*Purpose: HIV(+) renal transplant recipients were excluded from phase III trials of belatacept, and currently there are only scattered case reports.

*Methods: This was a single center, IRB approved, retrospective review of HIV(+) adult kidney transplant recipients converted for clinical indication from a calcineurin inhibitor (CNI) to belatacept between 05/2015-05/2019. Patients were excluded if they received an allograft from an HIV(+) donor or received < 4 doses of belatacept. All patients received non-depleting induction followed by triple CNI-based maintenance. Allograft and HIV-related outcomes were collected from the date of first belatacept infusion until 11/2019. Data was analyzed using descriptive statistics.

*Results: 10 HIV(+) first-time transplant recipients were identified for review, all of whom had a negative crossmatch. Mean baseline CD4 count was 590.5 cells/mm³, and all patients were maintained on a stable antiretroviral regimen with an undetectable viral load. Patients were converted to belatacept a median of 364 days post-transplant, utilizing the protocol of Rostaing et al. Primary indications for conversion were suboptimal nadir creatinine (40%) or chronic CNI toxicity (50%). At the conclusion of the study, patients had received a median of 632 days or 1.7 years of belatacept, and all patients were alive with functioning allografts. 8 patients remained on belatacept, and 7 patients had at least 1 year of treatment. Mean eGFR improved from 31.6 mL/min at baseline to 45.5 mL/min at 6 months and 40.0 mL/min at last follow-up. Two patients developed acute cellular rejection (ACR) within 6 months of belatacept initiation. One patient had 2A ACR that was treated with anti-thymocyte globulin and conversion back to a CNI, and one developed borderline ACR, which was managed with steroids. Both allografts continue to function, although eGFR failed to return to baseline in one case. No additional episodes of rejection occurred during the remainder of the review. De novo DSA > 2,000 MFI developed in one patient and was associated with ACR. All patients had undetectable HIV viral loads at last follow-up. One patient experienced a viral blip > 50 copies/mL, which resolved with continuation of antiretrovirals. Two patients developed opportunistic infections post-conversion. One patient acquired pneumocystis, which resolved with intravenous antibiotics, and one patient developed Kaposi sarcoma and was converted to sirolimus. Malignancy occurred in one patient who developed Gleason 7 prostate cancer, treated by radical prostatectomy. This patient remains on belatacept with undetectable prostate specific antigen levels.

*Conclusions: In our cohort of stable HIV(+), first-time renal transplant recipients, conversion to belatacept salvage therapy after a median of 1 year was associated with excellent early patient and allograft survival and improved eGFR. Opportunistic infections were infrequent, and no patients required alterations to their antiretroviral therapy due to virologic failure.

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