Conversion From Tacrolimus to Belatacept to Prevent the Progression of Chronic Kidney Disease in Pancreas Transplantation: Case Report of Two Patients

Abstract

y Both authors contributed equally.Belatacept is a novel immunosuppressive agent that may be used as an alternative to calcineurin inhibitors (CNI) in immunosuppression (IS) regimens. We report two cases of pancreas transplant that were switched from tacrolimus (TAC) to belatacept. Case 1: 38-yearold female with pancreas transplant alone maintained on TAC-based IS regimen whose serum creatinine (SCr) slowly deteriorated from 0.6 mg/dL at baseline to 2.2 mg/dL, 16 months posttransplant. A native kidney biopsy performed showed CNI toxicity. The patient was started on belatacept and TAC was eliminated. Case 2: 49-year-old female with simultaneous pancreas-kidney transplant, maintained on TAC-based regimen where the SCr worsened over an initial 3-month period from a baseline of 1.0 to 3.0 mg/dL. Belatacept was started and TAC was lowered. Due to persistent graft dysfunction and kidney transplant biopsy still showing changes consistent with CNI toxicity, the TAC was then discontinued. At >1 year postbelatacept and off TAC follow-up, kidney function as measured by SCr remains stable at 1.0 AE 0.2 mg/dL in both recipients. Neither patient developed rejection following the switch, and pancreas allograft function remains stable in both recipients.

Microvascular inflammation is a risk factor in kidney transplant recipients with very late conversion from calcineurin inhibitor-based regimens to belatacept

“…Few data are available on switching pancreas transplant patients to belatacept. A previous study reported successful conversion of two patients from tacrolimus to belatacept and sirolimus [30]. Furthermore, belatacept together with sirolimus has been successfully used in rhesus monkeys with islet transplantation [31].…”

Simultaneous pancreas and kidney transplantation

“…reported their experience in two patients switching from CNIs to belatacept to prevent progressive CKD. Both patients weaned safely from tacrolimus to belatacept and sirolimus [ 21 ], and both enjoyed measurable improvement in renal function. Mirroring larger experiences in kidney transplantation [ 22 ], belatacept may prove an important strategy for preservation of renal and pancreatic function after SPK transplantation, either as a first-line or rescue therapy.…”

Tacrolimus‐Induced Cardiomyopathy in an Adult Renal Transplant Recipient

“…Belatacept has most commonly been compared to cyclosporine‐based immunosuppression in de novo renal transplant recipients and has consistently shown a higher incidence of acute rejection but no significant difference in patient or allograft survival and superior renal function end points . Recent case reports and case series have suggested the safe and effective use of belatacept when tacrolimus cannot be used, such as in our patient …”