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Presenter: Anil, Vaidya, , United Kingdom
Authors: Anil Vaidya1, Srikanth Reddy1, Andrea Devaney1, Georgina Watson1, Peter Friend1
Anil Vaidya1, Srikanth Reddy1, Andrea Devaney1, Georgina Watson1, Peter Friend1
1Vaidya, Oxford University hospitals, Oxford, United Kingdom
Calcineurin inhibitors (CNI) have been successfully used as maintenance therapy after intestinal transplantation. However, they have been linked to a higher incidence of acute renal failure (ARF) due to its nephrotoxic effects. This may be related to its erratic area under the curve (AUC) immediately after transplantation in patients with caval drainge of the grafts. We describe our preliminary experience with the use of Belatacept in patients demonstrating a significant decline in their pre-transplant glomerular filtration rate (eGFR) after transplantation.
Materials and Methods:
This is a single centre experience of Belatacept maintenance therapy for patients demonstrating a significant decline in their GFR after intestinal transplantation. The decline was quantified using the MDRD equation. EBV status of the patient was documented before the switch. Any episodes of rejection after the switch was recorded.
From October 2008 to March 2013, 18 patients underwent intestinal transplantation in our institute. All had Campath induction and Tacrolimus monotherapy. Six (33%) demonstrated a mean decline of 45mls/min (range 25-70mls/min) in their eGFR from pre-transplant values. This decline was noted at a mean of 45 days (range 7-720 days) post transplantation. All 6 patients were switched to Belatacept. All patients had a positive EBV serology at the time of the switch. Mean time post-transplant to switch was 208 days (range 23-1195 days). The switch was done with a loading dose of 10mg/kg in 4 patients and 5mg/kg in 2. The switch was accompanied with Azathioprine (50mg OD) and prednisolone (10mg OD) in 2 patients, low dose tacrolimus (levels<3) in 2 and no other maintenance therapy in 2 patients. Five patients (83%) demonstrated an immediate improvement in their eGFR. Four of these five returned to their pre-transplant eGFR's. One patient (intestine and abdominal wall transplant) demonstrated an improvement of the eGFR by 20mls/min, however did not return to the pre-transplant level (patient on low dose tacrolimus). One patient (17%) did not demonstrate any improvement in the eGFR despite being completely off tacrolimus. One patient (17%) demonstrated moderate rejection, 15 days post switch to Belatacept. This patient was switched to Belatacept on its own at 5mg/kg.
Majority of patients demonstrated a significant improvement of their eGFR. One patient demonstrated moderate rejection. One patient had no change in the eGFR. Our preliminary experience shows that Belatacept may be a valid option for patients demonstrating significant decline in their eGFR after transplantation. Belatacept on its own may be a high risk strategy for rejection. The dose of belatacept (loading versus maintenance) may depend upon the timing of the switch (early versus late).
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