One-Year Outcomes After Belatacept Conversion in Adolescent Kidney Transplant Recipients.
In 45 adolescent kidney transplant recipients converted from calcineurin inhibitors to belatacept, rejection occurred in 24% within a year, but rejection and de novo donor-specific antibody rates did not differ from a propensity-matched cohort kept on calcineurin inhibitors, and non-rejecting belatacept patients gained kidney function.
Background
Belatacept (CTLA4-Ig) has shown efficacy in adult kidney transplantation, with improved graft and patient survival and reduced de novo donor-specific antibody (DSA) compared with calcineurin inhibitors (CNIs). Its long-term benefits and monthly intravenous administration have raised interest in pediatric use, particularly for adolescents, who face increased risk of graft loss because of nonadherence. Data on belatacept in pediatrics remain limited.
Study design
This was a multicenter retrospective study conducted in the USA and France reporting 1-year outcomes for all 45 adolescents who underwent CNI-to-belatacept conversion between 2018 and 2021. Median age was 17 years. Indications included long-term CNI avoidance because of toxicity (histological changes, post-transplant diabetes, tremors), suboptimal creatinine, or an attempt to improve adherence. Outcomes were compared with a propensity-matched cohort of adolescents who remained on CNIs.
Key findings
Rejection occurred in 11 of 45 patients (24%) at a median of 10 months after conversion, comprising 7 T-cell-mediated rejections, 3 antibody-mediated rejections, and 1 mixed episode. Belatacept was discontinued in 3 of those 11 patients and a CNI was added in 2. Rejection and de novo DSA rates did not differ between the belatacept and CNI groups. At the individual level, eGFR in belatacept patients without rejection increased significantly (median +19%) compared with belatacept rejectors (-3%, P = 0.03) and with CNI patients (non-rejectors -11%, P = 0.0006; rejectors -14%, P = 0.012).
Safety
No apparent increase in infectious complications was observed after conversion to belatacept in this adolescent cohort.
Clinical implications
The authors note that although rejection rates in these pediatric patients on belatacept appeared higher than in adult cohorts, they were not significantly different from adolescents on CNIs, underscoring the challenges of nonadherence in this age group. They conclude that tailored immunosuppression strategies including belatacept may benefit selected adolescents, but further studies are needed to define optimal patient selection.
Category
Transplant
Source
Kidney Int Rep
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