*Purpose: Belatacept is a recombinant soluble fusion protein which selectively blocks T-cell co-stimulation. It received initial FDA approval for prophylaxis of organ rejection in Epstein-Barr virus seropositive kidney transplant recipients. Use of belatacept for prophylaxis of rejection in other transplanted organs has not been well established. Data from a limited number of small studies suggest a possible role of belatacept among lung transplant recipients (LTR).

*Methods: We report a case series on the use of belatacept in LTRs at a single comprehensive transplant center. Descriptive statistics were used to describe patient characteristics and univariate nonparametric statistical tests were used to assess differences before and after belatacept.

*Results: A total of twenty-three patients received belatacept as a calcineurin inhibitor (CNI) sparing or dose reducing strategy. Four patients were initiated on belatacept-based immunosuppression regimen (ISR) immediately after LT due to pre-lung transplant renal impairment. Indications for belatacept included CNI-associated renal impairment in 10/23 (43%) LTRs, CNI-associated thrombotic microangiopathy in 3/23 (13%) LTRs, CNI-associated stroke in 2/23 (7%) LTRs, and CNI-associated posterior reversible encephalopathy syndrome in 4/23 (17%) LTRs. Within the two-year study period, 15/23 (65%) LTRs were transitioned back to CNI or had addition of CNI to their ISR. Statistically significant increase in mean glomerular filtration rate (GFR) was seen in all patients with pre-belatacept mean GFR 52ml-min/m² versus post-belatacept mean GFR 85ml-min/m², p < 0.001 using two tailed Man Whitney U. All five patients who needed post-operative dialysis were liberated from dialysis at discharge and remained dialysis free throughout the 2-year study period. No patients experienced belatacept-treatment limiting adverse events or cellular rejection (average CRSS while on belatacept = 0.184). Fifteen positive bronchoalveolar lavage cultures were identified, consisting of 4/15 (27%) gram positive cultures and 11/15 (73%) gram negative cultures. Four patients died while on belatacept attributed to chronic lung allograft dysfunction in 3/4 (75%) LTRs and multiorgan system failure in the fourth patient.

*Conclusions: Belatacept-based ISRs seems to be a reasonable option for LTRs with contraindication to or intolerance to CNI. Larger trials are needed to establish the effectiveness of belatacept in LTRs.

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