Belatacept as an alternative immunosuppressive agent for bone marrow-sparing in idiopathic pulmonary fibrosis lung transplant recipients with short telomeres

As we have previously shown, idiopathic pulmonary fibrosis lung transplant recipients (IPF-LTRs) with short-telomere length are prone to develop significant cytopenias and poor tolerance to cell-cycle inhibitors, specifically mycophenolate mofetil (MMF), post transplant. We investigated the use of belatacept as an alternative immunosuppressive agent in a prospective, open-label cohort of 9 ST-IPF-LTRs at our institution. These patients were either challenged with MMF (majority) or immediately started on belatacept post transplant with the goal to bridge to everolimus, an mammalian target of rapamycin inhibitor that is commonly used post transplant. We describe outcomes in the first-year post transplant, including the incidence of acute cellular rejection, Epstein-Barr virus viremia, and 1 case of post-transplant lymphoproliferative disorder (PTLD) at 13 months. The use of belatacept postlung transplant may be an acceptable short-term alternative therapy to cell-cycle inhibitors in ST-IPF-LTRs with cytopenias but may lead to a higher risk of Epstein-Barr Virus viremia and PTLD when belatacept is used long term in these patients.