1
|
Gülbağ Pınar S, Pezik E, Mutlu Ağardan B, Çelebi N. Development of cyclosporine A nanosuspension: cytotoxicity and permeability on Caco-2 cell lines. Pharm Dev Technol 2021; 27:52-62. [PMID: 34931593 DOI: 10.1080/10837450.2021.2020817] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Cyclosporine A is a calcineurin inhibitor and is usually used as an immunosuppressant medication. The main purpose of this study is to develop nanosuspension of polypeptide cyclosporine A by using the wet milling method for oral administration. Cell culture studies were also performed with human intestinal Caco-2 cell lines. Hydroxypropyl methylcellulose and sodium dodecyl sulfate were used as stabilizers in nanosuspension. In vitro characterization studies such as Fourier-transform infrared analysis and morphological imaging with scanning electron microscopy have been carried out with obtained cyclosporine A nanosuspension. The particle size, particle size distribution, and zeta potential values of the nanosuspension were measured approximately 400 nm, 0.4, and -25 mV, respectively. The solubility of cyclosporine A was increased 4.5 times in nanosuspension compared to the coarse cyclosporine A powder. As a result of cytotoxicity studies conducted with different concentrations, it was decided to conduct permeability studies at a dose equivalent to 150 µg/mL cyclosporine A. Permeation studies have shown that the nanosuspension increases cyclosporine A transport by 5 and 1.5 times, respectively, compared to coarse powder and commercial product.
Collapse
Affiliation(s)
- Sıla Gülbağ Pınar
- Department of Pharmaceutical Technology, Faculty of Pharmacy, Gazi University, Ankara, Turkey.,Department of Pharmaceutical Technology, Faculty of Pharmacy, Süleyman Demirel University, Isparta, Turkey
| | - Esra Pezik
- Department of Pharmaceutical Technology, Faculty of Pharmacy, Hacettepe University, Ankara, Turkey
| | - Başaran Mutlu Ağardan
- Department of Pharmaceutical Technology, Faculty of Pharmacy, Gazi University, Ankara, Turkey
| | - Nevin Çelebi
- Department of Pharmaceutical Technology, Faculty of Pharmacy, Gazi University, Ankara, Turkey.,Department of Pharmaceutical Technology, Faculty of Pharmacy, Başkent University, Ankara, Turkey
| |
Collapse
|
2
|
Messner F, Etra JW, Shores JT, Thoburn CJ, Hackl H, Iglesias Lozano M, Fidder SAJ, Guo Y, Kambarashvili K, Alagol K, Kalsi R, Beck SE, Cooney C, Furtmüller GJ, Krapf J, Oh BC, Brandacher G. Noninvasive evaluation of intragraft immune responses in upper extremity transplantation. Transpl Int 2021; 34:894-905. [PMID: 33626223 DOI: 10.1111/tri.13854] [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: 11/24/2020] [Revised: 01/01/2021] [Accepted: 02/17/2021] [Indexed: 01/24/2023]
Abstract
In vascularized composite allotransplantation (VCA), invasive tissue biopsies remain the gold standard in diagnosing rejection carrying significant morbidity. We aimed to show feasibility of tape-stripping for noninvasive immune monitoring in VCA. Tape-stripping was performed on allografts and native skin of upper extremity transplant recipients. Healthy nontransplanted individuals served as controls. The technique was also used in swine on naïve skin in nontransplanted animals, native skin of treated, transplanted swine, nonrejecting VCAs, and rejecting VCAs. Extracted protein was analyzed for differences in cytokine expression using Luminex technology. Significantly decreased levels of INFγ and IL-1Ra were seen between human allograft samples and native skin. In swine, rejecting grafts had increased IL-1Ra compared to naïve and native skin, decreased levels of GM-CSF compared to native skin, and decreased IL-10 compared to nonrejecting grafts. Unsupervised hierarchical clustering revealed rejecting grafts separated from the nonrejecting (P = 0.021). Variable importance in projection scores identified GM-CSF, IL-1Ra, and IL-2 as the most important profiles for group discrimination. Differences in cytokine expression are detectable in human VCA patient native skin and VCA graft skin using a noninvasive tape-stripping method. Swine studies suggest that differences in cytokines between rejecting and nonrejecting grafts are discernable.
Collapse
Affiliation(s)
- Franka Messner
- Department of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation (VCA) Laboratory, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Visceral, Transplant and Thoracic Surgery, Medical University Innsbruck, Innsbruck, Austria
| | - Joanna W Etra
- Department of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation (VCA) Laboratory, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jaimie T Shores
- Department of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation (VCA) Laboratory, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Christopher J Thoburn
- Department of Oncology, The Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA
| | - Hubert Hackl
- Institute of Bioinformatics, Biocenter, Medical University of Innsbruck, Innsbruck, Austria
| | - Marcos Iglesias Lozano
- Department of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation (VCA) Laboratory, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Samuel A J Fidder
- Department of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation (VCA) Laboratory, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Yinan Guo
- Department of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation (VCA) Laboratory, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ketevan Kambarashvili
- Department of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation (VCA) Laboratory, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kemal Alagol
- Department of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation (VCA) Laboratory, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Richa Kalsi
- Department of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation (VCA) Laboratory, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sarah E Beck
- Department of Molecular and Comparative Pathobiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Carisa Cooney
- Department of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation (VCA) Laboratory, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Georg J Furtmüller
- Department of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation (VCA) Laboratory, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Johanna Krapf
- Department of Plastic and Reconstructive Surgery, Medical University Innsbruck, Innsbruck, Austria
| | - Byoung Chol Oh
- Department of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation (VCA) Laboratory, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Gerald Brandacher
- Department of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation (VCA) Laboratory, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| |
Collapse
|
3
|
Infectious complications of vascularized composite allograft transplantation. Curr Opin Organ Transplant 2021; 25:377-382. [PMID: 32487889 DOI: 10.1097/mot.0000000000000780] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Vascularized composite allograft (VCA) transplants constitute multiple tissues transplanted together as one functional unit. These procedures are increasing in frequency and complexity, yet data about graft survival, quality of life, and infection risk remain limited. RECENT FINDINGS Informative guidance for this patient population is often inferred from the solid organ transplantation literature. Yet, it is important to understand that VCA transplantation additionally carries its own significant and distinctive risk factors for infection. SUMMARY In this review, we give an overview of previously described infectious complications of VCA transplantation in the literature, discuss risk factors for future infection in these patients, and discuss how to manage such obstacles.
Collapse
|
4
|
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.
Collapse
|
5
|
Kotsougiani D, Hundepool CA, Bulstra LF, Friedrich PF, Shin AY, Bishop AT. Bone vascularized composite allotransplantation model in swine tibial defect: Evaluation of surgical angiogenesis and transplant viability. Microsurgery 2018; 39:160-166. [PMID: 29504151 DOI: 10.1002/micr.30310] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Revised: 02/02/2018] [Accepted: 02/08/2018] [Indexed: 11/10/2022]
Abstract
INTRODUCTION In prior small animal studies, we maintained vascularized bone allotransplant viability without long-term immunotherapy. Instead, an autogenous neoangiogenic circulation is created from implanted vessels, sufficient to maintain bone viability with only 2 weeks immunosupression. Blood flow is maintained despite rejection of the allogeneic vascular pedicle thereafter. We have previously described a large animal (swine) pre-clinical model, reconstructing tibial defects with vascularized tibial allotransplants. In this manuscript, autologous angiogenesis is evaluated in this model and correlated with bone viability. MATERIALS AND METHODS Allogeneic tibial segments were transplanted across a major swine leukocyte antigen mismatch. Microvascular repair of the bone VCA pedicle was combined with intraosseous implantation of an autogenous arteriovenous (AV) bundle. The bundle was ligated in group 1 (n = 4), and allowed to perfuse in group 2 (n = 4). Three-drug immunotherapy was given for 2 weeks. At 16 weeks micro-CT angiography quantified neoangiogenic vessel volume. Bone viability, rejection grade, and bone healing were analyzed. RESULTS A substantial neoangiogenic circulation developed from the implanted AV-bundle in group 2, with vessel density superior to ligated AV-bundle controls (0.11 ± 0.05 vs. 0.01 ± 0.01, P = .029). Bone allotransplant viability was also significantly enhanced by neoangiogenesis (78.7 ± 4.4% vs. 27.7 ± 5.8%, P = .028) with higher bone healing scores (21.4 ± 2.9 vs. 12.5 ± 3.7, P = .029). Ligated control tibias demonstrated disorganized bone morphology and higher local inflammation (P = .143). CONCLUSION Implantation of autogenous AV bundles into vascularized bone allotransplants resulted in the rapid formation of a neoangiogenic autogenous blood supply in a swine tibia model that maintained bone viability, improved bone healing, and minimized rejection.
Collapse
Affiliation(s)
- Dimitra Kotsougiani
- Microvascular Research Laboratory, Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota.,Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Department of Plastic Surgery, University of Heidelberg, Heidelberg, Germany
| | - Caroline A Hundepool
- Microvascular Research Laboratory, Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Liselotte F Bulstra
- Microvascular Research Laboratory, Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Patricia F Friedrich
- Microvascular Research Laboratory, Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Alexander Y Shin
- Microvascular Research Laboratory, Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Allen T Bishop
- Microvascular Research Laboratory, Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
6
|
Kwon J, Jung SM, Kim SY, Kwon NK, Park SJ. Anesthetic management of the first forearm transplantation in Korea. Korean J Anesthesiol 2018; 71:66-70. [PMID: 29441177 PMCID: PMC5809710 DOI: 10.4097/kjae.2018.71.1.66] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Revised: 09/20/2017] [Accepted: 09/25/2017] [Indexed: 11/29/2022] Open
Abstract
Vascularized composite allotransplantation for the forearm is a complex surgical procedure, requiring multidisciplinary collaboration. It is important to provide optimal blood flow to the grafts, effective immunosuppression, and early rehabilitation for graft survival and good functional outcomes. As ischemia-reperfusion injury and substantial but unquantifiable blood loss are inevitable in this type of surgery, anesthetic management should focus on providing adequate hemodynamic management with proper monitoring, and anesthetic and analgesic strategies to prevent vasoconstriction in the graft. In this paper, we describe the anesthetic management of the first forearm transplantation performed in Korea.
Collapse
Affiliation(s)
- Jinyeol Kwon
- Department of Anesthesiology and Pain Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Sung Mee Jung
- Department of Anesthesiology and Pain Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Sae-Yeon Kim
- Department of Anesthesiology and Pain Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Nyeong Keon Kwon
- Department of Anesthesiology and Pain Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Sang-Jin Park
- Department of Anesthesiology and Pain Medicine, Yeungnam University College of Medicine, Daegu, Korea
| |
Collapse
|
7
|
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.
Collapse
|
8
|
The Influence of Timing and Frequency of Adipose-Derived Mesenchymal Stem Cell Therapy on Immunomodulation Outcomes After Vascularized Composite Allotransplantation. Transplantation 2017; 101:e1-e11. [PMID: 27893612 DOI: 10.1097/tp.0000000000001498] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Cellular therapies for immunomodulation in vascularized composite allotransplantation (VCA) have gained importance due to their potential for minimization of immunosuppression. Adipose-derived (AD) mesenchymal stem cells (MSCs) especially have shown encouraging potential. We investigated the influence of timing and frequency of AD-MSC treatment on immunologic and graft survival as well as graft vasculopathy outcomes after VCA. METHODS Lewis rats received full-mismatched Brown Norway rat hindlimb transplants. Recipient animals were assigned to groups receiving donor-derived AD-MSCs (10 cells/animal) either on postoperative day (POD) 1, POD 4, or repeatedly on POD 4, 8, and 15, and compared to untreated controls. RESULTS Although AD-MSC administration on POD 1 or POD 4, 8, and 15 resulted in 50% long-term graft acceptance, recipients treated on POD 4, and controls rejected before POD 50. All treated animals revealed peripheral blood chimerism (4 weeks), most pronounced after repetitive cell administration (12.92% vs 5.03% [POD 1] vs 6.31% [POD 4]; P < 0.05; all P < 0.01 vs control 1.45%). Chimerism was associated with the generation of regulatory T cells (CD4CD25FoxP3). In vitro mixed lymphocyte reactions revealed modulation of the recipient immune response after AD-MSC treatment. Graft arteries at end point revealed significant differences of arterial intimal thickness between rejecting and AD-MSC-treated animals (P < 0.01). CONCLUSIONS Taken together, our results point to the potential for repetitive AD-MSC administration in improving outcomes after VCA. Future studies are warranted into optimization of the dosing and frequency of AD-MSC therapy, either alone or used in, combination with other cell therapies (such as hematopoietic stem cells or bone marrow-derived MSC or dendritic cells) for optimization of appropriate conditioning or maintenance regimens.
Collapse
|
9
|
Raval JS, Gorantla VS, Shores JT, Lee WPA, Planinsic RM, Rollins-Raval MA, Brandacher G, King KE, Losee JE, Kiss JE. Blood product utilization in human upper-extremity transplantation: challenges, complications, considerations, and transfusion protocol conception. Transfusion 2017; 57:606-612. [PMID: 28297082 DOI: 10.1111/trf.14009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Revised: 11/06/2016] [Accepted: 11/06/2016] [Indexed: 01/27/2023]
Abstract
BACKGROUND Upper-extremity transplantation (UET) is a reality. Immunologic, functional, and graft survival outcomes have been encouraging. However, these complex reconstructions have unique considerations that pose distinct challenges. Transplant programs have reported morbidity and mortality due to significant intraoperative blood losses, but similar data are scant during other phases of recovery. We report experience from two centers on complete blood component demands and utilization with UET. STUDY DESIGN AND METHODS Inpatient medical records of UET recipients from intraoperative (time from initiation of transplant surgery to exit from the operative suite) and postoperative (exit from the operative suite to discharge from the hospital) phases were retrospectively reviewed. RESULTS Six patients received various UETs and mean (±SD) postoperative hospital stay was 46 (±14.4) days. Mean (±SD) intraoperative blood unit utilization was 14.8 (±10.2) red blood cells (RBCs), 10.5 (±11.8) plasma, 0.8 (±1.2) platelets (PLTs), and 0.3 (±0.8) cryoprecipitate units. Mean postoperative blood unit utilization was 9.3 (±10.4) RBCs, 5.3 (±6.7) plasma, 1.2 (±2.0) PLTs, and 0.7 (±1.6) cryoprecipitate units. Both intraoperative and postoperative blood utilization for unilateral versus bilateral transplant were different, but not significantly so. However, total inpatient blood use in bilateral transplants was significantly greater than in unilateral transplants. CONCLUSION Substantial blood loss may occur in UET and require transfusion of many blood components, primarily RBCs and plasma. We propose an UET transfusion protocol and suggest that centers preparing to perform these transplants should actively engage the transfusion medicine service to ensure availability and access to appropriate blood components for the entire hospitalizations of these unique patients.
Collapse
Affiliation(s)
- Jay S Raval
- Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Vijay S Gorantla
- Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jaimie T Shores
- Department of Plastic and Reconstructive Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - W P Andrew Lee
- Department of Plastic and Reconstructive Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Raymond M Planinsic
- Department of Anesthesiology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Marian A Rollins-Raval
- Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Gerald Brandacher
- Department of Plastic and Reconstructive Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Karen E King
- Department of Pathology, Johns Hopkins University, Baltimore, Maryland
| | - Joseph E Losee
- Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Joseph E Kiss
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.,The Institute for Transfusion Medicine, Pittsburgh, Pennsylvania
| |
Collapse
|
10
|
Kumnig M, Jowsey-Gregoire SG. Key psychosocial challenges in vascularized composite allotransplantation. World J Transplant 2016; 6:91-102. [PMID: 27011907 PMCID: PMC4801807 DOI: 10.5500/wjt.v6.i1.91] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Revised: 12/16/2015] [Accepted: 01/08/2016] [Indexed: 02/05/2023] Open
Abstract
Psychosocial factors are important elements in the assessment and follow-up care for vascularized composite allotransplantation (VCA) and require multidisciplinary evaluation protocols. This review will highlight differences between VCA with solid organ transplantation (SOT), provide information on the psychosocial selection of VCA candidates, ethical issues, psychological outcomes, and on the need for multicenter research. VCA is primarily a life-enhancing procedure to improve recipients' quality of life and psychological well-being and it represents a potential option to provide reproduction in case of penile or uterine transplantation. The risk benefit ratio is distinctly different than SOT with candidates desiring life enhancing outcomes including improved body image, return to occupations, restored touch, and for uterine transplant, pregnancy. The Chauvet Workgroup has been convened with membership from a number of transplant centers to address these issues and to call for multicenter research. A multicenter research network would share similar evaluation approaches so that meaningful research on psychosocial variables could inform the transplant community and patients about factors that increase risk of non-adherence and other adverse psychosocial and medical outcomes.
Collapse
|
11
|
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.
Collapse
Affiliation(s)
- Subramania Iyer
- Department of Plastic and Reconstructive Surgery, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| |
Collapse
|
12
|
Diaz-Siso JR, Fischer S, Sisk GC, Bueno E, Kueckelhaus M, Talbot S, Carty MJ, Treister NS, Marty F, Milford EL, Pomahac B, Tullius SG. Initial experience of dual maintenance immunosuppression with steroid withdrawal in vascular composite tissue allotransplantation. Am J Transplant 2015; 15:1421-31. [PMID: 25777324 DOI: 10.1111/ajt.13103] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Revised: 11/07/2014] [Accepted: 11/08/2014] [Indexed: 01/25/2023]
Abstract
Current immunosuppression in VCA is largely based on the experience in solid organ transplantation. It remains unclear if steroids can be reduced safely in VCA recipients. We report on five VCA recipients who were weaned off maintenance steroids after a median of 2 months (mean: 4.8 months, range 2-12 months). Patients were kept subsequently on a low dose, dual maintenance consisting of tacrolimus and mycophenolate mofetil/mycophenloic acid with a mean follow-up of 43.6 months (median = 40 months, range 34-64 months). Early and late acute rejections responded well to temporarily augmented maintenance, topical immunosuppression, and/or steroid bolus treatment. One late steroid-resistant acute rejection required treatment with thymoglobulin. All patients have been gradually weaned off steroids subsequent to the treatment of acute rejections. Low levels of tacrolimus (<5 ng/mL) appeared as a risk for acute rejections. Although further experience and a cautious approach are warranted, dual-steroid free maintenance immunosuppression appears feasible in a series of five VCA recipients.
Collapse
Affiliation(s)
- J R Diaz-Siso
- Department of Surgery, Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
13
|
Biro M, Munoz MA, Weninger W. Targeting Rho-GTPases in immune cell migration and inflammation. Br J Pharmacol 2014; 171:5491-506. [PMID: 24571448 PMCID: PMC4282076 DOI: 10.1111/bph.12658] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Revised: 02/19/2014] [Accepted: 02/20/2014] [Indexed: 12/28/2022] Open
Abstract
Leukocytes are unmatched migrators capable of traversing barriers and tissues of remarkably varied structural composition. An effective immune response relies on the ability of its constituent cells to infiltrate target sites. Yet, unwarranted mobilization of immune cells can lead to inflammatory diseases and tissue damage ranging in severity from mild to life-threatening. The efficacy and plasticity of leukocyte migration is driven by the precise spatiotemporal regulation of the actin cytoskeleton. The small GTPases of the Rho family (Rho-GTPases), and their immediate downstream effector kinases, are key regulators of cellular actomyosin dynamics and are therefore considered prime pharmacological targets for stemming leukocyte motility in inflammatory disorders. This review describes advances in the development of small-molecule inhibitors aimed at modulating the Rho-GTPase-centric regulatory pathways governing motility, many of which stem from studies of cancer invasiveness. These inhibitors promise the advent of novel treatment options with high selectivity and potency against immune-mediated pathologies.
Collapse
Affiliation(s)
- Maté Biro
- Centenary Institute of Cancer Medicine and Cell Biology, Immune Imaging Program, Newtown, NSW, Australia; Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | | | | |
Collapse
|
14
|
Characterization, prophylaxis, and treatment of infectious complications in craniomaxillofacial and upper extremity allotransplantation: a multicenter perspective. Plast Reconstr Surg 2014; 133:543e-551e. [PMID: 24675206 DOI: 10.1097/prs.0000000000000015] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Vascularized composite allotransplants consist of heterogeneous tissues from different germ layers, which include skin, muscle, bone, fat, nerves, and lymph nodes. The antigenic diversity of these tissues, particularly of the highly immunogenic skin component, necessitates potent immunosuppressive regimens similar to that of some solid organ transplants. Indeed, the lifelong, high-dose, multidrug immunosuppressive protocols expose vascularized composite allotransplant recipients to considerable risk of infectious, metabolic, and neoplastic sequelae. In this article, the authors review the infectious risk to patients after vascularized composite allotransplantation, with special attention to the somewhat limited experience with the prophylaxis and treatment of infections after this innovative reconstructive surgery. METHODS A review of the literature was undertaken to elucidate the characterization, prophylaxis, and treatment of all documented infectious complications. RESULTS Infections in face and hand vascularized composite allotransplants follow a course similar to that of solid organ transplants. Several differences exist, including the unique flora of craniomaxillofacial transplants, the increased risk of donor-derived infections, and the alteration of the risk-to-benefit ratio for cytomegalovirus infections. CONCLUSIONS The patient with a face or limb transplant has many of the same infectious risks as a lung transplant recipient, which include bacterial, viral, and fungal infections. Because of the anatomy, mucosal exposure, and differing donor flora, however, the face or limb transplant is susceptible to invasive diseases from a variety of microbes.
Collapse
|
15
|
Abstract
PURPOSE OF REVIEW Psychosocial aspects are important indicators for reconstructive hand transplantation (RHT). They warrant further research attention given the influence of psychosocial factors on the success of RHT. This review will contrast RHT with solid organ transplantation, provide information to guide selection of RHT candidates and ethical implications, share information on psychological outcomes, and address the importance of a multicenter research approach. RECENT FINDINGS Previously published RHT reports have tried to identify psychosocial factors that are essential to guide selection of RHT candidates and that predict psychosocial outcomes. These issues in RHT are receiving increased attention, but standardized psychosocial evaluation and follow-up protocols are still needed. Recent study highlights the potential for a multicenter research approach that uses standardized assessment strategies and also emphasizes the need for a shared assessment approach to understand psychosocial outcomes. SUMMARY RHT combines the technical rigors of hand surgery and microsurgery with the complex multidisciplinary care that defines modern transplantation medicine. As recent work has provided a more complete picture of the complexities of the psychosocial factors in RHT, a psychosocial assessment protocol developed with input across the centers currently performing this procedure would capitalize on the collective diverse clinical experiences and standardize the assessment and follow-up protocol. With such standardized procedures in place, psychosocial risk factors for both poor psychosocial and medical/surgical outcomes can be identified which can inform the selection or preparation of future candidates.
Collapse
|
16
|
Abstract
Vascularized composite allotransplantation (VCA) is a novel therapeutic option for treatment of patients suffering from limb loss or severe facial disfigurement. To date, 72 hand and 19 facial transplantations have been performed worldwide. VCA in hand and facial transplantation is a complex procedure requiring a multidisciplinary team approach and extensive surgical planning. Despite good functional outcome, courses after hand and facial transplantation have been complicated by skin rejection. Long-term immunosuppression remains a necessity in VCA for allograft survival. To widen the scope of these quality-of-life-improving procedures, minimization of immunosuppression to limit risks and side effects is needed.
Collapse
|
17
|
Elliott RM, Tintle SM, Levin LS. Upper extremity transplantation: current concepts and challenges in an emerging field. Curr Rev Musculoskelet Med 2014; 7:83-8. [PMID: 24241894 PMCID: PMC4094126 DOI: 10.1007/s12178-013-9191-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Loss of an isolated upper limb is an emotionally and physically devastating event that results in significant impairment. Patients who lose both upper extremities experience profound disability that affects nearly every aspect of their lives. While prosthetics and surgery can eventually provide the single limb amputee with a suitable assisting hand, limited utility, minimal haptic feedback, weight, and discomfort are persistent problems with these techniques that contribute to high rates of prosthetic rejection. Moreover, despite ongoing advances in prosthetic technology, bilateral amputees continue to experience high levels of dependency, disability, and distress. Hand and upper extremity transplantation holds several advantages over prosthetic rehabilitation. The missing limb is replaced with one of similar skin color and size. Sensibility, voluntary motor control, and proprioception are restored to a greater degree, and afford better dexterity and function than prosthetics. The main shortcomings of transplantation include the hazards of immunosuppression, the complications of rejection and its treatment, and high cost. Hand and upper limb transplantation represents the most commonly performed surgery in the growing field of Vascularized Composite Allotransplantation (VCA). As upper limb transplantation and VCA have become more widespread, several important challenges and controversies have emerged. These include: refining indications for transplantation, optimizing immunosuppression, establishing reliable criteria for monitoring, diagnosing, and treating rejection, and standardizing outcome measures. This article will summarize the historical background of hand transplantation and review the current literature and concepts surrounding it.
Collapse
Affiliation(s)
- River M. Elliott
- />The Curtis National Hand Center, 3333 North Calvert Street, Baltimore, MD 21209 USA
| | - Scott M. Tintle
- />Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, America Building, 19 2nd Floor, Bethesda, MD 20889-5600 USA
| | - L. Scott Levin
- />Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, 2 Silverstein, 3400 Spruce Street, Philadelphia, PA 19104 USA
| |
Collapse
|
18
|
|
19
|
Kumnig M, Jowsey SG, Moreno E, Brandacher G, Azari K, Rumpold G. An overview of psychosocial assessment procedures in reconstructive hand transplantation. Transpl Int 2013; 27:417-27. [PMID: 24164333 DOI: 10.1111/tri.12220] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2013] [Revised: 08/20/2013] [Accepted: 10/20/2013] [Indexed: 12/18/2022]
Abstract
There have been more than 90 hand and upper extremity transplants performed worldwide. Functional and sensory outcomes have been reported in several studies, but little is known about the psychosocial outcomes. A comprehensive systematic literature review was performed, addressing the psychosocial impact of reconstructive hand transplantation. This review provides an overview of psychosocial evaluation protocols and identifies standards in this novel and exciting field. Essentials of the psychosocial assessment are discussed and a new protocol, the 'Chauvet Protocol', representing a standardized assessment protocol for future multicenter psychosocial trials is being introduced.
Collapse
Affiliation(s)
- Martin Kumnig
- Department of Medical Psychology, Center for Advanced Psychology in Plastic and Transplant Surgery, Innsbruck Medical University, Innsbruck, Austria
| | | | | | | | | | | |
Collapse
|
20
|
Diaz-Siso JR, Bueno EM, Sisk GC, Marty FM, Pomahac B, Tullius SG. Vascularized composite tissue allotransplantation--state of the art. Clin Transplant 2013; 27:330-7. [PMID: 23581799 DOI: 10.1111/ctr.12117] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/06/2013] [Indexed: 01/07/2023]
Abstract
Vascularized composite tissue allotransplantation is a viable treatment option for injuries and defects that involve multiple layers of functional tissue. In the past 15 yr, more than 150 vascularized composite allotransplantation (VCA) surgeries have been reported for various anatomic locations including - but not limited to - trachea, larynx, abdominal wall, face, and upper and lower extremities. VCA can achieve a level of esthetic and functional restoration that is currently unattainable using conventional reconstructive techniques. Although the risks of lifelong immunosuppression continue to be an important factor when evaluating the benefits of VCA, reported short- and long-term outcomes have been excellent, thus far. Acute rejections are common in the early post-operative period, and immunosuppression-related side effects have been manageable. A multidisciplinary approach to the management of VCA has proven successful. Reports of long-term graft losses have been rare, while several factors may play a role in the pathophysiology of chronic graft deterioration in VCA. Alternative approaches to immunosuppression such as cellular therapies and immunomodulation hold promise, although their role is so far not defined. Experimental protocols for VCA are currently being explored. Moving forward, it will be exciting to see whether VCA-specific aspects of allorecognition and immune responses will be able to help facilitate tolerance induction.
Collapse
Affiliation(s)
- J Rodrigo Diaz-Siso
- Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02215, USA
| | | | | | | | | | | |
Collapse
|
21
|
Chimerism-based experimental models for tolerance induction in vascularized composite allografts: Cleveland clinic research experience. Clin Dev Immunol 2013; 2013:831410. [PMID: 23573114 PMCID: PMC3612438 DOI: 10.1155/2013/831410] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2012] [Revised: 02/12/2013] [Accepted: 02/12/2013] [Indexed: 11/20/2022]
Abstract
The preclinical experimental models of vascularized composite allografts (VCAs) have been rapidly developed for the assessment of immunomodulatory protocols for clinical application. Recently, researchers have focused on immunomodulatory protocols which overcome the immunologic barrier between the allogeneic donor and recipient and may lead to tolerance induction. In order to test the feasibility of chimerism induction, experimental VCAs have been performed in different models including rodents, large animals, and nonhuman primates. These models differ in the complexity of transplanted tissue and in their responses to immunomodulatory protocols. In most applications, VCA contains multiple-tissue components; however, each individual component of CTA possesses unique immunologic characteristics that ultimately contribute to the chimerism induction and successful outcome of the VCA. Heterogenic character and complexity of tissue components in different VCA models determine the quality and robustness of donor-specific chimerism. As introduced in experimental studies, variable immunomodulatory options have been studied to achieve tolerance to VCA in rodents and large animal models allowing for widespread application in clinic. In this paper, based on our own experience, we have analyzed the current knowledge of tolerance-inducing strategies via chimerism induction in VCA experimental models in the context of immunomodulatory protocols and VCA complexity and their relevance and applicability to clinical practice.
Collapse
|
22
|
Hautz T, Zelger BG, Weißenbacher A, Zelger B, Brandacher G, Landin L, Morelon E, Kanitakis J, Jablecki J, Lee WA, Pratschke J, Schneeberger S. Standardizing skin biopsy sampling to assess rejection in vascularized composite allotransplantation. Clin Transplant 2013; 27:E81-90. [DOI: 10.1111/ctr.12086] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/26/2012] [Indexed: 11/29/2022]
Affiliation(s)
- Theresa Hautz
- Department of Visceral, Transplant and Thoracic Surgery; Center for Operative Medicine; Innsbruck Medical University; Innsbruck; Austria
| | - Bettina G. Zelger
- Department of Pathology; Innsbruck Medical University; Innsbruck; Austria
| | - Annemarie Weißenbacher
- Department of Visceral, Transplant and Thoracic Surgery; Center for Operative Medicine; Innsbruck Medical University; Innsbruck; Austria
| | - Bernhard Zelger
- Department of Dermatology; Innsbruck Medical University; Innsbruck; Austria
| | | | - Luis Landin
- Division of Plastic and Reconstructive Surgery; “La Paz” University Hospital; Madrid; Spain
| | - Emmanuel Morelon
- Department of Transplantation; Edouard Herriot Hospital; Hospices Civils de Lyon; Université de Lyon; Lyon; France
| | - Jean Kanitakis
- Department of Dermatology; Edouard Herriot Hospital; Hospices Civils de Lyon; Lyon; France
| | - Jerzy Jablecki
- Subdepartment of Replantation of Limbs; St Jadwiga Hospital; Trzebnica; Poland
| | - W.P. Andrew Lee
- Department of Plastic and Reconstructive Surgery; Johns Hopkins University School of Medicine; Baltimore; MD; USA
| | - Johann Pratschke
- Department of Visceral, Transplant and Thoracic Surgery; Center for Operative Medicine; Innsbruck Medical University; Innsbruck; Austria
| | | |
Collapse
|
23
|
Lang RS, Gorantla VS, Esper S, Montoya M, Losee JE, Hilmi IA, Sakai T, Lee WPA, Raval JS, Kiss JE, Shores JT, Brandacher G, Planinsic RM. Anesthetic management in upper extremity transplantation: the Pittsburgh experience. Anesth Analg 2012; 115:678-88. [PMID: 22745115 DOI: 10.1213/ane.0b013e31825da401] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Hand/forearm/arm transplants are vascularized composite allografts, which, unlike solid organs, are composed of multiple tissues including skin, muscle, tendons, vessels, nerves, lymph nodes, bone, and bone marrow. Over the past decade, 26 upper extremity transplantations were performed in the United States. The University of Pittsburgh Medical Center has the largest single center experience with 8 hand/forearm transplantations performed in 5 recipients between January 2008 and September 2010. Anesthetic management in the emerging field of upper extremity transplants must address protocol and procedure-specific considerations related to the role of regional blocks, effects of immunosuppressive drugs during transplant surgery, fluid and hemodynamic management in the microsurgical setting, and rigorous intraoperative monitoring during these often protracted procedures. METHODS For the first time, we outline salient aspects of upper extremity transplant anesthesia based on our experience with 5 patients. We highlight the importance of minimizing intraoperative vasopressors and improving fluid management and blood product use. RESULTS Our approach reduced the incidence of perioperative bleeding requiring re-exploration or hemostasis and shortened in-hospital and intensive care unit stay. Functional, immunologic and graft survival outcomes have been highly encouraging in all patients. CONCLUSIONS Further experience is required for validation or standardization of specific anesthetic protocols. Meanwhile, our recommendations are intended as pertinent guidelines for centers performing these novel procedures.
Collapse
Affiliation(s)
- R Scott Lang
- Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
24
|
Ravindra K, Haeberle M, Levin LS, Ildstad ST. Immunology of vascularized composite allotransplantation: a primer for hand surgeons. J Hand Surg Am 2012; 37:842-50. [PMID: 22464235 DOI: 10.1016/j.jhsa.2012.01.042] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2011] [Accepted: 01/31/2012] [Indexed: 02/02/2023]
Abstract
Vascularized composite allotransplantation is a recent innovation in the fields of transplantation surgery, plastic and reconstructive surgery, and orthopedic surgery. The success of hand and face transplantation has been based on extensive experience in solid organ transplantation. Advances in understanding the immunology of transplantation have had a major role in achieving excellent results in this new field. The purpose of this article is to introduce the basics of human immunology (innate and adaptive systems) and the immunological basis of human transplantation (the importance of human leukocyte antigen, direct and indirect pathways of antigen recognition, the 3 signals for T-cell activation, and mechanisms and types of allograft rejection) and focus on the mode of action of immunosuppressive drugs that have evolved as the mechanisms and pathways for rejection have been defined through research. This includes recent studies involving the use of costimulatory blockade, regulatory T cells, and tolerance induction that have resulted from research in understanding the mechanisms of immune recognition and function.
Collapse
Affiliation(s)
- K Ravindra
- Duke University Medical Center, Durham, NC, USA
| | | | | | | |
Collapse
|
25
|
Shores JT, Imbriglia JE, Lee WPA. The current state of hand transplantation. J Hand Surg Am 2011; 36:1862-7. [PMID: 22036285 DOI: 10.1016/j.jhsa.2011.09.001] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2011] [Accepted: 09/01/2011] [Indexed: 02/02/2023]
Abstract
Hand transplantation is the most common form of modern composite tissue allotransplantation. Successful application of this technology requires a multidisciplinary approach incorporating not only skilled hand surgeons, transplant surgeons, and transplant immunologists, but also hand therapists, psychiatrists, medical specialists, anesthesiologists, and others. Functional outcomes can be life changing for properly selected candidates. Hand transplantation is becoming more common, with more centers offering this relatively new reconstructive modality. Its success depends on proper patient selection, a technically successful operation, postoperative rehabilitation, and an immunotherapy protocol that prevents rejection but has minimal or acceptable morbidity.
Collapse
Affiliation(s)
- Jaimie T Shores
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21224, USA.
| | | | | |
Collapse
|
26
|
|