Currently calcineurin inhibitors are the gold standard for immunosuppression of solid organ transplant recipients. Unfortunately long term
CNI use is associated with both patient morbidity ( HTN, hyperuricemia, hyperlipidemia, diabetes) and renal toxicity.
Belatacept is a selective co-stimulation blocker (given IV), which binds surface costimulatory ligands (CD80 and CD86) of antigen-presenting cells. After antigen recognition by the T cell receptor (signal 1), the interaction of CD80 and CD86 with the surface costimulatory receptor CD28 of T cells (signal 2) is required for full activation of T cells. Blockade of signal 2 inhibits T-cell activation, promoting anergy and apoptosis.
The purpose of this study was to switch patients from maintenance
CNI use to belatacept in order to reduce toxicity without compromising immunosuppression.
Rostaing et al. randomized 173 patients (6-36 months post transplant) to remain on
CNI based therapy or switch to belatacept. Primary endpoint was change in EGFR at 12 months. Secondary outcomes included rejection and safety outcomes. At month 12 the belatacept group had an increase in GFR of 7 ml/min while the CNI group had an increase in GFR of 2.1 ml/min. Patient and graft survival was 100% and 99% in the belatacept and CNI group respectively. 7% of the belatacept group had ACR vs. none in the CNI group (including grade IIa and IIb). There were 3 cases of BK viremia in the belatacept group but none in the CNI group. There were more fungal skin infections in the belatacept group. PTLD was not seen.
Conclusions/ Comments: Authors concluded that switching to a belatacept based regimen was safe, associated with low risk of rejection and resulted in improved renal function. However, there are several concerns with this study. First, even the
CNI group had an increase in GFR which does not occur in clinical practice. Second, patients greater than 1 yr post transplant had a 7% rejection rate which is significant. In fact, these rejections were not mild (several vascular rejections, all cell mediated). BK viremia was also increased in the belatacept group and studies have proven that it has a poor prognosis. Finally other studies with belatacept have been associated with PTLD and this is still a concern. Longer term f/u is needed to compare graft survival and safety profile of belatacept compared to CNI’s, however belatacept therapy may be beneficial in a subset of patients. Of note, several experts believe too high of a dose of belatacept may lead to both overimmunosuppression and rejection by blocking negative costimulatory pathways. Proper dosing may be key in reducing rates of rejection and opportunistic infections.
By Vinay Nair