Use of a Belatacept-based Immunosuppression for Kidney Transplantation From Donors After Circulatory Death: A Paired Kidney Analysis

Abstract

Background: Efficacy and safety of belatacept have not been specifically reported for kidney transplantations from donors after circulatory death.

Methods: In this retrospective multicenter paired kidney study, we compared the outcome of kidney transplantations with a belatacept-based to a calcineurin inhibitor (CNI)-based immunosuppression. We included all kidney transplant recipients from donors after uncontrolled or controlled circulatory death performed in our center between February 2015 and October 2020 and treated with belatacept (n = 31). The control group included the recipients of the contralateral kidney that were treated with CNI in 8 other centers (tacrolimus n = 29, cyclosporine n = 2).

Results: There was no difference in the rate of delayed graft function. A higher incidence of biopsy-proven rejections was noted in the belatacept group (24 versus 6 episodes). Estimated glomerular filtration rate (eGFR) was significantly higher in the belatacept group at 3-, 12-, and 36-mo posttransplant, but the slope of eGFR was similar in the 2 groups. During a mean follow-up of 4.1 y, 12 patients discontinued belatacept and 2 patients were switched from CNI to belatacept. For patients who remained on belatacept, eGFR mean value and slope were significantly higher during the whole follow-up. At 5 y, eGFR was 80.7 ± 18.5 with belatacept versus 56.3 ± 22.0 mL/min/1.73 m² with CNI (P = 0.003). No significant difference in graft and patient survival was observed.

Conclusions: The use of belatacept for kidney transplants from either uncontrolled or controlled donors after circulatory death resulted in a better medium-term renal function for patients remaining on belatacept despite similar rates of delayed graft function and higher rates of cellular rejection.

FIGURE 1.

Comparison of kidney function (serum creatinine and eGFR) in kidney transplant recipients receiving belatacept or CNI. A, Comparison of serum creatinine in kidney transplant recipients in the belatacept group and CNI group. Serum creatinine is expressed in µmol/L. *P value <0.05 (Student’s t-test). B, Evolution of GFR in kidney transplant recipients in the belatacept group and CNI group. *P value <0.05. C, Individual evolution and slope of change of eGFR in kidney transplant recipients in the belatacept group and the CNI group. P value: comparison of slopes of change in eGFR using a mixed-linear model. D, Comparison of eGFR in patients receiving belatacept or CNI at the time of assessment (“on-treatment” analysis). *P value <0.05 (Student’s t-test). E, Individual evolution and slope of change of eGFR in patients receiving belatacept or CNI at the time of assessment (“on-treatment” analysis). P value: comparison of slopes of change in eGFR using a mixed-linear model. CNI, calcineurin inhibitors; D, day; eGFR, estimated GFR expressed in mL/min/1.73 m²; M, month; Y, year.

FIGURE 2.

A, Death-censored graft survival in the belatacept and CNI groups. B, Overall graft survival in the belatacept and CNI groups. CNIs, calcineurin inhibitors.