Background: Poor outcomes of high-MELD liver transplant recipients are driven by multisystem organ dysfunction. Renal failure post-transplant has been associated with mortality of greater than 50%. Our center developed a clinical pathway for belatacept bridging in critically ill patients post liver transplant.

Methods: A retrospective review of adult liver transplant recipients receiving belatacept was conducted. Transient belatacept therapy was administered either alone, with steroids, with mycophenolate, or both, but without concomitant calcineurin inhibitor (CNI) or mTOR. All patients were required to be EBV IgG seropositive. Results were death-censored to eliminate patient deaths after bridging therapy had been completed.

Results: Belatacept was administered to 23 liver transplant recipients from 2011-2014. 20 patients underwent liver transplantation alone. 3 patients underwent combined liver-kidney transplant. Mean MELD at transplant was 30±10. Belatacept indication was renal failure in 83% and neurologic impairment in 17%. Belatacept was initiated a median of 11 (2-203) days post-transplant and was used for a median of 51 (14-209) days. 1 patient remains on therapy. The majority were transitioned to CNI. 14 patients who received belatacept due to renal failure were on dialysis at the time of belatacept initiation. Of these patients, 10 attained renal recovery, 1 experienced primary non-function of a renal transplant, and 3 remained on dialysis until death. 2 patients experienced rejection on belatacept therapy at 19 and 55 days after belatacept initiation. Banff scores were 5 and 4. One patient was diagnosed with PTLD 4 months post-transplant that had a complete response to rituximab. This patient received 2 doses of belatacept in the first post-transplant month, and was receiving tacrolimus for 3 months prior to diagnosis. 3 patients expired on post-operative days 18, 37, and 98 while on belatacept therapy due to endocarditis, fungal sepsis, and cardiac arrest.

Conclusions: Critically ill patients demonstrated renal recovery and the ability to be transitioned to conventional immunosuppression after temporary therapy with belatacept. Mild rejection did occur in the presence of multisystem organ dysfunction, but appeared at low rates while on belatacept therapy. Infectious status is critical to choosing between belatacept and titratable immunosuppressive options.

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