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Shah AM, Aral AM, Zamora R, Gharpure N, El-Dehaibi F, Zor F, Kulahci Y, Karagoz H, Barclay DA, Yin J, Breidenbach W, Tuder D, Gorantla VS, Vodovotz Y. Peripheral nerve repair is associated with augmented cross-tissue inflammation following vascularized composite allotransplantation. Front Immunol 2023; 14:1151824. [PMID: 37251389 PMCID: PMC10213935 DOI: 10.3389/fimmu.2023.1151824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 04/20/2023] [Indexed: 05/31/2023] Open
Abstract
Introduction Vascularized composite allotransplantation (VCA), with nerve repair/coaptation (NR) and tacrolimus (TAC) immunosuppressive therapy, is used to repair devastating traumatic injuries but is often complicated by inflammation spanning multiple tissues. We identified the parallel upregulation of transcriptional pathways involving chemokine signaling, T-cell receptor signaling, Th17, Th1, and Th2 pathways in skin and nerve tissue in complete VCA rejection compared to baseline in 7 human hand transplants and defined increasing complexity of protein-level dynamic networks involving chemokine, Th1, and Th17 pathways as a function of rejection severity in 5 of these patients. We next hypothesized that neural mechanisms may regulate the complex spatiotemporal evolution of rejection-associated inflammation post-VCA. Methods For mechanistic and ethical reasons, protein-level inflammatory mediators in tissues from Lewis rats (8 per group) receiving either syngeneic (Lewis) or allogeneic (Brown-Norway) orthotopic hind limb transplants in combination with TAC, with and without sciatic NR, were compared to human hand transplant samples using computational methods. Results In cross-correlation analyses of these mediators, VCA tissues from human hand transplants (which included NR) were most similar to those from rats undergoing VCA + NR. Based on dynamic hypergraph analyses, NR following either syngeneic or allogeneic transplantation in rats was associated with greater trans-compartmental localization of early inflammatory mediators vs. no-NR, and impaired downregulation of mediators including IL-17A at later times. Discussion Thus, NR, while considered necessary for restoring graft function, may also result in dysregulated and mis-compartmentalized inflammation post-VCA and therefore necessitate mitigation strategies. Our novel computational pipeline may also yield translational, spatiotemporal insights in other contexts.
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Affiliation(s)
- Ashti M. Shah
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, United States
| | - Ali Mubin Aral
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, United States
| | - Ruben Zamora
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, United States
| | - Nitin Gharpure
- Department of Surgery, Wake Forest Institute for Regenerative Medicine, Wake Forest Baptist Medical Center, Winston Salem, NC, United States
| | - Fayten El-Dehaibi
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, United States
| | - Fatih Zor
- Department of Surgery, Wake Forest Institute for Regenerative Medicine, Wake Forest Baptist Medical Center, Winston Salem, NC, United States
| | - Yalcin Kulahci
- Department of Surgery, Wake Forest Institute for Regenerative Medicine, Wake Forest Baptist Medical Center, Winston Salem, NC, United States
| | - Huseyin Karagoz
- Department of Surgery, Wake Forest Institute for Regenerative Medicine, Wake Forest Baptist Medical Center, Winston Salem, NC, United States
| | - Derek A. Barclay
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, United States
| | - Jinling Yin
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, United States
| | | | - Dmitry Tuder
- Plastic Surgery, San Antonio Military Medical Center, Fort Sam Houston, San Antonio, TX, United States
| | - Vijay S. Gorantla
- Department of Surgery, Wake Forest Institute for Regenerative Medicine, Wake Forest Baptist Medical Center, Winston Salem, NC, United States
| | - Yoram Vodovotz
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, United States
- Center for Inflammation and Regeneration Modeling, McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, United States
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Boczar D, Seu M, O’Connell A, Gersh E, Chaya BF, Berman Z, Ruiz N, Welsh L, Rodriguez ED. Hand Therapy Regimen for Functional Recovery Following Combined Face and Bilateral Hand Transplantation. Hand (N Y) 2023; 18:NP7-NP15. [PMID: 36214276 PMCID: PMC10152528 DOI: 10.1177/15589447221124250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
Intensive postoperative rehabilitation therapy is associated with positive functional recovery in hand transplants (HTs). Our goal is to share the hand therapy protocol developed for our patient who underwent a combined face and bilateral HT. The patient is a 23-year-old right-hand-dominant male with a history of third-degree burns to 80% of his body following a motor vehicle accident. A multidisciplinary evaluation established his candidacy for a combined face and bilateral HT, and surgery took place in August 2020. Our individualized hand therapy protocol consisted of 4 phases. The pre-surgery phase focused on planning the orthotics and patient/caregivers' education on the rehabilitation process. The intensive care unit (ICU)/acute care phase involved hand allograft protection and positioning via orthotic fabrication, safe limb handling, and edema/wound management. The inpatient rehabilitation phase aimed to prepare the patient for independent living via neuromuscular and sensory re-education, improvement of upper extremities strength/flexibility, training basic activities of daily living, and providing a home exercise program (HEP). Finally, the outpatient phase aimed to maximize our patient's range of motion and independency in performing his routine activities and HEP. The patient's post-transplant functional outcomes showed a significant improvement compared to the pre-operative baseline. We hope this report sheds light on a comprehensive hand therapy program in HT.
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Affiliation(s)
- Daniel Boczar
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY, USA
| | - Monica Seu
- Department of Outpatient Occupational Therapy, NYU Langone Health, New York, NY, USA
| | - April O’Connell
- Department of Outpatient Occupational Therapy, NYU Langone Health, New York, NY, USA
| | - Eugene Gersh
- Department of Outpatient Occupational Therapy, NYU Langone Health, New York, NY, USA
| | - Bachar F. Chaya
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY, USA
| | - Zoe Berman
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY, USA
| | - Natalia Ruiz
- Department of Outpatient Occupational Therapy, NYU Langone Health, New York, NY, USA
| | - Laura Welsh
- Department of Outpatient Occupational Therapy, NYU Langone Health, New York, NY, USA
| | - Eduardo D. Rodriguez
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY, USA
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Aral AM, Zamora R, Barclay D, Yin J, El-Dehaibi F, Erbas VE, Dong L, Zhang Z, Sahin H, Gorantla VS, Vodovotz Y. The Effects of Tacrolimus on Tissue-Specific, Protein-Level Inflammatory Networks in Vascularized Composite Allotransplantation. Front Immunol 2021; 12:591154. [PMID: 34017323 PMCID: PMC8129572 DOI: 10.3389/fimmu.2021.591154] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 04/14/2021] [Indexed: 12/26/2022] Open
Abstract
Systems-level insights into inflammatory events after vascularized composite allotransplantation (VCA) are critical to the success of immunomodulatory strategies of these complex procedures. To date, the effects of tacrolimus (TAC) immunosuppression on inflammatory networks in VCA, such as in acute rejection (AR), have not been investigated. We used a systems biology approach to elucidate the effects of tacrolimus on dynamic networks and principal drivers of systemic inflammation in the context of dynamic tissue-specific immune responses following VCA. Lewis (LEW) rat recipients received orthotopic hind limb VCA from fully major histocompatibility complex-mismatched Brown Norway (BN) donors or matched LEW donors. Group 1 (syngeneic controls) received LEW limbs without TAC, and Group 2 (treatment group) received BN limbs with TAC. Time-dependent changes in 27 inflammatory mediators were analyzed in skin, muscle, and peripheral blood using Principal Component Analysis (PCA), Dynamic Bayesian Network (DyBN) inference, and Dynamic Network Analysis (DyNA) to define principal characteristics, central nodes, and putative feedback structures of systemic inflammation. Analyses were repeated on skin + muscle data to construct a "Virtual VCA", and in skin + muscle + peripheral blood data to construct a "Virtual Animal." PCA, DyBN, and DyNA results from individual tissues suggested important roles for leptin, VEGF, various chemokines, the NLRP3 inflammasome (IL-1β, IL-18), and IL-6 after TAC treatment. The chemokines MCP-1, MIP-1α; and IP-10 were associated with AR in controls. Statistical analysis suggested that 24/27 inflammatory mediators were altered significantly between control and TAC-treated rats in peripheral blood, skin, and/or muscle over time. "Virtual VCA" and "Virtual Animal" analyses implicated the skin as a key control point of dynamic inflammatory networks, whose connectivity/complexity over time exhibited a U-shaped trajectory and was mirrored in the systemic circulation. Our study defines the effects of TAC on complex spatiotemporal evolution of dynamic inflammation networks in VCA. We also demonstrate the potential utility of computational analyses to elucidate nonlinear, cross-tissue interactions. These approaches may help define precision medicine approaches to better personalize TAC immunosuppression in VCA recipients.
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Affiliation(s)
- Ali Mubin Aral
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, United States
| | - Ruben Zamora
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, United States.,Center for Inflammation and Regenerative Modeling, McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Derek Barclay
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, United States
| | - Jinling Yin
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, United States
| | - Fayten El-Dehaibi
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, United States
| | - Vasil E Erbas
- Department of Plastic, Reconstructive and Aesthetic Surgery, Medicalpark Gaziantep Hospital, Gaziantep, Turkey
| | - Liwei Dong
- Plastic and Aesthetic Surgery Department, XiJing Hospital, Xi'an, China
| | - Zhaoxiang Zhang
- Plastic and Aesthetic Surgery Department, XiJing Hospital, Xi'an, China
| | | | - Vijay S Gorantla
- Department of Surgery, Wake Forest Institute for Regenerative Medicine, Wake Forest Baptist Medical Center, Winston Salem, NC, United States
| | - Yoram Vodovotz
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, United States.,Center for Inflammation and Regenerative Modeling, McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, United States
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Subbotin VM. Pattern of organ remodeling in chronic non-communicable diseases is due to endogenous regulations and falls under the category of Kauffman's self-organization: A case of arterial neointimal pathology. Med Hypotheses 2020; 143:110106. [PMID: 32759005 DOI: 10.1016/j.mehy.2020.110106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 06/07/2020] [Accepted: 07/11/2020] [Indexed: 01/10/2023]
Abstract
Clinical diagnosis is based on analysis of pathologic findings that may result in perceived patterns. The same is true for diagnostic pathology: Pattern analysis is a foundation of the histopathology-based diagnostic system and, in conjunction with clinical and laboratory findings, forms a basis for the classification of diseases. Any histopathology diagnosis is based on the explicit assumption that the same diseased condition should result in formation of the same (or highly similar) morphologic patterns in different individuals; it is a standard approach in microscopic pathology, including that of non-communicable chronic diseases with organ remodeling. During fifty years of examining diseased tissues under microscopy, I keep asking the same question: Why is a similarity of patterns expected for chronic organ remodeling? For infection diseases, xenobiotic toxicity and deficiencies forming an identical pathologic pattern in different individuals is understandable and logical: The same infection, xenobiotic, or deficiency strikes the same target, which results in identical pathology. The same is true for Mendelian diseases: The same mutations lead to the same altered gene expressions and the same pathologic pattern. But why does this regularity hold true for chronic diseases with organ remodeling? Presumable causes (or risk factors) for a particular chronic disease differ in magnitude and duration between individuals, which should result in various series of transformations. Yet, mysteriously enough, pathological remodeling in a particular chronic disease always falls into a main dominating pattern, perpetuating and progressing in a similar fashion in different patients. Furthermore, some chronic diseases of different etiologies and dissimilar causes/risk factors manifest as identical or highly similar patterns of pathologic remodeling. HYPOTHESIS: I hypothesize that regulations governing a particular organ's chronic remodeling were selected in evolution as the safest response to various insults and physiologic stress conditions. This hypothesis implies that regulations directing diseased chronic remodeling always preexist but normally are controlled; this control can be disrupted by a diverse range of non-specific signals, liberating the pathway for identical pathologic remodeling. This hypothesis was tested in an analysis of arterial neointimal formation, the identical pathology occurring in different diseases and pathological conditions: graft vascular disease in organ transplantation, in-stent restenosis, peripheral arterial diseases, idiopathic intimal hyperplasia, Kawasaki disease, coronary atherosclerosis and as reaction to drugs. The hypothesis suggests that arterial intimal cells are poised between only two alternative pathways: the pathway with controlled intimal cell proliferation or the pathway where such control is disrupted, ultimately leading to the progressive neointimal pathology. By this property the arterial neointimal formation constitutes a special case of Kauffman's self-organization. This new hypothesis gives a parsimonious explanation for identical pathological patterns of arterial remodeling (neointimal formation), which occurs in diseases of different etiologies and due to dissimilar causes/risk factors, or without any etiology and causes/risk factors at all. This new hypothesis also suggests that regulation facilitating intimal cell proliferation cannot be overwritten or annulled because this feature is vital for arterial differentiation, cell renewal, and integrity. This hypothesis suggests that studying numerous, and likely interchangeable, non-specific signals that disrupt regulation controlling intimal cell proliferation is unproductive; instead, a study of the controlling regulation(s) itself should be a priority of our research.
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Affiliation(s)
- Vladimir M Subbotin
- University of Pittsburgh, Pittsburgh, PA 15260, USA; University of Wisconsin, Madison, WI 53705, USA; Arrowhead Parmaceuticals, Madison, WI 53719, USA.
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Wang H, Sobral MC, Snyder T, Brudno Y, Gorantla VS, Mooney DJ. Clickable, acid labile immunosuppressive prodrugs forin vivotargeting. Biomater Sci 2020; 8:266-277. [DOI: 10.1039/c9bm01487j] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Clickable immunosuppressive prodrugs enablein vivoreplenishment of drugs in biomaterial depots to maintain long-term immunosuppression in tissue/organ transplantation.
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Affiliation(s)
- Hua Wang
- Harvard John A. Paulson School of Engineering and Applied Sciences
- Harvard University
- Cambridge
- Massachusetts 02138
- USA
| | - Miguel C. Sobral
- Harvard John A. Paulson School of Engineering and Applied Sciences
- Harvard University
- Cambridge
- Massachusetts 02138
- USA
| | - Tracy Snyder
- Wyss Institute for Biologically Inspired Engineering
- Cambridge
- USA
| | - Yevgeny Brudno
- Harvard John A. Paulson School of Engineering and Applied Sciences
- Harvard University
- Cambridge
- Massachusetts 02138
- USA
| | - Vijay S. Gorantla
- Surgery
- Ophthalmology and Bioengineering
- Wake Forest School of Medicine
- Winston-Salem
- USA
| | - David J. Mooney
- Harvard John A. Paulson School of Engineering and Applied Sciences
- Harvard University
- Cambridge
- Massachusetts 02138
- USA
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Graft-implanted, enzyme responsive, tacrolimus-eluting hydrogel enables long-term survival of orthotopic porcine limb vascularized composite allografts: A proof of concept study. PLoS One 2019; 14:e0210914. [PMID: 30677062 PMCID: PMC6345449 DOI: 10.1371/journal.pone.0210914] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Accepted: 01/03/2019] [Indexed: 11/19/2022] Open
Abstract
Background Currently, patients receiving vascularized composite allotransplantation (VCA) grafts must take long-term systemic immunosuppressive therapy to prevent immunologic rejection. The morbidity and mortality associated with these medications is the single greatest barrier to more patients being able to receive these life-enhancing transplants. In contrast to solid organs, VCA, exemplified by hand or face transplants, allow visual diagnosis of clinical acute rejection (AR), directed biopsy and targeted graft therapies. Local immunosuppression in VCA could reduce systemic drug exposure and limit adverse effects. This proof of concept study evaluated, in a large animal forelimb VCA model, the efficacy and tolerability of a novel graft-implanted enzyme-responsive, tacrolimus (TAC)—eluting hydrogel platform, in achieving long-term graft survival. Methods Orthotopic forelimb VCA were performed in single haplotype mismatched mini-swine. Controls (n = 2) received no treatment. Two groups received TAC hydrogel: high dose (n = 4, 91 mg TAC) and low dose (n = 4, 49 mg TAC). The goal was to find a dose that was tolerable and resulted in long-term graft survival. Limbs were evaluated for clinical and histopathological signs of AR. TAC levels were measured in serial blood and skin tissue samples. Tolerability of the dose was evaluated by monitoring animal feeding behavior and weight. Results Control limbs underwent Banff Grade IV AR by post-operative day six. Low dose TAC hydrogel treatment resulted in long-term graft survival time to onset of Grade IV AR ranging from 56 days to 93 days. High dose TAC hydrogel also resulted in long-term graft survival (24 to 42 days), but was not well tolerated. Conclusion Graft-implanted TAC-loaded hydrogel delays the onset of Grade IV AR of mismatched porcine forelimb VCA grafts, resulting in long term graft survival and demonstrates dose-dependent tolerability.
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Janjic JM, Gorantla VS. Novel Nanoimaging Strategies for Noninvasive Graft Monitoring in Vascularized Composite Allotransplantation. CURRENT TRANSPLANTATION REPORTS 2018. [DOI: 10.1007/s40472-018-0221-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Zor F, Sengezer M, Davis MR. Penile Reconstruction Versus Transplantation: Which One Is Ideal? CURRENT TRANSPLANTATION REPORTS 2018. [DOI: 10.1007/s40472-018-0215-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Espinel-Pinzón DA, Figueroa-Bohorquez D, Lozano-Márquez E. Inducción de tolerancia inmunológica: alotrasplantes compuestos vascularizados y trasplantes de órgano sólido. REVISTA DE LA FACULTAD DE MEDICINA 2018. [DOI: 10.15446/revfacmed.v66n3.61735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Introducción. La inducción de tolerancia inmunológica solucionaría los problemas asociados con la inmunosupresión de por vida, necesaria para evitar el rechazo de aloinjertos.Objetivos. Revisar aspectos inmunológicos, modelos clínicos utilizados y resultados obtenidos en la tolerancia y comparar los resultados obtenidos con trasplante de órgano sólido y alotrasplante compuesto vascularizado.Materiales y métodos. Se realizó una búsqueda en la base de datos PubMed que arrojó 299 resultados; se revisaron las bibliografías de los artículos y se consultaron las referencias pertinentes. Al final se seleccionaron 83 artículos.Resultados. Existen mecanismos centrales y periféricos para mantener la tolerancia a antígenos propios; en la práctica clínica, la tolerancia central ha sido más utilizada, esto se ha hecho mediante estrategias que utilizan trasplante conjunto de medula ósea. Varios ensayos clínicos, la mayoría en pacientes con trasplante renal, han mostrado resultados prometedores pero inconsistentes.Conclusiones. En trasplantes renales fue posible suspender de forma exitosa la inmunosupresión, mientras que en trasplantes de mano se logró disminuirla considerablemente. El quimerismo inmunológico parece ser indispensable para el desarrollo de tolerancia a aloinjertos, por lo que es necesario desarrollar protocolos para inducir quimerismo mixto persistente.
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Carrillo-Moreno CI, Escobar-Serna DP, González-Vélez SDJ, Lozano-Marquez E. Hand Transplantation: Current concepts and management algorithm. REVISTA DE LA FACULTAD DE MEDICINA 2017. [DOI: 10.15446/revfacmed.v65n3.56151] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Introducción. El trasplante de mano ha sido uno de los retos del siglo XXI, cuyo primer caso reportado ocurrió en 1964. En este campo se han hecho estudios y avances que permitieron explorar nuevas alternativas para el manejo del paciente con trasplante de mano, por lo que diversos centros de referencia han realizado análisis basados en sus experiencias, las cuales permitieron lograr la viabilidad de este tipo de trasplante.Objetivo. Esta revisión busca dar una visión general sobre el trasplante de mano y proponer un algoritmo de manejo.Materiales y métodos. La selección de candidatos requiere una serie de criterios, tales como evaluación clínica, paraclínica y psicosocial, desarrollados por un equipo multidisciplinario. La inmunosupresión busca evitar el rechazo y los inmunosupresores deben tener los niveles séricos apropiados para reducir sus efectos adversos. Se han reportado casos de rechazo agudo clásico y atípico, donde la piel es el principal tejido blanco, y rechazo crónico, en el cual se afectan los vasos sanguíneos. El seguimiento se realiza con varias pruebas, de modo que la de oro es la biopsia de piel.Resultados. Las complicaciones del tratamiento farmacológico derivan de la toxicidad de los medicamentos y se manifiestan como alteraciones metabólicas, infecciones oportunistas y neoplasias. La rehabilitación y los aspectos sociales, como el grado de satisfacción del paciente, deben ser evaluados durante la recuperación para asegurar adherencia al tratamiento. En 2011 el registro internacional de alotransplante compuesto de mano reportó 39 casos de trasplante de extremidades superiores con resultados variables; todo esto evidencia que para lograr un resultado óptimo y viable del trasplante debe realizarse seguimiento por un equipo multidisciplinario, red de apoyo del paciente y motivación del mismo, junto con el cumplimiento del manejo farmacológico.Conclusión. Se espera que nuevas investigaciones puedan crear estrategias para desarrollar tolerancia y, de esta forma, reducir el manejo mediante inmunosupresión.
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Angiosome-Based Allografts: Vascularized Composite Allotransplantation for Tailored Subunit Reconstruction with Volkmann Ischemic Contracture as a Case in Point. Plast Reconstr Surg 2017; 139:1291e-1304e. [PMID: 28538571 DOI: 10.1097/prs.0000000000003360] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND As we enter an age with new approaches to tissue reconstruction, the emphasis on the adage "like for like" has become even more relevant. This study illustrates the potential for several tailored vascularized composite allotransplantation reconstructive techniques and, in particular, for the management of Volkmann contracture. METHODS Twenty fresh cadaver dissections and 30 archival lead oxide radiographic studies were examined to (1) identify potential upper limb vascularized composite allotransplantation donor sites (i.e., elbow, forearm, and flexor tendon complex) and (2) demonstrate a "mock transplant" of the vascularized volar forearm allograft for a severe Volkmann ischemia defect. They were designed without skin to reduce antigenicity. RESULTS The elbow joint was supplied within the brachial angiosome and the flexor tendon complex of the flexor digitorum superficialis and flexor digitorum profundus by the superficial palmar arch of the ulnar angiosome. The forearm allograft of flexor muscles, median, ulnar, and anterior interosseous nerves, when harvested on the brachial vessels, was supplied within the radial, ulnar, and anterior interosseous angiosomes but could be based on the ulnar artery alone because of intramuscular connections with the other territories. A mock transplant was performed with a distal-to-proximal dissection of the allograft, facilitating the best and fastest technique. CONCLUSIONS This application of the angiosome concept highlights the anatomical feasibility of the volar forearm vascularized composite allotransplantation donor site focusing on a complex subunit problem in the upper limb-severe Volkmann ischemic contracture. It demonstrates the potential use and immunologic advantage of subdivided and modified nonskin variations of vascularized composite allotransplantation in reconstructive transplantation surgery. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, V.
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Psychosocial Evaluation for First Hand Allotransplantation in Taiwan. Ann Plast Surg 2016; 78:347-353. [PMID: 27984215 DOI: 10.1097/sap.0000000000000950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Hand transplantation has raised ethical and psychological concerns. Few studies have focused on reasons for not selecting candidates on waiting lists. To describe the psychosocial evaluation of referred prospective hand transplant candidates, we investigated candidate suitability by using 22-month follow-up data regarding the first hand transplant recipient in Taiwan. Pretransplant psychosocial assessments comprised an interview with 2 psychiatrists, a social worker, and a psychologist, followed by intelligence quotient scoring with the Wechsler Adult Intelligence Scale and Taiwanese Depression Questionnaire. After team member consensus, of the 20 patients referred to our team to confirm their hand transplantation suitability during April 26, 2013, to March 19, 2015, 7 potential recipients were placed on the waiting list after completing all prehand transplant evaluations. On September 3, 2014, the left distal forearm and hand of a brain-dead man was transplanted to a 45-year-old man who had undergone traumatic amputation of the distal third of his right forearm 30 years previously. During a 22-month follow-up, he complied with scheduled visits, including routine posttransplant laboratory tests, skin biopsies, and intensive physical therapy. Moreover, he overcame repeated graft rejections, bacterial and viral infections, immunosuppressant side effects, considerable economic stress, and the difficulties associated with the adhesion of hand tendons. Finally, he regained some satisfactory function of the transplanted hand. Considering posttransplantation difficulties, suitable candidates for hand transplantation should have persistent motivation, appropriate expectations, patience, immediate availability, fair intelligence, fair social functioning, and adequate economic and familial support.
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Sabapathy SR, Bhardwaj P. Setting the Goals in the Management of Mutilated Injuries of the Hand-Impressions Based on the Ganga Hospital Experience. Hand Clin 2016; 32:435-441. [PMID: 27712746 DOI: 10.1016/j.hcl.2016.07.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Mutilated injuries need to be treated aggressively and appropriately to avoid amputation or severe disability in the individual. Assessment of the management of these injuries on a global level reveals that there is a gap between the need and availability of the skilled manpower to manage these injuries. There is also a gap in the utilization of the available services. These gaps need to be covered or narrowed as far as possible. Although some measures need policy changes and improvement of health care delivery infrastructure, simpler measures taken at the final health care delivery level can significantly improve the final outcome.
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Affiliation(s)
- S Raja Sabapathy
- Division of Plastic Surgery, Hand Surgery, Reconstructive Microsurgery and Burns, Ganga Hospital, 313, Mettupalayam Road, Coimbatore, Tamil Nadu 641 043, India.
| | - Praveen Bhardwaj
- Hand & Wrist Surgery and Reconstructive Microsurgery, Ganga Hospital, 313, Mettupalayam Road, Coimbatore, Tamil Nadu 641 043, India
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Emerging Implications for Extracellular Matrix-Based Technologies in Vascularized Composite Allotransplantation. Stem Cells Int 2016; 2016:1541823. [PMID: 26839554 PMCID: PMC4709778 DOI: 10.1155/2016/1541823] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 10/05/2015] [Indexed: 12/21/2022] Open
Abstract
Despite recent progress in vascularized composite allotransplantation (VCA), limitations including complex, high dose immunosuppression regimens, lifelong risk of toxicity from immunosuppressants, acute and most critically chronic graft rejection, and suboptimal nerve regeneration remain particularly challenging obstacles restricting clinical progress. When properly configured, customized, and implemented, biomaterials derived from the extracellular matrix (ECM) retain bioactive molecules and immunomodulatory properties that can promote stem cell migration, proliferation and differentiation, and constructive functional tissue remodeling. The present paper reviews the emerging implications of ECM-based technologies in VCA, including local immunomodulation, tissue repair, nerve regeneration, minimally invasive graft targeted drug delivery, stem cell transplantation, and other donor graft manipulation.
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Iyer S. Vascularised composite allotransplants: Transplant of upper extremities and face. Indian J Plast Surg 2015; 48:111-8. [PMID: 26424972 PMCID: PMC4564491 DOI: 10.4103/0970-0358.163037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Transplantation of solid organs and bone marrow has become a highly acceptable and often the only available clinical solution in many situations. It has been practiced across the globe for quite a long time since the first kidney transplant in 1954. Transplantation of tissues other than these, which was termed composite tissue allotransplantation and currently as vascularised composite allotransplantation (VCA) is gaining acceptance as a solution for complex reconstructive problems. This involves the transfer of multiple types of tissue such as bone, muscle, nerve, skin and blood vessels. The advantage of these over the conventional reconstructive methods is its ability to give aesthetically and functionally superior equal composite substitute to the missing or deformed part. The composite tissues transplanted commonly include the upper extremities, face and abdominal wall. Among these, hand transplants were the first to be done and have been carried out more than any other VCA. This article reviews the current scenario of VCA especially of the hand and face, in the light of experience of the two bilateral hand transplants done recently in India.
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Affiliation(s)
- Subramania Iyer
- Department of Plastic and Reconstructive Surgery, Amrita Institute of Medical Sciences, Kochi, Kerala, India
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16
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Abstract
Composite tissue transplantation is an emerging new era in transplant medicine and has become a viable reconstructive option for patients with large and devastating tissue defects. Advances in microsurgical techniques, transplant immunology and the development of potent immunosuppressive agents have enabled the realization of such types of transplants. Over the past decade, a rapidly growing number of face and upper extremity transplantations have been performed worldwide with highly encouraging outcomes. However, despite the fact that surgical, immunological and functional results are highly encouraging, the need for long-term and high-dose immunosuppression to enable graft survival and to treat/reverse acute skin rejection episodes remains a pace-limiting obstacle towards wide spread application. In this chapter we review the history and development of this novel field, the functional and immunological outcomes based on the world experience, unique biological features of such transplants, mechanisms and treatment protocols for acute skin rejection, as well as novel concepts for immune modulation and tolerance induction.
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Affiliation(s)
- Gerald Brandacher
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Tolerance induction strategies in vascularized composite allotransplantation: mixed chimerism and novel developments. Clin Dev Immunol 2012; 2012:863264. [PMID: 23320020 PMCID: PMC3540904 DOI: 10.1155/2012/863264] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2012] [Revised: 11/06/2012] [Accepted: 12/03/2012] [Indexed: 12/29/2022]
Abstract
Since the start of the clinical vascularized composite allotransplantation (VCA) era over a decade ago this field has witnessed significant developments in both basic and translational research. Transplant tolerance, defined as rejection-free acceptance of transplanted organs or tissues without long-term immunosuppression, holds the potential to revolutionize the field of VCA by removing the need for life-long immunosuppression. While tolerance of organ and vascularized composite transplants may be induced in small animal models by a variety of protocols, only mixed-chimerism-based protocols have successfully bridged the gap to preclinical study and to clinical trial in solid organ transplantation to date. In this paper we review the mixed-chimerism approach to tolerance induction, with specific reference to the field of VCA transplantation, and provide an overview of some novel cellular therapies as potential adjuvants to mixed chimerism in the development of tolerance induction protocols for clinical vascularized composite allotransplantation.
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18
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Minimization of Immunosuppression and Tolerance Induction in Reconstructive Transplantation. CURRENT SURGERY REPORTS 2012. [DOI: 10.1007/s40137-012-0008-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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