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Solla F, Pan H, Watrelot D, Leveneur O, Dubernard JM, Gazarian A. Composite tissue allotransplantation in newborns: A swine model. J Surg Res 2013; 179:e235-43. [DOI: 10.1016/j.jss.2012.01.030] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2011] [Revised: 01/16/2012] [Accepted: 01/18/2012] [Indexed: 11/25/2022]
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Janowski M, Jablonska A, Kozlowska H, Orukari I, Bernard S, Bulte JWM, Lukomska B, Walczak P. Neonatal desensitization does not universally prevent xenograft rejection. Nat Methods 2012; 9:856-8; author reply 858. [PMID: 22936164 DOI: 10.1038/nmeth.2146] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Issa F, Wood KJ. Translating tolerogenic therapies to the clinic - where do we stand? Front Immunol 2012; 3:254. [PMID: 22934094 PMCID: PMC3422982 DOI: 10.3389/fimmu.2012.00254] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2012] [Accepted: 07/30/2012] [Indexed: 12/12/2022] Open
Abstract
Manipulation of the immune system to prevent the development of a specific immune response is an ideal strategy to improve outcomes after transplantation. A number of experimental techniques exploiting central and peripheral tolerance mechanisms have demonstrated success, leading to the first early phase clinical trials for tolerance induction. The first major strategy centers on the facilitation of donor-cell mixed chimerism in the transplant recipient with the use of bone marrow or hematopoietic stem cell transplantation. The second strategy, utilizing peripheral regulatory mechanisms, focuses on cellular therapy with regulatory T cells. This review examines the key studies and novel research directions in the field of immunological tolerance.
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Affiliation(s)
- Fadi Issa
- Transplantation Research Immunology Group, Nuffield Department of Surgical Sciences, Level 6, John Radcliffe Hospital, University of Oxford Oxford, UK
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Hand transplantation and vascularized composite tissue allografts in orthopaedics and traumatology. Orthop Traumatol Surg Res 2010; 96:283-90. [PMID: 20488148 DOI: 10.1016/j.otsr.2010.03.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Composite tissue allograft (CTA) is defined as heterologous transplantation of a complex comprising skin and subcutaneous, neurovascular and mesenchymal tissue. Such techniques allow complex reconstruction using matched tissue, without donor site morbidity. The potential indications in orthopaedics-traumatology could in the future be more frequent than the present indications of heart, lung, liver, kidney and pancreas transplantation. International clinical experience clearly demonstrates the feasibility of CTA, both surgically and immunologically. However, immunosuppression remains indispensable, exposing the patient to risks that are not acceptable for purely functional surgery, except in very particular indications. The main hope for the future lies in induction of graft-specific tolerance.
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Misawa R, Soeda J, Ise H, Takahashi M, Kubota K, Mita A, Nakata T, Miyagawa S. Potential Feasibility of Early Bone Marrow Cell Injection Into the Spleen for Creating Functional Hepatocytes. Transplantation 2009; 87:1147-54. [DOI: 10.1097/tp.0b013e31819e0528] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Immunosuppression in an emerging field of plastic reconstructive surgery: composite tissue allotransplantation. J Plast Reconstr Aesthet Surg 2008; 61:245-9. [DOI: 10.1016/j.bjps.2007.10.048] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2006] [Revised: 04/23/2007] [Accepted: 10/17/2007] [Indexed: 11/19/2022]
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Gazarian A, Abrahamyan DO. Allogreffe de main chez le nouveau-né agénésique: étude de faisabilité. ANN CHIR PLAST ESTH 2007; 52:451-8. [PMID: 17688993 DOI: 10.1016/j.anplas.2007.05.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2007] [Accepted: 05/22/2007] [Indexed: 11/22/2022]
Abstract
Would a newborn with a single hand benefit from hand allograft? Transantebrachial aplasia is the chosen clinical form of agenesia in our interrogation. The feasibility study presents several aspects: 1) ethical and psychological aspects. Is this a desired surgery for agenesic population? Which are the functional, psychological and social situations of agenesic patient? Is the hand transplantation in newborn ethically acceptable? What is the parents' attitude toward agenesia? Can we envisage organ donation in neonatal period? 2) immunological aspects. The non-vital character of this condition and its' good functional tolerance cannot make accepting the risk of adverse effects of hand allotransplantation. Hence, one may consider this surgery only without immunosuppression. Can the peculiarities of the neonate "immature" immune system represent an opportunity of easier tolerance obtaining, avoiding immunosuppression? 3) anatomical and technical aspects. The proximal tissues at the level of amputation are all hypoplastic in agenesic patients. Can we efficaciously suture those structures with donor eutrophic tissues? 4) cognitive aspects. Is a neonate born with only one hand is able to use two? A feasibility study on such a subject needs to take into account all these aspects. This research is useful because, even if hand allograft in agenesic newborn will never be done, the provided information will allow to progress in the vaster domain of composite tissue allotransplantation in perinatology.
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Affiliation(s)
- A Gazarian
- Chirurgie de la main et du membre supérieur, clinique du Parc, hôpital Debrousse, pavillons Tbis (orthopédie pédiatrique) et V (transplantation), hôpital Edouard-Herriot, 86, boulevard des Belges, 69006 Lyon, France.
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Abstract
In 1943, Gibson and Medawar opened the modern era of transplantation research with a paper on the problem of skin allograft rejection. Ten years later Billingham, Brent and Medawar demonstrated that it was possible to induce selective immune acceptance of skin grafts in mice, a state of tolerance. After over six decades, however, the precise mechanism of skin allograft rejection remains still ill-defined. Furthermore, it has not been possible to achieve reliably clinical tolerance allowing the widespread application of skin allotransplantation techniques. The first successful applications of skin allotransplantation have included the hand and face. However, complications from the chronic immunosuppression regimens limit the application of these techniques. Induction of tolerance to skin (and the other tissues in the allograft) would be the most effective way to overcome all these difficulties, but this is yet to be achieved reliably, stimulating some to look for other ways to surmount the current limitations. This paper summarizes alternatives to enlarge the scope of skin allotransplantation techniques, current understanding of mechanisms of skin rejection, and the utility and limitations of animal models used to study skin rejection and tolerance induction. Finally, manipulation strategies to achieve skin tolerance are outlined.
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Affiliation(s)
- Benjamin M Horner
- Transplantation Biology Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02129, USA
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Sacks JM, Horibe EK, Lee WPA. Cellular Therapies for Prolongation of Composite Tissue Allograft Transplantation. Clin Plast Surg 2007; 34:291-301, x. [PMID: 17418678 DOI: 10.1016/j.cps.2006.10.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Complex musculoskeletal defects resulting from cancer, congenital absence, and trauma represent a unique reconstructive challenge. Autologous tissue is often unavailable to reconstruct these deformities. Composite tissue allograft transplantation represents a unique solution for these clinical problems. Face, hand, or limb transplants can be performed in a single procedure. However, the use of chronic nonspecific systemic immunosuppression can lead to side effects such as drug toxicity, opportunistic infections, and malignancies. This article explores various cell-based therapies that represent promising modalities to reduce chronic immunosuppression and alter the risk/benefit ratios for the prospect of composite tissue allograft transplantation.
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Affiliation(s)
- Justin M Sacks
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Pittsburgh, 3550 Terrace Street, 690 Scaife Hall, Pittsburgh, PA 15261, USA
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Schuind F, Abramowicz D, Schneeberger S. Hand transplantation: the state-of-the-art. J Hand Surg Eur Vol 2007; 32:2-17. [PMID: 17084950 DOI: 10.1016/j.jhsb.2006.09.008] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2006] [Revised: 08/04/2006] [Accepted: 09/04/2006] [Indexed: 02/03/2023]
Abstract
The feasibility of hand transplantation has been demonstrated, both surgically and immunologically. Levels of immunosuppression comparable to regimens used in solid organ transplantation are proving sufficient to prevent graft loss. Many patients have achieved discriminative sensibility and recovery of intrinsic muscle function. In addition to restoration of function, hand transplantation offers considerable psychological benefits. The recipient's pre-operative psychological status, his motivation and his compliance with the intense rehabilitation programme are key issues. While the induction of graft specific tolerance represents a hope for the future, immunosuppression currently remains necessary and carries significant risks. Hand transplantation should, therefore, only be considered a therapeutic option for a carefully selected group of patients.
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Affiliation(s)
- F Schuind
- Service d'Orthopédie-Traumatologie, Cliniques Universitaires de Bruxelles, Hôpital Erasme, 808 route de Lennik, B-1070, Brussels, Belgium.
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Quatra F, Lowenberg DW, Buncke HJ, Romeo OM, Brooks D, Buntic RF, Baxter-Lowe LA. Induction of tolerance to composite tissue allograft in a rat model. Microsurgery 2006; 26:573-8. [PMID: 17091475 DOI: 10.1002/micr.20297] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
The goal of this study was to establish a rat model that can be used to determine the variables in influencing induction of tolerance to composite tissue allografts. An anti T-cell depleting agent (R73) and 15-deoxyspergualin were given in different doses and schedule to four groups of Lewis rats receiving a limb transplant from Brown-Norway donors. Graft survival prolongation was maximal combining a single dose of R73 and a 20-day administration of 15-deoxyspergualin. Long-term survivors accepted a skin graft from Brown-Norway donors at 80 days, but rejected grafts from an unrelated donor. Skin grafting did not influence survival of the transplanted limb. Mixed allogeneic chimerism was not detectable in peripheral blood by flow cytometry, but immunohistochemistry identified donor-derived cells in the thymus of tolerant recipients at 100 days. These results suggest a state of donor-specific, dynamic tolerance, with potential for future application in human composite tissue allotransplantation.
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Affiliation(s)
- Fabio Quatra
- The Buncke Clinic and the H.J. Buncke Microsurgical Laboratory, Department of Orthopaedic Surgery, California Pacific Medical Center, University of California, San Francisco, CA, USA
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Babuccu O. A new and objective definition of the term "indefinite survival" in organ transplantation in the animal model. Transpl Int 2003. [DOI: 10.1111/j.1432-2277.2003.tb00224.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
The decision to perform a human hand transplant was justified perhaps on less than an ideal scientific basis-only approximately 60 rat limb transplants and 2 primate limb transplants have survived for longer than 200 days and only 8 of 19 pig limb osteomyocutaneous transplants showed no signs of rejection at 90 days. It seems unlikely that the survival of a human hand transplant will be any better than the survival of a kidney transplant, which has a half-life of approximately 7.5 to 9.5 years. Fourteen hand transplants, however, have now been performed in 11 humans with the skin component of 1 remaining viable up to 3 years after surgery. Intermittent episodes of acute rejection seem to have been relatively simple to reverse by temporarily increasing the dose of immunosuppressive agents and steroids. Chronic rejection has occurred in 1 patient, necessitating re-amputation of the transplanted hand. Active range of motion of the digits has been surprisingly better than would have been expected based on previous results of replantation, but return of sensibility has been less than optimal. The immunosuppression has been well tolerated without any major medical problems or life-threatening episodes, but some patients have developed chronic viral and fungal infections and several have developed posttransplant diabetes. Extrapolating from the previous experience of solid-organ transplants, chronic immunosuppression may predispose a hand transplant patient to an 80% chance of developing an infection, a 20% potential risk of developing posttransplant diabetes, and a 4% to 18% potential risk of developing a malignancy. Even though there is universal agreement that composite tissue allograft transplantation will become the ultimate reconstructive option, no one can predict the eventual role of hand transplantation in the future, but perhaps an international database of these hand transplant patients should be established so that independent reviewers can more objectively evaluate their functional outcome, the incidence of chronic rejection, and the risks of long-term immunosuppression.
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Affiliation(s)
- Neil F Jones
- UCLA Hand Center, Department of Orthopaedic Surgery and Division of Plastic and Reconstructive Surgery, University of California, Los Angeles, CA 90095, USA
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Fukada SI, Miyagoe-Suzuki Y, Tsukihara H, Yuasa K, Higuchi S, Ono S, Tsujikawa K, Takeda S, Yamamoto H. Muscle regeneration by reconstitution with bone marrow or fetal liver cells from green fluorescent protein-gene transgenic mice. J Cell Sci 2002; 115:1285-93. [PMID: 11884527 DOI: 10.1242/jcs.115.6.1285] [Citation(s) in RCA: 107] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The myogenic potential of bone marrow and fetal liver cells was examined using donor cells from green fluorescent protein (GFP)-gene transgenic mice transferred into chimeric mice. Lethally irradiated X-chromosome-linked muscular dystrophy (mdx) mice receiving bone marrow cells from the transgenic mice exhibited significant numbers of fluorescence+ and dystrophin+ muscle fibres. In order to compare the generating capacity of fetal liver cells with bone marrow cells in neonatal chimeras,these two cell types from the transgenic mice were injected into busulfantreated normal or mdx neonatal mice, and muscular generation in the chimeras was examined. Cardiotoxin-induced (or -uninduced, for mdx recipients) muscle regeneration in chimeras also produced fluorescence+ muscle fibres. The muscle reconstitution efficiency of the bone marrow cells was almost equal to that of fetal liver cells. However, the myogenic cell frequency was higher in fetal livers than in bone marrow. Among the neonatal chimeras of normal recipients, several fibres expressed the fluorescence in the cardiotoxin-untreated muscle. Moreover,fluorescence+ mononuclear cells were observed beneath the basal lamina of the cardiotoxin-untreated muscle of chimeras, a position where satellite cells are localizing. It was also found that mononuclear fluorescence+ and desmin+ cells were observed in the explantation cultures of untreated muscles of neonatal chimeras. The fluorescence+ muscle fibres were generated in the second recipient mice receiving muscle single cells from the cardiotoxin-untreated neonatal chimeras. The results suggest that both bone marrow and fetal liver cells may have the potential to differentiate into muscle satellite cells and participate in muscle regeneration after muscle damage as well as in physiological muscle generation.
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Affiliation(s)
- So-ichiro Fukada
- Department of Immunology, Graduate School of Pharmaceutical Sciences, Osaka University, Suita, Osaka 565-0871, Japan
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Lee WP, Butler PE, Randolph MA, Yaremchuk MJ. Donor modification leads to prolonged survival of limb allografts. Plast Reconstr Surg 2001; 108:1235-41. [PMID: 11604625 DOI: 10.1097/00006534-200110000-00021] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Chronic immunosuppression is essential for maintaining human hand transplant survival because composite tissue allografts are as susceptible to rejection as visceral organ allografts. Limb allografts comprise different types of tissues with varying antigenicities, and the immunosuppressive doses required for these allografts are as high or higher than those required for solid organ allotransplantation. In particular, bone marrow is an early target of the host immune response. This study reports on donor limb modification of the marrow compartment leading to prolonged survival of limb allografts. Chimeric limb allografts comprising a Lewis rat vascularized allograft and Brown Norway rat bone marrow were created. These chimeric limbs were transplanted into three recipients: (1) Buffalo rats (n = 12), where the chimeric limb was allogeneic for both vascular graft and bone marrow; (2) Lewis rats (n = 12), where the limb was allogeneic for marrow alone; and (3) Brown Norway rats (n = 12), where the limb was allogeneic for graft alone. This study found that Brown Norway recipients elicited significantly reduced cell-mediated and humoral immune responses in comparison with the Buffalo and Lewis recipients (p < 0.001 and p < 0.01, respectively). The Buffalo and Lewis recipients both elicited high cell-mediated and humoral responses. The Brown Norway recipients also had prolonged survival of limb tissue allograft in comparison with the other experimental groups.
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Affiliation(s)
- W P Lee
- Division of Plastic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA.
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Lee WP, Rubin JP, Bourget JL, Cober SR, Randolph MA, Nielsen GP, Ierino FL, Sachs DH. Tolerance to limb tissue allografts between swine matched for major histocompatibility complex antigens. Plast Reconstr Surg 2001; 107:1482-90; discussion 1491-2. [PMID: 11335822 DOI: 10.1097/00006534-200105000-00027] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Transplantation of limb tissue allografts would greatly expand the realm of reconstructive surgery. However, the toxicity of chronic immunosuppression has adversely tilted the risk-benefit balance for clinical transplant. In this study, a procedure was sought to achieve host tolerance to limb tissue allografts through matching of the major histocompatibility complex (MHC) antigens between donor and host swine using only a 12-day course of cyclosporine. Massachusetts General Hospital (MGH) miniature swine were used as a large animal model with defined MHC, and musculoskeletal grafts from the donor hind limb were transplanted heterotopically to the recipient femoral vessels. Allografts from MHC-mismatched donors treated with cyclosporine (n = 4) were rejected in less than 6 weeks by gross inspection and histologic sections. Allografts from MHC-matched, minor antigen mismatched donors not treated with cyclosporine (n = 4) were rejected between 9 and 12 weeks. Allografts from similarly matched donors treated with 12 days of cyclosporine (n = 7) showed no evidence of rejection until sacrifice between 25 and 47 weeks. Thus allograft tolerance was achieved between MHC-matched swine using a limited course of cyclosporine. Demonstration of limb tissue allograft survival in a large animal model without long-term immunosuppression represents an important step toward clinical transplantation.
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Affiliation(s)
- W P Lee
- Plastic Surgery Research Laboratory and Transplantation Biology Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, USA.
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Abstract
In September 1998, a surgical team in Lyon, France, performed the first successful hand transplant. After this historic event, in January 1999, the University of Louisville performed the first hand transplant in the United States. These events sparked interest and debate concerning the justification of performing limb allotransplantation. The field of composite tissue allotransplantation (CTA) has made significant advances in the past two decades, yet advancement of the applications of CTA into the clinical arena had been fairly limited to this point. The most inherent controversy in CTA involves the fact that the clinical applications for the most part involve restoration of function and/or structural integrity. These procedures are done essentially for quality-of-life concerns, not life-saving issues. Present concern involves subjecting CTA recipients to a lifetime of postoperative immunosuppressive therapy. We cannot fully understand where we stand at present and in what future directions the field is heading unless we have an understanding of where we have been in composite tissue transplantation. This article reviews the historical aspects of CTA, discusses the present state of CTA, and speculates on potential future applications of CTA.
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Affiliation(s)
- B R Kann
- Department of Surgery, Division of Surgical Research, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, Cooper Hospital/University Medical Center, Camden, NJ, USA
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