*Purpose: Analyze the long-term evolution after calcineurin inhibitors (CNIs) to Belatacept conversion in kidney allograft recipients.

*Methods: In this single-center retrospective study, we collected all patients with switch from CNI-based immunosuppressive therapy to Belatacept from 01/2012 to 12/2018. We analyzed kidney allograft function (estimated glomerular filtration rate (eGFR)) evolution, allograft and patient survivals, acute rejection and opportunistic infections incidences, anti-HLA donor specific antibody (DSA) profile and histology evolution after the switch.

*Results: A total of 114 kidney transplant recipients were included and followed 19 (7-46) months. Among those, N=39 (34%) switch were performed within the first 3 months after transplant. Late conversion median delay was 16 (9-67) months. eGFR increased significantly from 29 (20-38) ml/min/1.73m2 to 33 (25-45) ml/min/1.73m2 12-months after conversion (P=0.0049) and at the end of follow-up to 32 (23-45) ml/min/1.73m2 (P = 0.002). Proteinuria remained stable over time. 5-years patient and kidney allograft survivals were 76% and 78% respectively (Figure 1). Incidence of acute rejection was 12% with 15 episodes. N=23 (20%) opportunistic infections occurred after 12 (2-19) months. One sole case of post-transplant EBV lymphoproliferative disorder was diagnosed 24 months after conversion. DSA incidence remained stable 12-months after treatment (18% vs.25%; P=0.38). Among the 40 (35%) patients with complete histological data, chronic histologic lesions remained also stable 10 (4-15) months after the switch.

*Conclusions: Long term follow-up of CNI to Belatacept conversion showed significant improvement of kidney allograft function with almost 80% 5-years patients and kidney allograft survivals and low rate of acute rejection. Incidence of opportunistic infections is high. DSA incidence and histological chronic lesions remained stable over time.

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