Researchers reported successful treatment of recurrent liver transplant rejection with belatacept in a 20-year-old patient with Alagille syndrome (ALGS). The case report, published in Transplantation Direct, noted that 3.5 years after transplantation, the patient had regular liver tests and no inflammation or fibrosis.

“Herein, we report an illustrative case of a young 20-y-old otherwise healthy woman who underwent liver replacement for [ALGS] from an ABO-compatible, 6 antigen-mismatched crossmatch-negative 24-y-old man,” the authors wrote.

“Despite verified continual immunosuppression compliance, 1.5 y after liver replacement she experienced 6 more rejection episodes over the following 18 months and development of de novo [donor-specific antibody].”

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Belatacept is a fusion protein that selectively inhibits T-cell activation as well as the development of donor-specific antibodies, although the mechanisms underlying these processes are not yet entirely clear.

Despite inferior results in previous liver transplantation trials, belatacept had been found remarkably effective in kidney trials in preventing de novo antibody formation and treating T-cell mediated rejection. Thus, after several failed immunosuppressive regimens, her clinical team decided to attempt treatment with belatacept in this patient.  

The patient’s liver function tests normalized quickly after starting the treatment and she has not had any further episodes of rejection since then. A biopsy 6 years after transplantation was normal and negative for C4d, and her renal function is normal. Donor-specific antibody persists at a low level and the patient is currently on belatacept 5 mg/kg monthly and slow-release tacrolimus 2 mg daily.

The authors hope this case might indicate a potentially effective treatment for patients with persistent, low-grade immunopathology after liver transplantation.


Klintmalm G, Trotter J, Demetris A. Belatacept treatment of recurrent late-onset t cell–mediated rejection/antibody-mediated rejection with de novo donor-specific antibodies in a liver transplant patient. Transplant Direct. 2022;8(7):e1076. doi:10.1097/TXD.0000000000001076