A case of belatacept-induced chilblain lupus

Kinariwalla, Neha; Tarazi, M.; Lewin, John M.; Husain, Sameera; Husain, S. Ali; Gallitano, Stephanie M.

doi:10.1016/j.jdcr.2022.01.007

Cited by 2 publications

(1 citation statement)

References 8 publications

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“…Belatacept was shown to have superior renal function and similar 12-month patient and graft survival to cyclosporine [7]. However, trial data also showed increased acute cellular rejection within the first-year post-transplant [8], with other reports linking CTLA-4 inhibitors with new onset psoriasis [9] and chilblain lupus [10]. Though the exact mechanisms behind these pro-inflammatory phenomena remain unknown, several theories may explain the reactivation of AAV in our patient, and formed the basis for conversion to tacrolimus, without subsequent AAV recurrence.…”

Section: Discussionmentioning

confidence: 96%

Early post-transplant recurrence of ANCA vasculitis while on belatacept maintenance immunosuppression

et al. 2023

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Post-transplant recurrence of ANCA-associated vasculitis (AAV) is infrequent, with recurrence within weeks of transplantation being even rarer. We describe an unusual case of AAV recurrence within 2 weeks post-transplant. Our patient received a deceased donor kidney transplant (KDPI 60%) after 6 years on hemodialysis for end-stage renal disease from AAV. She was induced with thymoglobulin and steroids, and maintained on belatacept, mycophenolate and prednisone. Time-zero biopsy showed acute tubular injury. Due to persistent delayed graft function by post-operative day 14, she underwent repeat biopsy, which showed focal segmental necrotizing and crescentic glomerulonephritis, with positive MPO, PR3 and negative anti-glomerular basement membrane antibodies. As her findings were in keeping with recurrent AAV, she underwent induction with rituximab, prednisone and intravenous immunoglobulin, with repeat rituximab 14 days later because of increasing B-lymphocyte counts. Belatacept was replaced with tacrolimus due to concerns with autoimmunity. Fortunately, renal function began to recover 4 days after treatment. In addition to highlighting potential immunologic mechanisms in AAV and the use of rituximab in post-transplant recurrence, our case suggests that for systemic autoimmune disease, patients maintained on belatacept must be monitored closely for recurrence, particularly in the setting of delayed graft function. Graphical Abstract

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