Induction Regimens and Kidney Re-Transplant Outcomes after BK Nephropathy–Related Graft Loss: A U.S. Cohort Study

This study investigated the association between induction type and long-term outcomes in kidney retransplant recipients who experienced graft loss due to BK virus–associated nephropathy (BKVAN). Using Scientific Registry of Transplant Recipients data (2003–2021), we identified 277 adult kidney-alone retransplant recipients with BKVAN-related graft loss and categorized them by induction regimen: depletional (n = 217) and nondepletional (n = 60). The groups were similar overall, except the nondepletional cohort had lower panel-reactive antibodies, a shorter time between transplants, and more live donor kidneys. Kaplan–Meier curves assessed 10-year recipient and graft survival, and Cox proportional hazards models, adjusted for key donor and recipient factors, evaluated associations between induction type and outcomes. Rates of delayed graft function, one-year rejection, and estimated glomerular filtration rate were comparable between groups. Ten-year recipient and death-censored graft survival did not differ by induction type (recipient survival: HR 1.09; 95% CI 0.43–2.77; p = 0.85; graft survival: HR 0.85; 95% CI 0.24–2.97; p = 0.79). Recurrent BKVAN-related graft failure occurred only in the depletional group (5 of 217; 2.3%), while rejection-related graft failure was more common in the nondepletional group (5 of 60; 8.3% vs. 6 of 217; 2.8%). Although these differences did not translate into long-term graft survival disparities, they highlight the competing risks of viral recurrence and rejection. Thus, clinicians should interpret these results with caution and weigh the risks and benefits of induction choice in retransplant recipients with prior BKVAN, recognizing that this observational study cannot establish causality.