(64) - Belatacept as Primary Immunosuppression in a Lung Transplant Recipient

Abstract

Listen

Translate article

s S31 agent has a potential benefit over standard calcineurin (CNI) based immunosuppression in that it avoids CNI nephrotoxicity. To our knowledge, available literature regarding the use of belatacept in lung transplantation is currently limited to one case study. Case Report: We report on a 64 year old female who underwent bilateral lung transplantation 2 years prior secondary to Idiopathic Pulmonary Fibrosis. Current immunosuppression consisted of tacrolimus, sirolimus and prednisone. The patient presented to the acute care setting with decreased appetite, tiredness, shortness of breath and minimal epistaxis. Empiric antibiotics were initiated and a bronchoscopy showed alveolar hemorrhage. Of note, the patient also presented with acute kidney injury, thrombocytopenia, and confusion/lethargy. A peripheral smear showed the presence of schiztocytes, and a diagnosis of Thrombocytopenic Thrombotic Purpura / Hemolytic Uremic Syndrome (TTP/HUS) was made. She received 5 sessions of therapeutic plasma exchange. At that time, her TTP/HUS was thought to be secondary to tacrolimus which was discontinued. Sirolimus was also stopped due to the uncertain nature of her alveolar hemorrhage. After extensive deliberation, this patient was started on belatacept every 2 weeks and ciprofloxacin for meningococcal prophylaxis. She could not be placed on cell cycle inhibitors due to leucopenia and existing bone marrow suppression. The patient’s platelet count, mental status and renal function eventually improved with plasma exchange, and she was discharged to a rehabilitation facility. A surveillance bronchoscopy performed 4 weeks after initiating belatacept was negative for acute rejection. Furthermore, donor specific antibodies remained negative at this time. Summary: In summary, we present the case of a lung transplant patient unable to tolerate CNI or mTOR based immunosuppression who is successfully maintained on the costimulatory antagonist belatacept at present. Belatacept may be considered in lung transplant recipients as an immunosuppressive agent of last resort for those unable to tolerate more conventional therapies, and further studies are needed to fully elucidate its utility in this population.