Initial experience with de novo belatacept-based immunosuppression with tacrolimus discontinuation in simultaneous pancreas kidney transplant recipients

UVA P; QUEVEDO A; DOTTA A; LEON L; TONIOLO F; PILOTTI R; CHULUYAN E; CASADEI D

Oxford

Congreso; 2017 IPITA International Congress; 2017

The Transplantation Society - TTS

Introduction: In simultaneous pancreas kidney transplantation (SPK) the most common immunosuppression (IS) regimen includes tacrolimus, mycophenolate and steroids. Long term IS with tacrolimus may produce kidney and pancreas graft toxicity and dysfunction. In selective patients, belatacept may allow tacrolimus withdrawal while maintaining adequate immunosuppression for the pancreas. Materials and Methods: Standard protocol included ATG and steroid induction with tacrolimus, mycophenolate and steroids for maintenance. De novo belatacept-based immunosuppression with tacrolimus discontinuation at 6 months was used in selected patients. Results: Case 1: 49 y/o male with history of coronary artery by pass surgery, dyslipemia, high blood presure and severe peripheral vascular disease received a SPK transplant. Based on these comorbidities, belatacept was started on day 0. He had a biopsy proven grade 1 rejection of the pancreas during the first month postransplant treated with steroids. Tacrolimus was discontinued at 5 months. Case 2: 42 y/o female with congenital partial lipodystrophy and severe dyslipemia received a SPK transplant. Due to this unique glucose resistance setting, belatacept was started on day 0 and tacrolimus was discontinued at 6 months. Case 3: 37 y/o received a SPK transplant. During surgery he had thrombosis of the head of the pancreas and duodenum. A Whipple procedure of the graft wasperformed during the same surgical procedure, resulting in a partial pancreas graft. Belatacept was started on day 10 and tacrolimus was discontinued at 6 months. All three patients have normal kidney (Cr 0.8-1.0mg/dL), and pancreas function (glucose 75-90mg/dL) with no episodes of rejection during follow up (15-21 months). In addition they all have negative anti-HLA antibodies. Discussion: Belatacept based immunosuppression has been seldom used in pancreas transplantation to reverse tacrolimus long term graft toxicity, with very safe profile for the pancreas graft. In this small cohort of selected patients, this protocol resulted in good kidney and pancreas graft function after a mean follow up of 1.5 years with no episodes of rejection after tacrolimus discontinuation and no formation of anti-HLA antibodies.