*Purpose: Adolescents are at high risk for kidney transplant rejection due to non-compliance. While intravenous (IV) maintenance medications are FDA approved for adults, there is limited data on use in pediatric populations. IV Belatacept (Nulojix) is a fusion protein that binds to CD80 and CD86 on antigen presenting cells and prevents binding to CD28 on T-cells; thereby inhibiting T-cell activation. It is contra-indicated in EBV seronegative patients due to increased risk for post-transplant lymphoproliferative disorder, limiting its use in certain populations, such as pediatrics. Belatacept infusions in comparison to oral calcineurin inhibitors allow for supervised administration and are associated with decreased nephrotoxicity and cardiovascular burden. In this abstract we report on the use of Belatacept in three adolescent patients.

*Methods: At our institution, three adolescent patients were started on monthly Belatacept after at least one kidney transplant rejection episode due to non-compliance. The initial dose for all patients was 10 mg/kg . Subsequent dosing of 5 mg/kg was used for patients 17 years of age or greater than 70 kg. For patients 12-17 years of age, maintenance dosing of 7.5mg/kg was used based on review of limited pediatric pharmacokinetic and clinical data. Labwork was checked during monthly infusions and included a comprehensive metabolic panel, a complete blood count, EBV quantitative PCR, donor specific antibodies (DSAs), and tacrolimus troughs for the patients that remain on tacrolimus. A multidisciplinary team, including transplant nephrologist, pharmacist and nurse practitioner met monthly to review lab results, side effects, weight change, and any other concerns to determine whether treatment adjustments were needed.

*Results: For our patients, initiation of therapy occurred at six months, one year, and two years after kidney transplantation. Patient age range was 13 – 18 years at initiation of therapy. The average time that these patients received Belatacept was 20 months. No adverse effects were noted during this time period. Two patients received monthly infusions with stable renal function and DSAs despite continued fluctuations in tacrolimus trough levels. The third patient experienced mild to moderate acute T-cell rejection and ultimately developed chronic changes (40% interstitial fibrosis) related to missing several infusions after starting college out of state.

*Conclusions: The use of Belatacept as an anti-rejection maintenance medication (when administered as directed) may be beneficial in non-compliant adolescents with kidney transplants. Future research is needed to study outcomes, dosing, and side effects in the pediatric population.

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