Viral Infection Across the Kidney Transplant Continuum: Screening, Prevention, Management, and Oncogenesis

Viral infections influence every stage of the kidney transplantation continuum, shaping immunologic risk, graft outcomes, and long term patient survival. Pre transplant serologic assessments guide critical decisions, including vaccinations, the avoidance of lymphocyte depleting induction in Epstein-Barr virus (EBV) mismatched candidates and the selection of Cytomegalovirus (CMV) prophylaxis tailored to donor–recipient serostatus. Acceptance of hepatitis C viremic donor organs has significantly reduced wait times, while human immunodeficiency virus (HIV) positive donor organs remain restricted to HIV positive recipients. Post transplant, viral pathogens are major drivers of morbidity: CMV functions as an immunomodulator that increases susceptibility to rejection and opportunistic fungal infections, and routine surveillance for CMV and BK viremia is essential, especially following rejection therapies. BK virus nephropathy, adenovirus nephropathy, and JC virus nephropathy can lead to progressive allograft dysfunction. Additionally, COVID 19 and parvovirus infections have been associated with collapsing focal segmental glomerulosclerosis (FSGS) and severe graft injury. Persistent viral infections and virus associated glomerulopathies contribute to chronic graft loss, while EBV driven post transplant lymphoproliferative disorder (PTLD) remains a significant cause of cancer related mortality. Transplant recipients are also at increased risk for persistent human papillomavirus infection (HPV) and progression to anogenital and oropharyngeal malignancies. Finally, donor derived viral infections, including rabies, West Nile virus (WNV), and lymphocytic choriomeningitis virus (LCMV), though rare, are well described in the literature. Collectively, these viral complications substantially impact morbidity, graft survival, and overall mortality in kidney transplant recipients.