Purpose: Describe response of belatacept (BELA) immunosuppression regimen (ISR) conversion in lung transplantation recipients (LTRs) after calcineurin inhibitor (CNI) failure on incidence of cellular rejection (ACR), bronchiolitis obliterans syndrome (BOS) progression, infections, and cardiorenal function.

Methods: Single center, retrospective medical record review of adult LTRs before and after conversion to BELA from CNI-based ISRs. Patients were evaluated at fixed time points before and after BELA conversion. Primary outcome was incidence of ACR (composite rejection standardized score (CRSS)). Secondary outcomes included incidence of infections (positive bronchoalveolar lavage or blood cultures), change in FEV1, BOS progression, death; change in MAP and serum creatinine (SCr). Descriptive statistics; both univariate parametric and nonparametric statistical tests were used to assess characteristics and outcomes.

Results: 8 LTRs underwent BELA conversion and had mean of 287 (range 62-1064) days of follow-up. 5 (62.5%) were male, mean age at transplant was 53.8 (SD 9.4) years, 7 (87.5%) received bilateral lungs primarily for COPD (4, 50%) or ILD (2, 25%), 8 (100%) were EBV D+R+, 6 (75%) received alemtuzumab induction, 4 (50%) were converted for TTP; 3 (37.5%) for PRES; 1 (12.5%) for BOS. 6 (75%) received labeled dose (10 mg/kg then 5 mg/kg); 2 (25%) received conversion dose (5 mg/kg). ACR was not different before and after BELA conversion (CRSS, 0.55 vs. 0.35, p=0.49). Incidences of infections were not different: BAL gram negative (0.79 vs. 0.57, p=0.44), BAL gram positive (0.17 vs. 0, p=0.32), viral (0.04 vs. 0.13, p=0.18), and fungal (0.35 vs. 0.4, p=0.19). FEV1 prior to BELA conversion and lowest FEV1 after BELA conversion were not different (1.51 vs. 1.44, p=0.38). 1 (12.5%) patient experienced BOS progression. 3 patients died a mean of 445 days after BELA conversion. MAP (95.1 vs. 92.4 mmHg, p=0.81) and SCr (2.63 vs. 1.8 mg/dL, p=0.24) were not different 3 months prior to and 3 months after BELA conversion.

Conclusion: BELA-based ISRs appear to produce reasonable results in LTRs intolerant to CNI-based ISRs in this small case series. SCr was numerically lower after BELA conversion. Larger prospective trials clearly appear warranted.

CITATION INFORMATION: Ensor C, Winstead R, Johnson B, Morrell M, Kilaru S, Moore C, Hayanga J, Zeevi A, Lendermon E, McDyer J. Successful Maintenance Belatacept-Based Immunosuppression in Lung Transplantation Recipients Who Failed Calcineurin Inhibitors. Am J Transplant. 2016;16 (suppl 3).

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