1 or 2 steps to target trough concentrations of tacrolimus of 3–5 ng/mL and cyclosporine trough concentrations of 75–125 ng/mL)

• We suggest further immunosuppression reduction if BKPyV-DNAemia does not decrease by 10-fold at 4 wk or does not clear below the lower limit of detection (weak, C), as follows:

II. Reduction of the antimetabolite by 50% and tapering of corticosteroid dose to 5–10 mg/d of prednisone or equivalent, if applicable

III. Discontinuation of the antimetabolite

• We suggest adding prednisone (or equivalent) 5–10 mg/d for patients who are not on corticosteroids to avoid CNI monotherapy (weak, C)

• The target concentrations of further reduction are not well defined and need to be individualized. Expert opinion and case reports discuss tacrolimus target trough concentrations of 3 ng/mL and cyclosporine target trough concentrations of 75 ng/mL followed by tacrolimus target trough of 1.5 ng/mL; cyclosporine target trough of 50 ng/mL (no recommendation—statement only)

BKPyV, BK polyomavirus; CNI, calcineurin inhibitor.