Conversion to belatacept maintenance immunosuppression in HIV‐positive kidney transplant recipients

Abstract

There are only scattered case reports documenting belatacept use in HIV + kidney transplant recipients. We performed a retrospective review to describe short‐term outcomes following conversion to belatacept in a cohort of HIV + patients. Patients were included if they were converted to belatacept between May 2015 and May 2019, had an HIV‐ donor, and received ≥4 doses of belatacept. All patients were treated with non‐depleting induction and triple maintenance immunosuppression. Allograft and HIV‐related outcomes were collected from the date of belatacept infusion until May 2020. Ten HIV + kidney transplant recipients were identified, who were converted to belatacept a median of 364 days post‐transplant. At last follow‐up (median 3.3 years), 8 patients remained on belatacept therapy, and all patients were alive with functioning allografts. Mean estimated glomerular filtration rates (eGFR) improved from 31.6 mL/min at baseline to 42.8 mL/min at 1 year (P = .03). Two patients developed acute rejection, with one necessitating conversion back to tacrolimus. All patients maintained undetectable HIV‐1 viral loads at last follow‐up. One patient each developed pneumocystis pneumonia and Kaposi sarcoma following conversion, which were responsive to standard medical therapy. In our cohort of stable HIV + kidney transplant recipients, conversion to belatacept was associated with excellent early patient and allograft survival and improved eGFR at 1 year.

Belatacept Use after Kidney Transplantation and Its Effects on Risk of Infection and COVID-19 Vaccine Response

“…One patient developed Pneumocystis pneumonia and Kaposi sarcoma following conversion but was responsive to standard medical therapy. No other major side effect was noted [ 63 ].…”

“…In the two published studies, allograft survival and eGFR were good. Incidence of acute rejection and opportunistic infection was acceptable, HIV disease remained under control after belatacept treatment, and CD4+ and CD8+ T-cell counts remained stable [ 63 , 64 ]. We recommend performing conversion from CNI to belatacept at least six months after transplantation in HIV+ KTx.…”

Immunosuppression in HIV-positive kidney transplant recipients

“…Patients with HIV were not included in BENEFIT, BENEFIT-EXT, and BEST studies, while the conversion studies did not mention HIV patients [48–51,52 ▪▪ ]. Therefore, current evidence comes from four case reports and two retrospective cohort studies with small numbers of patients [53–58]. In one retrospective study, of 10 HIV-positive KTR with low immunological risk, conversion from CNI to belatacept was associated with an improvement of graft function and excellent early patient and graft survival [57].…”

“…Therefore, current evidence comes from four case reports and two retrospective cohort studies with small numbers of patients [53–58]. In one retrospective study, of 10 HIV-positive KTR with low immunological risk, conversion from CNI to belatacept was associated with an improvement of graft function and excellent early patient and graft survival [57]. In a French multicentric case–control study of 12 HIV-positive KTR switched from CNI to belatacept, among whom 50% had donor-specific antibodies (DSA), graft function has been significantly improved, DSA remained stable, but acute rejection occurred in patients with early conversion (<3 months) [58].…”

“…Patients with HIV were not included in BENEFIT, BENEFIT-EXT, and BEST studies, while the conversion studies did not mention HIV patients [48-51,52 && ]. Therefore, current evidence comes from four case reports and two retrospective cohort studies with small numbers of patients [53][54][55][56][57][58]. In one retrospective study, of 10 Fifty-three percent of patients received induction with ATG, 8% with alemtuzumab, and 32% with anti-IL2R-Ab.…”