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4. A 41-year-old man had a successful second renal transplant 13 months ago, 212 mismatch, no DSA and negative FAXM. His remains stable at 143 µmol/L. He is currently on Tacrolimus (trough 8.8 ng/ml), MMF 750 bd and prednisolone 5 mg od. Routine urine cytology for BK-infected cells demonstrated decoy cells (see below).
- What is a decoy cell?
- What are the sensitivity and specificity of this test?
- What are the positive and negative predictive values of this test?
- Describe this technique.
- Does it correlate well with BK nephropathy?
- What is the difference between decoy cells and CMV inclusion bodies?
- How do you manage this case?
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Decoy cells are epithelial cells containing inclusion bodies which is present in the urine of BK virus infected patients
sensitivity 25%. Spescificity 84%
it can be present in urine of diabetic patients ,and immunocompromised
Work up :Renal function tests , BKV PCR
graft biopsy
decrease immunosuppression
.> Decoy cell: epithelial cell with viral inclusion found in urine with individual having polyoma virus.
> sensitivity : 25% & specificity : 84%.
> PPV : 29%, NPV : 100%
> does not correlate well with BKVN as individuals with diabetes, other immunosuppressed patients, transplant patient with BK viruria without nephropathy or even sometimes healthy persons can sheeds decoy cell in urine.
> decoy cell ( intranuclear inclusion with incomplete halo) & CMV (intranuclear inclusion with complete halo).
> as patient renal function stable, monitor serum & urine PCR for BK virus, if significant viral load present do graft biopsy & treat the patient ( reduce immunosuppression).
What is a decoy cell?
What are the sensitivity and specificity of this test?
What are the positive and negative predictive values of this test?
Describe this technique.
Papanicolaou staining or phase-contrast microscopy.
Does it correlate well with BK nephropathy?
No
What is the difference between decoy cells and CMV inclusion bodies?
Decoy cells- involved epithelial cells
CMV inclusion body- involved epithelial and endothelial cells, and complete halo (owl’s eye appearance
How do you manage this case?
Reference
What is a decoy cell?
They are viral infected renal tubular epithelial cells and urothelial cells that are found in urine cytology…They are classically seen with enlarged nucleus with a single large intra nuclear inclusion body. .Decoy cells are early markers of BK virus reactivation.. They can be confused with malignant cells… decoy cells are one of the early markers of BKV reactivation…
decoy cells can be confused for malignant cells
There are 4 types of decoy cells described in the urine
Type 1: Classical decoy cells – single large homogenous amorphous ground glass like intranuclear inclusion bodies
Type 2 – Granular intranuclear inclusions surround like a halo
Type 3 – multinucleated decoy cells with granular chromatin
type 4 – intranuclear clumped and vesicular chromatin in the nucleus
What are the sensitivity and specificity of this test?
In BKVAN, the sensitivity is 100% and the specificity is 71%…
Positive predictive value is 30% only and the negative predictive value is 100% for BKVAN…
urine cytology smears are prepared from fresh urine samples and fixed in alcohol and stained with papiniculao stain…They are then seen in phase contrast microscopy…more than 3 cells/hpf are significant…
High negative predictive value of 100% implies that the absence of decoy cells rules of BKVN…however the correlation with BK virus is poor in comparison to Plasma PCR or urine PCR testing
Decoy cells are basically renal tubular epithelial cells with intra nuclear viral inclusion which are granular, ground glass in appearance with cytopalsmic degenration….
CMV infection, the intra nuclear inclusions are seen in epithelial and endothelial cells and have a characteristic owl eye appearance with clear halo around them
This patient is a high sensitized patient due to second transplant and has stable graft function…we should check urine BK virus PCR and plasma for BK virus PCR….if there is urine or BK virus PCR we should reduce the immunosuppression…Stop the MMF for time being and continue tacrolimus and steroids…if the urine PCR BK virus shows a 2 log fold reduction we can restart MMF at a lower dose…Another approach is to change Tacrolimus to cyclosporine which has anti viral activity…
·
Human polyoma virus causes renal dysfunction and graft loss as a result of tubulo-interstial nephritis in renal transplant recipients after reactivation of latent virus in renal epithelium.
The infected cells in the urinary sediments are characterized by large homogenous inclusions, which may cause diagnostic error in urine cytology.
The epithelial cells with polyoma viral inclusions in urine cytology specimens are termed Decoy cells to caution pathologists not to misdiagnose these cells as cancer cells.
The report of a case of decoy cells in the urine of a patient with renal transplantation focuses the importance of cytologic analysis of urine as a diagnostic tool for screening renal transplant recipients at risk of risk of polyoma viral infection.
https://pubmed.ncbi.nlm.nih.gov/20551555/
Decoy cells are BK virus infected tubulo-epithelial cells shed in urine characterized by large basophilic intranuclear BK virus inclusion body.
The sensitivity of this test is linked to the period of viruria when detected by cytology their sensitivity is 100% while specificity is doubtful as they could be mistaken for malignant cells.
This test offers a proper screening tool for BK viral infection, however the predictive value is low (29%). So, further evaluation by immunohistochemistry (IHC), electron microscopy or polymerase chain reaction (PCR) may be necessary for confirmation.
This technique relies on cytospin smears being prepared from fresh urine samples, fixed in alcohol and stained with Papanicolaou stain. Then this cytospin smears in presence of BK virus infection demonstrate degenerating epithelial cells, enlarged cells with high nuclear: cytoplasmic ratio showing peripheral clumped chromatin, intranuclear smudgy, ground glass and owl eye-like viral inclusions surrounded by incomplete halo in a clean background.
No, it doesn’t correlate well to BK viral infection as undergoing further tests as PCR serology and renal biopsy with IHC staining as SV40 staining is the gold standard tool to detect viral inclusion for Polyoma viruses.
The difference between decoy cells of BK virus is they have incomplete halo while CMV demonstrate a complete halo on microscopy of urine cytology.
Management of this case by further confirmation as stated before on renal biopsy basis in order to exclude CNI toxicity or rejection episodes occurring concurrently with BK viral infections.
Management options include reduction of immunosuppression, other agents can be tried as IVIG, leflunamide, quinolones, cidofovir yet their effect is still doubtful.
-Decoy cells are urothelial cells containing intra-nuclear basophilic inclusions.
-Presence of Decoy cells is highly suggestive of BKV infection.
-The positive predictive value ranges between 27-90% with very over 90% negative predictive value.
-CMV inclusion bodies are made of CMV DNA.
-Management starts by PCR for BKV + optimization of IS by decreasing the trough FK levels ( 1 year passed post transplant ) , if found +ve for PCR, we should decrease accordingly the antimetabolite ( a level may be useful) to preserve the graft hand in hand eradicating the virus .
● What is a decoy cell?
☆ Decoy cells are infected tubular epithelial cells, with an enlarged nucleus that contains a single, large basophilic intranuclear BK inclusion body and looks
similar to those cells seen frequently in uroepithelial malignancy .
● What are the sensitivity and specificity of this test?
☆ Sensitivity: 25%
☆ Specificity: 85%
● What are the positive and negative predictive values of this test?
This test has low positive predictive values ( 5% ) and high negative predictive values ( 97%) when use decoy cells to screen for PVN in transplant patients.
● Does it correlate well with BK nephropathy?
Presence of decoy cells is strongly suggestive of polyomavirus infection and
considered a useful marker of BKV reactivation, though it is not a real diagnostic tool for BKVN.
● What is the difference between decoy cells and CMV inclusion bodies?
Decoy cells are urothelial and tubular epithelial cells with enlarged nuclei cells containing BKV
But CMV bodies are nucleus and cytoplasmic inclusions resembling owl eyes presented in epithelial and endothelial cells .
● Describe this technique.
Cytological analysis of fresh urinary smear after staining by papanicolaou method.
● How do you manage this case?
A reduction of immunosuppression is the gold standard of treatment BKVN especially anti-metabolite that must reduce by 50 % or withdrawal for a time and if the viral load dosen’t decrease after 2 weeks we must decrease CNi by 25- 50%
☆ Other therapies include quinolones, cidofovir, leflunomide, and (IVIG) may be useful
☆ Steroid pulses combind with RTX for treatment the rejection
☆ Monitoring every 2 weeks by PCR BKV
What is a decoy cell?
· Decoy cells are viral infected renal tubular epithelial cells that are present on cytological examination of urine.
· They have an enlarged nucleus with a single, large basophilic intra-nuclear inclusion body that can be seen on E/M
What are the sensitivity and specificity of this test?
In BKVAN nephropathy, the finding of urinary decoy cells showed a 100% sensitivity, 71% specificity.
What are the positive and negative predictive values of this test?
The positive predictive value was 29% and the negative predictive value was 100% for BKVAN.
Describe this technique.
· Urine cytology smears are prepared from fresh urine samples, then fixed in alcohol and stained with Papanicolaou stain.
· Smears are evaluated for presence of decoy cells (cells with intra-nuclear viral inclusions). Cells >3/HPF are significant
Does it correlate well with BK nephropathy?
· The high NPV (100%) implies that the absence of decoy cells rules out BKVAN. However, its correlation with BKVAN is poor in comparison to plasma PCR which correlate better with BKVAN than urine decoy cells or urine PCR testing
· What is the difference between decoy cells and CMV inclusion bodies?
Decoy cell (BKVAN) involve tubular epithelial cells, and the intra-nuclear viral inclusions are granular, ground-glass in appearance with cytoplasmic degeneration.
· In CMV infection, the intra-nuclear inclusions are seen in epithelial and the endothelial cells, and have characteristic owl-eye appearance with clear halo around them.
· How do you manage this case?
This high immunological risk case has stable graft function, but he has viuria that usually precedes viremia. So, he requires checking of plasma BK virus by PCR If the BK viral load is sustainably > 3 log/ml> 3 weeks, or if >4 log per ml. This indicates BKVAN and requires reduction of immunosuppression in stepwise approach with monitoring in BKV PCR/2 weeks
– 50% reduction in the dose of MMF should be reduced by 50%. If no response
– Reduce the dose of Tacrolimus to a target trough level 4-6 ng/ml. If no response,
– Stop MMF. If no response.
– Shift Tacrolimus to Cyclosporine and keep trough level 50-75 mcg/L) or Sirolimus. The use of adjunctive therapies (IVIG, Cidofovir, Leflunomide, and Quinolones) is controversial. Once BK viremia has been cleared, return to routine maintenance immunosuppression and monitor BKV-PCR
References:
1. Saleh A, El Din Khedr MS, Ezzat A, Takou A, Halawa A. Update on the Management of BK Virus Infection. Exp Clin Transplant. 2020 Nov;18(6):659-670
2. Mallat SG, Tanios BY, Itani HS, Lotfi T, McMullan C, Gabardi S, Akl EA, Azzi JR. CMV and BKPyV Infections in Renal Transplant Recipients Receiving an mTOR Inhibitor-Based Regimen Versus a CNI-Based Regimen: A Systematic Review and Meta-Analysis of Randomized, Controlled Trials. Clin J Am Soc Nephrol. 2017 Aug 7; 12(8):1321-1336.
3. Hirsch HH, Randhawa PS; AST Infectious Diseases Community of Practice. BK polyomavirus in solid organ transplantation-Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant. 2019 Sep; 33(9):e13528.
4. Geetha V, Rao L, Monappa V, Susmitha M, Prabhu R. Decoy cells in urine cytology: A useful clue to post-transplant polyoma virus infection. J Cytol. 2012 Apr; 29(2):133-4.
What is a decoy cell?
Decoy cells are renal tubular epithelial cells that are infected with BK virus and have basophilic intranuclear inclusion ,around which there is a thin rim of chromatin.
What are the sensitivity and specificity of this test?
Sensitivity of urine for decoy cells is 25% and specificity is 84
What are the positive and negative predictive values of this test?
Negative Predictive value is 100% and the positive predictive value is 29%.
Describe this technique.
Fresh sample of urine-preferably second morning sample is taken and immediately transported to the laboratory for analysis. It is prepared via semi-automated Bales method. Sample is centrifuged at 1500vpm and fixation done with equal volume of 50-70% ethyl alcohol (2% polyethylene glycol).Two slides made usually and after drying and fixation , staining done with papaniclaou stain and then visualized under microscope for light microscopy.
.
Does it correlate well with BK nephropathy?
It has poor correlation with BKVN in renal transplant recipients.
What is the difference between decoy cells and CMV inclusion bodies?
Decoy Cell-large nucleus with basophilic intranuclear inclusion ,around which there is thin rim of chromatin
CMV inclusion bodies: a large cell with prominent intranuclear inclusion surrounded by a clear halo, giving the appearance of owl’s eye.
How do you manage this case?
First ,we will get PCR for both CMV and BK virus, then will reduce antimetabolite(MMF) by 50%-monitoring every 2 week with PCR, if no response then will reduce tacrolimus and stop MMF –may start mTORi –close monitoring of graft function needed to early pick rejection. If still no response ,then following drugs can be tried though no strong evidence: Cidofovir,Brincidofovir, Leflunomide Quinolones.
REFERENCES:
1. BKV in Kidney Transplantation By Ahmed Halawa (lecture), consultant Transplant Surgeon Associate Professor, University of Liverpool –UK, 2023.
2. Alalawi F, Alnour H, El Kossi M, Jenkins J, Taku A, Sharma AK, Halawa A. BK virus infection in renal transplant recipients: an overview. J Egypt Soc Nephrol Transplant 2020;20:127-50
Q1: decoy cells are desquamated collecting duct cells followed by cytotoxic changes and tubular destruction having the intranuclear viral inclusions seen on urine cytology.
There are four morphologic types of decoy cell
Q2: decoy cells in the urine have about 100% sensitivity for BK virus infection and about 70% specificity for BK virus.
Q3: positive prediction value (PPV) about 5-20% and negative predictive value 97-100%.
Q4: A papanicolau staining on fresh urine is used.
Q5 : decoy cell shows 100% sensitivity and 100% NPV for BK virus infection but PPV was about 5-20%. Therefore, by finding a decoy cell, an allograft biopsy is needed to confirm the diagnosis.
Q6: the presence of a clear halo around nuclear inclusion along with the identification of concurrent cytoplasmic inclusion is a helpful clue of CMV infection. However, severe cytoplasmic degeneration is characteristic of polyomavirus infection.
Q7: performing diagnostic tests such as Bk viral load in urine and blood, allograft biopsy and SV40staning by IHC are needed treatment consists reduction of immunosuppression drugs.
Reduce 50% MMF and 25%CNI will be useful.
If no response, stop MMF and switch to m TOR inhibitors.
IV IG may be used. Other adjunctive therapy apart from IVIG such as quinolones or cidofovir are not recommended.
Reference:
Boothpur R, Brennan DC. Human polyoma viruses and disease with emphasis on clinical BK and JC. J Clin Virol. 2010 Apr;47(4):306-12. doi: 10.1016/j.jcv.2009.12.006. Epub 2010 Jan 8. PMID: 20060360; PMCID: PMC3774018.
What is a decoy cell?
Decoy cells are renal tubular epithelial cells and other uroepithelial cells that manifest changes associated with viral infection. They appear in the urine presenting as glassy appearing, homogenous intranuclear inclusions.The classical description of the morphology of the DCs, consists in nuclear enlargement, which confers a ground glass appearance and displacement of the nucleus toward the periphery of the cell as if the nucleus were escaping from the cell (comet-like morphology); single nuclear inclusion body surrounded by a peripheral halo, which confer a bird’s eye appearance to the cells.
What are the sensitivity and specificity of this test?
The use of urine cytology to detect the presence of infected decoy cells in the urine has approximately 100% sensitivity for BK virus infection specificity of 71%.it Does not distinguish among polyomaviruses (ie, JCPyV versus BKPyV).
What are the positive and negative predictive values of this test?
It has low positive predictive and high postive predictive value
Technique-
Decoy cells can be seen in a fresh urine sample through Papanicolaou staining or phase contrast microscopy. By Papanicolaou stain, most decoy cells have an enlarged nucleus that bears inclusion which is surrounded by chromatin that confers a ground-glass or gelatinous appearance.
Does it correlate well with BK nephropathy?
Decoy cells alone do not necessarily indicate pathology and they may be found in the urine of healthy individuals. Only in presence of BK virus viruria and viremia it is significant in immunodeficient persons.
What is the difference between decoy cells and CMV inclusion bodies?
Presence of a clear halo around nuclear inclusion along with identification of concurrent cytoplasmic inclusion is a helpful clue to diagnose CMV infection.Bk virus have intranuclear inclusion along with incomplete halo around nuclear inclusion.
How do you manage this case?
Since he has stable graft with decoy cells in Urine,next step is to check for viral PCR for Bk virus.If There is viremia we should decrease MMF dose to 50% and check for Viremia by PCR after 2 weeks.If there is no viremia, I will not reduce dose of immunosuppression and follow this case with viral PCR.
· What is a decoy cell?
Decoy cell is a renal tubular cell that was affected and modified by BKV where its nucleus enlarges with viral inclusion bodies.
· What are the sensitivity and specificity of this test?
Sensitivity 100%, specificity 71%.
· What are the positive and negative predictive values of this test?
PPV 50%, NPV 100%.
· Does it correlate well with BK nephropathy?
Severe infection is associated with high decoy cells in urine, however it is not specific for diagnosis of BKV is more
· What is the difference between decoy cells and CMV inclusion bodies?
Owl’s eye is detected with CMV (halo around the inclusion bodies.
· How do you manage this case?
· Reduction of immunosuppression: stop MMF, aim lower therapeutic trough level of tacrolimus.
·
· No single agent was deemed effective against BKV.
·
CONTINOUS REGULAR FOLLOW-UP of routine bloods and BKV PCR TITER.
What is a decoy cell?
It is a renal tubular cell with nuclear changes due to cytopathic changes of the virus, with a nuclear enlargement (ground glass appearance), chromatin imagination, abnormal chromatin pattern, and viral inclusion bodies.
What are the sensitivity and specificity of this test?
2. Hirsch et al;
3. Viscount et al;
What are the positive and negative predictive values of this test?
2.Viscount et al ;
Describe this technique.
Does it correlate well with BK nephropathy?
What is the difference between decoy cells and CMV inclusion bodies?
How do you manage this case?
References;
Zeljko Vidas 1, Maja Misić, Arijana Pacić, Franjo Jurenec, Mladen Knotek, Ika Kardum-Skelin
2.Comperhensive clinical nephrology
3.Nickeleit V, Singh HK, Gilliland MGF. et al. Latent polyomavirus type BK loads in native kidneys analyzed by Taqman PCR: What can be learned to better understand BK virus nephropathy? J Am Soc Nephrol. 2003;14:42–4A.
4.Chesters PM, Heritage J, McCance DJ. Persistence of DNA sequences of BK virus and JC virus in normal human tissues and in diseased tissues. J Infect Dis. 1983;147(4):676–684. [PubMed]
5.Heritage J, Chesters PM, McCance DJ. The persistence papovavirus BK DNA sequences in normal human renal tissue. J Med Virol. 1981;8:143–150. [PubMed]
decoy cells are uroepithelium cell with large nucleus and inclusion body s/o BKV
very specific for BKV 70-80% with NPP of 100 %
not sensitive , low PPP of 30%
opd based urine cytology can detect it
high decoy cells like 10 /HPF is associated with BKVN
reduction of IS is mainstay
BKV PCR should become nil in the blood at the end
1- Decoy cells are virally infected epithelial cells characterized by ground-glass type intranuclear inclusions that are positive for polyoma virus .DC are better examined n early morning urine sample of kidney recipient.
2- Decoy cells has 25% sensitivity as can be detect in urine of 25%of kidney recipients with stable graft function and has 84 % specificity for BKV infection.
3- Positive predictive value of 29% and negative predictive value of 100% ,so it is a very good negative test to exclude BKV infection .
DC shedding vary over time and if persist positive in consecutive urine samples for 3 consecutive months this is defined as continuous shedding. DC shedding >10 HPF and <10 HPF is defined has high grade and low grade shedding respectively and risk of BKVN is higher among HG shedding patients .
DC is a good negative test for BKVN but not sensitive indicator for active viral replication as false positive results occur in around 25% of patients with stable graft function.
Ref:
Koh MJ, Lim BJ, Noh S, Kim YH, Jeong HJ. Urinary decoy cell grading and its clinical implications. Korean J Pathol. 2012 Jun;46(3):233-6. doi: 10.4132/KoreanJPathol.2012.46.3.233. Epub 2012 Jun 22. PMID: 23110008; PMCID: PMC3479773.
.
These are infected tubular cells that shed into the urine which has enlarged nucleus with a single, large basophilic intranuclear inclusion( >10 decoy cells/ hpf suggests disease)
Sensitivity – 25% and Specificity- 84%
PPV- 29% and NPV- 100%
This test requires a freshly voided specimen that should be centrifuge, fixed with alcohol and stained with the papnicoloau stain.
-The presence of decoy cells in the urine only has a PPV of 29% meaning that it does not correlate well with BKVAN
– Presence of decoy cells precedes viraemia by weeks and nephropathy by months
Decoy cell- These are infected tubular cells that shed into the urine which has enlarged nucleus with a single, large basophilic intranuclear inclusion.
CMV inclusion bodies- These are central large eosinophilic intranuclear inclusion surrounded by a circumferential halo resembling a typical owls eye.
– Monitoring with blood & urine PCR for BK virus
– If viraemia or viruria then renal biopsy to confirm BK viral nephropathy.
– If nephropathy present – Reduction of immunosuppression and adjuvant drug if require.
What is a decoy cell?
Decoy cells are BK virus infected epithelial cells that can be found in the urine.
What are the sensitivity and specificity of this test?
Sensitivity 25%; Specificity 84%
What are the positive and negative predictive values of this test?
PPV 29% and NPV 100%.
Describe technique
Decoy cells can be seen in a urine sample through Papanicolaou staining or phase-contrast microscopy. By Papanicolaou stain, most decoy cells have an enlarged nucleus that bears a basophilic inclusion which is surrounded by chromatin that confers a ground-glass or gelatinous appearance.
Does it correlate well with BK nephropathy?
Presence of decoy cells in urine is suggestive of BK virus infection but not confirmatory, BK PCR and graft biopsy needs to be done for confirmation.
What is the difference between decoy cells and CMV inclusion bodies?
Decoy cells are BK virus infected uroepithelial cells, they have enlarged nuclei with ground glass intranuclear inclusions and condensed chromatic material, with clear cytoplasm
CMV inclusion body
Large ovoid or pleomorphic nucleus with basophilic intranuclear inclusions (Cowdry bodies) surrounded by a clear halo
How do you manage this case?
Detection of decoy cells should be followed by BK virus PCR, if more than 10,000 copies then reduction of immunosuppression, 50% reduction of MMF, Tacrolimus to cyclosporin switch. Monitoring CNI levels, monitoring for rejection.
Decoy cells are uro epithelial cells infected by the virus. They can be detected in urine sediment.
Sensitivity 25%, specificity 84%
Low positive predictive value of 29%
Its absence has a negative predictive value of almost 100%.
Unstained urine sample is obtained and
examined under bright field microscope.
Not very well, as studies showed that the area under the ROC curve of predicting BKPyVAN by decoy cells was 0.531 (0.431–0.630), with an optimal cut-off value of 29 (per 10 high power field), a sensitivity of 45.8% (95% CI: 34.0–58.0%), and a specificity of 68.8% (95% CI: 50.0–83.9%).
Both are virus-infected cells. However, the presence of a clear halo around nuclear inclusion along with the identification of concurrent cytoplasmic inclusion is a helpful tool clue to diagnose CMV infection.
Since this patient’s graft function is stable, this is his second transplant with 212 mismatch and this test is urine decoy cells which has a poor correlation with BKVN, we don’t need to take action except keeping the immunosuppression at the usual target and monitor the patient serum BK PCR and graft function. In this case, the FK level is 8,8, which is above the target, usually 4-6 unless there is a recent rejection, so we need to reduce the dose to keep FK at 4-6. If serum BK PCR is positive then we need to consider reducing MMF by 50% and monitoring the graft function. If there is a rise in creatinine, graft biopsy is the way to go to role out BKVN.
References:
1-Nephrol Dial Transplant (2015) 30: 209–217 BK virus infection: an update on diagnosis and treatment doi: 10.1093/ndt/gfu023 Advance Access publication 25 February 2014
2-Annals of Translational Medicine. Non-invasive urinary sediment double-immunostaining predicts BK polyomavirus associated-nephropathy in kidney transplant recipients Ann Transl Med 2020;8(5):235 | http://dx.doi.org/10.21037/atm.
What is a decoy cell?
What are the sensitivity and specificity of this test?
Sensitivity 25%; Specificity 84%
What are the positive and negative predictive values of this test?
PPV 29% and NPV 100%.
Describe this technique.
Decoy cells can be seen in urine cytology
– fresh urine full void sample (>100ml) centrifuged; cells fixed on slide with alcohol
– stained with H&E or Papanicolaou stain, or phase-contrast microscopy
On Papanicolaou stain – decoy cells have an enlarged nucleus that bears a large basophilic inclusion that confers ground-glass / vesicular / gelatinous appearance, which is surrounded by ring /clumps of chromatin.
Phase-contrast microscopy shows the same abnormalities – enlarged nucleus with a ground-glass or vesicular appearance, altered chromatin, enlarged nucleoli, the presence of a halo, and at times cytoplasmic vacuoles.
Electron microscopy – shows the contrast between the inclusion and the darker chromatin surrounding it. The nuclear inclusion formed by dark, smudged material representing thousands of newly formed virions
Found in urine in about 30-40% of BKV infected patients – especially renal transplant recipients, immunocompromised, pregnancy.
Presence of “decoy cells” in urine cytology are suggestive but not specific, sensitive, or definitive for BKV infection
– Also present in other renal viral infections (CMV or adenovirus)
– poorly correlates with biopsy-proven BKVN in renal transplant recipients
– absence of decoy cells does not exclude BKV infection
Decoy cells
– mostly epithelial cells
– more enlarged nucleus and nucleolus
– Viral inclusion – basophilic ground glass / gelatinous / vesicular
– Chromatin – condensed ring like / clumped, surrounding the basophilic inclusion without halo / incomplete halo
– Owl’s eye appearance may be seen when nucleus is bilobed
– Extensive cytoplasmic degeneration present
CMV inclusion body
– Epithelium, Endothelium or Mononuclear cells
– Owl’s eye appearance
– Complete Halo
– No cytoplasmic degeneration
How do you manage this case?
Detection of decoy cells in urine indicates testing blood PCR for BKV
if PCR is > 10,000 copies /ml – reduction of immunosuppression is warranted
– MMF dose reduction by 50% and later stop (if viremia still continues),
– reducing Tac to minimum dose (trough level 4-5ng/ml)
– 2 weekly plasma BKV PCR testing till it becomes undetectable / below threshold value.
References:
1. Ahmed Saleh, Mohamed Salah E, Ahmed Halawa, et al. Update on the Management of BK Virus Infection. Experimental and Clinical Transplantation (2020) 6: 659-670
2. V Geetha, Lakshmi-Rao, Vidya M. Decoy cells in urine cytology: A useful clue to post-transplant polyoma virus infection. J Cytol. 2012 Apr;29(2):133-4
3. Hirsch H, Knowles W, Dickenmann M, et al. Prospective study of Polyomavirus type BK replication and nephropathy in renal transplant recipients, N Engl J Med, 2002; 347: 488–496
4. wikipedia.org /wiki / Decoy_cells
What is a decoy cell?
Decoy cell is a uroepithelial or tubular epithelial cells that are infected by BK virus and shed in urine with different morphological patterns according to the stage of infection and preservation of the cells architecture.
These are large basophilic intraneuclear inclusions surrounded by cell chromatin .
What are the sensitivity and specificity of urine cytology?
The sensitivity is 25%
The specificity 84%
The limitations of this test is due to observer depending, qualitative test rather than quantitative, and the urine sample must be rich in infected cells and inflammation for better correlation with clinical picture.
What are the negative and positive predictive values of the test?
The positive predictive value is 29%
The negative predictive value is 100%.
Describe the technique:
Always use fresh urine sample
Rapid use and fix if with alcohol.
Decoy cells can also be detected in the unstained urine sediment using phase contrast microscopy.
standard analysis is then done by Papanicolaou stained cytology specimens
Does it correlate well with BK nephropathy?
Because the sensitivity 25% and the PPV is 29% , this test not recommended for screening purposes.
What is the difference between decoy cells and CMV inclusion bodies?
Decoy cells are large basophilic intranuclear inclusion bodies ,while CMV is cytoplasmic esonophilic inclusion bodies with complete halo resembling owl eye appearance.
How do you manage this case?
First do urine and plasma PCR
RFT
Abdomen USS
Pelvic USS
Treatment
RI by decrease the Tac to 25-50%
Stop MMF
Reduce steroid
Consider mTORi
Monitoring of RFT and viral load.
Reference:
Viscount HB, Eid AJ, Espy MJ et al. Polyomavirus polymerase chain reaction as a surrogate marker of polyomavirus associated nephropathy. Transplantation 2007; 84: 340–345.
Decoy cells are virally infected epithelial cells that can be found in the urine. Decoy cells owe their name to their strong resemblance to cancer cells, and may as such confuse the diagnosis of either viral infection or urothelial malignancy
Sensitivity 100% while specificity around 70%,
With PPV OF 29%, and NPV of 100%.
Decoy cells can be seen in a urine sample through Papanicolaou staining or phase-contrast microscopy.
By Papanicolaou stain, most decoy cells have an enlarged nucleus that bears a basophilic inclusion which is surrounded by chromatin that confers a ground-glass or gelatinous appearance. Sometimes the nuclear inclusion has a vesicular aspect, the chromatin may be clumped, and it may be surrounded by a halo. When decoy cells derive from the urothelium, the heavily enlarged and altered nuclei as well as the irregular shape of the cell body can mimic the changes observed in neoplastic cells.
By phase-contrast microscopy, decoy cells show the same abnormalities described for stained specimens, namely, enlargement of the nucleus with a ground-glass or vesicular appearance, altered chromatin, enlarged nucleoli, the presence of a halo, and at times also cytoplasmic vacuoles
Cytological urine abnormalities (decoy cells) are suggestive but not specific, sensitive, or definitive for BKV infection because decoy cells can be present in other renal viral infections (such as CMV or adenovirus42) and decoy cells correlate poorly with biopsy-proven BKVN in renal transplant recipients. Of note, their absence does not exclude the disease ,
Table attached below
Detection of decoy cells will indicate close monitoring of blood PCR for BKV and if PCR is > 10,000 copies /ml reduction of immunosuppression is warranted,
like reduction in (antimetabolites) MMF to 1 gram daily then followed for 2 weeks with PCR testing then second option would be withdrawal of MMF, then followed for every 2 weeks with PCR and subsequently reduction in CNI doses to lower limits .
References :
1)https://en.wikipedia.org/wiki/Decoy_cells#:~:text=Decoy%20cells%20are%20virally%20infected,viral%20infection%20or%20urothelial%20malignancy.
2) Decoy cells in urine cytology: A useful clue to post-transplant polyoma virus infectionV Geetha, Lakshmi Rao, Vidya Monappa, MS Susmitha, and Ravindra Prabhu1
3) Update on the Management of BK Virus Infection Ahmed Saleh,1,4,5 Mohamed Salah El Din Khedr,1 Abeer Ezzat,2 Anna Takou,3 Ahmed Halawa4,5
.
· What is a decoy cell?
· The decoy cells are renal tubular cells with enlarged rounded basophilic nuclei containing inclusion bodies may appear morphologically similar to adenovirus, CMV, and basically infected tubular shaded cells with BKV.
· They shed into urine after reactivation of BKV, and can be detected in early stage of infection.
· What are the sensitivity and specificity of this test?
· Sensitivity 100% while specificity around 70%,
· What are the positive and negative predictive values of this test?
· With PPV OF 29%, and NPV of 100%.
· Describe this technique.
· Slide is prepared from fresh urine sample fixed in alcohol and this is stained with papanicolaou staining.
· Does it correlate well with BK nephropathy?
· Yes, but for definite diagnosis of BKVN tissue sample for histopathology is mandatory. Usually it can help in diagnosis of reactivation of BKVN.
· What is the difference between decoy cells and CMV inclusion bodies?
· The inclusion bodies are virus cells found in nucleus of infected cells with clear halo around nuclear inclusion.
Decoy cells contains basophilic inclusion, ground glass appearance, while
CMV infected cell appear OWEL’s eye with enlarged nuclei, basophilic inclusion bodies with surrounding halo appearance.
· How do you manage this case?
The key treatment of BKV management is immunosuppression modification,
Corticosteroid dose reduction, Tacrolimus dose reduction by 25 to 50%, MMF dose reduction by 50%, however, if no response switch to mTORi.
Other options are IVIG and other drugs like leflonemide, cidofivir,
but no clear evidence and no recommendation in using all these drugs.
Refrences;
1. https://academic.oup.com/ndt/article/30/2/209/2337134.
2. https://europepmc.org/article/med/30896679.
3. uptodate :Prevention and management of BK virus-induced (polyomavirus-induced) nephropathy in kidney transplantation.
4. https://academic.oup.com/ndt/article/30/2/209/2337134.
What is a decoy cell?
Decoy cells are renal tubular cells that have been infected by BK virus and shed into the urine.
They have enlarged nuclei with viral inclusions that look like granules
They are one of the early signs of BK virus reactivation in kidney transplant patients
What are the sensitivity and specificity of this test?
What are the positive and negative predictive values of this test?
Positive predictive value (%) – 29 %
Negative predictive value (%) – 100%
Sensitivity (%) – 25 %
Specificity (%) – 84%
Hirsch HH, Knowles W, Dickenmann M, et al. Prospective study of polyomavirus type BK replication and nephropathy in renal transplant recipients, N Engl J Med, 2002, vol. 347 (pg. 488–496)
Describe this technique.
Basic Procedure for Papanicolaou Staining (Pap stain) on urine cytology
https://microbenotes.com/papanicolaou-staining/
Does it correlate well with BK nephropathy?
In a comparison of urine cytology with urine PCR, decoy cells had a sensitivity of only 25% and a specificity of 84% for BKVN compared with urine PCR which was 100% sensitive and 78% specific
Viscount HB, Eid AJ, Espy MJ, et al. Polyomavirus polymerase chain reaction as a surrogate marker of polyomavirus associated nephropathy, Transplantation, 2007, vol. 84 (pg. 340–345)
What is the difference between decoy cells and CMV inclusion bodies?
Geetha V, Rao L, Monappa V, Susmitha M, Prabhu R. Decoy cells in urine cytology: A useful clue to post-transplant polyoma virus infection. J Cytol. 2012 Apr;29(2):133-4. doi: 10.4103/0970-9371.97157. PMID: 22787295; PMCID: PMC3391795.
How do you manage this case?
Poloni, J.A., Pinto, G.G., Giordani, M.S., Keitel, E., Inocente, N., Voegeli, C.F., Fogazzi, G.B., Pasqualotto, A.C. and Rotta, L.N., 2016. Bright field microscopy to detect decoy cells due to BK virus infection in the fresh and unstained urine sediment in kidney allograft recipients. Journal of Clinical Laboratory Analysis, 30(6), pp.1044-1050.
Hirsch HH, Randhawa PS, AST Infectious Diseases Community of Practice. BK polyomavirus in solid organ transplantation—Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clinical transplantation. 2019 Sep;33(9):e13528.
decoy cells:
BK virus infected tubular epithelial cells that have been shed into the urine.
Rounded basophilic nuclei larger than the average transitional and tubular epithelial
cells
nuclei have viral inclusions appearing as dense granular basophilia and no halo
Dirty background: transitional, tubular and inflammatory cells and clumps of
amorphous basophilic material .
Graded as rare, up to 4 per cytospin and > 10 per cytospin; when rare cells are
present with lack of inflammation, chances of positive infection in biopsy.
Sensitivity 100 percent specificity 70 percent ,low PPV, high NPV.
Low PPV 29 ,high NPV 100 .
While viruria is a sensitive marker for progression to BKPyV-associated nephropathy ,it is nonspecific .
Shedding of BKPyV in the urine (as detected by highly sensitive polymerase chain
reaction [PCR] methods) is common among otherwise healthy older adult patients,
pregnant women, and others with suppressed cellular immunity and is generally without
clinical consequence .
Urine decoy cells do not have a significantly greater prognostic value for progression to
viremia than detection of viruria by more sensitive methods such as PCR.
What is the difference between decoy cells and CMV inclusion bodies?
Decoy cells are intranuclear where as CMV are both intra and extranuclear inclusion
bodies.
Reference :
Deirdre Sawinski , Simon Goral. virus infection: an update on diagnosis and treatment.
Nephrol Dial Transplant. 2015 Feb;30(2):209-17.
1- Decoy cells are degenerated epithelial cells, enlarged with high nuclear: cytoplasmic ratio shows peripheral clumped chromatin, intranuclear smudgy, groundglass and owl eye-like viral inclusions surrounded by incomplete halo in a clean background, may be mistaken as malignant cells.
Four morphological types of “Decoy cells” have been described in literature:
Type 1- classic decoy cells characterized by large, homogenous, amorphous ground-glass like intranuclear inclusion bodies and a condensed rim of chromatin
Type 2- granular intranuclear inclusions surrounded by a clear halo, i.e., cytomegalovirus (CMV)-like
Type 3- multinucleated decoy cells with granular chromatin
Type 4- vesicular nuclei with clumped chromatin and nucleoli. These inclusions may appear morphologically similar to CMV and adenoviral inclusions. However, trivial morphologic differences do exist which lend a hand to tell them apart.
It is sheded infected urothelial cells due to reactivation of BK virus, can be detected in early stage in urine sample without stain just by bright field microscopy (BFM), it is simple, available and cheap test.
Its presence in the urine is enough to diagnose BKV reactivation, but BKVN should be diagnosed by graft biopsy.
2- It is 100% sensitivity, 84% specificity.
3- 100% negative predictive value and 6% positive predictive value
4- Cytospin smears were prepared from fresh urine samples, fixed in alcohol and stained with Papanicolaou stain.
5- It is not diagnostic for BKVN, it can diagnose BKV reactivation, and graft biopsy is mandatory for diagnosis of BKVN
6- CMV inclusions are found in non-epithelial cells and, less commonly, in epithelial cells. An enlarged cell with a big, reddish-purple intranuclear inclusion surrounded by a clear halo and peripherally clumped chromatin is characteristic for CMV infection, inclusion bodies are made up of virus antigens that are found at the site where the synthesis of the virus takes place, it is generally acidophilic but it is intranuclear basophilic in case of CMV, it can also be present as crystalline aggregates of virions, and it represents degenerative changes that are produced by a viral infection.
7- Management of the case:
a- Do BK PCR
b- Do graft biopsy
c- If diagnosed too early, RIS will not induce graft rejection.
d- RIS reduce MMF by 50% , tacrolimus dose should be decreased to 25-50% of tacrolimus trough level.
References:
1- Zeljko Vidas 1, Maja Misić, Arijana Pacić, Franjo Jurenec, Mladen Knotek, Ika Kardum-Skelin. The value of urinary decoy cells finding in patients with kidney transplantation.
Coll Antropol. 2010 Mar;34(1):153-7.
2- Konietzny, R., Fischer, R., Ternette, N. et al. Detection of BK virus in urine from renal transplant subjects by mass spectrometry. Clin Proteom 9, 4 (2012). 3- Poloni JA, Pinto GG, Giordani MS, Keitel E, Inocente N, Voegeli CF, Fogazzi GB, Pasqualotto AC, Rotta LN. Bright Field Microscopy to Detect Decoy Cells Due to BK Virus Infection in the Fresh and Unstained Urine Sediment in Kidney Allograft Recipients. J Clin Lab Anal. 2016 Nov; 30 (6):1044-1050. 4- V Geetha, Lakshmi Rao, Vidya Monappa, MS Susmitha, Ravindra Prabhu. Decoy cells in urine cytology: A useful clue to post-transplant polyoma virus infection. J Cytol. 2012 Apr-Jun; 29(2): 133–134.
Decoy cells are uro epithelial cells infected by the virus. They can be detected in urine sediment.
Sensitivity 25%, specificity 84%
Low positive predictive value of 29%
Its absence has a negative predictive value of almost 100%.
Unstained urine sample is obtained and
examined under bright field microscope.
Not very well, as studies showed that the area under the ROC curve of predicting BKPyVAN by decoy cells was 0.531 (0.431–0.630), with an optimal cut-off value of 29 (per 10 high power field), a sensitivity of 45.8% (95% CI: 34.0–58.0%), and a specificity of 68.8% (95% CI: 50.0–83.9%).
Both are virus-infected cells. However, the presence of a clear halo around nuclear inclusion along with the identification of concurrent cytoplasmic inclusion is a helpful tool clue to diagnose CMV infection.
Since this patient’s graft function is stable, this is his second transplant with 212 mismatch and this test is urine decoy cells which has a poor correlation with BKVN, we don’t need to take action except keeping the immunosuppression at the usual target and monitor the patient serum BK PCR and graft function. In this case, the FK level is 8,8, which is above the target, usually 4-6 unless there is a recent rejection, so we need to reduce the dose to keep FK at 4-6. If serum BK PCR is positive then we need to consider reducing MMF by 50% and monitoring the graft function. If there is a rise in creatinine, graft biopsy is the way to go to role out BKVN.
References:
1-Nephrol Dial Transplant (2015) 30: 209–217 BK virus infection: an update on diagnosis and treatment doi: 10.1093/ndt/gfu023 Advance Access publication 25 February 2014
2-Annals of Translational Medicine. Non-invasive urinary sediment double-immunostaining predicts BK polyomavirus associated-nephropathy in kidney transplant recipients Ann Transl Med 2020;8(5):235 | http://dx.doi.org/10.21037/atm.
· What is a decoy cell?
Decoy cells are desquamated apoptotic cells with intranuclear viral inclusions, which are clearly visible in urine cytology. One of the signs of tubular damage.1
· What are the sensitivity and specificity of this test?
In BK nephropathy, the finding of urinary decoy cells showed 100% sensitivity and 84% specificity.2
· What are the positive and negative predictive values of this test?
100% negative predictive value and 6% positive predictive value.2
· Describe this technique.
Cytocentrifuged (cytospin) smears prepared from fresh urine samples, fixed in alcohol, and stained with Papanicolaou stain.
· Does it correlate well with BK nephropathy?
Sensitive for BK virus infection but not specific for BKVN.
· What is the difference between decoy cells and CMV inclusion bodies?
The expanded nucleus of Decoy cells has a basophilic inclusion that is encircled by chromatin, giving it a ground-glass or gelatinous appearance.3
Owl’s eye: Enlarged visceral epithelial cells, marked increase in the size of the cell (cytomegaly), enlarged nuclei, intranuclear glassy-appearing basophilic inclusions with surrounding halo (owl’s eye–) appearance.4
· How do you manage this case?
While maintaining the same dosages of calcineurin inhibitor and/or prednisone, cut the antimetabolite dose in half. Every 2 weeks in the interim, it is essential to check serum creatinine and serial plasma BK PCR values from the same lab (to lower inter-assay variability). Complete anti-metabolite cessation should be implemented if virus loads stay the same or rise. If viral loads do not decrease over the course of 4 weeks despite the discontinuation of anti-metabolite (4-6 ng/mL for tacrolimus and 50-100 ng/L for cyclosporine), the next step is to lower calcineurin-inhibitor trough objectives.5Other adjunctive therapies
· IVIG.
· Quinolones.
· Cidofovir.
· Leflunomide.
References:
Drachenberg CB, Beskow CO, Cangro CB, Bourquin PM, Simsir A, Fink J, et al. Human polyomavirus in renal allograft biopsies: Morphological findings and correlation with urine cytology. Hum Pathol. 1999;30:970–7.Z. Vidas, M. Misić, et al 2010, The Value of Urinary Decoy Cells Finding in Patients with Kidney Transplantation. Coll. Antropol. 34 (2010) 1: 153–157.Singh, Harsharan K.; Bubendorf, Lukas; Mihatsch, Michael J.; Drachenberg, Cinthia; Nickeleit, Volker (2000). “Urine Cytology Findings of Polyomavirus Infections”. Madame Curie Bioscience Database. Austin: Landes Bioscience.Fogo, Agnes B.; Lusco, Mark A.; Najafian, Behzad; Alpers, Charles E. (2016). AJKD Atlas of Renal Pathology: Cytomegalovirus Infection. American Journal of Kidney Diseases, 68(6), e35–e36. doi:10.1053/j.ajkd.2016.10.008.Kant, S.; Dasgupta, A.; Bagnasco, S.; Brennan, D.C. BK Virus Nephropathy in Kidney Transplantation: A State-of-the-Art Review. Viruses 2022, 14, 1616.
☆ What is a decoy cell?
▪︎Decoy cells are virally infected epithelial cells that can be found in the urine. Decoy cells owe their name to their strong resemblance to cancer cells, and may as such confuse the diagnosis of either viral infection or urothelial malignancy.
▪︎Urine cytology samples when stained using the Papanicolaou method and examined for the presence of urine decoy cells will show a (characteristic cell with a ground-glass appearance and an enlarged nucleus, occupied by a basophilic inclusion surrounded by chromatin) [1].
☆ What are the sensitivity and specificity of this test?
▪︎There are many studies which had determined the sensitivity and specificity of this test. One study shows sensitivity and specificity of decoy cells for diagnosing BKN of 99% and 95%, respectively. Another study shows that: in BK nephropathy, the finding of urinary decoy cells showed a 100% sensitivity, 84% specificity.
☆ What are the positive and negative predictive values of this test?
▪︎Urine cytology is inexpensive and displays a high negative predictive value, but polyomavirus shedding in urine is very common and occurs in 20% to 45% of renal transplant recipients.
▪︎Another study shows that the positive predictive value varies between 27% and more than 90%, and the negative predictive value is 99% [2].
▪︎The predictive characteristics of urinary decoy cell shedding are limited, and distinguishing between the BK and JCV cannot be made based on urine cytology [3] ▪︎The positive predictive value can be further increased to over 90% by taking additional parameters into consideration: (a) a “dirty” cytological background, (b) decoy cell shedding in the setting of allograft dysfunction, (c) extended and persistent decoy cell shedding over more than 6 weeks, and (d) the detection of decoy cell casts.The latter finding is A combination of significant viremia and viruria leads to a diagnosis of presumptive BKVN.
☆ Does it correlate well with BK nephropathy?
▪︎In histologically confirmed cases of BKN, the number of decoy cells correlates with the number of inclusion bearing renal tubular epithelial cells. Urine cytology is an effective screening method for monitoring renal transplant patients, with high sensitivity and a high negative predictive value, and can therefore be used routinely in the follow-up of renal transplant patients.
☆ Describe this technique
▪︎Decoy cells can best be identified and quantified in standard alcohol fixed and Papanicolaou stained urine cytology specimens from either smeared or cytocentrifuged (i.e., cytospin) urine samples.
▪︎By Papanicolaou stain, most decoy cells have an enlarged nucleus that bears a basophilic inclusion which is surrounded by chromatin that confers a ground-glass or gelatinous appearance.
☆ What is the difference between decoy cells and CMV inclusion bodies?
▪︎ Decoy cells: are characterized by large, homogenous, amorphous ground-glass like intranuclear inclusion bodies and a condensed rim of chromatin.
CMV inclusion bodies: are characterized by the presence of a clear complete halo around the nuclear inclusion with identification of cytoplasmic inclusion i.e., typical owl’s eye appearance
☆How do you manage this case ?
– In this case scenario it is important to request plasma BK virus – PCR to confirm the diagnosis of BKVAN.
– Reduce the dose of immunosuppression while we are monitoring the plasma BKV viral load and the serum creatinine levels every 2 weeks.
– Reduce of MMF therapy with monitoring of the viral load in 2 weeks, if still high, then stop the MMF completely and reduce the tacrolimus dose.
___________________________________________
References
[1] Sung Hak Lee∙Youn Jun Park1 Chul Woo Yang2 ∙Yong So.Comparison of Detecting Methods of BK Virus Infection in Patients with Renal Allograft Recipients. The Korean Journal of Pathology 2010; 44: 636-41 DOI: [2] Nickeleit V, Singh HK, Mihatsch MJ. Polyomavirus nephropathy: Morphology, pathophysiology, and clinical management. Curr Opin Nephrol Hypertens. 2003;12:599–605.
[3] Randhawa P, Vats A, Shapiro R. Monitoring for polyomavirus BK and JC in urine: comparison of quantitative polymerase chain reac- tion with urine cytology. Transplantation 2005; 79
What is a decoy cell?
These are tubular epithelial or urothelial cells with ground-glass nuclear inclusions surrounded by a condensed rim of chromatin. They can have “owl eye” inclusion.
What are the sensitivity and specificity of this test?
Does it correlate well with BK nephropathy?
They have poor correlation with BKVAN and they do not necessarily indicate BKVAN.
The absence of decoy cells in urine cytology screens have high negative predictive values for BKVAN.
What is the difference between decoy cells and CMV inclusion bodies?
How do you manage this case?
As his renal Function is stable we need to monitor Plasma BK PCR viral load, if it is persistently high > 4 log10 copies per ml or worsening renal function then he may require confirmation of diagnosis with graft kidney biopsy and reduction in immunosuppression.
What is a decoy cell?
These renal tubular and urothelial cells with intranuclear inclusions. It is indicative of infected urinary cells with BKV
What are the sensitivity and specificity of this test?
Sensitivity- 25%
Specificity- 85%
What are the positive and negative predictive values of this test?
Positive predictive value- 30%
Negative predictive value- 95%
Describe this technique.
These are seen in fresh urine sample and fixation is done with alcohol. Phase contrast microscopy required.
Does it correlate well with BK nephropathy?
It is non specific test but half of such patients may progress to viremia.
What is the difference between decoy cells and CMV inclusion bodies?
Decoy Cells
These renal tubular and urothelial cells with single large basophilic intranuclear inclusion.
CMV Inclusion Bodies
Cytoplasmic basophilic inclusion bodies with complete halo around in epithelial and edothelial cells – Owl eye apppearance.
How do you manage this case?
Patient requires monitoring with BKV PCR. Immune suppression should be reduced if >10000 copies / ml are detected on PCR. Reduce MMF to 1 gm daily and then monitor. MMF can also be withdrawn and follow up PCR 2 weekly.
Tacrlimus can be reduced to achieve TAC levels of 4-6 ng/ml.
Starting leflunamide has no proven efficacy.
Immune suppression can be started again once BK viremia has been cleared wiith close monitoring.
· Geetha V, Rao L, Monappa V, Susmitha M, Prabhu R. Decoy cells in urine cytology: A useful clue to post-transplant polyoma virus infection. J Cytol. 2012 Apr;29(2):133-4.
· Sharma R, Zachariah M. BK Virus Nephropathy: Prevalence, Impact and Management Strategies. Int J Nephrol Renovasc Dis. 2020 Aug 7;13:187-192.
Whatis decoy cells?
2.
3. Descriptionof technique:
4. Dose it correlate with BKVN?
5.what is the difference between decoy cells and CMV viral inclusion bodies?
6. Mangement of this patient?
References:
1. Comprehensive clinical Nephrology ( Fourth edition 2010
2. V Geetha,etal. Decoy cells in Urine Cytology.Journal of Cytology /Indian Academy of Cytologist 2012,29(2) ,133-134.
3. Sam Kant, etal. BK Virus Nephropathy in Kidney Transplantion: A state of the Art Review, Viruses 2020, 14,1616
What is a decoy cell?
Decoy cells are renal tubular cells with nuclear changes due to the viral cytopathic effect. There is nuclear enlargement (“ground glass appearance”), chromatin margination, abnormal chromatin patterns, and viral inclusion bodies of various sizes and shapes with or without a perinuclear halo
Decoy cell is an early indicator of BKV reactivation that can be detected in the urine sediment.
Different morphologic variants of decoy cells (types 1 through 4) are detected depending upon the state of viral replication and maturation as well as the state of cellular preservation.
What are the sensitivity and specificity of this test?
The use of urine cytology to detect the presence of infected decoy cells in the urine has approximately 100% sensitivity for BK virus infection and 66% specificity.
What are the positive and negative predictive values of this test?
The detection of decoy cells at 6 months or more on urine cytology had high predictive value for BK virus nephropathy in kidney transplant recipients.
11 % positive predictive value, and 100 %negative predictive value for BK virus nephropathy
Describe this technique.
The cells can be seen by phase contrast microscopy in unstained samples and in the fresh and unstained urine sediment by Bright field microscopy even though they are usually detected by cytocentrifuged smears with the Papanicolaou stain
Ancillary techniques (immunohistochemistry, electron microscopy (EM), and fluorescence-in-situ-hybridization (FISH)) for proper identification and characterization are used
Does it correlate well with BK nephropathy?
Yamada et al study demonstrated that there was positive correlation between the decoy cell count and the data from urine BKV-DNA PCR quantification. Measurement of decoy cells may predict the early detection of BK viruria as the decoy cells count increase after the appearance of the decoy cells tended to increase in all of the patients with BK viremia and tended to decrease in cases whom predicted not to progress to BK viremia.
Measurement of decoy cells in urine sediment is economic, easy, and quick, so it is a useful test for the screening and continuous monitoring of BKV infection
What is the difference between decoy cells and CMV inclusion bodies?
Sometimes, decoy cells reveal granular intranuclear inclusions surrounded by a clear halo, i.e., cytomegalovirus (CMV)-like (type 2)
These inclusions may appear morphologically similar to CMV and adenoviral inclusions. However, trivial morphologic differences exist including
· viral inclusions in endothelial cellsand mononuclear cells for CMV which is not present with BKV
· ground glass inclusion and cytoplasmic degeneration is more in BKV
· Owl’s eye inclusion has incomplete halo in BKV and complete halo for CMV
· The cytoplasmic inclusion is in CMV and absent in BKV
How do you manage this case?
His creatinine is stationary on TAC ,MMF ,prednisolone
Routine urine cytology for BK-infected cells demonstrated decoy cells
Analysis of BKV DNA in serum should be considered
Tacrolimus dose can be decreased by 25–50%.
MMF dose lowered by 50%
And the dose of glucocorticoids can be reduced.
BKV DNA levels usually decrease slowly, and viral levels can be tested with 2–4-week intervals.
If BKV DNA in
plasma did not decrease , tacrolimus or MMF dose can be reduced even more, with the possible complete discontinuation of mycophenolate mofetil and glucocorticoid treatment. mTOR-inhibitor can be introduced instead of MMF because it is associated with lower rates of BKV.
Antiviral use can be tried particularly if immunosuppression reduction did not work meanwhile there is no strong evidence for antiviral treatment of BKV
Reduction of immunosuppression increase graft rejection risk necessitating a close follow-up of renal function and drug levels monitoring.
A renal biopsy should be considered if the serum-creatinine level goes up during the adjustment of the patient’s immunosuppression.
Reference
-Poloni JA, Pinto GG, Giordani MS, Keitel E, Inocente N, Voegeli CF, Fogazzi GB, Pasqualotto AC, Rotta LN. Bright Field Microscopy to Detect Decoy Cells Due to BK Virus Infection in the Fresh and Unstained Urine Sediment in Kidney Allograft Recipients. J Clin Lab Anal. 2016 Nov;30(6):1044-1050.
-Giovanni B. Fogazzi. Urinalysis .Comprehensive Clinical Nephrology (Fourth Edition)
2010, CHAPTER 4 – Pages 39-55
– Jay A. Fishman, Infection in Kidney Transplant Recipients ,in Kidney Transplantation–Principles and Practice (Seventh Edition), 2014
– Sekito T et al .Presence of decoy cells for 6 months on urine cytology efficiently predicts BK virus nephropathy in renal transplant recipients. International Journal of Urology 2021. Volume28, Issue12 ,Pages 1240-1246
-Yamada, Yoshiteru PhD1; Tsuchiya, Tomohiro MD, PhD1; Inagaki, Isao2; Seishima, Mitsuru MD, PhD2; Deguchi, Takashi MD, PhD1. Prediction of Early BK Virus Infection in Kidney Transplant Recipients by the Number of Cells With Intranuclear Inclusion Bodies (Decoy Cells). Transplantation Direct 4(2):p e340, February 2018.
-Singh HK, Bubendorf L, Mihatsch MJ, et al. Urine Cytology Findings of Polyomavirus Infections. In: Madame Curie Bioscience Database [Internet]. Austin (TX): Landes Bioscience; 2000-2013.
– Geetha V, Rao L, Monappa V, Susmitha M, Prabhu R. Decoy cells in urine cytology: A useful clue to post-transplant polyoma virus infection. J Cytol. 2012;29(2):133-134. doi:10.4103/0970-9371.97157
– Tina Dalianis, Britt-Marie Eriksson, Marie Felldin, Vanda Friman, Anna-Lena Hammarin, Maria Herthelius, Per Ljungman, Johan Mölne, Lars Wennberg & Lisa Swartling (2019) Management of BK-virus infection – Swedish recommendations, Infectious Diseases, 51:7, 479-484
What is a decoy cell?
Decoy cells are the characteristic BK virus-infected cells. These are tubular epithelial or urothelial cells with ground-glass nuclear inclusions surrounded by a condensed rim of chromatin, may exhibit “owl eye” inclusions, multi- nucleation, or clumped chromatin.
What are the sensitivity and specificity of this test?
The sensitivity and specificity of decoy cells for diagnosing BKN is 99% and 95%, respectively(1).
What are the positive and negative predictive values of this test?
The positive predictive value varies between 27% and more than 90%, and the negative predictive value is 99%(1).
Describe this technique.
Papanicolaou stained urine cytology: Papanicolaou stain is a multichromatic (multicolored) cytological staining technique developed by George Papanicolaou in 1942.
Pap staining is used to differentiate cells in smear preparations (in which samples are spread or smeared onto a glass microscope slide) from various bodily secretions and needle biopsies.
Does it correlate well with BK nephropathy?
Although decoy cells are a marker of PV replication, they do not necessarily indicate PVN. Some studies have shown high false-positive rates and low positive predictive values when attempting to use the presence of decoy cells to screen for PVN in transplant patients(2).
What is the difference between decoy cells and CMV inclusion bodies?
A. Four morphological types of “Decoy cells” have been described in literature(3):
1) Type 1: classic decoy cells characterized by large, homogenous, amorphous ground- glass like intranuclear inclusion bodies and a condensed rim of chromatin;
2) Type 2: granular intranuclear inclusions surrounded by a clear halo, i.e., cytomegalovirus (CMV)-like;
3) Type 3: multinucleated decoy cells with granular chromatin;
4) Type 4: vesicular nuclei with clumped chromatin and nucleoli. These inclusions may appear morphologically similar to CMV and adenoviral inclusions. However, trivial morphologic differences do exist which lend a hand to tell them apart.
B. CMV inclusion bodies: presence of a clear halo around nuclear inclusion along with identification of concurrent cytoplasmic inclusion is a helpful clue to diagnose CMV infection.
How do you manage this case?
Although decoy cells carry high false-positive rate, it may be a warning sign to BKVN as the presence of sustained viruria may progress to viremia which is a better predictor of progression to BKVAN.
1. It is crucial to repeat urine cytology to rule out sustained viruria and to perform BKV PCR for further establishment of the diagnosis while attempting the initial therapeutic steps in the management of BKV infection.
2. Reduction of immunosuppression.
a) I will reduce the dose of antimetabolite(MMF) by half while continuing on the same doses of calcineurin inhibitor and/or prednisone.
b) If viral loads continue to be at similar levels or increase, proceed with complete cessation of anti-metabolite(MMF).
c) The next step is to reduce calcineurin-inhibitor trough goals if viral loads do not reduce over 4 weeks despite cessation of anti-metabolite (4–6 ng/mL for tacrolimus).
References
1. NIH; National Library of Medicine Urine Cytology Findings of Polyomavirus Infections Harsharan K. Singh, Lukas Bubendorf, Michael J. Mihatsch, Cinthia Drachenberg, and Volker Nickeleit
2. Kant S, Dasgupta A, Bagnasco S, Brennan DC. BK Virus Nephropathy in Kidney Transplantation: A State-of-the-Art Review. Viruses. 2022 Jul 25;14(8):1616. doi: 10.3390/v14081616. PMID: 35893681; PMCID: PMC9330039.
3. Colvin RB, Nickeleit V. Renal transplant pathology in: Jennet JC, Olson JL, Schwartz, Silva FG. Heptinstall’s Pathology of the kidney. 6th ed. Philadelphia: William and Wilkins; 2007. p. 1441-8.
👉 Decoy cells are polyoma virus infected tubular epithelial cells (which resemble the urothelial atypia ) and has large basophilic inclusion bodies surrounded by condensed chromatin.
👉Sensitivity is 100 % and specificity is 84%.
👉 NPV is 100% while PPV is 6%.
This means that presence of decoy cells means presence of Polyoma virus viuria but not correlated with BK nephropathy.
👉 The technique involves examination of fresh urine sample, alcohol ficlxation then examination by high power field microscopy .
👉 Presence of decoy cells indicates infection but not nephropathy. Poor correlation with biopsy proven BKN.
⭐ decoy cells of Polyoma virus reprents epithelial cells (urothelial cells )with large inclusion body surrounded by condensed chromatin., While CMV inclusion bodies have large inclusion bodies surrounded by clear halo giving owl eye appearance.
👉 management of the case:
_ confirmation of presence of viremia by blood PCR if count more than 10000 copies/ml it is considered as presumed BKN.
_ confirmation of diagnosis needs allograft biopsy and also it is beneficial to diagnose concomitant rejection.
_IHC staining using SV 40 helps in diagnosis of BKN.
_ presence of postive viremia more than 10000 copies/ml or persistent postive more than 1000 copies/ml for more than 3 weeks is an indication for preemptive reduction of immunosupression to prevent the progression to BKN with eventual graft dysfunction and graft loss, even in the absence of pathological criteria in the biopsy (presumed BKN).
_Reduction of IS as reduction of MMf dose by 50% or even stop it .
Reduction of CNI dose therafter if no decrease in viral load.
–shift from MMF to mTOR and shift from tacrolimus to cyclosporin may be beneficial.
What is a decoy cell?
Decoy cells are epithelial
cells with polyoma viral inclusions in urine cytology specimen
The infected cells in urinary sediments characterized by
enlarged nucleus, basophilic intranuclear homogenous inclusions, and ground
glass chromatin.
these are shed as viral particles and infected cells into the urine.
Types of decoy cells
I Most common
type, classic decoy cells showing large, amorphous ground glass like
intranuclear viral inclusion bodies and a condensed rim of chromatin. May have
“comet tail” cytoplasm.
II “Cytomegalovirus (CMV)” like cells with granular central intra-nuclear inclusion bodies
surrounded by irregular and incomplete clear halo. May have “comet tail” cytoplasm.
III Cells with granular chromatin, multinucleated and no halo. Misinterpreted as “cancer cells.”
IV Vesicular nuclei with a distinct network of often coarsely granular and clumped
chromatin; Nucleoli can be seen. Misinterpreted as “cancer cells.”
What are the sensitivity and specificity of this test?
Studies showed difference in sensitivity and specificity of this test.
Singh et al had conducted a prospective study of 194
patients and had sensitivity of 100%, specificity of 19%, PPV of 54%, and NPV
of 100%.
What are the positive and negative predictive values of this test?
Geramizadeh et al had observed that despite a low positive
predictive value (PPV), Decoy cell absence has a negative predictive value
(NPV) 99 to 100%.
Describe this technique.
Decoy cells can best be identified and quantified in Papanicolaou
(Pap) stained direct smears or cyto-centrifuged urine samples.
The second morning midstream voided urine specimen is best
suited as cellular degeneration interferes with proper interpretation of the
first morning specimen.
An alternative and more
frequently used method is the fixation of the urine with an equal volume of 50%
to 70% ethyl alcohol, preferably with added 2% carbowax (polyethylene
glycol).18 The urine samples can be classified semiquantitatively as:
1 to 4 infected cells per cytospin—1+
5 to 10 infected cells per cytospin—2+
≥11 infected cells per cytospin (minority)—3+
Too many infected cells to count (majority)—4+
Decoy cells should not be mistaken for malignant cells. The former are medium-sized basophilic cells with comet tail cytoplasm and nuclei with ground glass chromatin, while the later have unevenly distributed
hyperchromatic chromatin with irregular nuclear membrane and little cytoplasm.
Does it correlate well with BK nephropathy?
Mere presence of decoy cells in urine does not mean the
patient has BKV nephropathy but only means that there is reactivation
What is the difference between decoy cells and CMV inclusion bodies?
Differentials of decoy cells can be CMV inclusions,
mimicking type II decoy cells, with a complete perinuclear halo in former.
Adeno virus also has ground glass nuclear appearance of epithelial cells, but
background is usually necrotic with many inflammatory cells.
How do you manage this case?
The patient has stable kidney function with positive decoy
cells in urine.
Analysis of BKV DNA in serum/plasma should a be considered.
He needs reduction of immunosuppression to a target level of
4-6 ng/ml
With close monitoring of graft function if deterioration occurs
biopsy should be done to confirm diagnosis and differentiat it from rejection
Reference
Santosh Tummidi.Diagnostic utility of urine cytology in
detection of decoy cells in renal transplant patients: Report of five cases and
review of literature.Diagnostic CytopathologyVolume 48, Issue 3 p. 222-227.2019
Decoy cells:
– Decoy cells are desquamated tubular epithelial cells or uroepithelial cells with intranuclear viral inclusions.
– they are present in urine as glassy homogenous intranuclear inclusions in association with polyoma interstitial nephritis; early marker of BKV reactivation.
– they are confused for malignant cells.
– They have 4 morphological types:
-Type 1 – classic i.e., large, homogenous, amorphous ground-glass intranuclear inclusion bodies with a condensed rim of chromatin.
-Type 2- granular intranuclear inclusions surrounded by a clear halo ;CMV similar.
-Type 3 – multinucleated decoy cells with granular chromatin
-Type 4 – vesicular nuclei with clumped chromatin and nucleoli
Sensitivity and specificity
Decoy cell positivity has a sensitivity and specificity for BKVAN of 100% and 66% respectively.
Positive and negative predictive value
Decoy cell positivity has positive & negative predictive value for BKVAN of 11% and 100% respectively.
Technique
Using early morning fresh and unstained urine sample/ sediment is detected under bright field microscopy ;BFM.
– Decoy cells can also be counted on standard Papanicolaou-stained slides using cytospin .
– Decoy cells can be identified in urine sediment with phase contrast microscopy .
Correlation with BK nephropathy
– Decoy cells may be detected accurately under unstained bright field microscopy and this correlates with the amount of viruria as detected by BKV quantitative PCR
– Decoy cells are not totally sensitive or specific for BKV infection
– Plasma BKV PCR is correlated better with BKVAN than urine decoy cells and urine BKV PCR test
– Biopsy remains the gold standard for diagnosis of BKVAN
Difference between decoy cells and CMV inclusion bodies:
– CMV inclusion bodies are characterized by the presence of a clear complete halo around the nuclear inclusion with identification of cytoplasmic inclusion i.e., typical owl’s eye appearance while decoy cells are desquamated renal tubular epithelial cells or uroepithelial cells with intranuclear ground glass viral inclusions, incomplete halo, a comet-like cytoplasm ;associated with severe cytoplasmic degeneration
Management
– Plasma BKV PCR to help in diagnosis of BKVAN; if the BKV viral is >3 log 10/ml persistently for more than 3 weeks of if it is >4 log 10/ml (10,000 copies) a diagnosis of BKVAN can be entertained.
– Reduction of immunosuppression as we monitor the plasma BKV viral load and the serum creatinine levels every two weeks to determine response to treatment
– Reduction of MMF by 50% with monitoring the BKV viral load in 2 weeks, if still high, stopping the MMF completely and reduction of CNI dose by 50% aiming a tacrolimus trough level of 4-6ng/mL
– In case of acute rejection, then antirejection therapy have priority then it is followed by immunosuppression reduction usually after 2 weeks
Well done
What is a decoy cell?
Decoy cells is desquamated tubular epithelial cells, degenerative epithelial cells with high nuclear: cytoplasmic ratio showing peripheral clumped chromatin, intranuclear smudgy, ground glass, and owl eye-like viral inclusions surrounded by an incomplete halo in a clean background [ (1) , its considered one of the early markers for the BKV reactivation and urine cytology to assess for decoy cells.
Viruria is one of the earliest manifestations of BKV as reported in about 50% of the cases after kidney transplantation the main route of infection is through latent reactivation of infection or new infection from the donor-positive source about 50% of patients it no more recommended to do urine viral load despite its high sensitivity and BKV viremia and viral load is more predictive for development of BKVAN.
Screening for BKV infection
Only sustained viruria can develop viremia in 2-6 weeks duration. (2), with a similar percentage of viremic patients developing BKVAN in the above-mentioned time period [18–22]. This
correlates with the clinical observation that urine BK viral loads >8 log10 c/mL predict the the onset of viremia, while plasma BK viral loads >4 log10 c/mL are associated with higher
rates of biopsy-proven BKVAN and loads peaking above 6 log10 c/mL are even predictive of extensive BKVN pathology measured by SV40 immunohistochemistry and associated
inflammatory infiltrates (2)
What are the sensitivity and specificity of this test?
constant BK viruria showed a sensitivity of 100% and specificity of 94% for BK viremia and was associated with a significantly higher level of BK load than the patients with transient viruria (P<0.01).
.
What are the positive and negative predictive values of this test?
The positive predictive value, negative predictive value, specificity, and accuracy of BFM were 80%, 75%, 97%, and 75%, respectively. Test sensitivity was 16%. The comparative method was the qPCR (4).
Many studies have confirmed a correlation between higher viral load in plasma and disease, with a positive predictive value ranging from 60% to 85%.
Describe this technique.
fresh and unspotted urine sediment under bright field microscopy (BFM), in concomitance to the determination of the amount of BK viruria by qPCR. Papanicolaou‐stained slides
Does it correlate well with BK nephropathy? No, Urinary shedding of the virus has been detected in 0.5%–20% of the asymptomatic population, the decoy cells early markers of reactivation but alone is no more used in clinical practice due to lack of specificity while quantitative BKV PCR in plasma (rapid, sensitive, and non-invasive for the diagnosis of polyomavirus BK and tissue biopsies is more specific for the diagnosis of BKV nephropathy.
What is the difference between decoy cells and CMV inclusion bodies?
Decoy cells referred to desquamated epithelial cells with no endothelial cell involvement, with incomplete hallo inclusion while the CMV inclusion bodies have a complete halo(owl eyes) and basophilic cytoplasm and involve both epithelial, endothelial, and mononuclear cells.
How do you manage this case?
To date there is no specific antiviral drug is existing and the management of BKVAN is just based on the reduction of the immunosuppressive drugs, antimetabolites reduction by 50% or even stopped in case of stable graft function, and no previous history of graft rejection with close monitoring every two weeks with q BKV PCR, graft function, tacrolimus trough level target 4-6ng and observe for any proteinuria.
Rule out co-infection with another virus like CMV, or rejection and treat accordingly.
References
1. Geetha V, Rao L, Monappa V, Susmitha M, Prabhu R. Decoy cells in urine cytology: A useful clue to post-transplant polyoma virus infection. J Cytol. 2012 Apr;29(2):133-4. doi: 10.4103/0970-9371.97157. PMID: 22787295; PMCID: PMC3391795.
2.. BK Virus Nephropathy in Kidney Transplantation: A State-of-the-Art RevieSam Kant 1,2,* Alana Dasgupta 3, Serena Bagnasco 3 and Daniel C. Brennan 1
3. Dziubianau M, Bethke N, Meisel C, Grütz G, Reinke P. Sustained BK viruria as an early marker for the development of BKV-associated nephropathy: analysis of 4128 urine and serum samples. Transplantation. 2009 Jul 15;88(1):89-95.
4. Poloni JA, Pinto GG, Giordani MS, Keitel E, Inocente N, Voegeli CF, Fogazzi GB, Pasqualotto AC, Rotta LN. Bright Field Microscopy to Detect Decoy Cells Due to BK Virus Infection in the Fresh and Unstained Urine Sediment in Kidney Allograft Recipients. J Clin Lab Anal. 2016 Nov;30(6):1044-1050. doi: 10.1002/jcla.21978. Epub 2016 Apr 28. PMID: 27122351; PMCID: PMC6807007.
5. Pakfetrat M, Yaghobi R, Salmanpoor Z, Roozbeh J, Torabinezhad S, Kadkhodaei S. Frequency of Polyomavirus BK Infection in Kidney Transplant Patients Suspected to Nephropathy. Int J Organ Transplant Med. 2015;6(2):77-84. PMID: 26082831; PMCID: PMC4464281.
What is a decoy cell?
“Decoy cells” have been described in literature:
1- Type 1- classic decoy cells characterized by large, homogenous, amorphous ground-glass like intranuclear inclusion bodies and a condensed rim of chromatin.
2- Type 2- granular intranuclear inclusions surrounded by a clear halo, i.e., cytomegalovirus (CMV)-like .
3- Type 3- multinucleated decoy cells with granular chromatin.
4-Type 4- vesicular nuclei with clumped chromatin and nucleoli.
What are the sensitivity and specificity of this test?
Decoy cells has 100% sensitivity and has 84 % specificity for BKV infection
What are the positive and negative predictive values of this test?
Geramizadeh et al., observed that despite a low positive predictive (29%) value of decoy cells in urine, its absence has a negative predictive value of 100%, as almost all patients who did not have decoy cells had normal renal function.
Describe this technique.
Cytology is the examination of cells from the body under a microscope. In a urine cytology exam, a doctor looks at cells collected from a urine specimen after centrifugation . The urine smears must be fixed in alcohol and stained with Papanicolaou stain .
Does it correlate well with BK nephropathy?
decoy cells correlate poorly with biopsy-proven BKVN in renal transplant
recipients.
What is the difference between decoy cells and CMV inclusion bodies?
Presence of a clear halo around nuclear inclusion along with identification of concurrent cytoplasmic inclusion is a helpful clue to diagnose CMV infection.
.
How do you manage this case?
The presence of decoy cells along with normal creatinine levels indicate no need for further treatment . While presence of decoy cell in patient with abnormal serum creatinine indicate further evaluation and reduction of immunosuppression .
Reference ;
1-Geramizadeh B, Roozbeh J, Hosseini M, Salahi H. Urine cytology: useful screening method for polyoma virus nephropathy in renal transplant patients. IJMS. 2006;31:109–11. [PubMed] [Google Scholar].
2-https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3391795/ Decoy cells in urine cytology: A useful clue to post-transplant polyoma virus infection
1-What is a decoy cell?
-A “decoy cell” with an enlarged nucleus and clumped chromatin, mimicking high-grade urothelial atypia.
-Tubular epithelial or urothelial cells with ground-glass nuclear inclusions surrounded by a condensed rim of chromatin.
-Enlarged nucleus with a single , large basophilic intranuclear inclusion.
2-What are the sensitivity and specificity of this test?
-Earlier report showed;
Sensitivity 100% / Specificity 71%
-Recent reported for BKVN;
Sensitivity of only 25% / Specificity of 84% .
3-What are the positive and negative predictive values of this test?
–NPV (100%)
–PPV (29%)
4-Describe this technique.
–Cytospin smear is prepared from a fresh urine sample, fixed in alcohol & stained with Papanicolaou stain or contrast phase microscopy.
-Most ‘decoy cells’ show a much enlarged nucleus and can be easily identified by phase‐contrast microscopy.
5-Does it correlate well with BK nephropathy?
–Presence of Decoy cells in urine is highly suggestive of BKVN.
–But not sensitive, specific or definitive for BKV infection due to; it may be present in other renal viral infections e.g.CMV, adenovirus , correlate poorly with biopsy-proven BKVN , their absence does not exclude the disease.
–It is not recommended for screening purposes Based on Sensitivity 25% and PPV of 29%.
–The test is nonspecific for BK nephropathy but 50% may progress to increase in viremia within weeks to months.
-It is pertinent to mention that PCR level of > 10,000 copies/ml has a positive predictive value for progression to nephropathy of 40-60% within 2-4 weeks.
6-What is the difference between decoy cells and CMV inclusion bodies?
–Decoy cells; represent renal tubular or uroepithelial cells (only in epithelial, sparing endothelial cells) with enlarged nucleus, containing single large basophilic intranucelar viral inclusions, forming incomplete hallo, mimicking high-grade urothelial atypia.
–CMV inclusion bodies; there are cytoplasmic basophilic inclusions bodies with complete halo around (Owl eye appearance) in epithelial and endothelial cells.
7-How do you manage this case?
-Presence of Decoy cells in urine is highly suggestive of BKVN.
-But detecting Decoy cells in the urine is not enough to diagnose BKAN.
-However, patient needs to be closely monitored especially when considered as high risk as in current case ( 2nd Kidney Tx and HLA mismatch).
-Closely monitor PCR every 2 -4 weeks since half of the cases may progress to viremia.
-If levels >1000 copies/mL are considered positive in most assays, and levels >10,000 copies/mL correlate with biopsy-confirmed BKPyVAN.
-Biopsy can be considered if there is evidence of graft dysfunction.
-For patients with viremia (eg, viral loads >1000 copies/mL) and normal allograft function, we typically reduce immunosuppression and monitor the viral load every 2-4 weeks thereafter to ensure that it is downtrending.
-In the current case;
-I will reduce MMF to 500 mg bid, and decrease to 250 mg bid or stop it after 2 weeks if BKV PCR not decreased.
-I will adjust tacrolimus dose to attain a trough between 4-6 ng/ml.
-Continue the same dose of steroid 5mg od,
-Blood BKV PCR, until the viral level is undetectable.
-References;
-Nankivell, B.J.; Renthawa, J.; Jeoffreys, N.; Kable, K.; O’Connell, P.J.; Chapman, J.R.; Wong, G.; Sharma, R.N. Clinical Utility of Urinary Cytology to Detect BK Viral Nephropathy. Transplantation 2015, 99, 1715–1722.
-Nickeleit, V.; Hirsch, H.H.; Binet, I.F.; Gudat, F.; Prince, O.; Dalquen, P.; Thiel, G.; Mihatsch, M.J. Polyomavirus infection of renal allograft recipients: From latent infection to manifest disease. J. Am. Soc. Nephrol. 1999, 10, 1080–1089.
-Singh, H.K.; Andreoni, K.A.; Madden, V.; True, K.; Detwiler, R.; Weck, K.; Nickeleit, V. Presence of Urinary Haufen Accurately Predicts Polyomavirus Nephropathy. J. Am. Soc. Nephrol. 2009, 20, 416–427.
-Singh, H.K.; Reisner, H.; Derebail, V.K.; Kozlowski, T.; Nickeleit, V. Polyomavirus Nephropathy. Transplantation 2015, 99, 609–615.
-Randhawa, P.S.; Vats, A.; Zygmunt, D.; Swalsky, P.; Scantlebury, V.; Shapiro, R.; Finkelstein, S. Quantitation of viral DNA in renal allograft tissue from patients with BK virus nephropathy. Transplantation 2002, 74, 485–488.
Why not discontinue MMF for some time rather than waiting for effect of reduction in MMF ?
4. A 41-year-old man had a successful second renal transplant 13 months ago, 212 mismatch, no DSA and negative FAXM. His remains stable at 143 µmol/L. He is currently on Tacrolimus (trough 8.8 ng/ml), MMF 750 bd and prednisolone 5 mg od. Routine urine cytology for BK-infected cells demonstrated decoy cells.
What is a decoy cell? (1, 2)
– decoy cells are desquamated renal tubular epithelial cells or other uroepithelial cells with intranuclear viral inclusions
– they appear in urine as glassy appearing homogenous intranuclear inclusions
– they are easily seen on urine cytology in association with polyoma interstitial nephritis
– decoy cells are one of the early markers of BKV reactivation
– decoy cells can be confused for malignant cells
– 4 morphological types of decoy cells have been described: –
What are the sensitivity and specificity of this test? (3)
Decoy cell positivity has a sensitivity and specificity for BKVAN (BK virus associated nephropathy) of 100% and 66% respectively.
What are the positive and negative predictive values of this test? (3)
Decoy cell positivity has a positive and negative predictive value for BKVAN of 11% and 100% respectively.
Describe this technique (2)
– presence of decoy cells in the early morning fresh and unstained urine sample/ sediment is detected under bright field microscopy (BFM)
– BFM of unstained urine sediment is an available, cheap and fast method which can be used to identify decoy cells among kidney transplant recipients
– decoy cells can also be easily identified and counted on standard Papanicolaou-stained slides using cytospin although there are variations to this method
– decoy cells can be identified in the urine sediment using phase contrast microscopy (4)
Does it correlate well with BK nephropathy? (2)
– with experienced hands, decoy cells may be detected quite accurately under unstained bright field microscopy (BFM) and this correlates well with the amount of viruria as detected by BKV quantitative PCR
– decoy cells are not entirely sensitive or specific for BKV infection
– plasma BKV PCR correlates better with BKVAN than urine decoy cells or urine BKV PCR test
– kidney biopsy remains the gold standard for diagnosis of BKVAN
What is the difference between decoy cells and CMV inclusion bodies? (1)
– CMV inclusion bodies are characterized by the presence of a clear complete halo around the nuclear inclusion along with identification of concurrent cytoplasmic inclusion i.e., typical owl’s eye appearance whereas
– decoy cells are desquamated renal tubular epithelial cells or other uroepithelial cells with intranuclear ground glass viral inclusions, incomplete halo, a comet-like cytoplasm and are associated with severe cytoplasmic degeneration
How do you manage this case? (5-7)
– current issues: –
– usually, viruria precedes viremia which also precedes BKVAN
– the patient requires plasma BKV PCR to assist in making a presumptive diagnosis of BKVAN
– if the BKV viral is >3 log 10/ml persistently for more than 3 weeks of if it is >4 log 10/ml (10,000 copies) a presumptive diagnosis of BKVAN can be made
– the mainstay of treatment in BKVAN is reduction of immunosuppression as we monitor the plasma BKV viral load and the serum creatinine levels every two weeks to determine response to treatment
– we should reduce the immunosuppressive therapy with an aim of restoring the immunity without triggering rejection i.e., reduce MMF by 50% then monitor the BKV viral load in 2 weeks, if still high, withdraw the MMF completely and reduce CNI dose by 50% targeting a tacrolimus trough level of 4-6ng/mL
– another option would be switching from tacrolimus to cyclosporine or mTORi
– if there is evidence of acute rejection during the course of this treatment, then antirejection therapy takes priority after which it is followed by immunosuppression reduction as a second step – usually after 2 weeks
– several adjunctive therapies (leflunomide, cidofovir, fluoroquinolones) have been shown to have in vitro activity against BKV activity but the efficacy of these agents has not been established neither have they been shown to be superior to immunosuppression reduction (8)
References
1. Colvin R, Nickeleit V. Heptinstall’s Pathology of the Kidney. Jennette, JC. 2007:1347-490.
2. Poloni JA, Pinto GG, Giordani MS, Keitel E, Inocente N, Voegeli CF, et al. Bright Field Microscopy to Detect Decoy Cells Due to BK Virus Infection in the Fresh and Unstained Urine Sediment in Kidney Allograft Recipients. Journal of clinical laboratory analysis. 2016 Nov;30(6):1044-50. PubMed PMID: 27122351. Pubmed Central PMCID: PMC6807007. Epub 2016/10/30. eng.
3. Sekito T, Araki M, Yoshinaga K, Maruyama Y, Sadahira T, Nishimura S, et al. Presence of decoy cells for 6 months on urine cytology efficiently predicts BK virus nephropathy in renal transplant recipients. International journal of urology : official journal of the Japanese Urological Association. 2021 Dec;28(12):1240-6. PubMed PMID: 34467590. Epub 2021/09/02. eng.
4. Fogazzi GB, Cantú M, Saglimbeni L. ‘Decoy cells’ in the urine due to polyomavirus BK infection: easily seen by phase-contrast microscopy. Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association – European Renal Association. 2001 Jul;16(7):1496-8. PubMed PMID: 11427650. Epub 2001/06/28. eng.
5. Hirsch HH, Randhawa PS. BK polyomavirus in solid organ transplantation-Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clinical transplantation. 2019 Sep;33(9):e13528. PubMed PMID: 30859620. Epub 2019/03/13. eng.
6. Sawinski D, Trofe-Clark J. BK Virus Nephropathy. Clinical journal of the American Society of Nephrology : CJASN. 2018 Dec 7;13(12):1893-6. PubMed PMID: 30242026. Pubmed Central PMCID: PMC6302319. Epub 2018/09/23. eng.
7. Mallat SG, Tanios BY, Itani HS, Lotfi T, McMullan C, Gabardi S, et al. CMV and BKPyV Infections in Renal Transplant Recipients Receiving an mTOR Inhibitor-Based Regimen Versus a CNI-Based Regimen: A Systematic Review and Meta-Analysis of Randomized, Controlled Trials. Clinical journal of the American Society of Nephrology : CJASN. 2017 Aug 7;12(8):1321-36. PubMed PMID: 28576905. Pubmed Central PMCID: PMC5544521. Epub 2017/06/04. eng.
8. Johnston O, Jaswal D, Gill JS, Doucette S, Fergusson DA, Knoll GA. Treatment of polyomavirus infection in kidney transplant recipients: a systematic review. Transplantation. 2010 May 15;89(9):1057-70. PubMed PMID: 20090569. Epub 2010/01/22. eng.
I appreciate that your reply is well structured and well-referenced. I agree that a reduction of immunosuppression is the key. One may have to discontinue MMF for some time
Well noted Prof. Thank you.
Decoy cells are BK virus infected epithelial cells shed in the urine. The most characteristic abnormality of the infected cells is an enlarged nucleus with a single, large basophilic intranuclear inclusion owes their name to their strong resemblance to cancer cells .
There are different studies showed different sensitivities and specificities as well as different negative and positive predictive values .
Urine decoy cells had 25% sensitivity, 84% specificity,(1). In another study the finding of urinary decoy cells showed a 100% sensitivity, 84% specificity, (2) . Other similar studies reported a sensitivity of 41.9-84.6%, specificity of 65.8-100% and accuracy of 69.9-82%.(3)
Urine decoy cell has 5% positive predictive value, and 97% negative predictive value for the diagnosis of concurrent PVAN , in another study positive and negative predictive values are 85%, and 83%,respectively (4)
Macroscopically urine samples were evaluated for the volume, color and appearance , after that The samples were centrifuged , and the supernatant was removed. Two microscopic slides were prepared for each urine sample and stained with Papanicolaou and Hematoxylin and Eosin stains . Finally, the slides were screened by a cytotechnologist and double checked by a cytopathologist. Actually, the reporting terminology in the cytology. laboratory for positive cases of polyomaviruses were: adequate, negative for malignant cells and presence of decoy cells.(3) .decoy cells can also be detected in the unstained urinary sediment by phase contrast microscopy.
. Presence of decoy cells indicates reactivation and shedding of BK virus but cant confirm BKVN ,on the other hand decoy cells can be present in other viral infections like CMV , JC polyomaviruses, and in malignancy. The gold standard test for BKVN is renal biopsy.
Classic decoy cells characterized by large, homogenous, amorphous ground-glass like intranuclear inclusion bodies and a condensed rim of chromatin; known as type 1 .Other morphological types are :Type 2- granular intranuclear inclusions surrounded by a clear halo, i.e., cytomegalovirus (CMV)-like; Type 3- multinucleated decoy cells with granular chromatin; Type 4- vesicular nuclei with clumped chromatin and nucleoli. These inclusions may appear morphologically similar to CMV and adenovirus inclusions.(5)
The CMV causes very characteristic changes which can be readily recognized in the urinary sediment. The principal abnormality is large, usually basophilic inclusion, surrounded by a large clear zone. There is typical distinct outer belt of condensed chromatin. As these inclusions are very similar to an eye of a bird, they bear the name owl’s or bird’s eye.
This patient has stable graft function discovered to have decoy cells in urine so the main intervention now is to optimize the dose of proraf to the recommended target level (5-6 ng/ml ) since he is 13 month post transplant .
-The duration from viruria to viremia is one to three months, and from viremia to PVAN is one to twelve weeks. Plasma-PCR is superior to urine-PCR or urine cytology in specificity and positive predictive value for detection of BKVAN. If viral is load >4 log copies/ml we should proceed to kidney biopsy, if viral load is found <4 log copies/ml the patient should be monitored with serial plasma PCR.
-If the patient proved to have BKVN the mainstay of treatment is reduction of immunosuppression by decreasing CNI (25%-50%,) and reduction of anti metabolite by 50% or even stopping . The use of antiviral treatment is center dependent but as general there is no strong evidence beyond its use.
Reference :
1. Transplantation 2007 Aug 15;84(3):340-5. doi: 10.1097/01.tp.0000275205.41078.51
2. Xing J, Procop GW, Reynolds JP, Chiesa-vottero A, Zhang Y. Diagnostic utility of urine cytology in early detection of polyomavirus in transplant patients. J Am Soc Cytopathol. 2017;6:28–32. [PubMed] [Google Scholar]
3. J Cytol. 2020 Jan-Mar; 37(1): 30–33. Published online 2019 Dec 23. doi: 10.4103/JOC.JOC_167_18
4. J Am Soc Cytopathol. 2017 Jan-Feb;6(1):28-32. doi: 10.1016/j.jasc .2016.08.004. Epub 2016 Aug 20.
5.J Cytol. 2012 Apr-Jun; 29(2): 133–134. doi: 10.4103/0970-9371.97157
I like that you would consider optimising immunosuppression in such a patient even if the renal function is stable
Thank you prof. Ajay Sharma
1- Decoy cells: viral infected cells present on cytological examination of urine
characterized by an enlarged nucleus with a single, large basophilic intranuclear inclusion body.
called decoy because it is similar to renal carcinoma cells.
2- Decoy cells has 100% sensitivity and has 84 % specificity for BKV infection.
3- Positive predictive value of 29% and negative predictive value of 100% for BKV
infection.
“Therefore a useful screening tool but cannot establish a firm diagnosis”
4- Technique:
5- presence of decoy cells in urine alone is poorly correlated with BKVN.
presence of decoy cells together with viral PCR in patients with ipaired kidney function can diagnose BKVN in presence of normal biopsy.
6- Differences between decoy cells of CMV and BKV:
7- Mangement:
Reference:
Geetha V, Rao L, Monappa V, Susmitha M, Prabhu R. Decoy cells in urine cytology: A useful clue to post-transplant polyoma virus infection. J Cytol. 2012 Apr;29(2):133-4
I like your clinical approach. Would you consider reduction in immunosuppression in such a patient even if the renal function is stable?
Decoy cells are tubular cells of the kidney that are desquamated after injury. In other words, they are renal tubular cells with nuclear changes due to viral infection (Epithelial cells w. intranuclear viral inclusion). They have 4 types described in the literature. In the picture attached, we can see the differences in decoy cell patterns.
Type 1- classic decoy cells ( large, homogenous, amorphous ground-glass-like intranuclear inclusion bodies and a condensed rim of chromatin)
Type 2- granular intranuclear inclusions surrounded by a clear halo (CMV)-like
Type 3- multinucleated decoy cells with granular chromatin
Type 4- vesicular nuclei with clumped chromatin and nucleoli.
(Geetha V, Rao L, Monappa V, Susmitha M, Prabhu R. Decoy cells in urine cytology: A useful clue to post-transplant polyoma virus infection. J Cytol. 2012;29(2):133-134. doi:10.4103/0970-9371.97157)
It has a low positive predictive value as low as 29% (Infection in Kidney Transplant Recipients Jay A. Fishman, in Kidney Transplantation–Principles and Practice (Seventh Edition), 2014). Its sensitivity is around %100.
Best evaluated in second midstream urine samples. can be done by staing of direct saple or pinned urine like PAP smear. (Tummidi, S., Kothari, K., Agnihotri, M., Naik, L., & Rojekar, A. (2019). Diagnostic utility of urine cytology in detection of decoy cells in renal transplant patients: Report of five cases and review of literature. Diagnostic Cytopathology, 48(3), 222–227. doi:10.1002/dc.24337).
In Tummidi et al paper it was ascerteined that more>10/cytospin decoy cells correlate with BK nephropathy and renal function deterioration.
In CMV infections it is mostlylike owel’s eye with complete halo.
You can not depend upon Decoy cells alone
The gold standard is plasma PCR
What is a decoy cell?
Decoy cell is renal tubular epithelial cell. Their nucleus gets modified due to cytopathic effect of virus. The nucleus gets enlarged showing ground glass appearence. It also has viral inclusion bodies and viruses can be seen on electron microscopy.
What are the sensitivity and specificity of this test?
Sensitivity – 100%
Specificity 71%
What are the positive and negative predictive values of this test?
PPV – 50%
NPV – 100%
Describe this technique.
Cyto-centifuged urine smears are prepared from fresh urine samples, then fixed in alcohol and stained with Papanicolaou stain
Does it correlate well with BK nephropathy?
Presence of decoy cells in urine is sufficient to diagnose reactivation of BK virus infection. Generally, higher is the number of decoy cells in urine, more severe is the infection
What is the difference between decoy cells and CMV inclusion bodies?
In decoy cells Severe cytoplasmic degeneration characteristic whereas presence of a clear halo (owl’s eye) around nuclear inclusion along with identification of concurrent cytoplasmic inclusion is a helpful clue to diagnose CMV infection.
How do you manage this case?
Every patient with presence of urine decoy cells does not indicate clinically significant infection. Patients can still be asymptomatic. But concomitant presence of BK viremia poses high risk of BKVN and requires immediate reduction of immunosuppression.
Rising creatinine indicates progressed BKVN or BKVN+acute rejection. Requires urgent biopsy to stage the disease and plan the therapy.
Urine decoy cells + normal kidney function+ no BK viremia: Does that warrant kidney biopsy? I could no find good literature.
REF:
Well done
What is a decoy cell?
-Decoy cells are renal tubular epithelial cells and other uroepithelial cells that manifest changes associated with viral infection. They appear in the urine presenting as glassy appearing, homogenous intranuclear inclusions.
What are the sensitivity and specificity of this test? What are the positive and negative predictive values of this test?
In BK nephropathy, the finding of urinary decoy cells showed a 100% sensitivity, 84% specificity, 100% negative predictive value and 6% positive predictive value.(1)
Describe this technique.
-Decoy cells can be seen by phase contrast microscopy in unstained samples ,even though they are usually identified by cytocentrifuged smears with the Papanicolaou stain.
Does it correlate well with BK nephropathy?
The use of urine cytology to detect the presence of infected decoy cells in the urine has approximately 100% sensitivity for BK virus infection but a low predictive value. It is therefore a useful screening tool but cannot establish a firm diagnosis.(2) Their absence does not exclude
the disease.
What is the difference between decoy cells and CMV inclusion bodies?
In CMV, The involvement of endothelial cells is characterized by a central large eosinophilic intranuclear inclusions surrounded by a circumferential halo resembling a typical owl’s eye. When endothelial cells are predominantly CMV-infected cells, tubular epithelium tends to be spared. while Decoy cells are renal tubular epithelial cells and other uroepithelial cells that manifest changes associated with viral infection.
How do you manage this case?
-management of BK virus replication involves reduction of immunosuppression with close monitoring for rejection. Recommended protocols include either 50% reduction or cessation of mycophenolate mofetil, followed by dose reduction of CNI if this change is not effective.
References:
1- Zeljko Vidas et al. The value of urinary decoy cells finding in patients with kidney transplantation. Coll Antropol . 2010 Mar;34(1):153-7.
2-Giovanni B. Fogazzi, in Comprehensive Clinical Nephrology (Fourth Edition), 2010.
3.Večerić-Haler Željka and Kojc Nika. Viral Infections after Kidney Transplantation: CMV and BK. May 1st, 2019.DOI: 10.5772/intechopen.86043
How do you follow up the progression of your treatment plan.
-follow up of viral load
A decoy cell is degenerating tubular epithelial cell infected by virus, which is enlarged in size, with high nuclear: cytoplasmic ratio. The cells show peripherally clumped chromatin, and intranuclear smudgy, ground-glass, viral inclusions surrounded by incomplete halo in a clean background (1,2).
The decoy cell shedding has been shown to be 25% sensitive with 84% specificity for BKV associated nephropathy although another study showed a sensitivity of 100% with specificity of 71% (3,4).
The decoy cell has a positive predictive value of 29% and a negative predictive value of 100% for BKV associated nephropathy (2).
Urinary cytologic smears are evaluated for presence of decoy cells (cells with intranuclear viral inclusions) after staining by the Papanicolaou method (5). Cells >3/ high power field are taken as significant.
A high negative predictive value (100%) implies that the absence of decoy cells rules out BK virus associated nephropathy. Studies have shown conflicting values with respect to sensitivity and specificity of urine decoy cells (3,4). Urine BK virus PCR testing is more specific and sensitive than urine decoy cell for BK virus associated nephropathy (3). Plasma BK virus PCR values correlate better with BK virus associated nephropathy than urine decoy cells or urine PCR testing (2).
Decoy cell seen with BK virus associated nephropathy involve tubular epithelial cells, and the intranuclear viral inclusions seen are irregular, granular, ground-glass in appearance, with cytoplasmic degeneration. In cytomegalovirus (CMV) infection, the intranuclear inclusions are seen in epithelial as well as endothelial cells, and have typical ‘owl eye’ appearance with clear halo around them (1).
The index patient is a 41-year-old male, 2nd renal transplant recipient (13 months ago), presenting with detection of multiple urinary decoy cells on routine screening. He is a high immunological risk patient (2nd transplant, 212 mismatch). His current immunosuppression is tacrolimus, MMF and steroids. His graft function is stable.
As viruria precedes viremia by approximately 2-6 weeks, the patient requires additional laboratory testing in form of plasma BK virus PCR quantitative testing (6).
If the BK viral load is > 3 log per ml sustained for > 3 weeks, or if >4 log per ml, then the presumptive diagnosis is BK virus associated nephropathy. As the graft function is normal, kidney biopsy is not required. The treatment is in form of reduction in immunosuppression and continuous monitoring of BKV plasma PCR, as well the graft function (7). The stepwise approach includes:
1) The dose of anti-metabolite (MMF) should be reduced by 50%. Monitor plasma BKV PCR every 2 weeks. If no reduction, then step 2.
2) The dose of calcineurin inhibitor (Tacrolimus) should be reduced to attain target trough level 4-66 ng/ml. Monitor plasma BKV PCR every 2 weeks. If no reduction, then step 3.
3) Stop anti-metabolite (MMF). Monitor plasma BKV PCR every 2 weeks. If no reduction, then step 4.
4) Shift from Tacrolimus to Cyclosporine (trough level 50-75 microg/l) or Sirolimus (6). A trend towards decreased incidence of BK virus associated nephropathy is seen in patients on mTOR inhibitors (8).
5) Use of adjunctive therapies (IVIG, Cidofovir, Leflunomide, Fluoroquinolones) can be considered in case of sustained BK viremia despite immunosuppression reduction (6). But the evidence regarding role of antivirals is weak (9).
Return to routine maintenance immunosuppression should be considered (to prevent rejection) once BK viremia has been cleared with careful and close monitoring of BK virus PCR levels. If acute rejection takes place while reducing immunosuppression, it should be treated as per standard protocols (4).
References:
1) Geetha V, Rao L, Monappa V, Susmitha M, Prabhu R. Decoy cells in urine cytology: A useful clue to post-transplant polyoma virus infection. J Cytol. 2012 Apr;29(2):133-4. doi: 10.4103/0970-9371.97157. PMID: 22787295; PMCID: PMC3391795.
2) Sawinski D, Goral S. BK virus infection: an update on diagnosis and treatment. Nephrol Dial Transplant. 2015 Feb;30(2):209-17. doi: 10.1093/ndt/gfu023. Epub 2014 Feb 25. PMID: 24574543.
3) Viscount HB, Eid AJ, Espy MJ, Griffin MD, Thomsen KM, Harmsen WS, Razonable RR, Smith TF. Polyomavirus polymerase chain reaction as a surrogate marker of polyomavirus-associated nephropathy. Transplantation. 2007 Aug 15;84(3):340-5. doi: 10.1097/01.tp.0000275205.41078.51. PMID: 17700158.
4) Hirsch HH, Knowles W, Dickenmann M, Passweg J, Klimkait T, Mihatsch MJ, Steiger J. Prospective study of polyomavirus type BK replication and nephropathy in renal-transplant recipients. N Engl J Med. 2002 Aug 15;347(7):488-96. doi: 10.1056/NEJMoa020439. PMID: 12181403.
5) Nickeleit V, Hirsch HH, Binet IF, Gudat F, Prince O, Dalquen P, Thiel G, Mihatsch MJ. Polyomavirus infection of renal allograft recipients: from latent infection to manifest disease. J Am Soc Nephrol. 1999 May;10(5):1080-9. doi: 10.1681/ASN.V1051080. PMID: 10232695.
6) Hirsch HH, Randhawa PS; AST Infectious Diseases Community of Practice. BK polyomavirus in solid organ transplantation-Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant. 2019 Sep;33(9):e13528. doi: 10.1111/ctr.13528. Epub 2019 Apr 10. PMID: 30859620.
7) Sawinski D, Trofe-Clark J. BK Virus Nephropathy. Clin J Am Soc Nephrol. 2018 Dec 7;13(12):1893-1896. doi: 10.2215/CJN.04080318. Epub 2018 Sep 21. PMID: 30242026; PMCID: PMC6302319.
8) Mallat SG, Tanios BY, Itani HS, Lotfi T, McMullan C, Gabardi S, Akl EA, Azzi JR. CMV and BKPyV Infections in Renal Transplant Recipients Receiving an mTOR Inhibitor-Based Regimen Versus a CNI-Based Regimen: A Systematic Review and Meta-Analysis of Randomized, Controlled Trials. Clin J Am Soc Nephrol. 2017 Aug 7;12(8):1321-1336. doi: 10.2215/CJN.13221216. Epub 2017 Jun 2. PMID: 28576905; PMCID: PMC5544521.
9) Saleh A, El Din Khedr MS, Ezzat A, Takou A, Halawa A. Update on the Management of BK Virus Infection. Exp Clin Transplant. 2020 Nov;18(6):659-670. doi: 10.6002/ect.2019.0254. Epub 2020 Jun 16. PMID: 32552624.
Well done
1- Decoy cells are virally infected tubular ot urolithial epithelial cells characterized by ground-glass type intranuclear inclusions that are positive for polyoma virus .DC are better examined in early morning fresh urine sample stained with Papanicolaou stain.
2- Management:
Presence of decoy cells correlates with high viral load , this patient has stable graft function, so we need to reduce the IS dose to decrease risk of BKVN, start by decreasing tacrolimus by 25-50%,MMF by 50% .
3- Decoy cells has25% sensitivity and has 84 % specificity for BKV infection.
4- Positive predictive value of 29% and negative predictive value of 100% ,so it is a very good negative test to exclude polyoma virus infection .
DC is a good negative test for BKVN but not sensitive indicator for active viral replication as false positive results occur in around 25% of patients with stable graft function.
Ref:
Koh MJ, Lim BJ, Noh S, Kim YH, Jeong HJ. Urinary decoy cell grading and its clinical implications. Korean J Pathol. 2012 Jun;46(3):233-6. doi: 10.4132/KoreanJPathol.2012.46.3.233. Epub 2012 Jun 22. PMID: 23110008; PMCID: PMC3479773.
Is there a possible occurrence of subclinical rejection in some cases even with apparent stable graft function.
Decoy cells:
Are urothelial or tubular epithelial cells with large nuclei containing intra-nuclear basophilic inclusions. detected by urine cytology study.
Presence of Decoy cells represent high grade viruria equivalent to a viral load of almost 7.5 Log 10 copy/ml in urine.
The specificity and sensitivity: of Decoy cells identified by Papanicolaou stained urine for cytology are , in diagnosing BKPyv infection and BKPN is 95% and 99% respectively.
The positive predictive value:
varies between 27-90%, Meanwhile, negative predictive value stretched to over 99%.
Decoy cells:
is strongly suggestive of BKPy infection. However, its correlation with BKPyVAN is poor in comparison to plasma PCR.
CMV inclusion vs BKPyV inclusion:
CMV inclusion are made of CMV DNA, and early protein detected in tubular cells in kidney biopsy. Decoy cells are urothelial and tubular epithelial cells with enormously enlarged nuclei containing BKPyV that is detected in urine.
The finding of decoy cells might be a harbinger for development of BKPYAN in 50% of cases, therefore its recommended to reduce the level of immunosuppression by stopping Mycophenolic acid switch tacrolimus to Cyclosporin or CNi to Sirolimus .
Reference:
1]Harsharan K. Singh et al.Urine Cytology Findings of Polyomavirus Infections.https://www.ncbi.nlm.nih.gov/coreutils/nwds/img/logos/AgencyLogo.svg.
2] Ajit P Limaye et al.Kidney transplantation in adults: BK polyomavirus-associated nephropathy.Uptodate. Jan 2023.
Thankyou
What is a decoy cell?
They are tubular epithelial cells or uroepithelial cells infected with BK virus and detected in urine.They have a large basophilic nuclei with viral inclusion.
There are four types of decoy cells:
What are the sensitivity and specificity of this test?
Urine decoy cells have low sensitivity and specificity for BKVAN.
The sensitivity is at 25% and a specificity of 84%
What are the positive and negative predictive values of this test?
They have a low PPV of 29% and a negative predictive value of 100%
Describe this technique.
Fresh urine sample that has been smeared or centrifuged is fixed with alcohol and stained with Papanicolaou stain.
Does it correlate well with BK nephropathy?
They are a marker of viral replication but don’t necessarily indicate BKVAN.
Hence they correlate poorly with BKVAN.
What is the difference between decoy cells and CMV inclusion bodies?
CMV inclusion bodies have a clear halo around nuclear inclusion along with identification of concurrent cytoplasmic inclusion.
How do you manage this case?
This patient with a second graft 13 months post-transplant has a fairly stable creatinine and tacrolimus trough levels of 8.8ng/ml.He is on triple immunotherapy and we are not told of his induction protocol.
The fact that he has decoy cells in the urine they are not diagnostic for BKVAN, this also correlates with the fact that his Scr has remain fairly stable.
The next step would be to do a plasma BK PCR and patients with a viral load >4 log copies/ml should have a kidney biopsy.
Viral loads <4log copies/ml the patient should be monitored with serial every 3 months plasma PCR.
If biopsy not feasible then patients with high plasma viral load can be treated for suspected BKVAN with reduced immunosuppression.
The mainstay of BKVAN is reduced immunosuppression.
First reduce the antimetabolite by 25-50% and monitor the viral loads and Scr every 2 weeks
If viral loads don’t reduce over 4 weeks then the next step is reduction of CNI trough levels
References.
Decoy cells in urine cytology: A useful clue to post-transplant polyoma virus infectionV Geetha, Lakshmi Rao, […], and Ravindra Prabhu
BK virus infection: an update on diagnosis and treatment Deirdre Sawinski and Simin Goran
BK Virus Nephropathy in Kidney Transplantation: A State-of-the-Art Review
Sam Kant, Alana Dasgupta 3, Serena Bagnasco 3 and Daniel C. Brennan
Update on the Management of BK Virus Infection Ahmed Saleh, Mohamed Salah El Din Khedr, Abeer Ezzat, Anna Takou, Ahmed Halawa
Well done very comprehensive plan.
History
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What is a decoy cell?
What are the sensitivity and specificity of this test?
What are the positive and negative predictive values of this test?
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Describe this technique
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Does it correlate well with BK nephropathy?
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What is the difference between decoy cells and CMV inclusion bodies?
Decoy cells
CMV inclusion bodies
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How do you manage this case?
Plan
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Reference
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Thankyou well done
Many thanks Prof.Dawlat
What is a decoy cell?
Epithelial cells with viral infection called “decoy cells” are discovered in urine.
Decoy cells, so named because of their striking resemblance to cancer cells, can make it difficult to distinguish between a viral infection and a malignant urothelial tumor.
In the 1950s, cytotechnologist Andrew Ricci noticed cells in a group of people working in certain industries that appeared to be cancer cells but were actually not. He called these cells “decoy cells,” similar to “decoy ducks” used to hunt wild ducks. Ricci was a cytotechnologist working for renowned cytopathologist Dr. Leopold G. Koss.
What are the sensitivity and specificity of this test? What are the positive and negative predictive values of this test?
Urinary decoy cell detection has a 100% sensitivity, 84% specificity, 100% negative predictive value, and 6% positive predictive value in BK nephropathy.
Technique .
smear made from a urine sample that was processed by a semi-automated Bales technique.
Centrifugation at 1500 rpm with ethanol added to the sediment, fabrication of two glass slides for each sample, drying of the samples, and fixation in alcohol for 10 minutes prior to staining are all steps in the preparation of the smear.The ten-step papaniclaou staining procedure.examined the obtained microscope slide using a light microscope to look for common dummy cells.
What is the difference between decoy cells and CMV inclusion bodies?
TABLE ATTACHED
Management
Asymptomatic rise in creatinine with decoy cell need further clarification by doing the BK PCR and graft biopsy. If PCR report indicate high viral load and biopsy shows specific BK pathology than, I will treat this patient as a BK nephropathy
, Reduce or stop the MMF and the CNI by 25–50% (to a lower therapeutic level), while keeping him on low-dose steroid and closely monitoring graft function and the BKV PCR every two weeks.
The value of urinary decoy cells finding in patients with kidney transplantation
Zeljko Vidas 1 , Maja Misić, Arijana Pacić, Franjo Jurenec, Mladen Knotek, Ika Kardum-Skelin
Urine Cytology Findings of Polyomavirus Infections
Harsharan K. Singh M.D., Lukas Bubendorf M.D., Michael J. Mihatsch M.D., Cinthia B. Drachenberg & Volker Nickeleit M.D.
Decoy cells in urine cytology: A useful clue to post-transplant polyoma virus infectionV Geetha, Lakshmi Rao, Vidya Monappa, MS Susmitha, and Ravindra Prabhu1
van Aalderen MC, Heutinck KM, Huisman C, ten Berge IJ. BK virus infection in transplant recipients: clinical manifestations, treatment options and the immune response. Neth J Med 2012; 70:172.
Thankyou
OUR CASE;
DECOY CELL.
-This is a BK infected cell with cytopathologic changes that make it look like RCC cells hence the name decoy cells.
-Types;
SENSITIVITY AND SPECIFICITY.
-They are 100% sensitive and 71% specific in detecting BK nephropathy.
PREDICTIVE VALUE.
-This test has a low PPV(6%) and high NPV(100%) in diagnosing BK nephropathy.
TECHNIQUE.
–Urine samples are obtained, cytospin smears then get prepared from the urine samples, thereafter the smear preparation are fixed in alcohol and stained with papanicolau stain. Positive results will show degenerative epithelial cells, large cells with high nuclear; cytoplasmic ration with peripheral clumped chromatin, intranuclear, smudged,owl eye like ground glass viral inclusion.
CORELATION WITH BK NEPHROPATHY.
It does not distinguish amongst different polyomavirus(JCPyV vs BKPyV)
DECOY CELLS VS CMV INCLUSION BODIES.
1.Viral inclusion ;
Endothelial cells
CMV –
Polyomovirus ++
Mononuclear cells
CMV –
Polyomovirus +
2.Type of inclusion.
Ground glass
CMV ++
Polyomovirus +
Owls eye
CMV +Incomplete halo
Polyomovirus +++complete halo
Cytoplasmic
CMV –
Polyomovirus +
Cytoplasmic degeneration
CMV ++
Polyomovirus +/-
3.Background inflammation cell
CMV +/-
Polyomovirus +
MANAGEMENT
1.BK PCR VL.
2 MGT ACCORDING TO VIRAL LOADS;
.
REFERENCES.
Thankyou,
adjunctive therapy apart from IVIg is controversial.
Noted Prof.
cytopathologic changes in infected cells are strongly suggestive of PKPYV infection, but the sensitivity of the decoy cells test showed 100%sensitvity and 84%specifity.
REFERENCES
CMV has a complete halos around.
What will be your conclusion when you reduce ,viremia decrease or even disappears but still chemistry is rising?
Decoy cells are renal tubular cells with nuclear changes due to the cytopathic effect of the BK virus. (1)
These cells has high nuclear: cytoplasmic ratio showing peripheral clumped chromatin, intranuclear smudgy, ground glass and owl eye-like viral inclusions surrounded by incomplete halo in a clean back ground. There are 4 morphological types of “Decoy cells”:
Type 1- classic decoy cells characterized by large, homogenous, amorphous ground-glass like intranuclear inclusion bodies and a condensed rim of chromatin
Type 2- granular intranuclear inclusions surrounded by a clear halo, i.e., cytomegalovirus (CMV)-like
Type 3- multinucleated decoy cells with granular chromatin
Type 4- vesicular nuclei with clumped chromatin and nucleoli. (2)
the positive predictive value (PPV) is 29% and the negative predictive value (NPV) is 100%. (5,6).Geramizadeh observed that despite a low positive predictive value of decoy cells in urine, its absence has a negative predictive value of 100%, as almost all patients who did not have decoy cells had normal renal function. They further elaborated that presence of decoy cells along with high creatinine levels is a better indicator of virus presence.(2)
a) Ten ml of freshly voided urine are concentrated by centrifugation
b) the deposit is resuspended in 1 ml of the supernatant urine.
c) Three slides are made from the cell suspension by cytocentrifugation (Shandon-Elliot).
d) Two slides are stained by the Papanicolaou method and the third by methyl green pyronin.
e) The slides are screened by light microscopy for activated lymphocytes, inclusionbearing cells, renal tubular cells, and casts.(7)
Another method includes centrifugation at 1500 rpm, decanting the supernatant and vortex, adding from 3 to 5 ml 2% of Carbowax in 70% ethanol to the sediment, centrifugation at 1500 rpm, decanting the supernatant and using 50 μl of the sediment. Two glass slides of each sample are prepared. The samples are air-dried and then fixed for 10 min in absolute alcohol before applying the stain procedure. Urine cytology Papanicolaou stain in the following 10 steps: (a) Rinsing the glass slide under running water for 1 min; (b) Hematoxylin for 1 min; (c) Rinsing under running water till the hematoxyline is completely discarded; (d) Dipping in 2-propanol for 5 times; (e) Polychromic solution for 1 min; (f) 80% 2-propanol (5 times); (g) Absolute 2-propanol (5 times); (h) Absolute 2-propanol (5 times); (i) Xylene-1 (5 times); (j) Xylene-2 (5 times). The stained microscopic slides are immediately embedded into Canada balsam to be observed for typical “Decoy cells” bearing viral inclusions by Carl Zeiss light microscope(8)
Does it correlate well with BK nephropathy?
In BK nephropathy, the finding of urinary decoy cells showed a 100% sensitivity, 84% specificity, 100% negative predictive value and 6% positive predictive value. (9)
In one study the maximum decoy cell count was significantly higher (P = 0.04) in the BK viremia group than in the non-BK viremia group. (10)
Urine with large numbers of decoy cells (>10/cytospin), inflammatory sediments and biopsy proven PVN have been noted to have significantly greater decay in renal function than patients with no evidence of PVN.(2)
What is the difference between decoy cells and CMV inclusion bodies?
Presence of a clear halo around nuclear inclusion along with identification of concurrent cytoplasmic inclusion is a helpful clue to diagnose CMV infection. Severe cytoplasmic degeneration characteristic of polyoma infection; when present, serves as another useful morphologic clue. (2)
How do you manage this case?
Confirm the diagnosis through detection of urine BK virus by electron microscopy, urine BK viral (DNA) loads greater than 7 log gEq/mL or BK virus VP1 gene mRNA of > 6 log copies/ng total urine RNA , plasma viral loads (> 7700 BK virus copies per mL of plasma, P < 0.001, 50% positive predictive value, 100% negative predictive value) . the diagnosis should be made by demonstration of BK virus cytopathic changes with cellular infiltration consistent with the diagnosis of interstitial nephritis in the allograft and by immunohistology for BK virus proteins, or by in situ hybridization for BK virus nucleic acids in a renal biopsy.
The best studied treatment for BK viremia and nephropathy is careful reduction of immunosuppression; however, there is risk rejection or development of donor-specific antibodies with immunosuppression minimization.
In this case I will reduce the mycophenolate as this patient is considered immunologically high-risk patients (2 DR mismatch). Viremia is monitored with a goal of stabilization and ideally, a >0.3-log copies/ml decrease over 4–8 weeks.if no response , I will reduce the tac by 25% while still targeting tacrolimus trough levels >4 μg/L . Close monitoring of serum creatinine, BK viral loads, and calcineurin inhibitor trough levels is essential If viremia persists despite tac minimization, then conversion to modified cyclosporin (aiming for a trough level of 50–75 μg/L).
If no improvement I will switch tac into sirolimus or everolimus. Patients with an acute or progressive rise in serum creatinine despite declining viremia should be referred for biopsy to rule out concomitant rejection.
Ref:
1-Giovanni B. Fogazzi, in Comprehensive Clinical Nephrology (Fourth Edition), 2010
2-Geetha V, Rao L, Monappa V, Susmitha M, Prabhu R. Decoy cells in urine cytology: A useful clue to post-transplant polyoma virus infection. J Cytol. 2012 Apr;29(2):133-4. doi: 10.4103/0970-9371.97157. PMID: 22787295; PMCID: PMC3391795.
3-Camille Nelson Kotton M.D.,, Emilio Ramos M.D., in Chronic Kidney Disease, Dialysis, and Transplantation (Third Edition), 2010
4-Alkesh Jani, in Biomarkers of Kidney Disease, 2011
5-Camille Nelson Kotton M.D.,, Emilio Ramos M.D., in Chronic Kidney Disease, Dialysis, and Transplantation (Third Edition), 2010
6-Alkesh Jani, in Biomarkers of Kidney Disease, 2011
7.D.V. Coleman, E.F. Mackenzie, S.D. Gardner, J.M. Poulding, B. Amer, W.J. Russell,Human polyomavirus (BK) infection and ureteric stenosis in renal allograft recipients,J Clin Pathol, 31 (1978), pp. 338-347
8-S. Slavov, I. Nenkov, D. Dimova, P. Simeonov, L. Hristova, V. Vladimirov & Z. Kalvatchev (2007) Tracing of “Decoy Cells”: Rapid Screening Test for Demonstration of Active Polyomavirus Infection in Patients with Renal Transplants and Urologic Disorders, Biotechnology & Biotechnological Equipment, 21:1, 80-82, DOI: 10.1080/13102818.2007.10817419
9-Vidas Z, Misić M, Pacić A, Jurenec F, Knotek M, Kardum-Skelin I. The value of urinary decoy cells finding in patients with kidney transplantation. Coll Antropol. 2010 Mar;34(1):153-7. PMID: 20432744.
10-Yamada Y, Tsuchiya T, Inagaki I, Seishima M, Deguchi T. Prediction of Early BK Virus Infection in Kidney Transplant Recipients by the Number of Cells With Intranuclear Inclusion Bodies (Decoy Cells). Transplant Direct. 2018 Feb 2;4(2):e340. doi: 10.1097/TXD.0000000000000759. PMID: 29464201; PMCID: PMC5811269.
11. Sawinski, Deirdre1; Trofe-Clark, Jennifer1,2. BK Virus Nephropathy. Clinical Journal of the American Society of Nephrology 13(12):p 1893-1896, December 2018. | DOI: 10.2215/CJN.04080318
Thankyou well done
What is a decoy cell?
Decoy (smack/ snare) cell is a desquamated cells with an enlarged nucleus with a single, large basophilic intranuclear inclusion.
What are the sensitivity and specificity of this test?
The sensitivity is only 25%, and specificity of 84%, so it does not indicate a BKV infection, but may be another viral infection.
What are the positive and negative predictive values of this test?
The PPV is 29%, and the NPV is 100%, indicates exclusion of disease when it is not seen.
Describe this technique
This could be prepared in a cytospin smears butting in a fresh urine samples, fixed in alcohol and stained with Papanicolaou stain., that show enlarged cells with high nuclear: cytoplasmic ratio showing peripheral clumped chromatin, intranuclear smudgy, groundglass and owl eye-like viral inclusions surrounded by incomplete halo in a clean background.
light microscopy findings are definitive in most cases, further evaluation by immunohistochemistry (IHC), electron microscopy or polymerase chain reaction (PCR) may be necessary for confirmation.
Does it correlate well with BK nephropathy?
It does not correlate with BK nephropathy as it not specific for polyomaviruses and can be seen in other viral infections, including CMV, adenovirus, and it can resemble a tumor cells.
What is the difference between decoy cells and CMV inclusion bodies?
The decoy cell in CMV present an owl eye appearance, a type-2 granular intranuclear inclusions surrounded by a clear halo., while in BKV presents ground glass cytoplasmic degeneration.
How do you manage this case?
Our patient is asymptomatic, so I would ask for serum and urine BKV PCR , as well as serum CMV PCR, in order to better clarify these inclusions and its cause.
If BKV PCR is high, then I would consider a kidney biopsy to identify the stage of BKVNN (nephropathy) for better management plan. However, I would decrease the MMF dose by > 50%, decrease the CNI by 25-50% (lower therapeutic level), but keeping him on low dose steroid, with frequent monitoring of BKV PCR every two weeks, and close monitoring of graft function.
References:
(1) Geetha V, Rao L, Monappa V, Susmitha M, Prabhu R. Decoy cells in urine cytology: A useful clue to post-transplant polyoma virus infection. J Cytol. 2012 Apr;29(2):133-4. doi: 10.4103/0970-9371.97157. PMID: 22787295; PMCID: PMC3391795.
(2) Saleh A, El Din Khedr MS, Ezzat A, Takou A, Halawa A. Update on the Management of BK Virus Infection. Exp Clin Transplant. 2020 Nov;18(6):659-670. doi: 10.6002/ect.2019.0254. Epub 2020 Jun 16. PMID: 32552624.
(3) UpToDate- Kidney transplantation in adults: BK polyomavirus associated nephropathy.
Thankyou is there a place for IvIg
Thank you Prof. Dawlat,
yes the IVIG can be used, with doubtful results
Decoy cells?
These are renal tubular or uroepithelial cells containing viral inclusion (nuclear inclusion formed by dark, smudged material representing thousands of newly formed virions). There is nuclear enlargement (“ground glass appearance”), chromatin margination, abnormal chromatin patterns, and viral inclusion bodies of various sizes and shapes with or without a perinuclear halo. Generally, the higher the number of decoy cells, the more severe the infection. It’s called decoy cells because of its resemblance to cancer cells. The finding of decoy cells in the urine is sufficient to diagnose reactivation of the viral infection, however, for the diagnosis of BK virus nephropathy, a kidney biopsy is required. Prevalence of decoy cells from prospective screening studies of post-transplant patients by Hirsch et al. is 29%.
Sensitivity, specificity, positive and negative predictive value of decoy cells in urine?
Sensitivity is 25%, specificity is 84% with 29% positive predictive value and 100% negative predictive value. Identification does not differentiate between BK and other polyoma viruses and identification requires expertise.
In terms of detecting histologically confirmed BK virus nephropathy, sensitivity is 100%, specificity is 70%, positive predictive value is low but negative predictive value is high.
Describe this technique?
These cells can be seen by phase contrast microscopy in unstained samples or by cytocentrifuged smears with the use of Papanicolaou stain. Electron microscopy can also show virus particles. In addition to decoy cells, macrophages are frequently seen.
What is the difference between decoy cells and CMV inclusion bodies?
CMV inclusion bodies are basophilic intranuclear or sometimes eosinophlic cytoplasmic inclusions with typical owl’s eye appearance. Decoy cells are as described above.
Correlation with BK virus nephropathy?
Presence of urine decoy cells is sensitive for BKV infection but not specific for BK virus nephropathy. The gold standard for diagnosis of BK virus nephropathy is kidney biopsy. Although, BK virus DNA in the blood as detected by PCR is a better indicator of BK virus nephropathy, repeated presence of urine decoy cells is sensitive for diagnosis of BK virus nephropathy.
Management
Reference
Giovanni B. Fogazzi, in Comprehensive Clinical Nephrology (Fourth Edition), 2010
Hirsch et al Nephrol Dial Trans (2015) 30: 209-217
Up to date
That is a well-structured reply. Typing ‘uptodate’ as a reference is not a complete reply in a scientific write-up.
What is a decoy cell?
They are sheded BKV infected tubular cell it has the characteristic appearance of: infected cells with single, large, homogenous, basophilic, glassy nuclear inclusions and small condensed rim of chromatin
What are sensitivity and specificity, the positive and negative predictive values of this test?
What is the difference between decoy cells and CMV inclusion bodies?
o Cytomegalovirus (CMV)
§ Infected cells are markedly enlarged and have both nuclear and cytoplasmic inclusions
§ Nuclear inclusions: single, large, basophilic, surrounded by halo (owl’s eye appearance)
§ Cytoplasmic inclusions: multiple, smaller, basophilic, finely or coarsely granular
Decoy cells:
infected cells are descriptively known as decoy cells because they mimic malignant cells
Classic appearance: infected cells with single, large, homogenous, basophilic, glassy nuclear inclusions and small condensed rim of chromatin
Other appearances:
a- Central nuclear inclusion surrounded by irregular and incomplete clear halo (cytomegalovirus-like)
b- Granular chromatin, sometimes multinucleated
c- Degenerated, vesicular nuclei with coarsely granular and clumped (spider web) chromatin, nucleoli can be seen
· Round or oval, smooth but thickened nuclear membrane
· Many with eccentric comet-like cytoplasm
How do you manage this case?
History and clinical examination
Patient education including plan of management and risk assessment
Kidney function test and electrolytes
PCR for BKV : assess viral load
If viral load <1000 with stable KFT è follow up monthly
If viral load > 1000 copies reduction of IS reduce some centers are switching TAC è cycs , other are reducing CNI by 25-50% MMF by 50 % and assess viral load after 2weeks
If > 10000 copies : stop MMF , TAC level 5-8 ,
start luflonamide (PO: Loading- 100 mg daily for 3–5 days; maintenance- 20-60 mg qD; Trough Level −50-100 μg/mL) it has Anti-Inflammatory; Anti-Viral; Immunosuppressive effect
adjuvant therapy \
1- Cidofovir: Nucleoside analog IV: 0.25–1.0 mg/Kg at 1–3 weeks Used in refractory cases; Nephrotoxicity is the most serious adverse effect
2- Brincidofovir: Investigational Prodrug of Cidofovir; Anti-viral activity PO: 2 mg/Kg twice weekly Reasonably well tolerated; Investigational.
3- Intravenous immunoglobulin (IVIG): Immunoglobulin preparation with high titers of neutralizing antibodies to BK virus IV: 0.25–2.0 g/Kg Can be used as an adjunct to other measures in refractory cases
4- Levofloxacin: Fluoroquinolones; Antiviral, inhibit helicase activity of large T antigen PO: 500 mg qD (renally adjusted) Levofloxacin failed to show benefit in randomized controlled trials.
5- Everolimus: Inhibits mammalian target of rapamycin (mTOR) kinase activity, inhibiting T and B lymphocyte activation and proliferation. PO 0.75 mg twice daily adjusted to trough levels of 3–8 ng/mL. Can be used following discontinuation of MMF. Limited literature supporting its use.
Ref
Sharma R, Zachariah M. BK Virus Nephropathy: Prevalence, Impact and Management Strategies. Int J Nephrol Renovasc Dis. 2020;13:187-192
Saleh A, El Din Khedr MS, Ezzat A, Takou A, Halawa A. Update on the Management of BK Virus Infection. Exp Clin Transplant. 2020 Nov;18(6):659-670
https://www.pathologyoutlines.com/topic/bladdercytologynonneoplastic.html
That is a well-structured reply.
Typing the whole sentence in bold amounts to shouting, however.
thanks prof for your kind comment sorry for more Boldy writing mostly it un intended
A 41-year-old man had a successful second renal transplant 13 months ago, 212 mismatch, no DSA and negative FAXM. His remains stable at 143 µmol/L. He is currently on Tacrolimus (trough 8.8 ng/ml), MMF 750 bd and prednisolone 5 mg od. Routine urine cytology for BK-infected cells demonstrated decoy cells (see below).
What is a decoy cell?
Infected tubular epithelial or urothelial cells characterized by large basophilic viral nuclear inclusions with ground-glass that replace the normal chromatin (Papanicolaou stain) surrounded by a condensed rim of chromatin and reflects higher urinary viral load.
Referred to as “decoy cells”, analogous to “decoy ducks” used in hunting wild ducks
Decoy means fake, decoy cells own their name due to its Appears like those seen in uroepithelial cancer.
What are the sensitivity and specificity of this test?
Earlier report showed sensitivity 100% and specificity 71%
Recent reported sensitivity of only 25% and a specificity of 84% for BKVN
What are the positive and negative predictive values of this test?
PPV = value for progression to nephropathy is => 27 to > 90%
NPV = 99% this mean we can rule out BK nephropathy if decoy cells are negative
Describe this technique?
Problems in using Decoy cells as screening test:
– BKV shedding in the urine occurs in a substantial proportion of healthy Individuals, only quantitative cytology results are suitable for routine diagnostic use.
– It cannot distinguish between different types of polyomaviruses.
– Special skills are required for the detection of decoy cells, which limit its application.
Decoy cells can be detected in a fresh urine sample.
The sample should be processed rapidly.
Decoy cells detection needs experience
Decoy cells are seen with three methods => Smears should be fixed in alcohol and examined either by:
• Papanicolaou stains
• Electron microscopy
• Phase contrast microscopy
Limitations of using Decoy cells as screening test:
-BKV shedding in the urine occurs in a substantial proportion of healthy Individuals, only quantitative cytology results are suitable for routine diagnostic use.
– It is not necessary correlates with biopsy proven BK-induced interstitial nephritis.
– It is difficult to distinguish it from other viruses.
– It can be absent while other tests that directly detect BK virus in urine are positive.
-Special skills are required for the detection of decoy cells, which limit its application.
Does it correlate well with BK nephropathy?
Decoy cells are suggestive but not sensitive, specific, or definitive for BKV infection
50 % may progress to viremia within weeks to months
Decoy cells may be present in other renal viral infections e.g., CMV, adenovirus
Decoy cells correlate poorly with biopsy proven BKVN
Their absence does not exclude the disease
Positive predictive value for progression to nephropathy is 30% On the other hand, PCR level of > 1000 copies/ml has a positive predictive predictive value for progression to nephropathy of 40-60% within 1-2 weeks
Around half of patients with viruria can progress to viremia and around half of patients with viremia can progress to BK nephropathy.
What is the difference between decoy cells and CMV inclusion bodies?
Decoy cells?
Decoy cells represent renal tubular or uroepithelial cells (only in epithelial, sparing endothelial cells) ( no endothelial or mono nuclear cells )with enlarged nucleus, containing single large basophilic intranuclear viral inclusions, forming incomplete hallo, resemble malignant cancer cells
CMV inclusion bodies?
While in CMV there are cytoplasmic basophilic inclusions bodies with complete halo around (Owl eye appearance) in epithelial, endothelial cells and mono nuclear cells
How do you manage this case?
Detection of decoy cells is an indication for close monitoring of blood PCR and if PCR is > 1000 copies /ml reduction of immunosuppression is indicated
-Decrease MMF to 50% or D/C if no response after 2 weeks
-Decrease CNIs 25-50% => Keep tacrolimus trough level between 5-7 ng/ml.
-Prednisone same dose
-Blood BKV PCR Biweekly since half of the cases may progress to viremia.
References:
– BKV in Kidney Transplantation lecture By Ahmed Halawa
– Uptodate
That is a well-structured reply. Even though you have numbered your contents, it is not easy to read. I wish you could type headings and sub-headings as underline or in bold.
As much as I adore my academic brother Ahmed Halawa, writing that his lecture as a reference is not a complete reply in a scientific write-up.
What is a decoy cell?
It is a finding that suggests polyomavirus reactivation (in the case of kidney damage, the most likely BK virus) with asymptomatic viruria.
They are viral nuclear inclusions that can signal a possible nephropathy
What are the sensitivity and specificity of this test?
Sensitivity – 25%
Specificity – 84%
What are the positive and negative predictive values of this test?
PPV – 29%
NPV – 100%
Describe this technique.
Urine samples were fixed in alcohol and stained with Papanicolao. This needs to be done immediately.
Does it correlate well with BK nephropathy?
No. Decoy cells suggest reactivation with viruria but without systemic repercussions. Serum quantitative CRP for BK is more correlated with nephropathy, which is only confirmed by biopsy.
What is the difference between decoy cells and CMV inclusion bodies?
Cytoplasmic CMV inclusion findings affect the endothelium and renal tubule, while BK is more restricted to the latter. The cytoplasmic alterations of BK are more severe and intense when compared to CMV.
How do you manage this case?
Decreasing immunosuppression is mandatory, at least 25 to 50% of the tacrolimus dose and 50% of the mycophenolate dose. Consider switching the latter to mTOR inhibitors.
With worsening renal function it is necessary to biopsy the kidney to differentiate between acute rejection (high-risk patient) and viral disease activity.
That is a well-structured reply.
Reference?
What is a decoy cell?
– Infected tubular epithelial or urothelial cells characterized by large basophilic viral nuclear inclusions with ground-glass that replace the normal chromatin (Papanicolaou stain) surrounded by a condensed rim of chromatin
– The nuclear inclusion is formed by dark, smudged material representing thousands of newly formed virions.
– Appears similar to those seen in uroepithelial cancer.
– Referred to as “decoy cells”, analogous to “decoy ducks” used in hunting wild ducks
What are the sensitivity and specificity of this test?
Earlier report showed sensitivity 100% and specificity 71%
Recent reported sensitivity of only 25% and a specificity of 84% for BKVN
What are the positive and negative predictive values of this test?
NPV 100% and PPV 29%.
Describe this technique.
-Cytospin smears were prepared from fresh urine samples, fixed in alcohol and stained with Papanicolaou stain or phase contrast microscopy.
-The diagnostic utility of urine cytology is further limited by interobserver variability and the qualitative, rather than quantitative, nature of this test.
Does it correlate well with BK nephropathy?
-Urine decoy cells which typically represent higher-level viruria, but they do not have a significantly greater prognostic value for progression to viremia than detection of viruria by more sensitive methods such as PCR.
-Viruria is the earliest manifestation of BKAV infection in KTR, affecting 25-30 % of patients during the first year following transplantation.
– For most, viruria is asymptomatic, detected only by screening, and does not progress to viremia
-If only urine BK screening is to be performed, urine BK PCR as the superior assay, using the threshold of >1 Å~ 107 copies/mL as suggestive of BKVN.
-Given the widespread availability of the plasma PCR assay and its greater predictive value for BKVN, it is unnecessary to perform urine BK screening first before plasma testing.
What is the difference between decoy cells and CMV inclusion bodies?
Decoy cells:
Infected epithelial cells with single, large, homogenous, basophilic, glassy nuclear inclusions and small condensed rim of chromatin
Other appearances:
Central nuclear inclusion surrounded by irregular and incomplete clear halo (cytomegalovirus-like)
CMV inclusion bodies:
Infected epithelia and endothelia cells are markedly enlarged and have both nuclear and cytoplasmic inclusions
Nuclear inclusions: single, large, basophilic, surrounded by complete halo (owl’s eye appearance)
Cytoplasmic inclusions: multiple, smaller, basophilic, finely or coarsely granular
How do you manage this case?
– Generally viruria precede viremia by 4 weeks.
-Detecting Decoy cells in the urine is not enough to diagnose BKAN. However, patient needs to be closely monitored especially when considered as high risk ( our case 2nd KT and HLA mismatch).
– Monitoring plasma BK PCR .
– If plasma PCR > 1000 copies/ ml; IS reduction can be considered
– IF plsma PCR > 10000 copies/ ml : IS should be reduced.
– Biopsy can be considered if there is evidence of graft dysfunction.
Reduction of IS
– Reduction of IS is the mainstay to restore immunity and control viral replication.
– There is no generally accepted regimen for reduction of IS.
-Therefore, IS should be tailored for each patient according to the clinical situation.
– IS reduction may increase the risk of rejection the index case; high immunological risk ( 2nd KT, HLA- mismatch).
Approach:
– Reduce MMF dose to by 50 %.
– Reduction CNI by 25–50% targeting lower level to 4-6 (Tac level 8 is considered high at 13 months post KT)
– Continuing on the same doses of prednisone.
– Close monitoring of viral load and renal function every 2 weeks.
– If no improvement in viral load in 2 week; discontinuation of the anti-metabolite.
– If viral loads do not reduce over 4 weeks despite cessation of anti-metabolite; consider reduce CNI trough goals 3–5
References:
-Feng G, Choy B. Cytology-nonneoplastic. PathologyOutlines.com website. https://www.pathologyoutlines.com/topic/bladdercytologynonneoplastic.html. Accessed February 13th, 2023.
-Krajewski W, Kamińska D, Poterek A, Małkiewicz B, Kłak J, Zdrojowy R, Janczak D. Pathogenicity of BK virus on the urinary system. Cent European J Urol. 2020;73(1):94-103. doi: 10.5173/ceju.2020.0034. Epub 2020 Feb 27. PMID: 32395331; PMCID: PMC7203775.
– Hirsch HH, Randhawa P; AST Infectious Diseases Community of Practice. BK polyomavirus in solid organ transplantation. Am J Transplant. 2013 Mar;13 Suppl 4:179-88. doi: 10.1111/ajt.12110. PMID: 23465010.
-Shanmugham S, Bhadauria D, Agrawal V, Jain M, Yaccha M, Kaul A, Vamsidhar V, Meyyappan J, Prasad N. The diagnostic and therapeutic dilemma of the co-existence of BK virus nephropathy with acute rejection – an experience from a single Centre and review of the literature. Transpl Immunol. 2022 Jun;72:101581. doi: 10.1016/j.trim.2022.101581. Epub 2022 Mar 14. PMID: 35301106.
-Hirsch HH, Randhawa P; AST Infectious Diseases Community of Practice. BK polyomavirus in solid organ transplantation. Am J Transplant. 2013;13 Suppl 4:179-88. doi:10.1111/ajt.12110
-Saleh A, El Din Khedr MS, Ezzat A, Takou A, Halawa A. Update on the Management of BK Virus Infection. Exp Clin Transplant. 2020 Nov;18(6):659-670. doi: 10.6002/ect.2019.0254. Epub 2020 Jun 16. PMID: 32552624.
-Kant S, Dasgupta A, Bagnasco S, Brennan DC. BK Virus Nephropathy in Kidney Transplantation: A State-of-the-Art Review. Viruses. 2022 Jul 25;14(8):1616. doi: 10.3390/v14081616. PMID: 35893681; PMCID: PMC9330039.
Thankyou Exellent
What is a decoy cell?
Decoy cell is seen in Urine cytology sediment of renal transplant infected graft with BKV, characterized by large viral nuclear inclusions that replace the normal chromatin (Papanicolaou stain). The nuclear inclusion is formed by dark, smudged material representing thousands of newly formed virions.
What are the sensitivity and specificity of this test?
urine cytology is less sensitive and specific for the diagnosis of BKPyVAN compared with plasma quantitative PCR .The diagnostic utility of urine cytology is limited by interpretation variability and the qualitative, rather than quantitative, nature of the test.Sensitivity is 100% and specificity is 70% .The test does not distinguish among polyomaviruses (ie, JCPyV versus BKPyV).
What are the positive and negative predictive values of this test?
Viruria is the earliest manifestation of BKPyV infection in kidney transplant recipients, affecting approximately one-quarter to one-third of patients during the first year following transplantation. viruria is a sensitive marker for progression to BKPyV-associated nephropathy (BKPyVAN), it is nonspecific.Urine decoy cells represent higher level of viruria but they do not have a significantly greater prognostic value for progression to viremia than detection of viruria by more sensitive methods such as PCR.
Describe this technique.
Cytospin smears is prepared from fresh urine samples, fixed in alcohol and stained with Papanicolaou stain.The cytospin smear showed degenerating epithelial cells, enlarged cells with high nuclear: cytoplasmic ratio showing peripheral clumped chromatin, intranuclear smudgy, ground glass and owl eye-like viral inclusions surrounded by incomplete halo in a clean background.
What is the difference between decoy cells and CMV inclusion bodies?
-CMV inclusion bodies:The involvement of endothelial cells is characterized by a central large eosinophilic intranuclear inclusions surrounded by a circumferential halo resembling a typical owl’s eye.
-Decoy cells: The tubular epithelial cells with Intranuclear basophilic viral inclusions without a surrounding halo.
-There are 3 patterns for BKV inclusion bodies:
Type 1: an amorphous ground-glass inclusion body
Type 2: a central irregular inclusion body surrounded by nuclear halo
Type 3: finely granular nuclear alteration
Type 4: finely granular nuclear alteration
How do you manage this case?
In the current scenario with stable graft function and presence of decoy cells which is strongly suggestive of BKV infection ,but urine cytology is less sensitive and specific for the diagnosis of BKVAN compared with plasma quantitative PCR, so at the current stage no treatment needed except if there is BK viremia by plasma quantitative PCR or biopsy-proven BKVAN.
If there is definitive viremia or biopsy-proven BKVAN,treatment will be with reduction of immunosuppression as following:
Initially reduce the dose of the anti metabolite by 50 %. If the BKPyV viral load does not decrease within two to four weeks, we completely discontinue the anti metabolite. If there is still no decrease in viral load after another two weeks, we decrease the dose of tacrolimus by 25 to 50 %, targeting a whole blood tacrolimus trough level of 4 to 6 ng/ml.
References:
Nickeleit V, Klimkait T, Binet IF, et al. Testing for polyomavirus type BK DNA in plasma to identify renal-allograft recipients with viral nephropathy. N Engl J Med 2000; 342:1309.
Menter T, Mayr M, Schaub S, Mihatsch MJ, Hirsch HH, Hopfer H. Pathology of resolving polyomavirus-associated nephropathy. American Journal of Transplantation. 2013;13(6):1474-1483
In the index case if the kidney function is stable despite the viruria so it is either:
a low level viremia with BkV coies<10K
or presumptive BKVN (unlikely) with>10k
so blood PCR is mandatory in this case to decide how to deal with I S.
New start again
-What is a decoy cell?
-What are the sensitivity and specificity of this test?
-What are the positive and negative predictive values of this test?
-Describe this technique?
-Does it correlate well with BK nephropathy?
Decoy cells are suggestive but not sensitive, specific or definitive for BKV infection due to;
-What is the difference between decoy cells and CMV inclusion bodies?
1.Polyoma virus;
2.CMV
-How do you manage this case?
Key things to consider;
Source; decoy cells in urine cytology (V Geeth et al.), update on the management of BKV infection (Ahmed Saleh et al.), BKVN in kidney transplantation (Sam Kant et al.), prof Halawa lecture.
I like your decision-making process.
As much as I adore my academic brother Ahmed Halawa, writing that his lecture is a reference is not a complete reply in a scientific write-up.
Well taken prof.
New start again
-What is a decoy cell?
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/xK7unJzrJ11PWG8q7QZ7oNkh8NyR5mxRxmoG/5fPUFLmuk/LkmaeeoqLrush1wYOMKXkOLa/NZsmixyFp1ylyRTTqCBXQMbMlW3EQH/Rn8jVPwi6rftKhyVDoeWxSH5NfNPLNqCMKIQCPwMaKaxtvKWDRCStsqbdFINLJ63a0bZ1GNpZGXzZqwwjRsCURocYkCgAKR5gNGQR7L+cdr0rt4+FnnclWH9lPhAlE+iiz7XRmDkFFu54dFraW8wZF8V7lTE6vSMmhLR03DvI78F5DMcelJnma08p3fKE+ul02oENBIWtkJ4n0+o69O6ii5svFVRNpkfxuP5LV/SagJqo6llUm0upLspRwPxY1rBMDlec6yONjpwVulxmSDtYEZTUoijIyDzYyqibnPVlFlZUGcHeT3L5DDNWxjXHe/CNiuQjbk66rUsRHWmNVEa4ffQ25kF0BVYUcqUBZIvlUkZisuByaOGX70GiHyr7W02CO5gJTPuq3BtBJeGlgAJcMYKcvpKynrQ0dPycf6uz0DKdYYn0BFa+Fb7bgGCgt0lqdCx5IkIrug8YaH1iz7J/Vwh6J/dkD0SZuRvRYX8d9l4FOU42p4m3yMawm2y/5S/pIe5zjCdh8fRxSRRwPLqCEkW52YJEyXshNhuZMA1bvZNzH9703Qn/bkOPlRlsT51z34wcKG+fYsMgnCiKVo3kRjZOX5oz4oJnu0HHrIkIqZymXlf9ny0FJuSzl5q6sHuMBkiW9NrkZzJ8PawQKvFZwrqjzQp8TG2ZLtNB10Echku7BZc2dvipCCzZVhfNWhLLJQpfD/kTEMfe5c2oeJB7pdd4fgQr3K09kcrwafyhPVmcFFe+GKYFTeNUfp2TZCDo2czQEzFh5HOhRwRs7FJ/3iUw94IFkJuVbYn+eYyMUTYrDyyDJaKpc68xg1VCic3gyWh+evlACs8XUJt+ZqVa0jnWRPz3Ldz6iIWFaEFyv7zwABlm81YvNxXbGYFOWzTX2J26edES3GLQJ4r7WXBTY+Gk4lu93g7jgKYZutdntPu+29Kf8DVXDsiAkLz4HJVUr+sxuW5RhOfncviMOcuedWrrLKG4fMpkaZK1LAjmeNPAoO8tm4uHCm/ElMVqDt/JUosFJPin7kI6VIWstrS3Yl/jOmAcy2ifMRaNOcp+RNNWMmhSJphu+i2c44OI0XFMfBfWUjVbW2LUOUcaGItjdmXUm7Uv5pARHkuJ4vt20dvqeu8SYwl09vEX+tbPcjQaE55oUuSmiDzLyJTK0Erl8V5U4HJVv4p481hNzK6RcoQqxme/GzqdYXEwmyvUko4N0Xqmt0PLozSilZ/FbxCijRIuxnZNc3y33boKQerGT7/rIDlE/xcQuBzqodxTXxa+O2ZDGLxBt8P1XDWjnISSUCoc+UpiDMMdeLitxQN2fRQGFCOM5hdgFapkyiPrOvYr6GyW0PO3P0d+pJN+ObKRd0xbXHkgZuTmqZVUv/TvHo2K1Ic6THNnhdHiRsbxlE1+fPJUGybQ/sTM1UpanvOgRKdP5KifXpAOezvfUwpAnjcKoO/GutdcUNvLRk/7n4+ycoRNP4HHtUHSdMdkFQiT1qXXt4hpPlijoigo1/rmA6xJCS6lg5HXHKqN9zuKXWPwXW2W5edsfGR83bkW+3xCSR+BUGDs5ZwU9lkTaETmXtPux0jqGIx/D9UcbWt1/TqWMJ3mZz+q/8tuYi+oCnjIN1FPy9E/y5339HLG/WwLLKr6i7WNzZ9k02bmryC19ojlPzgxltFvkwUQEm68BwzrW9tSziupe+d71mJEMYVhL6Rg7jfWcu8bhIxVVao1C1que6Om9ghlFKsrNle4viTK/1Ye2RqHzdcjbUhKxPVk340zVazuI560RkHFI/lKvKnRNUaUY5yDi8X4o6xnyaGA+uu/JcznjVBE4HSpWaeCv01R+6+hiwj5/pS59yBx+DAe0uNZ8bN4o8XN16cXbWGodlDA45fxTogrhoCaPRlWSr6clxyp8JCwfC/EJpA++9fiOHnZ9GdniUhEti1dSk2VVr98mIg5TwXz+46MakcfcKofTy5Iy5kjwmcip0CxZgY72lQMpJxx9VvakbiGdNTDWxkwSY62nxD8g0AWsW5Zfq1nOWf6OtqH2jLm11pgns3Nuye7FZj9ZlU3cIHRYspOb/TsRlfg8LlI9cOHB9E98FCiuRPsrttQcGOkmHX1+BGP1ESY3T+5BuFfJhH5Cjt2qNE1M/e2L+aYHiN7pJyETxjJuO22rcvrQ5xGbAF9GbDnK6N+UCJDDN1O/W14sPv+X7p7rZzo/wt5+T1ygX4RT+QeZ09O1nok/hIvVNMfTVpalspjLQGJe9/fCMRakbTUoqqHgXJv9kWe9zNo2X6G90gI0eI0LxZvcdYApRdnh7KLIDlddqoqTMbWS48VAMh5fXS1MIxldqG2t/AAGsqBDOPuuHL0WdRHKkkpGcStBLCkSXXmh7OOEh3119g7Exms5GeSEU67VMyHH4FXAAoJgPvBVWQlQ/bp+zYmhzOqLuY5p2+I6R4Zy1MftHOpGr3iotgc4xb1J6ekDqDf1IZMgOqTVRrG49LSIXNuHGZQw2uj3dgUny3AILStDIqawHdVctj1xVPBaxHpBEK/Jpu6GaqttR06hOeJo9ZksGlUkkm114MUEyfa/QvfZSNMhjhShT7p9NuOvKjxE2XV+rovVarf7AJmW4+ibNQHhBZsAMeRtkIvtFuMtf7uLVPSQB8yvXBbevlglD3NvElI/45gBgP3qnIwRLWKYDynl734qkh9QSl5sw+vZQpPn0VQbh7kGqoQbW8NPyhLdVL1UmwtV2YhfRdzvQRenQlTwQzj9ehvytC0qdBFulS4xiPnCVmH8qFDtjAS2OcttcE7PaSVIe13iJK1JQLoJFopiT+K3KzPqCHMK9Ymt85axWVq6643eCrgmm1Afi6m3apxal9tfPiStIxec4bUGZUfexgn9EhCpSMdKr0vK9GvGBXzYtUVaEBMsaRk6lHZhOLwJcQSbE3cou6ukwI86IZ9Px856oRF3SY8QsH43ehMU/8YqX6w6O2UT0iMVubESNEeZafQ5I8aJQ0mKY4W3+hQWl470u9d4SJdaNc9dJnAzIb7SEX9W/8UbmnnNzhGDFKwtJt4hYGyjORppT0LfJLB8zmWxhkMuNinyjydWY3PMWmaCQaF/QDAJHeeFanxNrdIcYcFnOKEyVOQ5aXFJ6s/aSStC2/tmz6wlYcf7aSR9lbZrPXBjmiP+Q6B/MIabnYnofGJ5sbuI0SloTPa8Z7qA9dzb5yRCt9f1EUlIq5vbYp3QXG6zMtZZr3jtO+Jeu1M4zj99/rAZw36UKK52ePwYqWhU5SOvkUfGa5zsHX2t/NSVitYLTa/EqFec+QGGO4U1zvmlQfau7cuxb4Rw3MlXfHHv9K8svSW76Iuc4yAMg+QXnWT8mnqVDE9QAXIev1EclVVJ+dZTj74mrIsq7y0U9nmDwUSLmJORzw+gMS5d61hfYrN5lGUv6O+k2jIvVuP37jbOpza3+OifxJjxqWMFqV5N+qY9qc63/6UwUjpKWfSlZtfu8Q1Ux1g/I9Ejp7GOe4Cda45vCqyo89Xs43L2CLvugDPJcdAOSSFmk5CKZFSn7fR7MhTzpoN+Tx3x4IJi3bcwHROd3TaFRMQ/RpUV1Vj3OSv5fbEaQVuzG9/eXwlVPMJSmHoc4S+6eiyAjo9+IO1KaJusO9e4lc9TijyxVqpYjc/YFH/MPidkfiUeS1lzU5JU3QwAyrQaMVar/Rr4xcXZdv3/uYtVppBgo7PZTVO0jGGwWu7X1xTnO4kr4qY5oM/rOz+9OLPAzgEm55E9uDuUTibcwUQhleEwOX2RI77B6WrCk7tHkfDAlcF+PiRmBqE7sBfrIpgz6YPTMRkTumVRb1T3e9C5Jg1OOPskP0/2KnWF9RSmcObFODoSYilylPJkSNAkpIXj+zJRKaRXPKDR7faqHHJdqq2KrF+C/g4VqQTtKg/ASBKtQoV9qUPV8eTsW+egU8Yi3q7CSqLYeWmxS0XVhrQ4wD8JfXtDcfuMNrludKnXIKWGf6tSp+yDyCWDk4oLONgZTlq25KsoZkpvpaNHGBNb6VYrdLvyXFOQ8eTA3mUc550/ZMObCyqqIF0LIFHbr8b6SjL57dNICh4C6QlwcX6r/MY40rxV3GN72YQMXohyX7CS5rcks4GEHQnkPVdKwNWLmTxWBX4JzuUK+dyjtoyLVdeV3rcLRFzMVHRcpHoGVL4PkmN8p1/JYgSyCA9txYhvqEtx7Bdxs4AW4FP/yrc7oNwk3LBFrFVzzUJ72o+6bFKicqkJNfBUX6a16THWsK4AOWdq0xaPUxTb6SW0m6dA1L/8igrJ3a54qsBKlTuBL4A8UcPDaVcOYifgx8qdLWVpAyFHQemcbMLNWLBkGUTceksOZJ2utPJvJqlU6vQr2orRBkzra+lii5zQ4xb9SJIcZBYdhm4iOmK3GGK/GgazimJl+ccfxasN/ZXsrPUrBf5OaSUjEQ09R6kn0aQnZIPkPGYrBz0dpw0jHwUmxau6qrJHjIZM2kBOSPkaBNnsSFDtaX0nXJjX52J5s6OR20WIcIxUb9BWoppzXZWmhvaiSCLjYlXwGKUupbPRPXF5PB6gPTWU7ZXq3zToPum6Wnn/Wieo2WBKNheLkbf/Koodnp8KmdfWiZjSaIWAw93Fqoj1QeH4DQHbK1jBed5a8o2wgJ9/MyyvXLNXqXRcnKY1TprM6PFG3zIXkhEO+68EEijPbRNVfvQEdRlq+9PTisuGLr92nWeLrFh1MWnlKi1dN2qitZVrnwFfrCqLZqEza2XibovHX8Y45BUcEeqByb9JodDIGAkSWS9WQdc/2CrW5wt81nMP5DyudP5cpf2OQwRWr+yb6NficJvUIiXrGaei7rgAfpNsW+qCj/OABQeYTZmlzCd3lVIZVaOaZf6qJgV1hlJfkafcspebQWD3Y3jWId1mkRdUwHkq/ghslnBGD1U8HKVlmUeeaxXP8pcUucSafNTVr9vmT4dqL23QPiNvBoY7QMfap2mfhXPIYBIipcRgUc6qyiiZ0VLQebCPHaaPh+A3NFKSdSCQrjhTZYRwVN3qc/tP2akxfA3G9nFEp+sqVRA6UpVShN3fHJQ+Wb6zuxtadWLkdz4Aol3UEbNXo9Y5AXr8E86y6kXKajzkZkiV7+Zid8rUO87tLkocvtLqIzMhN2Kin5tMrcEhbqocjrdJ2f+jF6vv10k0xkM92LFTC6YaPzd+1/xDGyDH2dkdnOmsF2N7U6ApjtPKcVVYKMEREts7gZIWJY5Nzhs5QAxDfXeESMVzsbbX5Wj0y7ZFZ9dJnL0CYZdANY4E0q1dKV+IK+SCtRRmMYXDy5Uod+YsJUVn15is0ZEw/BnF595sMzhskxw4XxcT1KDatsR+i1a8wOR0UoZZP2FNJPyRE4FQ1fq1pAHue1GADaRSlhNDBPyjB7LLvl1EsdJJlWFPitJGFvZm7UmRpYiBT0L66iTc93XsPbFgHhesjV58HGCE5Ky98vsHaOw+Z4osXwyF+JgijkKabZWG5C11IMu/PjCqTX2id5uVkZfsBMUtWba33mErVAsh/7oGoGveaa3QdpQwZazmgo86EHr2VryXr+5F/OuNg8NzXWzKPhhVah4d6CPv/YU+ldAK+Lhg9avEjvMFffTQX4x0+s+OHuQnqzPpvlvDUB/5KF/zhx9Wqp4cZT4RkWtD0xYuVnuB9Voz9FvQ9rNCsPn2RpLxgazKfGFP+xXv/qAe/O5+dH5GO95BNx8uMprfoRXQd0qglPmPlPjJ4xi4FdKteVXFfO/XJarHsd38k7pdclmZSumZGWSVCmwfRbYT6GgbEqUw6hQ6WyE7qUTDYplkOS390wb5UXayQed7y7EFzPpK7QBRat2FZtIhf0Zsjl9zMyc3TPP6HQy9zmdL1hrPGOC7C1VJlVI4/OSYjJIH8XXk+8ml080gdsYUyPwphQrM0qEwNqeEIveDc1QrprSTvJGAl1LqVA2Mc31Avn6BHajhEqra2Asc+mSrUxr43lAoMW+mkE1LM97cZjuwPeWo9ccSlStNPlXDiiwfLiAz/int8YtGPvFXxzh/AXeZw+lbMM9/aMnl2HpjIecz8cKOgfrrUh+jpgOHuzgXJGIb7VZjIl/z1v5rEr/7W3EJs02j/uiTHQw+Uh7wyV3nY7ToI/vdKjqAYgXoAtQeLyrugR55vyHhaASsy/0Y+wHjpayb42a7R3qSQHLcElMeTfPFful1UHCzlXGzxnf0ar7IplGHC5Z5AYds6jUfXPO/biveGmtwlhUbP0C5os99DUaD66KtjkXS88VhMbdu90H4AU9WAba7Xzwwlap25V+btV78Kh7mfPUlt9YaxFpve4s3Ozjt+gaQs6zBN1nH0IFbdfeFFXskakvNUw8ctlbl3WP+sSe4JNgjk3rsDTF1Fax/gDnu4VdoP4eptQaxKGniqYNPQoR7f4fv/RETN3VRaN3Vv6157H/ab3MgBhJqDnSwhhljbBwCL6FjtESotorm6CMNX9Kj/0suuXBnQ56vbzlTQeuQh2s9Akjm90KAZK1yr59ScvqmBwlzEBJRFpzeO0REimVnWJWXi9XhNsJ2meL9plqa0QqkyzxiYK8w5kIrCdif1YpvtZYvZaXVb2gFVNZth1tk9qlzzDVQNlJOrseGPvgjF6t8pBw/VR2ltTTG6zc0PtgPnrLRO4I/1IvVbOVq4cdAnRx8V70WOf5P5zRzdU3yb/k9sdbGRGQjihDp+wbTfmW16PT0qNGLZGJ1lLORU5IAolV5XbDaR5l/jTgc0V0axEPYv/Zo7X0SE5/rVQUZYCVvGX2ua6Nto1lM8mTDF6jizWuuTA2Fkr91XQugDQ3l9VLVKbVIcecEC7Lo0vJue9rLky7DGwBxdNr6mAtWlJTbTmYGKIj2lPe4N4+EaNop/0QpKX3iE4+GqkfD1O1CZly4CWglSZmzxU6rkRoXq0rk9RulvCjGLyjzBYnit6oebLHVYsuFTnyftdJayVn6iJCkwnHWEblfuqUTHj+S8WJdvoS9N4Mg63b5sODvlJldlitMK2izEuKbr1miq1jX9Og/4on2VT9HvNNyLlYFIw6WOwSRl30JjF6gkueey4NbMZN3s1/zqvQI+YjP31mDX3leIhXxnWj4FL+pYemLPy9a3v7FcJFdn6iJUhZpfEM+yFbGszwf2cvrwr0JiflIZ/z75Et9ZRPfKel5nf+fzLgQJxQJ18UFojccor5YxX7GHz5BLSDwUyX4FWf82Bf6+LVE/KHQ/BiHIjgZHI6DXGjH+FJcIe30xYCa1+OkT1L+AYr8GUjTrkC5jsau5jrnzrmdiX06it8bklJySrpUWFW1a+ipi3XQPvBJCih9je/sVz4ZmNgXq+hzfS6zch/Xk6LnlNqXD2m0CMVSNZXNWR/WeF6KBWOE6NNxPE3j3YP6I8waFajv45yBnbT+2vpOG6iq/JnnTCc7C+TJmvJoI2OlqkOai5qkNXZrXYpekb9Hg70l785jrOJjzhvSLGf7zYyqMJJlWXUqv6YNXCZfd7mPUp/zhfQqQJt/gUEi5JqbOQOH9HBuIt9jX5n5PhpcQfo6/ZIj9ccD8Ish8Rp81lNPht1U2myfiHmsseKlDcvYt/6K4Avr9iEBReFirrpFhm2VIKFP26qT/VtaiAGg7JEi9LA+R2ONCqclLD2pp9qPPqGfqPZrrW0HoZcGCVljjI4OyWaORyNocVuFnfaJs/zvapqXX3tPLLpYBUG00budM7WXpI/9mjyqibEyYT/NdMlZjWAZFM8hz02Ugn/uPZgzq0Ip6NeoG72WDfgGoz5u8KTmm2tFam6EX+Or9deYsmE+P8RZ3NScIzI9TeO86ivs7WfeB0ncNZWvfbtfrIu0GVyNkown8/uYi1V+h2Q/eyMXDjhLhrGrzsyYjW9dkyIeRTZx1knMe9MwGl7fshlSSDzR9t+NYvY6SzjGrdqgvP5alddUxRx6oCqEkf/Tbp0aTYuuPMQhd966aJ+BNrt/Lf0QLcNNALAfJSqt/uWHEgGplklR8m9KQ7eHShOfIRaa9McMztP09A048T4i6O/z9gU8Y2yWIpazSU9Vc3FQNY5Lzu324hI/+zdxXCgQ2rdmDTBE5LGFLGBcmFnwXXRnjT4N1Fsqyi3bhnyhzKjJ0ft7Q31W1yr2XbexdHLMGOQTWfLOdGLIyMcXjBHVokbmA0M81BZHG6G97X7lCf1tV1ystkX3I4aphgc5kZlV0W54E6i4e1WEM00uNFb3B8W7EHW6XndOfwK/4lgbk9ylJTMBiNtkW0ZAUQLOiVW8oBIKXPuujOzK2Hm+K6SsunInSP0cGSAsneFfOQasQlwIjEpIE18aJqy1HhQtuquuLl/4zCPXDV7XuaYPQiFtyKJBOPQfGtBYZIG5hjGz2PqUvRTt4jsov4tiQU66nesjBa3dgQ52p2sichT7RQI0v2jt06F/5rVNl8HCQqhxYB2E3ooqHurXMrvc8Jc01LrZtN8zrK3UEZrI1R81J881ezPoDSEbY0KT+MhXnst0xr+uVYn/w+pf8+WufpWfQif1q75a+PJ/WhUqj1fuXCaKrELJUU496CDtXxCGLJt8TmLWrc0wuptn98vCKqc9bBB4cbL1tYdZSMVCs0NL3KiIfWJCliOfmeePeZOfWIWKhG9S62POty0h2ac+5wYL8ZzX4FS6DRUYDj0kehh4/dulV8pJptPM1I67BhmZeiAw21GnJ2VV6LiCqgvOXLi3X2mD8kWkUwfHXqEln91GofIcFjq6sjVU7zj/UsERdHGsSRp79tT+3dOxyp2fwkDxNTmgTKSagOvikwGiMbc3Op5L2OkJxStpfUtRPxEstYajLVL5S/EeduKsm+7thyC1VzUZpaTfWKEfk1UCgq3ROddda7acFUCyire6OubrQLrVELZ7PJgkJRUptlLfeyPP4gqHjQM9zhrLZtb6VSbdzqMOdAyGwpJe7vVZa/9IGAtHv4Hk42gHqUNCVucjRW23c46je2TA+xdJ90XwkFY4+mMeDYlnNiqXOktlx31TofMlN/uzsCR87rFqMlPgtjgmzOw9hjnNUORKVxKad/gwyJxZMnZY5GssdxofevhUOp6YoLrDUZLLy9KiKgmjY6ajTa3XuM0N9VXDHrP5CJNCPyFpjUnn0bZodWghwiE9Sg0laFmIdK1vDquV8lmvNXDPT9ID6XyhwllluMluPRX4jZYDdA7NNMiozASdAeEDXmTmBkKobzrkCA77ZWLEHanLNMVbO2jpXf+W3fA3gXVc2H9rZZewm3m7sOVaXN0x4utaxZrd6cp1rDFydOiSpNHWGoOUp41zZZitD5RmriuW0pQ04Yd9vOuoMTPGCCgb9mbs0Lras9F7b7NE6v5Qfg1YNVDJGXGF3XDgTaCMxGSerILegAHc1vzco7Mj1ZG+iyTqH1pBPkNycXQ5Hz7CU59NRDzJvdBWgNEgwX4iM35tjOy+G6R4T9+dbkjZfS8OUHtz2jyFaCFOjLaSO9aX4YhI+eiDhoKrr/woUHaerHowi8GdqyKahWXzZLmcdNFVsdOL/LAIIC8XOAq9gOMWDApWEwP5ui/mgZw+6qiFiv6dPaBwVJbyU15DUuj+VSNGsxKIP7/GSJo2YtacwCz60YMc7rnOhsfptDe/TirU3ar4GQWRwy7r0qcXU9tYm/t5Xz220ULr9VGw3mjJYiKbSg9trGpg8aGLRn/XmHIZgfwgKedEaFXQ+cqTGCWRUn75M0HirkwGeK5B9JX+plHbdqv+kaezTT1jgpOz23RMaj12eK2fnPKpuixfbKNKfxLmtBsG+r1YFalc5yX3HjaHag939fqOpZtX43J9hQ24l4dCnvxVf+mg68+IWnc85/Gjv+RQtWqWHW3j+cX8NdD4lv510uA1GVvSdWJ7K5PimkZlU9Upsg3645UvsyuToUBoG0qOJ5MGSvXX8l2cs3zN2aLm44Yb309sXZ43xdR5/Bqfo8x7yAYz1mHS35kslfE8QYE8N0T4gDbkQlVxmeEiK49+BYJaowJajmp4gO+yE78e2+lmbgp0b7ad+YEkUY8NNFFWyBO9IPU7Vh5hLW7/1jlD2SMu2dNav+DGdo+f+oDcDkjMivC3RSLH+tB1GjZ8pFRa48cZOKlCRaifjRfIcFaG2hlZ4vJJVy+MH8Myb+rn/4i3r3DieKuHQh3PmZ/dt/7wtIzzY8JTjx98FJ8gmLHfOuZ3ppKhiswoKD1+U0I+Zd3zdNSY7bmS/+OaWi1rYyWoPyylz5lvHnYqS50g8ZljRa7b86ts4EaT64aPttiRswUery2rMBeLohpE+fYgSsnVQX91xrDUdb60rVh8n50J6F4a7w24niAbaO0CNLb69JN2A7VYUY9PRdhvtC5r8HiUndZBWbUNiM3PodTPGZ8Kx/yvfiCfusgGJYp9/pgtmTGpfuKsqyj/9AXLHP/WPKgryCufslCK3Q760JXkvM/rUOkDels5/b2n9let48i5TRglp7kO6+L8ovYpo3J3GOcE+S0jX2ObRaFQp3FiU3rI8Jc33/h4EbIOUdvH+lvR7uv0V+ro16YRpZ8osXZlE/q/VRhKuV7R+mpzzR8054mT6vE8Jo8PP9BG715TXcwixagrpkio5LtNaNCYyI+s4WsYVZY/HTrS9arfNNasTgeGHcVm0XF6Uqgy4GEnjPOXPmRx9BzTH/n93DQtCPoCE1ycyYNOxwY8A5/PK6r8zP+HM6Mdm2H1ecwPk1JHE0zw4aN8K1+zWwUpq9Fhf/gy1wX5TjzziL4zp1yGrcrnrQr4k23YDh3aL/yiBejzoHkRsaHSz114IRfYaqMN1IFQMrd5n6pP1eFQZF3COftzIj5Qa/s7B9vBmmHnk6ty6fWDqTHMaJ8CkdvjuDWopN9sSP+ho0YDiZxfSHp+04LY0NTrBEf6mrCtdIka7LGBL5RsU+0Lyu2/jI1ostYRB/jyj/Cz3EfQ/XA/Iwa170AbfGjsMXR5u24P5drBCzUqng5IfFfu1i8ZNrCYmaGepbgaJ2egGm284AXFiuYEdbETyfdMVHpOkQVd3+WSS7CnPOGg1DYHUELs7RhY42sdia3H5t3bUS4w7UsKh5WJMlkygFfysRfxQut0qMPROoRxoeqjcBXjfWBfO3FSKLta4dU26TBOHPeGRb+FgjkacHCPjoXXSHzmtr2dp+Ois3OnVWsZoK7GfuHoExnUC9BKHnYrSrCGoMei12aF5OHbcUIS9dNKl4mRNF8L6Seb/TTU/0+Vp648SSWuMZ8wtHsqqvwmJU2Kjjo5jDniEKv4JIZAZlPnOavC5I48ERfBUGZ9twdCJnnE3TanAYUiYuYLgXB1WtIaT6Vl+XRtuQzoFBs6KHk6wUiJp6rC7kd6tMPdUgM5LwmPPYyIM4IOjUpYbilaeRxPRh/5JBZio8eY8IZvrdJ6dcjfZYgxmiq0P9P2VSL+Ta3m63XDU0z5pNmgVBgiHr4BDDrIS6ryDvk7/wpQP7bG3ravdVXg8ECPBSrvoCijINnWJZsmC2Wk2Hj0rFcv0yy3d1RrTDngUSRa1oCKjPHrzX7ijYzLtPAYeuPKzYu1bt9YU3UZhdLIAPYgVgvs565FfItgSq5tv/u+922f+VmP3z78wx4o+ijTx/zJP7W99O/9mNmpNu3P8X3v+53tcz7jc7aP+LCP3D6s6D/9k//Z9vde+mMuv4xUulrS6DXFbzOAYd/kTK2agc6yRUVAYeVHQkf9ee8pH3ePdl/uYBXRFdeqpnHCjjdd7ptg3Mqx6oHqjnsBe59YP1Ayu1OOwHBgpI38w2Hgylfhpjwxu1TPfeKIP4TUkDUvsWyVk1N+8dgtGgYv+zsj3oq/6mZ40YqWtv5FpXlVncPKA2GpxAH6PNWYPolUCBymG5JvFQe6wL7etXwIDVrFWSJx9a42NWi1N7GSdXyPzH1RFcYfO42WPNTYLL5etTtKzwLr9poSGV+UOyYw6Vy2oBJzbdnX1XDyIG+inNKoqH+3YFE5FSRMHyxkR4SGyFVgnURE0R3pQMhh9kn0RX3XURh5DVmlJLb55q7agKtbKkR+ynsedUiWs50X4I5YMu3IbsUpEzcKun9MRoeXsXj7/kHMCjruzUpRD7E0dmImS9qWildhd45LRiMbSiPcChxfeYbkAtIsVjg/HZDve06is1o0QevoVFrUIZTzV5cv/B0tMADymSeH0X4PPhrNZhS9yC+6hGxZSB1eqA4tIz+DreB6QYfNJz930wXnwcCKsYgHKtVfXDyXibSXMhcY8ULlS8CcpTKUI14YWKJVPJBNF/qoFf9Ep+cADF33PjDwJBnl0UvjL6hMLRJsqHZLXvkmOdKQ2Z5QkZ2bhx2V6VA0Tpq2QLQ/BorX5q25abd9RYLYWIycIYkZtyrqGyppcRlvkM64vcQq+C6kMkx8uCjsC0OV9x6NNHHa6otIE3l1gWlZlYt8QaoyniRxEeqLVC5OedV3R8m7AUmQH4kLRWbINo16sa9trI/zY2co5ea17MwLKc/to4y3IpjP0rHoklnepPZFtF9fNiEbe6JzL4MPlIznHapcn+t+yiDirY9oKEr/EOPea1+wO3cJa3/PiFDoY42ChCoypT7Gc9Ah49HrQxNSLSTq74c3/yhS3ab+dByZ5cOd73yH9zhRHUEwY9jS9k5tkuHgPKjG6UiHB+LiKK8f06Pxp3KLkEx+6qx6l+qH1i5ey1wpdLloTaAhvRgiDfUxkC2ScWtZc5Rjkpl+jRQ/yIH+f60kVcbF4fyk1eTP9bv1a3207kbnNyhkMdY5RFHrkALqau+wyo71wB9Cak2at5HSl8QpUT4VqmL3LzkapP52QqoyDSzrHANZNSkCAUIrM41cRd785t/a3vCGN1ZO8D5dwL7xjb9hbqpw23WA3vyv3nyU/w3iD1q7LalktVtkPysCudg/xAKFYVrZZ7I6q1N/fZoDwk84ymsBRIZo+piDj4K5C9KED2mcdVHLLcW0l+E7vTxp50LVG2jKoi12lz6JxTdJNtr2lfaQHs8pxVRobTp4mCYqrLZWPuNnpxW72HtBLXcVuvQwDGKztEtt93WXZGCWX6jLPqEcSt3jquzQbhueOFCza511yh/gcVFjOIux9LioOYtKNk+q94hHJ9ImPrqov564WZqko/VGNAXRPNtCnZU5Q8NCQUQrSwcabmr9qqvoGMiG2vfD/+QnJiSvvyaQdOXBJ5/5IqbBYsEQEWhprxfRT5gMr5eKpv9p/4nDvG0TAsO/dsi0ixopm+VFAt/VZWcNoZc3PK1TvmFPPp5utjKBaGc1TaWT0IjTmBd7uLX+8AfGK+UQaVH38GJ5VyY5BOuawHKdF7h/+KssD1uHqpW45gjxMZy1loTIk5AoXuGNLZ6loqiUCdRrgpUMKfWa4XkRq7E+Vw3QKn0Z9/trwGfqTB7DewDRqcoz2fo0xINUcZZ7wFsN7fzBT/soFPzDRnwU5gSdBb//j4/5zUNcRykinn8dQwKpnFh90qlOvagfAICrESsCbZkd0kXRPeOAdu75g86hrQwQp1uIuyUFylMoLRLuTV/nYSOAzfUqC31ulnDTg6YRvUkn3j+NnTtKKcsJRzF87oUvvP1LiBySA3/FMHSclSRtw9PXAUvsZfADTxatsL9TSdR0ff9raIyXbps962p6WMcMhxyIY5PCccdMwm5bKRwLWwlmjCgusynhgiVIXdbSBgj5kZC2Vx+YJIt6c7VBA+GckLzHWumuIu8jxNc1uW+XeGlnhLq+riubDuURJ6tspYre7Ma45N86sQbDPB1HWjbkJ/UFREqvk0wURxjhyKJP+iWTNIUCmzbFuS8X/fnUnxD/g6T3yLIqsv6sBsRwEPZYlzNAItW1xjCziNbEk8x2tbI6ihwsQV+H9Et+gEO8YTOhJSExbWq6QpSIvPJUvcyZiWTmmHZfeAMZHtQsrSo+jX9HcCz92zZE7JT1zXke1YH5ddDf3dV9rTNMipUi/+phFbhrMUL0f7zrnduL/vbf3t7+9rdT2NKjqRU4/KgHPnD7zz/+4×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
That is a very unreadable very very long reference, dear Dr Ben !!
Sorry prof, it was a system problem, but it is corrected
What is a decoy cell?
These are renal tubular cells with nuclear change due to the cytopathic effect of the virus . There is nuclear enlargement (ground glass appearance), chromatin margination, abnormal chromatin patterns and basophilic viral inclusion bodies of all sizes. They are called “decoy cells” because they can be mistaken for malignant cells
Sensitivity and Specificity of Decoy Cells
Decoy cells have a sensitivity of 25% and a specificity of 84%
Negative and Positive Predictive Values:
They have a negative predictive value of 100% and a positive predictive value of 29%
Technique:
This test requires a freshly voided specimen that should be centrifuge, fixed with alcohol and stained with the papnicoloau stain
The presence of decoy cells in the urine only has a PPV of 29% meaning that it does not correlate well with BKVAN
Difference between decoy cells and CMV inclusion bodies:
The decoy cells in BK virus infection have intranuclear basophilic inclusion bodies with chromatin margination
The CMV inclusion bodies are central large eosinophilic intranuclear inclusions surrounded by a circumferential halo resembling a typical owls eye
Management Of The Case
This patient has a BK viruria with a stable graft function. The decoy cells in urine have a very high NPP but a low PPV for BKVAN.
The patient should have a serum quantitative BK PCR done. If the PCR is more than 10 log 4, then he has BK viremia which has a PPV of 50-60% for BKVAN and the first step would be to reduce the immunosuppression. The tacrolimus dose should be reduced by 25-50% and the MMF dose should be reduced by 50%. The BK viral PCR and graft function should be monitored closely. If after 2 weeks, there is no reduction of the BK viral PCR or if the graft function starts to deteriorate then the patient should undergo a transplant biopsy to assess for BKVAN. The antimetabolite should be held if there is confirmation of BKVAN.
The use of antivirals like cidofovir have shown conflicting results
D Sawinski et al. Nephrology Dial Transplant (2015) 30:209-217
That is a well-structured reply.
Decoy cells:
Decoy cells staining technique:
Differences between decoy cells & CMV inclusion:
Management:
References:
That is a well-structured reply. As much as I adore my academic brother Ahmed Halawa, writing that his lecture is a reference is not a complete reply in a scientific write-up.
What is a decoy cell?
What are the sensitivity and specificity of this test?
What are the positive and negative predictive values of this test?
Describe this technique.
Does it correlate well with BK nephropathy?
What is the difference between decoy cells and CMV inclusion bodies?
How do you manage this case?
So … In the current case
References
1. Hirsch HH, Knowles W, Dickenmann M, et al. Prospective study of polyomavirus type BK replication and nephropathy in renal-transplant recipients. N Engl J Med 2002; 347:488.
2. Nickeleit V, Klimkait T, Binet IF, et al. Testing for polyomavirus type BK DNA in plasma to identify renal-allograft recipients with viral nephropathy. N Engl J Med 2000; 342:1309.
3. Colvin RB, Nickeleit V. Renal transplant pathology. In: Jennet JC, Olson JL, Schwartz, Silva FG, editors. Heptinstall’s Pathology of the kidney. 6th ed. Philadelphia: William and Wilkins; 2007. pp. 1441–8.
4. Asim M, Lopez AC, Nickeleit V. Adenovirus infection of a renal allograft. Am J Kidney Dis. 2003;41:696–701.
Decoy means fake or tricky, decoy cells own their name due to its resemblance to the cancer cells so it may be mistaken for malignant cells.
Thankyou Exellent as usual.
-What is a decoy cell?
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×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
I dont know what happened , my work is lost
Please stop for a while and start again
That is a very unreadable very very long reference, dear Dr Ben !!
What is a decoy cell?
Decoy cells are renal tubular and uro-epithelial cells containing intranuclear viral inclusions. this reflects urinary cells infected with viruses.
What are the sensitivity and specificity of this test?
Sensitivity 25%
Specificity 84%
What are the positive and negative predictive values of this test?
Positive predictive value 30%
Negative predictive value 95%,
Describe this technique.
Decoy cells are usually detected in a fresh urine sample and processing should be rapidly done with fixation in alcohol. Phase-contrast microscopy is required for its examination by an expert person.
Does it correlate well with BK nephropathy?
The test is nonspecific for BK nephropathy but 50% may progress to increase in viremia within weeks to months. It is pertinent to mention that PCR level of > 10,000 copies/ml has a positive predictive value for progression to nephropathy of 40-60% within 2-4 weeks.
What is the difference between decoy cells and CMV inclusion bodies?
Decoy cells are renal tubular / uroepithelial cells that have enlarged nucleus, containing single large basophilic intranuclear viral inclusion body,
While in CMV there are cytoplasmic basophilic inclusions bodies with complete halo around (Owl eye appearance) in epithelial and endothelial cells.
How do you manage this case?
Detection of decoy cells will indicate close monitoring of blood PCR for BKV and if PCR is > 10,000 copies /ml reduction of immunosuppression is warranted,
like reduction in (antimetabolites) MMF to 1 gram daily then followed for 2 weeks with PCR testing then second option would be withdrawal of MMF, then followed for every 2 weeks with PCR and subsequently reduction in CNI doses to lower limits and then addition of Leflunomide or Ciprofloxacin but no proven evidence in the last two options.
References
1. Nickeleit V, Klimkait T, Binet IF, et al. Testing for polyomavirus type BK DNA in plasma to identify renal-allograft recipients with viral nephropathy. N Engl J Med 2000; 342:1309
2. Asim M, Lopez AC, Nickeleit V. Adenovirus infection of a renal allograft. Am J Kidney Dis. 2003;41:696–701.
3. Colvin RB, Nickeleit V. Renal transplant pathology. In: Jennet JC, Olson JL, Schwartz, Silva FG, editors. Heptinstall’s Pathology of the kidney. 6th ed. Philadelphia: William and Wilkins; 2007. pp. 1441–8.
4. Hirsch HH, Knowles W, Dickenmann M, et al. Prospective study of polyomavirus type BK replication and nephropathy in renal-transplant recipients. N Engl J Med 2002; 347:488.
That is a well-structured reply.
Decoy cells are infected epithelial cells that can be found in the urine. Decoy cells owe their name to their strong resemblance to cancer cells, and may as such confuse the diagnosis of either viral infection or urothelial malignancy. During 1950s, cytotechnologist Andrew Ricci observed cells mimicking cancer cells by they were not, in a group of persons working in some kinds of industries – they were referred to as “decoy cells”, analogous to “decoy ducks” used in hunting wild ducks, by Andrew Ricci, a cytotechnologist working renown cytopathologist Dr. Leopold G. Koss.
Four morphological types of “Decoy cells” have been described in literature:[3] Type 1- classic decoy cells characterized by large, homogenous, amorphous ground-glass like intranuclear inclusion bodies and a condensed rim of chromatin; Type 2- granular intranuclear inclusions surrounded by a clear halo, i.e., cytomegalovirus (CMV)-like; Type 3- multinucleated decoy cells with granular chromatin; Type 4- vesicular nuclei with clumped chromatin and nucleoli. These inclusions may appear morphologically similar to CMV and adenoviral inclusions. However, trivial morphologic differences do exist which lend a hand to tell them apart
. In BK nephropathy, the finding of urinary decoy cells showed a 100% sensitivity, 84% specificity, 100% negative predictive value and 6% positive predictive value.
Cytospin smear is prepared from a fresh urine sample, fixed in alcohol & stained with Papanicolaou stain or contrast phase microscopy.
Polyoma virus (PV) infection is being increasingly recognized as a cause of renal allograft dysfunction. Association with high intensity of immune suppression, especially with tacrolimus, mycophenolate mofetil or sirolimus has been observed.
Polyoma interstitial nephritis includes an early infection of collecting ducts followed by cytolytic changes and tubular destruction. Evidence of tubular injury in the form of apoptosis, cell drop out, desquamation can be seen. These desquamated cells having the intranuclear viral inclusions, better described as “Decoy cells” can be easily seen on urine cytology. Although light microscopy findings are definitive in most cases, further evaluation by immunohistochemistry (IHC), electron microscopy or polymerase chain reaction (PCR) may be necessary for confirmation.
Presence of a clear halo around nuclear inclusion along with identification of concurrent cytoplasmic inclusion is a helpful clue to diagnose CMV infection.
Severe cytoplasmic degeneration characteristic of polyoma infection; when present, serves as another useful morphologic clue.
Decoy cells alone do not need to be treated since they do not necessarily indicate pathology. However, in the context of overt viral replication against the background of immunodeficiency, the viruses that cause the emergence of decoy cells must be treated. For polyomavirus BK, only the restoration of immunologic function and the subsequent reconstitution of cells with antiviral activity such as natural killer cells and cytotoxic T cells has proven to be effective. Restoration of the immune system can be achieved via different paths according to the different patient groups. For example, in severely immunocompromised HIV-patients, previously called AIDS-patients, immunologic function can be restored by treatment with highly active anti-retroviral therapy. In kidney transplant recipients who are treated with immunosuppressive agents, immunologic function can be treated by tapering of the immunosuppressive regimen. Other agents that have been proposed to target polyomavirus BK, such as cidofovir, fluoroquinolones, leflunomide, and statins are far from established and the published results on their effectivity are conflicting. Also, some of these agents may cause severe long-lasting side effects.
Reference :
1- Drachenberg CB, Beskow CO, Cangro CB, Bourquin PM, Simsir A, Fink J, et al. Human polyomavirus in renal allograft biopsies: Morphological findings and correlation with urine cytology. Hum Pathol. 1999;30:970–7. [PubMed] [Google Scholar].
2- Colvin RB, Nickeleit V. Renal transplant pathology. In: Jennet JC, Olson JL, Schwartz, Silva FG, editors. Heptinstall’s Pathology of the kidney. 6th ed. Philadelphia: William and Wilkins; 2007. pp. 1441–8. [Google Scholar].
3-. Drachenberg RC, Drachenberg CB, Papadimitriou JC. Morphological spectrum of polyoma virus disease in renal allografts: diagnostic accuracy of urine cytology. Am J Transplant. 2001;1:373–81. [PubMed] [Google Scholar].
4-Geramizadeh B, Roozbeh J, Hosseini M, Salahi H. Urine cytology: useful screening method for polyoma virus nephropathy in renal transplant patients. IJMS. 2006;31:109–11. [PubMed] [Google Scholar]
That is a well-structured reply.
-Decoy cells are renal tubular or uroepithelial cells containing intranuclear viral inclusions and denotes higher urinary viral load
.-Sensitivity and specificity:
sensitivity 25%, specificity is 84%
-Positive predictive value for progression to nephropathy is around 30%. Negative predictive value >95%. BK nephropathy could be ruled out if decoy cells are absent.
Procedure:
Fresh urine sampling with rapid processing. Fixation in alcohol and examination by Papanicolaou staining and phase-contrast microscopy.
Correlation with BK nephropathy:
This test is nonspecific for BK nephropathy, 50 % may progress to viremia within weeks to months.Positive predictive value for progression to nephropathy is 30%. PCR level of > 1000 copies/ml has a positive predictive value for progression to nephropathy of 40-60% within 1-2 weeks. Around 50%of patients with viruria can progress to viremia and 50% of patients with viremia can progress to BK nephropathy
-Difference between decoy cells and CMV inclusions:
Decoy cells are renal tubular or uroepithelial cells with enlarged nucleus, containing single large basophilic intranuclear viral inclusion with incomplete halo; mimicking malignant cells. CMV inclusions are cytoplasmic basophilic inclusions with complete halo; Owl eye appearance, in both epithelial and endothelial cells.
-Management:
Presence of decoy cells mandates close monitoring of blood PCR ; if PCR is > 1000 copies /ml, we proceed for reduction of immunosuppression; adjustment of tacrolimus dose to trough level of 5-7 ng/ml, reduction of MMF to 1 gram, close monitoring of PCR every 2 -4 weeks since half of the cases may progress to viremia .In case of viremia, we proceed for 50% reduction of MMF, and if no response , we proceed for reduction of tacrolimus to trough of 3-5 ng/ml
Very correct in your last statement a blood PCR is mandatory even with the stable graft function.
What is a decoy cell?
· Infected tubular epithelial cells, with an enlarged nucleus that contains a single, large basophilic intranuclear BK inclusion body and looks similar to those cells seen frequently in uroepithelial malignancy (may also be mistaken for malignant cells)
· They may also exhibit “owl eye” inclusions, multinucleation, or clumped chromatin
· It is a good screening test but not diagnostic of BKVN
· BKV shedding in the urine is common and can occur in up to 30% of renal transplant recipients
What are the sensitivity and specificity of this test?
*Sensitivity is 25% and specificity is 84%
*Urine BK PCR is more sensitive than urine cytology for detection and diagnosis of BKVN
*In a comparison of urine cytology with urine PCR, decoy cells had a sensitivity of only 25% and a specificity of 84% for BKVN compared with urine PCR which was 100% sensitive and 78% specific
What are the positive and negative predictive values of this test?
Positive predictive value is 29% and negative predictive value is 100%
Describe this technique.
* Decoy cells can be seen in a urine sample through Papanicolaou staining or phase-contrast microscopy
* By Papanicolaou stain, most decoy cells have an enlarged nucleus that bears a basophilic inclusion which is surrounded by chromatin that confers a ground-glass or gelatinous appearance
* This technique is easy, reliable, and inexpensive
* On Papanicolaou staining, the decoy cells exhibited 4 classical morphological types
1. Type 1 classic decoy cell contained enlarged, basophilic, homogeneous amorphous ground glass-like intra-nuclear inclusion body
2. Type 2 decoy cell contained a single nuclear inclusion body surrounded by a peripheral halo, appearing as a bird’s eye
3. Type 3 decoy cell contained scattered clumped chromatin
4. Type 4 are decoy cell contained cytoplasmic vesicles with fine-grained chromatin and nucleol
Does it correlate well with BK nephropathy?
· Presence of decoy cells is strongly suggestive of polyomavirus infection (a marker of PV replication) and considered a useful marker of BKV reactivation, though it is not a real diagnostic tool for BKVN
· Viruria is detected in approximately 30% of kidney transplant recipients. Around 50% of viruria develop viremia during a period of 2–6 weeks, with a similar proportion of viremic patients developing BKVAN in the aforementioned time period
What is the difference between decoy cells and CMV inclusion bodies?
CMV: involvement of endothelial cells is characterized by a central large eosinophilic intranuclear inclusions surrounded by a circumferential halo resembling a typical owl’s eye. In the cytoplasm of viral-infected cells, there are sometimes small basophilic cytoplasmic viral inclusions
Decoy cells: Infected tubular epithelial or urothelial cells, with an enlarged nucleus that contains a single, large basophilic intranuclear BK inclusion body
Presence of a clear halo around nuclear inclusion along with identification of concurrent cytoplasmic inclusion is a helpful clue to diagnose CMV infection. Severe cytoplasmic degeneration characteristic of polyoma infection
How do you manage this case?
*The KDIGO and AST-IDCOP guidelines recommend monthly screening for the first 6 months post-transplantation and then every 3 months for the next 18 months
*Screening for BK viremia is the preferred method (low specificity of urine BK viral loads, and higher PPV of plasma BK levels)
*If urinary decoy cells are consistently present, screen with BKV DNA
*BKV should also be monitored in plasma or serum when an increased serum creatinine level cannot clearly be explained by other causes, irrespective of time after transplantation
*Patients that are treated for an acute graft rejection (and have therefore received intensified immunosuppression) should be carefully monitored for a potential BKV infection/reactivation
*The risk to develop BKVAN is high when >10,000 BKV DNA copies/mL are observed in serum or plasma (can occur in patients with lower BKV levels (1000–10,000 BKV DNA copies/mL in serum/plasma)
*At serum/plasma levels of 1000–10,000 BKV DNA copies/mL, a decrease of immunosuppression can be considered (recommendation grade D) (), but the risk for rejection should always be considered.
*A renal biopsy is mandatory for the diagnosis of BKVAN and should be performed upon increasing serum-creatinine levels and/or the finding of >10,000 BKV DNA copies/mL in serum/plasma (BKVAN is graded into classes 1–3, depending on the grade of fibrosis and the numbers of infected cells)
*The diagnosis is based on immunohistochemistry using antibodies directed against SV40
Management/treatment of BKVAN:
Decrease of immunosuppression: If serum/plasma-levels are >10,000 BKV DNA copies/mL, or having a confirmed BKVAN
· Lower the dose of tacrolimus, with the aim to lower its concentration by 25–50%.
· Lower the dose of glucocorticoids
· Lower the dose of mycophenolate mofetil usually by 50%
Monitor serum creatinine and serial plasma BK PCR levels from the same laboratory every 2 weeks
When a decrease of immunosuppression has no effect, or is not possible due to a concomitant acute graft rejection, alternative treatment (no strong evidence):
1. Cidofovir
2. Brincidofovir
3. Leflunomide
4. Quinolones
5. IVIG
References
1. BKV in Kidney Transplantation By Ahmed Halawa (lecture), consultant Transplant Surgeon Associate Professor, University of Liverpool –UK, 2023.
2. Alalawi F, Alnour H, El Kossi M, Jenkins J, Taku A, Sharma AK, Halawa A. BK virus infection in renal transplant recipients: an overview. J Egypt Soc Nephrol Transplant 2020;20:127-50
3. Kant S, Dasgupta A, Bagnasco S, Brennan DC. BK Virus Nephropathy in Kidney Transplantation: A State-of-the-Art Review. Viruses. 2022 Jul 25;14(8):1616. doi: 10.3390/v14081616. PMID: 35893681; PMCID: PMC9330039.
4. Dall A, Hariharan S. BK virus nephritis after renal transplantation. Clin J Am Soc Nephrol. 2008 Mar;3 Suppl 2(Suppl 2):S68-75. doi: 10.2215/CJN.02770707. PMID: 18309005; PMCID: PMC3152275.
5. Deirdre Sawinski, Simin Goral, BK virus infection: an update on diagnosis and treatment, Nephrology Dialysis Transplantation, Volume 30, Issue 2, February 2015, Pages 209–217.
6. Management of BK-virus infection – Swedish recommendations
Well done but the role of adjunctive drugs is controversial .
Thank you prof, yes
What is a decoy cell?
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What are the sensitivity and specificity of this test?
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What are the positive and negative predictive values of this test?
===============================
Describe this technique.
===============================
Does it correlate well with BK nephropathy?
===============================
What is the difference between decoy cells and CMV inclusion bodies?
===============================
How do you manage this case?
References
Well done
Decoy cells:
BKV shedding in the urine is frequent and can occur in 13–30% of renal allograft recipients. Cytological analysis of urinary smear may reveal characteristic abnormal BK-infected cells, termed as decoy cells. Decoy cells are infected tubular epithelial cells, with an enlarged nucleus that contains a single, large basophilic intranuclear BK inclusion body and looks similar to those cells seen frequently in uroepithelial malignancy.
Four different phenotypes of decoy cells were identified based on the state of viral replication, maturation, and the state of cellular preservation.
The presence of decoy cells is strongly suggestive of polyomavirus infection and is considered a useful marker of BKV reactivation, though it is not a real diagnostic tool for BKVN.
The sensitivity of decoy cells for the diagnosis of BK nephropathy varies in different publications. Hirsch et al. reported a sensitivity of 100%, and a specificity of 71% [positive predictive value (PPV) of 29% and negative predictive value (NPV) of 100%] when they matched graft-biopsy samples as a diagnostic standard. Viscount et al., in contrast, reported a 25% sensitivity and 84% specificity (5% PPV and 97% NPV) to diagnose BKVN.
Decoy cell identification needs experience. Additionally, it does not distinguish among polyomaviruses (ie, JCPyV versus BKPyV).
CMV inclusion bodies have a large ovoid or pleomorphic nucleus with basophilic intranuclear inclusions (Cowdry bodies) surrounded by a clear halo. While decoy cells have an enlarged nucleus that contains a single, large basophilic intranuclear BK inclusion body without a surrounding halo.
Treatment strategy of BK virus nephropathy: The aim of treating BKV is to eradicate the virus while saving kidney function.
Unfortunately, BKVN has limited treatment options. As BK viremia and BKVN signify excessive cumulative immunosuppression, hence, decreasing immunosuppression is the only validated therapy to treat BKVN and restore antiviral immune response; however, reduction in immunosuppression should always be balanced against the risk of triggering acute or chronic rejection.
References:
1- Limaye AP, Brennan FDC, Blumberg EA, Bond S. BK polyoma virus associated nephropathy in kidney transplantation. Up-To-Date; 2019.
2- Hirsch HH, Knowles W, Dickenmann M, Passweg J, Klimkait T, Mihatsch MJ, et al. Prospective study of polyomavirus type BK replication and nephropathy in renal-transplant recipients. N Engl J Med 2002;347:488–496.
3- Singh HK, Bubendorf L, Mihatsch MJ, Drachenberg CB, Nickeleit V. Urine cytology findings of polyomavirus infections. In: Ahsan N. (ed) Polyomaviruses and human diseases. Advances in experimental medicine and biology. New York, NY: Springer 2006. 577.
4- Randhawa P, Brennan DC. BK virus infection in transplant recipients: an overview and update. American Journal of Transplantation. 2006 Sep 1;6(9):2000-5.
5- Alalawi F, Alnour H, El Kossi M, Jenkins J, Taku A, Sharma AK, Halawa A. BK virus infection in renal transplant recipients: an overview. Journal of The Egyptian Society of Nephrology and Transplantation. 2020 Jul 1;20(3):127.
The question in the index case is how to take a decision provided the graft function is stable.
a plasma PCR is mandatory.
What is a decoy cell?
Degenerating epithelial cells, enlarged cells with high nuclear: cytoplasmic ratio showing peripheral clumped chromatin, intranuclear smudgy, viral inclusions surrounded by incomplete halo in a clean background (1).
What are the sensitivity and specificity of this test?
Presence of infected decoy cells in the urine has approximately 100% sensitivity for BK virus infection but a low (29%) predictive value.
What are the positive and negative predictive values of this test?
a low positive predictive value of decoy cells in urine, its absence has a negative predictive value of 100%.(2)
Describe this technique.
By Papanicolaou stain, most ‘decoy cells’ show a much enlarged nucleus and can be easily identified by phase‐contrast microscopy(3).
Does it correlate well with BK nephropathy?
It is not clear so far but in the experience of some authors, the higher the number of ‘decoy cells’ in the urine, the greater the probability of finding the PVBK nephropathy and in contrast, other investigators have reported that even when the ‘decoy cells’ are ‘abundant’, the positive predictive value is as low as 27% , which indicates that ‘decoy cells’ may be present without any clinical disease. Patients at higher risk of developing PVBK nephropathy are those who have ‘decoy cells’ in the urine in association with impaired renal function and repeated episodes of acute rejection, and are under treatment with tacrolimus and/or Mycophenolate mofetil(3,4,5).
What is the difference between decoy cells and CMV inclusion bodies?
Decoy cells, which are infected cells shed into the urine from the renal tubules (especially the distal segments and the collecting ducts) and uroepithelium (especially the superficial layers) .
CMV inclusion bodies, Viral inclusion bodies intranuclear and cytoplasmic in tubular epithelial cell( (“owl’s eye” appearance).
How do you manage this case?
-Blood BK virus PCR.
-Lower the dose of tacrolimus, with the aim to lower its concentration by 25–50%
-Lower the dose of Mycophenolate mofetil. usually by 50% .
– Blood BKV PCR, until the viral level is undetectable.
References:
1- Geetha V, Rao L, Monappa V, Susmitha M, Prabhu R. Decoy cells in urine cytology: A useful clue to post-transplant polyoma virus infection. J Cytol. 2012;29(2):133-134. doi:10.4103/0970-9371.97157.
2-Geramizadeh B, Roozbeh J, Hosseini M, Salahi H. Urine cytology: useful screening method for polyoma virus nephropathy in renal transplant patients. IJMS. 2006;31:109–11.
3-Drachenberg CB, Beskow CO, Cangro CB et al. Human polyoma virus in renal allograft biopsies: morphological findings and correlation with urine cytology. Hum Pathol 1999; 30: 970–977.
4-Giovanni B. Fogazzi, Mariadele Cantú, Lucia Saglimbeni, ‘Decoy cells’ in the urine due to polyomavirus BK infection: easily seen by phase‐contrast microscopy, Nephrology Dialysis Transplantation, Volume 16, Issue 7, July 2001, Pages 1496 1498, https://doi.org/10.1093/ndt/16.7.1496
5- Nickeleit V, Hirsch HH, Zeiler M et al. BK‐virus nephropaty in renal transplants—Tubular necrosis, MHC class II expression and rejection in a puzzling game. Nephrol Dial Transplant2000; 15: 324–332
Thankyou well done
The epithelial cells with polyoma viral inclusions in urine cytology specimens are termed “decoy cells” to caution pathologists not to misdiagnose these cells as cancer cells. The infected cells in urinary sediments are characterized by an enlarged nucleus, basophilic intranuclear homogenous inclusions, and ground glass chromatin, which may cause a diagnostic error in urine cytology
has a 25% degree of sensitivity. On the other hand, specificity accounts for 84% of the total.
Cytological urine abnormalities (decoy cells) signal BKV infection but are not specific, sensitive, or definite since (1) they may be found in other renal viral infections such as CMV or adenovirus and (2) they correlate poorly with biopsy-proven BKVN in renal transplant patients. They do not rule out sickness.
PPV 29%, NPV 100%
Routine urine samples are the most sensitive and cost-effective
screening method for the detection of PV infection. IHC can be used for
confirmation of the presence of PV but does not increase the sensitivity
of diagnosis.
Decoy cells can best be identified and quantified in Papanicolaou
(Pap) stained direct smears or cytocentrifuge urine samples. The
second-morning midstream voided urine specimen is best suited as
cellular degeneration interferes with the proper interpretation of the first
morning specimen. An alternative and more frequently used
the method is the fixation of the urine with an equal volume of 50% to
70% ethyl alcohol, preferably with added 2% carbowax (polyethylene
glycol). The urine samples can be classified semiquantitatively as:
• 1 to 4 infected cells per cytospin—1+
• 5 to 10 infected cells per cytospin—2+
• ≥11 infected cells per cytospin (minority)—3+
• Too many infected cells to count (majority)—4+
No, they correlate poorly with biopsy-proven BKVN in renal transplant patients. They do not rule out sickness.
Decoy Cell: an enlarged nucleus, basophilic intranuclear homogenous inclusions
CMV inclusion: Large cells that contain conspicuous intranuclear viral inclusion bodies and are encircled by clear halos, giving the appearance of an owl’s eye.
first reducing the antiproliferative drug by 50%, followed by reducing calcineurin inhibitors by 25%–50%, and then discontinuing the antiproliferative drug.
Oral prednisone is typically 5 mg per day.
Immunosuppression is further adapted according to the plasma BKPyV load and the course of serum creatinine concentration during follow-up testing at least every 2 weeks until clearance of BKPyV DNAemia or as clinically indicated.
References:
Tummidi, S., Kothari, K., Agnihotri, M., Naik, L., & Rojekar, A. (2020). Diagnostic utility of urine cytology in the detection of decoy cells in renal transplant patients: report of five cases and review of the literature. Diagnostic Cytopathology, 48(3), 222-227.
Saleh, A., El Din Khedr, M. S., Ezzat, A., Takou, A., & Halawa, A. (2020). Update on the management of BK virus infection. Exp Clin Transplant, 18(6), 659-70.
BK polyomavirus in solid organ transplantation—Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice
Thankyou well done
What is a decoy cell?
Decoy cells represent tubular epithelial or urothelia cells that are infected by the BK virus and are shed in the urine as Decor cells because of their appearance like a renal carcinoma cell. They are viral inclusion bodies with different phenotypes – type 1 to 4 depending on the state of viral replication and preservation of the cells
They are large, basophilic nuclei with viral inclusions that are usually surrounded by a condensed rim of chromatin and may also exhibit an Owl’s eye inclusion.
What are the sensitivity and specificity of urine cytology?
The sensitivity and specificity of urine cytology in diagnosing BKVAN is 25% and 84% respectively. This test is limited by interobserver variability and secondly, it is a qualitative test and not a quantitative test. Lastly, only urine samples with inflamed sediments and abundant infected cells correlate with the clinical significance of the disease.
What are the negative and positive predictive values of the test?
The positive and negative predictive value is 29% and 100%
Describe the technique
What is the difference between decoy cells and CMV inclusion bodies?
Management of the case
Other investigations are :
Treatments
References
Well done
· What is a decoy cell?
Decoy cells are uroepithelial or tubular cells containing large intranuclear basophilic inclusion and having different morphologic types characterizing them from other viral inclusions like CMV and adenoviruses. Its presence in urine reflect higher viral load.
· What are the sensitivity and specificity of this test?
Sensitivity is 25%
Specificity is 84%
· What are the positive and negative predictive values of this test?
Positive predictive value is 29%
Negative predictive value is 100%
· Describe this technique.
Always used fresh sample for decoy cells, sample should be process quickly and fixed in alcohol.
· Does it correlate well with BK nephropathy?
Based on Sensitivity 25% and PPV of 29% it is not recommended for screening purposes but on the other hand its presence in urine is highly suggestive of BKVN.
· What is the difference between decoy cells and CMV inclusion bodies?
Decoy cells are large basophilic intranuclear inclusion bodies resembling malignant cells of uroepithelial origin while CMV is cytoplasmic basophilic inclusion bodies with complete halo resembling owl eye appearance.
· How do you manage this case?
Monitoring blood BKV PCR when higher than 104 copies/ml and sustained for more than 3 weeks duration is highly suggestive of BKVN and reduction in immunosuppression is recommended.
1. Low dose steroid 5mg/day
2. Tac level 4-6ng/dl
3. 50% reduction of MMF.
References
1. Geetha, V., Rao, L., Monappa, V., Susmitha, M., & Prabhu, R. (2012). Decoy cells in urine cytology: A useful clue to post-transplant polyoma virus infection. Journal of cytology, 29(2), 133–134. https://doi.org/10.4103/0970-9371.97157
2. Sawinski D, Goral S. BK virus infection: an update on diagnosis and treatment. Nephrol Dial Transplant. 2015 Feb;30(2):209-17. doi: 10.1093/ndt/gfu023. Epub 2014 Feb 25. PMID: 24574543.
3. UpToDate
Thankyou
What is a decoy cell?
Decoy cells represent renal tubular or uroepithelial cells containing intranucelar viral inclusions and reflects higher urinary viral load.What are the sensitivity and specificity of this test?
The test has low sensitivity (25%)On the other hand, specificity is 84%What are the positive and negative predictive values of this test?
Positive predictive value for progression to nephropathy is 30% (1, 2)Negative predictive value >95%, this mean we can rule out BK nephropathy if decoy cells are negativeDescribe this technique.
Decoy cells can be detected in a fresh urine sample. The sample should be processed rapidly.Smears should be fixed in alcohol and examined either by Papanicolaou staining or phase-contrast microscopy.Decoy cells detection needs experienceDoes it correlate well with BK nephropathy?
The test is nonspecific for BK nephropathy (most of patients are asymptomatic and do not progress to BK nephropathy), 50 % may progress to viremia within weeks to monthsPositive predictive value for progression to nephropathy is 30% On the other hand, PCR level of > 1000 copies/ml has a positive predictive predictive value for progression to nephropathy of 40-60% within 1-2 weeksIn conclusion around half of patients with viruria can progress to viremia and around half of patients with viremia can progress to BK nephropathy.What is the difference between decoy cells and CMV inclusion bodies?
Decoy cells represent renal tubular or uroepithelial cells (only in epithelial, sparing endothelial cells) with enlarged nucleus, containing single large basophilic intranucelar viral inclusions, forming incomplete hallo, resemble malignant cancer cellsWhile in CMV there are cytoplasmic basophilic inclusions bodies with complete halo around (Owl eye appearance) in epithelial and endothelial cells (3, 4)How do you manage this case?
Detection of decoy cells is an indication for close monitoring of blood PCR and if PCR is > 1000 copies /ml reduction of immunosuppression is indicatedSo … In the current case
I will adjust tacrolimus dose to attain a trough between 5-7 ng/mlI will reduce MMF to 1 gram daily which is the dose recommended with tacrolimus useI will closely monitor PCR every 2 -4 weeks since half of the cases may progress to viremiaIf viremia detected I will reduce MMF by 50%, and if no response I will reduce tacrolimus aiming a trough of 3-5 ng/mlReferences
1. Hirsch HH, Knowles W, Dickenmann M, et al. Prospective study of polyomavirus type BK replication and nephropathy in renal-transplant recipients. N Engl J Med 2002; 347:488.
2. Nickeleit V, Klimkait T, Binet IF, et al. Testing for polyomavirus type BK DNA in plasma to identify renal-allograft recipients with viral nephropathy. N Engl J Med 2000; 342:1309.
3. Colvin RB, Nickeleit V. Renal transplant pathology. In: Jennet JC, Olson JL, Schwartz, Silva FG, editors. Heptinstall’s Pathology of the kidney. 6th ed. Philadelphia: William and Wilkins; 2007. pp. 1441–8.
4. Asim M, Lopez AC, Nickeleit V. Adenovirus infection of a renal allograft. Am J Kidney Dis. 2003;41:696–701.
Thankyou well done.We have to agree they need expertise.
They can be mixed up with other viral infection.
PCR for urine and blood is the gold standard.
Thanks for mentioning adjuvant therepy but i have not seen anyone benefitting from these drugs,
Thank you, Mohamed
Still, you did not explain why these cells are called “decoy”.
Why the sensitivity and specificity is low?
Which one is basophilic and which one is acidophilic, CMV or BK inclusion bodies?
Which one is intranuclear and which one is cytoplasmic, CMV or BK inclusion bodies?
Decoy cell represent infected tubular epithelial cell with intranuclear viral inclusions. Decoy cells are characterized by large viral nuclear inclusions that replace the normal chromatin (Papanicolaou stain). The nuclear inclusion is formed by dark, smudged material representing thousands of newly formed virions
Sensitivity of urine decoy cells is very high reaching 100%, however it is les specific comparing to other diagnostic tests with a specificity of 71%.
It has high negative predictive value NPV and low PPV
The presence of decoy cell is strongly suggestive of BKPyV infection starting from the early stages of infection in particular in the viruria stage.
CMV inclusion are intracytoplasmic whereas BKPyV inclusions are intracytoplasmic.
The presence of decoy cells in a kidney transplant patient with otherwise stable kidney function indicates viruria. Viruria represents the earliest manifestation of BK virus nephropathy. For most, viruria is asymptomatic, detected only by screening, and does not progress to viremia. Viremia is detected in 5 to 10 percent of recipients after 6 months of transplantation. As with viruria, viremia is typically asymptomatic. However, viremia should be screened.
Management starts with reduction in the CNI dose targeting a whole blood tacrolimus trough level of 4 to 6 ng/mL, as the trough level is high for this patient 13 months following transplantation. Followup blood PCR is needed for PCR positive patients, however in patients with negative blood PCR, urine quantitative PCR or urine cytology is recommended.
You have not mentioned a single word about MMF?
Approach to immunosuppression
1. In this particular patient with a high Tacrolimus trough level, we start with a reduction of the CNI dose to achieve a lower trough level of 4-6 ng/mL. If the CNI trough level was within the lower target, we started with a reduction in the MMF dose.
2- If the previous step failed, reduction in the MMF dose by 50%
3- If there is still no decrease in viral load after another two weeks, we decrease the dose of the calcineurin inhibitor by 25 to 50 percent
4-If initial steps fail, discontinuation of the antimetabolite is recommended.
Other options include treatment with antivirals, IVIGs that contain anti-BK virus antibodies, leflunamide, and others.
Thank you, Mohamed
Your answers were not precise and accurate. I invite you to read the question and answer it again.
CMV inclusion are intracytoplasmic whereas BKPyV inclusions are intranuclear(not intracytoplasmic- BY MISTAKE)
degenerating epithelial cells, enlarged cells with high nuclear: cytoplasmic ratio showing peripheral clumped chromatin, intranuclear smudgy, ground glass and owl eye-like viral inclusions surrounded by incomplete halo in a clean background.
Type 1- classic decoy cells characterized by large, homogenous, amorphous ground-glass like intranuclear inclusion bodies and a condensed rim of chromatin
Type 2- granular intranuclear inclusions surrounded by a clear halo, i.e., cytomegalovirus (CMV)-like
Type 3- multinucleated decoy cells with granular chromatin; Type 4- vesicular nuclei with clumped chromatin and nucleoli
In BK nephropathy, the finding of urinary decoy cells showed a 100% sensitivity, 84% specificity, 100% negative predictive value and 6% positive predictive value.
despite a low positive predictive value of decoy cells in urine, its absence has a negative predictive value of 100%, as almost all patients who did not have decoy cells had normal renal function.
Cytospin smears were prepared from fresh urine samples
fixed in alcohol and stained with Papanicolaou stain.
According to certain authors’ observations, the likelihood of discovering PVBK nephropathy increases with the amount of “decoy cells” in the urine . However, other researchers have shown that even when “decoy cells” are “abundant,” the positive predictive value is only 27% , suggesting that “decoy cells” may exist even in the absence of a clinical condition. Patients who have “decoy cells” in their urine, have compromised renal function, have experienced acute rejection more than once, are receiving therapy with tacrolimus and/or mycophenolate mofetil, and are at a greater risk of developing PVBK nephropathy.
Large cells containing prominent intranuclear viral inclusion bodies surrounded by clear halos (“owl’s eye” appearance) in CMV.
Severe cytoplasmic degeneration characteristic of polyoma infection; when present, serves as another useful morphologic clue.
Stop MMF .
Second step is decrease tacrolimus dose to achieve a trough level of ~6ng/ml
If creatinine is still increasing T leflunomide 100mg x 3 days f/b 20 mg OD can be started.
Decoy cells in urine cytology: A useful clue to post-transplant polyoma virus infection
V Geetha
The value of urinary decoy cells finding in patients with kidney transplantation
Zeljko Vidas
‘Decoy cells’ in the urine due to polyomavirus BK infection: easily seen by phase‐contrast microscopy
Giovanni B. Fogazzi