*Purpose: The purpose of this study was to assess the incidence of opportunistic infections in elderly kidney transplant recipients (KTRs) who receive belatacept (BELA) for maintenance immunosuppression.

*Methods: All KTRs aged ≥ 65 years at our center who were initiated on BELA between March 2017 and August 2021 were retrospectively reviewed. Transition to BELA > 1 year post-transplant, multi-organ transplant, or use of non-standard BELA dosing were excluded. The primary outcome was incidence of cytomegalovirus (CMV) viremia. Secondary outcomes included incidence of CMV disease, time to CMV viremia, BK viremia (BKV), BK nephropathy (BKVN), pneumocystis jirovecii, rejection, infection-related readmissions, and patient and graft loss.

*Results: Twenty-nine patients were included in the analysis; 79% were male with a median age of 69 years. Nephrotoxicity, donor derived disease and neurotoxicity were the major indications for BELA conversion (59%, 31% and 21%, respectively). Tacrolimus was continued for at least 3 months in 7 patients. CMV viremia occurred in 9 KTRs (30%) with 2 progressing to CMV disease. Notably, 50% of CMV mismatch patients developed viremia. BKV occurred in 21% of patients and 1 KTR progressed to BKVN. Seventeen patients were readmitted 34 times for infection-related complications. There were 2 patient deaths with 1 related to infection.

*Conclusions: Elderly KTRs on BELA may be at an increased risk for CMV viremia and experience frequent infection-related readmission. Larger studies are warranted to determine the clinical impact in this population.

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