title: Tacrolimus to Belatacept Conversion Following Hand Transplantation: A Case Report.
abstract: Vascularized composite allotransplantation (VCA) has emerged as a viable limb replacement strategy for selected patients with upper limb amputation. However, allograft rejection has been seen in essentially all reported VCA recipients indicating a requirement for substantial immunosuppressive therapy. Calcineurin inhibitors have served as the centerpiece agent in all reported cases, and CNI-associated complications associated with the broad therapeutic effects and side effects of calcineurin inhibitors have been similarly common. Recently, belatacept has been approved as a calcineurin inhibitor replacement in kidney transplantation, but to date, its use in VCA has not been reported. Herein, we report on the case of a hand transplant recipient who developed recurrent acute rejection with alloantibody formation and concomitant calcineurin inhibitor nephrotoxicity, all of which resolved upon conversion from a maintenance regimen of tacrolimus, mycophenolate mofetil and steroids to belatacept and sirolimus. 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 nonlife threatening conditions typically treated by VCA.
authors.affiliation: Department of Surgery, Duke University School of Medicine, Durham, NC.
authors.forename: L
authors.initials: L
authors.lastname: Cendales
authors.affiliation: Department of Pathology, Emory University School of Medicine, Atlanta, GA.
authors.forename: R
authors.initials: R
authors.lastname: Bray
authors.affiliation: Department of Pathology, Emory University School of Medicine, Atlanta, GA.
authors.forename: H
authors.initials: H
authors.lastname: Gebel
authors.affiliation: Division of Vascular Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, GA.
authors.forename: L
authors.initials: L
authors.lastname: Brewster
authors.affiliation: Emory Transplant Center, Atlanta, GA.
authors.forename: R
authors.initials: R
authors.lastname: Elbein
authors.affiliation: Children's Healthcare of Atlanta, Atlanta, GA.
authors.forename: D
authors.initials: D
authors.lastname: Farthing
authors.affiliation: Emory Transplant Center, Atlanta, GA.
authors.forename: M
authors.initials: M
authors.lastname: Song
authors.affiliation: Department of Pathology, Emory University School of Medicine, Atlanta, GA.
authors.forename: D
authors.initials: D
authors.lastname: Parker
authors.affiliation: Department of Radiology, Emory University School of Medicine, Atlanta, GA.
authors.forename: A
authors.initials: A
authors.lastname: Stillman
authors.affiliation: Emory Transplant Center, Atlanta, GA.
authors.forename: T
authors.initials: T
authors.lastname: Pearson
authors.affiliation: Department of Surgery, Duke University School of Medicine, Durham, NC.|Emory Transplant Center, Atlanta, GA.
authors.forename: A D
authors.initials: AD
authors.lastname: Kirk
mesh_terms: D000069594:Abatacept / Q000008:administration & dosage*; D000328:Adult; D005260:Female; D063987:Hand Transplantation; D006801:Humans; D016559:Tacrolimus / Q000008:administration & dosage*; D055815:Young Adult
chemical_list: D000069594:Abatacept; D016559:Tacrolimus
keywords: clinical research/practice; costimulation; immunosuppressant; vascularized composite and reconstructive transplantation