Abstract
Vascularized composite allotransplantation (VCA) has emerged as a limb replacement strategy for selected patients.Rejection has been seen in essentially all reported VCA recipients indicating a requirement for substantial immunosuppressive therapy.Calcineurin inhibitors (CNIs) have served as the centerpiece agent in all reported cases,and CNI-associated complications are the most reported.Belatacept was approved in kidney transplantation,but to date,its use in VCA has not been reported.Herein,we report on a hand transplant recipient who developed recurrent acute rejection with alloantibody formation and concomitant CNI nephrotoxicity,all of which resolved upon conversion from a maintenance regimen of tacrolimus, mycophenolate mofetil and steroids to belatacept and sirolimus. Methods.A 21-year-old female received a unilateral hand transplant.Panel reactive antibody testing was 0% for Class I and Class II. The patient was CMV+ and EBV+. She received induction with rabbit antithymocyte globulin followed by tacrolimus, mycophenolate mofetil and steroids.At the one-year visit she was diagnosed with Banff I, C4d- skin rejection.HLA antibodies identified at this date were HLA-B*48, 60, 61 and 81 utilizing a LuminexTM-based microparticle assay,which,while not directly donor specific,likely recognize a shared epitope expressed by the donor's mismatched HLA-B* locus antigens.Creatinine increased to 2.08 mg/dl despite multiple attempts to lower her tacrolimus dose.The patient was treated for antibody mediated rejection and was started on belatacept and sirolimus.Tacrolimus and MMF were discontinued. Results.After 18-months on belatacept,the patient's renal function has returned toward normal serum creatinine levels,her skin biopsies have been free from rejection,and her quantitative upper extremity function test has improved from 21/99 to 42/99. Summary. This case indicates that belatacept may be a reasonable maintenance immunosuppressive alternative for use in VCA, providing sufficient prophylaxis from rejection with a reduced side effect profile, the latter being particularly relevant for non-life threatening conditions typically treated by VCA.
Sign-in/Register to access full text options 
Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have
Schedule a callDisclaimer: All third-party content on this website/platform is and will remain the property of their respective owners and is provided on "as is" basis without any warranties, express or implied. Use of third-party content does not indicate any affiliation, sponsorship with or endorsement by them. Any references to third-party content is to identify the corresponding services and shall be considered fair use under The CopyrightLaw.
