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Case Reports
. 2015 Aug;15(8):2250-5.
doi: 10.1111/ajt.13217. Epub 2015 Mar 13.

Tacrolimus to Belatacept Conversion Following Hand Transplantation: A Case Report

L Cendales  1 , R Bray  2 , H Gebel  2 , L Brewster  3 , R Elbein  4 , D Farthing  5 , M Song  4 , D Parker  2 , A Stillman  6 , T Pearson  4 , A D Kirk  1   4
Affiliations
Case Reports

Tacrolimus to Belatacept Conversion Following Hand Transplantation: A Case Report

L Cendales et al. Am J Transplant. 2015 Aug.

Abstract

Vascularized composite allotransplantation (VCA) has emerged as a viable limb replacement strategy for selected patients with upper limb amputation. However, allograft rejection has been seen in essentially all reported VCA recipients indicating a requirement for substantial immunosuppressive therapy. Calcineurin inhibitors have served as the centerpiece agent in all reported cases, and CNI-associated complications associated with the broad therapeutic effects and side effects of calcineurin inhibitors have been similarly common. Recently, belatacept has been approved as a calcineurin inhibitor replacement in kidney transplantation, but to date, its use in VCA has not been reported. Herein, we report on the case of a hand transplant recipient who developed recurrent acute rejection with alloantibody formation and concomitant calcineurin inhibitor nephrotoxicity, all of which resolved upon conversion from a maintenance regimen of tacrolimus, mycophenolate mofetil and steroids to belatacept and sirolimus. This case indicates that belatacept may be a reasonable maintenance immunosuppressive alternative for use in VCA, providing sufficient prophylaxis from rejection with a reduced side effect profile, the latter being particularly relevant for nonlife threatening conditions typically treated by VCA.

Keywords: clinical research/practice; costimulation; immunosuppressant; vascularized composite and reconstructive transplantation.

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Conflict of interest statement

Disclosure: The authors of this manuscript have no conflicts of interest to disclose as described by the American Journal of Transplantation.

Figures

Figure 1
Figure 1
(A) and (B) Preoperative and postoperative status of the recipient. The left hand was amputated at the level of the wrist and the allograft was transplanted at the level of the distal forearm.
Figure 2
Figure 2. Tacrolimus levels after transplantation
Figure 3
Figure 3. Visual and histologic findings during acute rejection
(A) Cutaneous eruption characterized by coalescent erythematous papules localized to the allograft. (B) VCA-Banff II rejection. Moderate perivascular and perieccrine lymphocytic infiltrate associated with epidermal spongiosis and exocystosis (Hematoxillin and Eosin 400×).
Figure 4
Figure 4. Creatinine levels after transplantation
The patient was initiated on tacrolimus on 3-2011 and converted to belatacept on 4-2012.
Figure 5
Figure 5
(A) and (B) Bimanual activities that the patient initiated after transplant.
Figure 6
Figure 6. Histologic findings after 17 months on belatacept
(A) Banff 0 Hematoxillin and Eosin 400×], (B) C4d staining nonreactive.
See this image and copyright information in PMC

References

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