Use of belatacept to maintain adequate early immunosuppression in calcineurin‐mediated microangiopathic hemolysis post‐renal transplant

We report a 17‐yr‐old boy who developed a microangiopathic hemolytic anemia presumed secondary to tacrolimus shortly following a living‐related donor renal transplant. This was initially managed by plasmapheresis. Reinstitution of calcineurin inhibition using cyclosporine led to recurrence of hemolysis, so an alternative agent was needed. He was commenced on monthly intravenous belatacept, with no further recurrence of the hemolysis, and subsequent stable graft function. Modulation via CTLA‐4 offers an alternative immunosuppressive tactic if current regimens produce graft threatening adverse effects. The method of administration and frequency of dosage of belatacept also lends itself well to the high‐risk period of adolescence and transition. We propose that belatacept may therefore also have utility in difficult cases complicated by poor concordance, common in the adolescent age group.