BK Viraemia Tacrolimus Reduction — ESENeph MCQ

Correct answer: D — Reduce tacrolimus exposure

After reducing or stopping Mycophenolate, the next step for persistent BK viraemia is Tacrolimus dose reduction targeting lower trough levels (typically 3-5 ng/mL rather than the standard 5-8). The aim is to allow immune reconstitution against BK virus while maintaining enough immunosuppression to prevent rejection. This is a delicate balance. If viraemia persists despite both reductions, switching from Tacrolimus to Sirolimus or Leflunomide has been tried but evidence is limited. The competing options do not fit the renal phenotype, temporal relationship, treatment threshold or safety constraint described. Management still requires confirmation of current medicines, renal trajectory and relevant contraindications, followed by timely biochemical and clinical reassessment. Escalate urgently if life-threatening electrolyte disturbance, respiratory compromise, shock, neurological deterioration or a dialysis indication develops.

Reference: KDIGO 2009 – Transplant Guideline; Hirsch et al 2019 – BK Virus Management: https://kdigo.org/guidelines/transplant-recipient/