Study purpose
Belatacept (CTLA4Ig) is an emerging treatment in solid organ transplantation Effects on the development of donor specific antibodies (DSA) as well as its clinical safety in challenging immunological settings have yet to be explored.
Methods
Three hand transplanted patients have been converted to a Belatacept-based immunosuppressive regimen at 4 months, 6 y and 9 y after unilateral or bilateral hand and forearm transplantation Patients have received 5 mg/kg Belatacept every 2 weeks, the dosing interval was then extended to 4 weeks after 5 applications All 3 patients were kept on their baseline immunosuppressive medication, consisting of a CNI (Patients A, B, C) or mTOR inhibitor (Patients A and B) plus steroids (Patients A and B) and CellCept (Patient B).
Results
No adverse effects of Belatacept have been noted so far Patient C, who received Belatacept 4 months after transplantation, can successfully be kept on Tacrolimus monotherapy with a low trough level of ∼4–5 ng/ml This patient has never developed donor-specific antibodies, and displays normal histologic findings Patient A, who had previously developed DSA but was in a stable immunological state at the time of conversion, is now successfully tapered from baseline immunosuppression without evidence of rejection Patient B, who had DSA at the time of conversion, showed an increase of DSA and worsening graft appearance despite stable levels of his baseline immunosuppression, and needed escalation of his immunosuppression.
Discussion
The addition of Belatacept to an immunosuppressive regimen can be beneficial in hand transplantation However, our patients showed variable results depending on the immunological state at the time of conversion The application of Belatacept as a “œrescue” medication has to be discussed critically.