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.
Education services for Stage-IV chronic kidney disease patients were added in 2010 as a Part B covered benefit under the Medicare Improvements for Patients and Providers Act. Desired outcomes include early pursuit of kidney transplantation by more patients and reduction of racial disparities in access to transplantation. During 2005-2007, a United States Renal Data System (USRDS) special study surveyed 1123 patients in a national cohort who had recently started dialysis, identified themselves as black or white, and were reported by their physician as potentially eligible transplant candidates. Patients were asked if kidney transplantation had been discussed with them before they initiated renal replacement therapy, and survey responses were linked with subsequent wait listing and transplant events in USRDS registry files. Kaplan-Meier analyses showed a significant association between early transplant awareness and subsequent wait listing. Adjusted Cox models showed a significant race/early transplant awareness interaction, however, with the impact of early awareness on wait listing much stronger for whites. Ongoing support and education about kidney transplantation for patients after dialysis start could help to build on early education and foster greater quality improvement in patient outcomes.