Introduction: In the long-term follow up of kidney transplants, chronic transplant nephropathy often in combination with CNI-toxicity is a major problem. With declining transplant function over time, there are only limited options for alternative immunosuppressive regimens.

Materials and Methods: We converted 58 long-term kidney transplant patients with histologically confirmed CNI-toxicity and/or severe chronic vascular damage (ah2-3) to belatacept. Renal function and rejection episodes were documented, minimal follow-up time was 6 months.

Results: Median time after transplantation was 70,0 ± 58,2 months. GFR at time of conversion was 25.3 ± 11.4 ml/min, 3 months after conversion 29.2 ± 13.2 mg/dl (n=57, p<0.05 compared to baseline, student's t-test) and 6 months after conversion 31.5 ± 12.5 mg/dl (n=49, p<0.01 compared to baseline, student's t-test). Belatacept infusion was well tolerated. 4/58 (7%) patients had a biopsy confirmed acute rejection after conversion to belatacept with consecutive transplant loss in 2 patients and 1 patient presenting with acute tuberculosis after rejection therapy. Patient survival was 57/58 (98%), 1 patient died two months after conversion from a heart attack. Five additional patients with severe chronic transplant damage before conversion experienced transplant loss resulting in 86% graft survival (incl. death) at 6 months.

Conclusion: For kidney transplant patients with chronic transplant nephropathy or CNI toxicity, belatacept might be a promising alternative, however, the risk of rejection and infections after conversion has to be carefully evaluated in a larger number of patients.

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