*Purpose: To determine whether the use of belatacept is associated with renal function preservation in kidney transplant recipients from donors with a kidney donor profile index (KDPI) >65% compared to tacrolimus.

*Methods: This single-center, retrospective cohort analysis included kidney transplant recipients from donors with KDPIs >65% between March 2012 and July 2017, received anti-thymocyte globulin induction, and received >1 month of maintenance immunosuppressive therapy with either tacrolimus (TAC) or belatacept (BELA) in addition to concomitant mycophenolate and prednisone. Patients were excluded if they received a multiple organ transplant or had a conversion from original BELA- or TAC-based immunosuppression. The primary outcome is the comparison of glomerular filtration rates (GFRs) at 1 year post-transplantation between the TAC and BELA arms. Secondary outcomes include GFRs at 1, 3, 6, and 9 months, graft and patient survival, incidences of acute cellular rejection (ACR), donor specific antibody (DSA) formation, antibody mediated rejection (AMR), cytomegalovirus (CMV) and BK virus infections, and development of hypertension, diabetes, and hyperlipidemia at 1 year.

*Results: One hundred and eighty-seven patients met inclusion criteria (TAC n=171, BELA n=16) with a mean KDPI of 77.2% and 75% in the TAC and BELA arms, respectively. Seventy-seven patients were analyzed for the primary outcome (TAC n=63, BELA n=14) with mean GFRs at 1 year of 52.7 mL/min/m² and 58.6 mL/min/m² (TAC vs BELA: p=0.19, 95% CI -14.8 – 2.9). There were significant differences in GFRs at 3 and 6 months between arms (p<0.05) (Figure 1). There were no differences in the incidences of ACR (TAC vs BELA: 5.8% vs 6.3%, p=1.0), mortality, graft loss, AMR, DSA development, CMV infections, or BK virus infections.

*Conclusions: Our retrospective analysis suggests that BELA-based immunosuppression was associated with a non-statistically significant higher GFR at 1 year compared to TAC-based immunosuppression in recipients from high KDPI donors. Secondary analysis of GFRs at 1, 3, 6, and 9 months suggest BELA was associated with statistically significant higher GFRs at 3 and 6 months compared to TAC. There were no differences in identifiable safety outcomes, including the incidence of ACR, between arms. Overall, BELA was associated with renal function preservation compared to TAC in this high KDPI population.

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