Chronic rejection, hand transplantation, and the monkey's paw

Graft vasculopathy in clinical hand transplantation

Allogeneic hand transplantation is now a clinical reality. While results have been encouraging, acute rejection rates are higher than in their solid-organ counterparts. In contrast, chronic rejections, as defined by vasculopathy and/or fibrosis and atrophy of skin and other tissues, as well as antibody mediated rejection, have not been reported in a compliant hand transplant recipient. Monitoring vascularized composite allograft (VCA) hand recipients for rejection has routinely involved punch skin biopsies, vascular imaging and graft appearance. Our program, which has transplanted a total of 6 hand recipients, has experience which challenges these precepts. We present evidence that the vessels, both arteries and veins may also be a primary target of rejection in the hand. Two of our recipients developed severe intimal hyperplasia and vasculopathy early post-transplant. An analysis of events and our four other patients has shown that the standard techniques used for surveillance of rejection (i.e. punch skin biopsies, DSA and conventional vascular imaging studies) are inadequate for detecting the early stages of vasculopathy. In response, we have initiated studies using ultrasound biomicroscopy (UBM) to evaluate the vessel wall thickness. These findings suggest that vasculopathy should be a focus of frequent monitoring in VCA of the hand.

World experience after more than a decade of clinical hand transplantation: update from the Louisville hand transplant program

In the last 12 years, the Louisville CTA program has screened more than 600 interested hand transplant candidates and has transplanted 6 patients with 7 hand allografts. The program is a collaborative effort between the surgeons and staff of Kleinert, Kutz and Associates, Jewish Hospital and St. Mary's Healthcare, the Christine M. Kleinert Institute, and the University of Louisville. The functional outcome and long-term results of clinical hand transplantation have exceeded initial expectations both within the program and in the community at large. This report summarizes the successes and challenges of the Louisville CTA experience in composite tissue allotransplantation.

A survey of north american hand surgeons on their current attitudes toward hand transplantation

PURPOSE

Although composite tissue allotransplantation (CTA) is unparalleled in its potential to reconstruct "like with like," the risk-benefit ratio and clinical indications are difficult to determine. We examined current attitudes regarding the emerging field of CTA from those who treat complex hand injuries.

METHODS

A web-based survey regarding CTA was sent to members of the American Society for Surgery of the Hand, which identified their demographic data and practice profiles. Respondents' support for CTA and their assessment of the level of risk associated with these procedures were addressed. Additional questions focused on the clinical application of CTA with current immunosuppression, ethical issues surrounding CTA, and the indications for hand transplantation. Finally, 2 clinical situations that closely mirrored past hand transplantations were presented, and members evaluated their suitability for allotransplantation.

RESULTS

A total of 474 surgeons responded to the survey (22% response rate), who were divided in their opinion of hand transplantation with 24% in favor, 45% against, and 31% undecided. The majority (69%) consider this surgery to be a high-risk endeavor; however, a large percentage (71%) still believe it to be an ethical procedure when performed on properly selected patients. The most accepted indications for hand transplantation were loss of bilateral hands (78%) and amputation of a dominant hand (32%). Only 16% were in favor of performing transplants with the immunosuppression available today. In response to the clinical situation, 66% would offer transplantation to a bilateral hand amputee, whereas only 9% would offer transplantation to a patient with diabetes who had lost his or her dominant hand.

CONCLUSIONS

This survey demonstrates support for hand allotransplantation as a solution for dominant-hand and bilateral hand amputees. However, surgeons continue to be concerned about the adverse effects of immunosuppression and the risks of acute and chronic rejection, and many want to wait for the development of better immunologic treatment options.