Belatacept Maintenance Immunosuppression for Calcineurin Inhibitor Sparing or Avoidance in Pancreas Transplant Recipients With Progressive Renal or Renal Allograft Dysfunction

Belatacept may be used to spare or replace calcineurin inhibitors (CNI) to preserve renal function. Use in pancreas transplant (PTx) is limited by increased risk of pancreas rejection. This retrospective analysis included all PTxs performed between 2004 and 2023. A 1:2 case/control analysis was performed to identify predictors of belatacept use and compare allograft and patient survival. Of 731 PTxs, 21 (3%) started belatacept (eight simultaneous pancreas and kidney (SPK), three pancreas after kidney (PAK), and 10 pancreas transplant alone (PTA). At 1 year, Δ estimated glomerular filtration rate (eGFR) was +7% SPK, -15% PAK, and +32% PTA. Case-control analysis found no demographic predictors for belatacept except older recipient age for PTA. No difference in median kidney, pancreas, or patient survival was observed compared to control. Pancreas rejection occurred in two SPKs. There were two death censored pancreas allograft failures, both PTAs. Kidney allografts failed in two SPK and one PAK. Eight patients died. Six were still receiving belatacept at time of death with functioning allografts. Belatacept use after PTx is safe and can provide some renal recovery. Belatacept was initiated with eGFR approaching 20 mL/min/1.73m². Earlier introduction may result in better outcomes.