Lung Transplant Plasmapheresis/Belatacept/Carfilzomib for Antibody Mediated Rejection and Desensitization

Inclusion Criteria: Inclusion criteria for the AMR post-transplant cohort * Positive DSAs and allograft dysfunction defined by changes in pulmonary physiology, gas exchange, radiological features or deteriorating functional performance that is highly suspicious for AMR * Recipient is Epstein-Barr virus positive (EBV+) by serology * Ability to provide signed and dated IRB approved written consent in accordance with regulatory and institutional guidelines prior to any protocol-related procedure Inclusion criteria for the pre-transplant desensitization cohort * Elevated HLA antibodies (defined as MFI \>1000) such that the calculated panel reactive antibodies are \>60% * At least 2 HLA antibodies with Mean Fluorescent Intensity (MFI) \<10,000 and at least 2 HLA antibodies with MFI \<5,000 on undiluted serum that do not demonstrate an increase in MFI with dilution at 1:16 (no evidence of a prozone effect). * EBV+ by serology * Clinically stable defined by not on invasive mechanical ventilation, extracorporeal membrane oxygenation support or other invasive life support requiring ICU level of care * Ability to provide signed and dated IRB approved written consent in accordance with regulatory and institutional guidelines prior to any protocol-related procedure Exclusion criteria for both AMR post-transplant cohort and pre-transplant cohort * Active systemic infection * Allergy to carfilzomib or belatacept * Known malignancy in the previous 2 years except for non-melanomatous skin cancer * Pregnancy * Inability to commit to complete treatment protocol at Duke as all procedures must be completed at Duke * Prisoners or those who are compulsory detained