The Role of Belatacept-Use and Senescence on Infectious and Mortality Complications After Kidney Transplantation

Introduction: Studies evaluating the incidence of infections after belatacept as a substitute for calcineurin inhibitors (CNI) or antimetabolite in kidney transplant (KT) yielded conflicting results. We compared infectious outcomes after belatacept-use to no belatacept-use in KT recipients. Methods: We included patients with primary KT between January 1, 2018, and December 31, 2022. We compared outcomes between those who received belatacept and those who did not. Cox proportional hazards models were used with belatacept as a time-varying covariate and adjusted for gender, age at transplant, donor type, underlying disease, CMV serostatus, and organ transplant type. Anderson-Gill hazard of the first Cox models was used to examine the recurrence of DNAemia. Results: Of 401 KT recipients, 25 received belatacept. Belatacept-use had a higher hazard for EBV and CMV first infection (3.71 [95% CI 1.57, 8.72; p = 0.003] and 2.63 [95% CI 1.04, 6.70; p = 0.042], respectively), and for allograft failure (14.5 [95% CI 5.15, 41.0; p < 0.001]) and acute cellular rejection (5.08 [95% CI 2.56, 11.5; p < 0.001]). Each year increase in zage had a higher hazard for first EBV (3.71 [1.01, 1.05]; p = 0.005) and CMV infection (1.02 [1.00, 1.04]; p = 0.019). D+/R− CMV serostatus had a higher hazard for first CMV infection relative to other serostatuses (4.96 [3.14, 7.85]; p < 0.001). Conclusion: Careful selection of KT for belatacept-use is recommended in older recipients (≥ 55 years) due to the increased hazard of mortality, CMV, and EBV DNAemia.