De Novo Belatacept Use in HIV-Positive Kidney Transplant Recipients

Background: There is limited data on the use of belatacept on HIV+ renal transplant recipients and most available data presents outcomes on belatacept conversion but not DeNovo therapy Methods: Retrospective review of adult HIV+ renal transplant recipients transplanted at our center and initiated on belatacept DeNovo between July 2015 and June 2024 Results: 3 HIV patients were initiated on DeNovo belatacept as they needed to remain on protease inhibitor therapy for HIV and the significant interactions between these agents and calcineurin inhibitors. Two patients were women, 2 were African Americans, and 1 Hispanic, age 54, 50, and 69. The etiology of ESRD were diabetes, hypertension, and HIV nephropathy and the median dialysis vintage was 73 months. All 3 patients received a deceased donor kidney transplant. One patient had a class I panel reactive antibody of 66% and class II 0%, but no donor specific antibodies (DSA). The other two patients were 0/0 for both class I and II. All patients received thymoglobulin 4.5mg/kg for induction, and maintained on mycophenolate mofetil 1000mg twice daily (MMF) prednisone 5 mg daily in addition to belatacept. The CD4 count was above 400 and HIV viral load was undetectable for all patients prior to transplant. The viral load remained undetectable for all patients. The CD4 count post thymo had recovered above 300 within 3 months post-transplant for 1 patient and above 200 at 1 year for the second patient. Data was not available for the 3rd patient. At 1-year post-transplant, the creatinine was 1.1-1.7mg/dl for all patients. One of the patients with an initial PRA 0/0 lost his allograft 2 years post-transplant secondary to acute cellular rejection 1b, after missing his belatacept infusion for 3 months. The other two patients maintain a creatinine of 1.1mg/dl at 5 years post-transplant. These 2 patients have not developed rejections despite reduction in MMF after 1 year post transplant due to infection and gastrointestinal intolerance. None of the patients developed DeNovo DSAs Conclusion: Despite the increased risk of rejection in HIV+ patients, DeNovo belatacept appears to be a safe option for patients unable to be transitioned off a protease inhibitor regimen. Compliance with infusion is important for prevention of rejection episodes. Larger studies are needed to corroborate this data