*Purpose: Donor arteriosclerosis in the kidney allograft predicts poorer graft outcomes and is a risk factor for tacrolimus-induced nephrotoxicity. Belatacept conversion has been utilized as a strategy to improve allograft function in patients with early allograft dysfunction.

*Methods: Assess change in renal function in kidney transplant recipients with early conversion from tacrolimus to belatacept-based immunosuppression for biopsy-proven donor arteriosclerosis.

*Results: Twenty-one patients transplanted between 2016-2021 had biopsy-proven donor arteriosclerosis (Banff arteriolar hyalinosis score 1-3) within 6 months of transplant and were converted from tacrolimus to belatacept. The majority were male (62%) and Caucasian (52%). Average time of conversion to belatacept was 91 days (median 91d). Average SCr was 3.49 mg/dL (median 2.81) and CrCl 31.4 ml/min (median 28.6) pre-conversion and average SCr was 2.15 mg/dL (median 1.92) and CrCl 43.3 ml/min (median 42.7) post-conversion. Serum creatinine decreased by an average of 1.35 mg/dL (range -0.09 to 9.06 mg/dL) and CrCl improved by an average of 11.9 ml/min (range -4 to 30.1 ml/min). Average length of follow up after belatacept conversion was 595 days (median 336). No patients had a clinically significant decline in kidney function after belatacept conversion. Three patients (14%) were treated for acute rejection after belatacept conversion. One had a Banff 2B ACR treated with Thymoglobulin and resumption of lower-dose tacrolimus with belatacept continuation. Two patients had borderline ACR 5 and 10 months following belatacept conversion; one patient was converted back to tacrolimus and the other remained on belatacept with tacrolimus. There have been no graft failures or patient deaths.

*Conclusions: Early conversion to belatacept-based CNI-free regimen for kidney allograft dysfunction due to donor arteriosclerosis is associated with improved kidney allograft function.

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