2026 Southeastern Residency Conference

Early post-transplant conversion from tacrolimus to belatacept in kidney transplant patients
Authors: Mikayla Morrow, Kwame Asare, Victoria Burnette, Nicole Melby

1)Background
Ascension Saint Thomas Hospital West (ASTHW) began using belatacept, a selective T-cell co-stimulation blocker, in kidney transplant recipients more frequently in the fall of 2023. It is used if the patient has slow or delayed graft function post-transplant or experiences intolerance to or toxicity from calcineurin inhibitors. This was the first study at ASTHW evaluating outcomes of belatacept in this patient population. Previous studies that have compared calcineurin inhibitors, such as tacrolimus, to belatacept have found similar patient and graft survival between the groups, and found that belatacept recipients had superior renal function but experienced higher rejection. The purpose of this study was to assess the effect that early conversion from tacrolimus to belatacept post-kidney transplant has on patient renal function.

2)Methods
This retrospective chart review included adult kidney transplant recipients transplanted at ASTHW between April 1, 2023 and April 31, 2025, who received either tacrolimus or belatacept within the first six months post-transplant. Data collected included demographics, transplant characteristics, induction therapy, immunosuppressive regimens, renal function, biopsy-proven acute rejection, incidence of delayed or slow graft function, incidence of infection , hospital length of stay after transplant, readmissions, and cost of therapy. Outcomes were analyzed using descriptive statistics; continuous variables with unpaired t-test and categorical variables with Chi-square or Fisher’s exact tests (alpha < 0.05).

3)Results
Overall, 361 patients were screened and 285 were excluded for incomplete documentation. Of the 76 patients included, 19 were in the belatacept group and 57 in the tacrolimus group. There was a statistically significant difference in age between groups, with the belatacept group having an older median age (p = 0.045). The majority of patients were male and the study was split evenly between Caucasian and African American races. The majority of patients in both groups had slow graft function. Serum creatinine and estimated glomerular filtration rate were statistically significantly better in the tacrolimus-only group at 1, 3, and 6 months post-transplant (p = <0.00001). Survival of the patient and their graft, incidence of infection, and length of stay were not statistically different between groups. Biopsy proven acute rejection was statistically significantly higher in the belatacept group (p = 0.036). There was a statistically significant difference in the readmission rate between the groups, with the belatacept group having more readmissions (p = 0.0051).

4)Conclusions
In this study of kidney transplant recipients receiving either tacrolimus, de novo belatacept, or who underwent early conversion from tacrolimus to belatacept, we observed a significant difference in renal allograft function in favor of tacrolimus use. Further studies are necessary to assess short- and long-term clinical outcomes of utilizing belatacept in place of tacrolimus in patients with slow or delayed graft function.

Title: Impact of pre-transplant midodrine use on simultaneous liver-kidney transplant outcomes

Authors: Matthew Molk1, Mojibola Awe2, Teresa Gennaro1, Heather Snyder1, Farjad Siddiqui1; Emory University Hospital, Atlanta, GA1; The Johns Hopkins Hospital; Baltimore, MD2

Objective: Determine the impact of pre-transplant midodrine use on outcomes after SLK transplant related to delayed graft function.

Self Assessment Question: Does midodrine use prior to simultaneous liver-kidney transplant increase the incidence of specific kidney delayed graft function. 

Background: Midodrine is commonly used in patients with end-stage kidney and liver diseases for various indications. A previous study suggested that midodrine use prior to kidney transplant worsens post-transplant outcomes, including delayed graft function (DGF), graft failure, and death. Alternatively, another study among simultaneous liver-kidney (SLK) transplant recipients found no significant difference in hospitalization, graft failure, or death in patients treated with pre-transplant midodrine. Given the paucity of data, the purpose of this study was to determine the impact of pre-transplant midodrine use on outcomes after SLK transplant.

Methods: This was a single-center, retrospective chart review of adult patients who received a SLK transplant at Emory Transplant Center between February 2015 and June 2024. Patients who died within 7 days post-transplant were excluded. Patients were placed into 2 study arms determined by their pre-transplant midodrine use. Pre-transplant midodrine use was defined as treatment with midodrine for at least 3 months prior to transplant. The primary outcome was the incidence of kidney-specific DGF, defined as the requirement for dialysis within the first 7 days after transplant. Secondary outcomes included post-transplant hospital length of stay, midodrine use at discharge from index admission, estimated glomerular filtration rate (eGFR) at discharge and 1 year, readmission rates, and kidney allograft survival and patient survival at 1-year post-transplant. Primary and secondary outcomes were analyzed using descriptive statistics.

Results: Of the 104 patients screened, 94 patients met inclusion criteria with 13 patients in the midodrine group and 81 in the non-midodrine group. Median age was similar between groups (57 vs. 58 years) and a majority of patients in both arms were Caucasian and male. Patients in the midodrine had a higher median MELD score at the time of transplant compared to the non-midodrine group (34 vs. 31; p < 0.001). Kidney-specific DGF occurred more frequently in the midodrine group vs. the non-midodrine group, however this difference was not statistically significant (30.8% vs. 12.3%, p = 0.083). The midodrine group had a significantly longer median post-transplant length of stay (17 vs. 11 days, p < 0.001) and a higher incidence of midodrine use at discharge (15.4% vs. 2.5%, p = 0.032). While eGFR at discharge trended lower in the midodrine group (47 vs. 66 mL/min/1.73m², p = 0.075), eGFR at 1-year post-transplant was comparable between groups (53 vs. 56 mL/min/1.73m², p = 0.462). Readmission rates at 6-12 months post-transplant were greater in the midodrine group (54% vs. 17%; p = 0.003). Kidney allograft survival and patient survival at 1-year post-transplant were similar between groups.

Conclusion: Pre-transplant midodrine use in SLK recipients does not appear to affect short term outcomes after transplant; however larger studies need to be conducted.