Tacrolimus to Belatacept Conversion Following Hand Transplantation: A Case Report

• 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
• Journal Title: American Journal of Transplantation
• Volume: Volume 15, Number 8
• Publisher: Wiley | 2015-08-01, Pages 2250-2255
• Type of Work: Article | Post-print: After Peer Review
• Publisher DOI: http://doi.org/10.1111/ajt.13217
• Subjects: Health Sciences, Oncology; Health Sciences, Medicine and Surgery; Health Sciences, Rehabilitation and Therapy
• Keywords: Science & Technology; Life Sciences & Biomedicine; Surgery; Transplantation; RENAL-ALLOGRAFT REJECTION; NONHUMAN-PRIMATES; T-CELLS; SURVIVAL; THERAPY; INDUCTION; ANTIBODY

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.