Selective Implementation of Belatacept (Bela) Every Other Month as a Standard Care Option with the Use of Donor-Derived Cell-Free DNA (dd-cfDNA) Testing

Background: The goal of this study is to safely transition selected kidney transplant recipients who are 24 months post-transplant to an every-other-month Bela regimen using dd-cfDNA monitoring. Methods: A cohort of 13 patients was included. Inclusion criteria were at least 24 months post-transplant, off calcineurin inhibitors for a minimum of 6 months, free from acute cellular rejection or donor-specific antibodies, and stable renal function for ten months. Increased monitoring for q2 months Bela included dd-cfDNA approximately monthly for six months, then every month until one year after the transition, followed by every six months. Results: dd-cfDNA was used to detect cell death, which is not rejection-specific. Creatinine values from 180 days before the beginning of cfDNA were used to help establish a baseline. In the study, the Subjects' creatinine (Cr) was stable. Two subjects experienced a concerning increase in cfDNA that was not associated with increased Cr. cfDNA levels and returned to baseline. Two subjects had a short interval of noncompliance with MMF without overt signs of rejection. One was advised to return to the standard regimen but refused. Cr remained at baseline. Conclusion: Bela preserves renal function, reduces DSA formation, and improves long-term survival. Standard monthly infusions lead to significant costs, monthly travel, and frequent healthcare encounters for life. In the current climate, the institution that provides this service facilitates crucial care coordination (recurrent scheduling, extensive tracking, etc.) with a strained infusion capacity for an ever-growing population. We have found that q2 monthly Bela with cfDNA monitoring is a safe alternative to monthly infusions. This regimen mitigates the risk of rejecting futile biopsies, improves compliance, and decreases the financial burden of healthcare.