Belatacept Conversion in Kidney After Liver Transplantation

Abstract

Background: Costimulatory blockade with belatacept has demonstrated long-term benefits in renal transplantation, but de novo use in liver transplant recipients has resulted in increased rejection, graft loss, and death. However, belatacept conversion as a calcineurin inhibitor (CNI) avoidance strategy has not been studied and may be of benefit in liver transplantation where CNI-induced renal dysfunction and toxicity are barriers to improved outcomes.

Methods: Using clinical data extracted from our institutional medical record, we report on 8 patients who underwent kidney after liver transplantation and were treated with belatacept-based immunosuppression and transient CNI therapy.

Results: All patients tolerated belatacept therapy without any patient deaths or graft losses. No episodes of rejection, de novo donor-specific antibody formation, or major systemic infections were observed, and all patients demonstrated preserved liver and excellent renal allograft function. Patients received belatacept for a median duration of 13.2 mo, and at a median follow-up of 15.9 mo post-kidney transplant, 6 of 8 patients continued on belatacept with 3 completely off and 3 poised to transition off CNI.

Conclusions: These findings are the first evidence that in liver transplant recipients requiring subsequent kidney transplantation, belatacept-based therapy can potentially facilitate CNI-free maintenance immunosuppression. This supports the possibility of belatacept conversion in stand-alone liver transplant recipients as a viable method of CNI avoidance.

FIGURE 1.

Schematic of the belatacept-based immunosuppression protocol. The protocol consists of basiliximab induction; transient, low-dose tacrolimus therapy; and belatacept, CellCept, and prednisone maintenance. Tacrolimus withdrawal initiated at 270 d (9 mo) and completed by 360 d (12 mo) posttransplant. Notably, tacrolimus is not administered in HLA-identical kidney transplants.

FIGURE 2.

Renal and liver allograft function in the postoperative period following kidney transplantation. ALT, alanine transaminase; AST, aspartate transaminase.