Introduction: Potent immunosuppression has reduced early rejection but increased risk of opportunistic viral infections, post kidney transplantation. Surveillance practices based on local epidemiology and population specific risk factors can help in detection of subclinical infection or early disease post transplantation, improving patient and graft outcomes. Ours is the first study on the outcomes of viral surveillance among Indian pediatric kidney
transplantation recipients (pKTRs).
Aims: The study CMV, BKV, EBV surveillance, among ≤18-year-old pKTRs who underwent transplantation from January 2019 to June 2024 at our center.
Objectives:
1. To study the incidence and to identify the risk factors for CMV, BKV and EBV infection in pKTRs
3. To analyze the outcome of surveillance on allograft function and patient mortality
Methods: Data of all pKTRs was retrieved from hospital records. Their demographic
parameters, pre transplant immune status, transplantation immunosuppression and post
transplantation chemoprophylaxis and infections were studied.CMV, BKV (Blood and urine), EBV surveillance by molecular DNA-PCR testing was done for all pKTRs at 1,3,6,12 months post transplantation and annually thereafter. Treatment given and outcomes of allograft function (estimated glomerular-filtration-rate using Schwartz’s formula) and patient mortality were analysed.
Results: Of the 110 pKTRs (M:F =2.05, median age 12 years), 14(12.7%) had 16 episodes of
BKV infection, 16(14.5%) had 19 episodes of CMV infection and 2(1.8%) had EBV infection.
BKV infection: Of the 14 asymptomatic children (9 males, median age 12 (IQR 10,14) years),
maximum cases (n=6, 42.8%) were detected at 3-month surveillance. Prior administration of IV
Rituximab (n=7, 50%), history of recurrent UTI or ureteric injury (n=3, 21%) and coinfections
(n=4, 28.5%) were identified. Treatment with immunosuppression reduction was done for all,
IVIg was required in 7(50%), leflunomide was given in 4(28.5%) and 1(7.14%) received
Cidofovir. One (7.14%) child who progressed to BKVAN eventually had graft loss, 12(85.71%)
recovered and 1 is presently on treatment with reducing viral copies.

CMV Infection: Among 16 children (12 males, median age 11 (IQR 9,13) years) with CMV
infection, maximum cases (n=8, 50%) were detected at 6-month surveillance. Three (18.75%)
children were immunologically naïve (CMVIgG negative), 7 (43.75%) had coinfections.
Asymptomatic children (n=14, 87.5%) were treated with oral valganciclovir, IV ganciclovir+IVIg
was given to 2 with CMV disease. All infection episodes recovered. Due to unrelated causes,
there was 1(6.25%) graft loss and 1(6.25%) mortality.

Conclusion: Incidence of opportunistic viral infections, particularly CMV and BKV is highest in
the first-year post transplantation among Indian pKTRs. Post transplantation surveillance helps
in detection of subclinical infection. Treatment of asymptomatic children prevents active or
chronic infection in >85% cases.