Tacrolimus to Belatacept Conversion Following Hand Transplantation: A Case Report

• Type of Material: Article
• Authors: L. Cendales, Duke University School of Medicine; Robert Bray, Emory University; Howard Gebel, Emory University; Luke Brewster, Emory University; R. Elbein, Emory University; D. Farthing, Children's Healthcare of Atlanta; M. Song, Emory University; Douglas Parker, Emory University; Arthur Stillman, Emory University; Thomas Pearson, Emory University; Allan Kirk, Emory University
• Language: English
• Date: 2015-08-01
• Publisher: Wiley
• Publication Version: Author Accepted Manuscript (After Peer Review)
• Copyright Statement: © 2015 The American Society of Transplantation and the American Society of Transplant Surgeons.
• Final Published Version (URL): http://dx.doi.org/10.1111/ajt.13217
• Title of Journal or Parent Work: American Journal of Transplantation
• ISSN: 1600-6135
• Volume: 15
• Issue: 8
• Start Page: 2250
• End Page: 2255
• Grant/Funding Information: This study was supported by The National Center for Advancing Translational Sciences of the National Institutes of Health under Award Number UL1TR000454, a grant from the Department of Defense administered through the Navy Bureau of Medicine and Surgery's Medical Development Program, and by resources at the Atlanta VA Medical Center.
• Keywords: Science & Technology; ANTIBODY; T-CELLS; THERAPY; Life Sciences & Biomedicine; INDUCTION; Transplantation; NONHUMAN-PRIMATES; SURVIVAL; RENAL-ALLOGRAFT REJECTION; Surgery
• Research Categories: Health Sciences, Rehabilitation and Therapy; Health Sciences, Medicine and Surgery; Health Sciences, Oncology

Abstract

Vascularized composite allotransplantation (VCA) has emerged as a viable limb replacement strategy for selected patients with upper limb amputation. However, allograft rejection has been seen in essentially all reported VCA recipients indicating a requirement for substantial immunosuppressive therapy. Calcineurin inhibitors have served as the centerpiece agent in all reported cases, and CNI-associated complications associated with the broad therapeutic effects and side effects of calcineurin inhibitors have been similarly common. Recently, belatacept has been approved as a calcineurin inhibitor replacement in kidney transplantation, but to date, its use in VCA has not been reported. Herein, we report on the case of a hand transplant recipient who developed recurrent acute rejection with alloantibody formation and concomitant calcineurin inhibitor nephrotoxicity, all of which resolved upon conversion from a maintenance regimen of tacrolimus, mycophenolate mofetil and steroids to belatacept and sirolimus. This case indicates that belatacept may be a reasonable maintenance immunosuppressive alternative for use in VCA, providing sufficient prophylaxis from rejection with a reduced side effect profile, the latter being particularly relevant for nonlife threatening conditions typically treated by VCA.