{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,13]],"date-time":"2026-09-13T02:19:18Z","timestamp":1789265958216,"version":"build-2803163510"},"reference-count":17,"publisher":"MDPI AG","issue":"5","license":[{"start":{"date-parts":[[2025,4,23]],"date-time":"2025-04-23T00:00:00Z","timestamp":1745366400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Viruses"],"abstract":"<jats:p>Belatacept is a recombinant fusion protein used in renal transplant recipients, particularly when side effects from standard immunosuppressants occur. It offers a superior renal safety profile and is associated with better long-term renal graft outcomes. However, belatacept has been linked to atypical presentations of cytomegalovirus (CMV) infections, characterized by a prolonged and unpredictable course of viremia. We report a case involving a middle-aged African American female who developed acute kidney injury while on tacrolimus and was subsequently switched to belatacept. During treatment with belatacept, she experienced persistent and erratic CMV viremia lasting 58 weeks. The viremia showed an incomplete response to first-line antiviral therapy with valganciclovir, and the use of the novel antiviral agent maribavir also failed to achieve long-lasting viremic clearance. The resolution of the viremia was ultimately achieved only after discontinuing belatacept while continuing maribavir therapy. This case and literature review underscores the need for clinicians to remain vigilant for atypical CMV infections in renal transplant recipients treated with belatacept. If the complete clearance of viremia cannot be achieved despite the use of different antiviral agents, consideration should be given to modifying immunosuppressive therapy.<\/jats:p>","DOI":"10.3390\/v17050595","type":"journal-article","created":{"date-parts":[[2025,4,23]],"date-time":"2025-04-23T03:43:37Z","timestamp":1745379817000},"page":"595","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["Interplay of Belatacept Immunosuppression and Maribavir Antiviral Activity in Recurrent CMV Viremia: Clinical Implications and Literature Review"],"prefix":"10.3390","volume":"17","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-4813-5022","authenticated-orcid":false,"given":"Imran","family":"Gani","sequence":"first","affiliation":[{"name":"Department of Nephrology, Hypertension and Transplant Medicine, Wellstar MCG Health, Augusta University, Augusta, GA 30912, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ahmad","family":"Mirza","sequence":"additional","affiliation":[{"name":"Transplant Surgery Division, Wellstar MCG Health, Augusta University, Augusta, GA 30912, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Usman","family":"Baig","sequence":"additional","affiliation":[{"name":"Department of Nephrology, Hypertension and Transplant Medicine, Wellstar MCG Health, Augusta University, Augusta, GA 30912, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2025,4,23]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"333","DOI":"10.1007\/s40121-022-00746-1","article-title":"New Insights on CMV Management in Solid Organ Transplant Patients: Prevention, Treatment, and Management of Resistant\/Refractory Disease","volume":"12","author":"Kotton","year":"2022","journal-title":"Infect. Dis. Ther."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"13983","DOI":"10.1111\/tid.13983","article-title":"Impact of belatacept and tacrolimus on cytomegalovirus viral load control and relapse in moderate and high-risk cytomegalovirus serostatus kidney transplant recipients","volume":"24","author":"Magua","year":"2022","journal-title":"Transpl. Infect. Dis."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"333","DOI":"10.1056\/NEJMoa1506027","article-title":"Belatacept and Long-Term Outcomes in Kidney Transplantation","volume":"374","author":"Vincenti","year":"2016","journal-title":"N. Engl. J. Med."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"405","DOI":"10.1016\/j.ccell.2011.06.001","article-title":"Pharmacology of immunosuppressive medications in solid organ transplantation","volume":"23","author":"Schonder","year":"2011","journal-title":"Crit. Care Nurs. Clin. N. Am."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"535","DOI":"10.1111\/j.1600-6143.2009.03005.x","article-title":"A Phase III Study of Belatacept-based Immunosuppression Regimens versus Cyclosporine in Renal Transplant Recipients (BENEFIT Study)","volume":"10","author":"Vincenti","year":"2010","journal-title":"Am. J. Transplant."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"515","DOI":"10.6061\/clinics\/2015(07)09","article-title":"Cytomegalovirus infection in transplant recipients","volume":"70","author":"Azevedo","year":"2015","journal-title":"Clinics"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"199","DOI":"10.1097\/ICB.0000000000000928","article-title":"Cytomegalovirus Retinitis with Belatacept Immunosuppression","volume":"16","author":"Fan","year":"2022","journal-title":"Retin. Cases Brief Rep."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"ofad500.2313","DOI":"10.1093\/ofid\/ofad500.2313","article-title":"2702. A Case Series of Kidney Transplant Recipients on Belatacept with CMV Infection in a Single Academic Center","volume":"10","author":"Feller","year":"2023","journal-title":"Open Forum Infect. Dis."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"277","DOI":"10.1016\/j.ajt.2024.09.035","article-title":"Belatacept-related cytomegalovirus infection: Advocacy for tailored immunosuppression based on individual assessment of immune fitness","volume":"25","author":"Zuber","year":"2024","journal-title":"Am. J. Transplant."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"11785","DOI":"10.3389\/ti.2023.11785","article-title":"New Treatment Options for Refractory\/Resistant CMV Infection","volume":"36","author":"Walti","year":"2023","journal-title":"Transpl. Int."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"e0240521","DOI":"10.1128\/aac.02405-21","article-title":"New Perspectives on Antimicrobial Agents: Maribavir","volume":"66","author":"Blumberg","year":"2022","journal-title":"Antimicrob. Agents Chemother."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"1255","DOI":"10.1093\/cid\/ciy706","article-title":"Maribavir for Refractory or Resistant Cytomegalovirus Infections in Hematopoietic-cell or Solid-organ Transplant Recipients: A Randomized, Dose-ranging, Double-blind, Phase 2 Study","volume":"68","author":"Papanicolaou","year":"2019","journal-title":"Clin. Infect. Dis."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"690","DOI":"10.1093\/cid\/ciab988","article-title":"Maribavir for Refractory Cytomegalovirus Infections With or Without Resistance Post-Transplant: Results From a Phase 3 Randomized Clinical Trial","volume":"75","author":"Avery","year":"2022","journal-title":"Clin. Infect. Dis."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"208","DOI":"10.1111\/ajt.16132","article-title":"CMV high-risk status and posttransplant outcomes in kidney transplant recipients treated with belatacept","volume":"21","author":"Karadkhele","year":"2021","journal-title":"Am. J. Transplant."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"121","DOI":"10.1681\/ASN.2020121753","article-title":"mTOR Inhibitors Prevent CMV Infection through the Restoration of Functional \u03b1\u03b2 and \u03b3\u03b4 T cells in Kidney Transplantation","volume":"33","author":"Kaminski","year":"2022","journal-title":"J. Am. Soc. Nephrol."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"e14393","DOI":"10.1111\/tid.14393","article-title":"Secondary anti-viral prophylaxis in solid organ transplant recipients for the prevention of cytomegalovirus relapse: A systematic review and meta-analysis","volume":"26","author":"Moynan","year":"2024","journal-title":"Transpl. Infect. Dis."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"3502","DOI":"10.1111\/ajt.15976","article-title":"Cytomegalovirus serologic matching in deceased donor kidney allocation optimizes high- and low-risk (D+R\u2212 and D\u2212R\u2212) profiles and does not adversely affect transplant rates","volume":"20","author":"Lockridge","year":"2020","journal-title":"Am. J. 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