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Arenas Hoyos I, Helmer A, Yerly A, Lese I, Hirsiger S, Zhang L, Casoni D, Garcia L, Petrucci M, Hammer SE, Duckova T, Banz Y, Montani M, Constantinescu M, Vögelin E, Bordon G, Aleandri S, Prost JC, Taddeo A, Luciani P, Rieben R, Sorvillo N, Olariu R. A local drug delivery system prolongs graft survival by dampening T cell infiltration and neutrophil extracellular trap formation in vascularized composite allografts. Front Immunol 2024; 15:1387945. [PMID: 38887281 PMCID: PMC11180892 DOI: 10.3389/fimmu.2024.1387945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Accepted: 05/20/2024] [Indexed: 06/20/2024] Open
Abstract
Introduction The standard treatment for preventing rejection in vascularized composite allotransplantation (VCA) currently relies on systemic immunosuppression, which exposes the host to well-known side effects. Locally administered immunosuppression strategies have shown promising results to bypass this hurdle. Nevertheless, their progress has been slow, partially attributed to a limited understanding of the essential mechanisms underlying graft rejection. Recent discoveries highlight the crucial involvement of innate immune components, such as neutrophil extracellular traps (NETs), in organ transplantation. Here we aimed to prolong graft survival through a tacrolimus-based drug delivery system and to understand the role of NETs in VCA graft rejection. Methods To prevent off-target toxicity and promote graft survival, we tested a locally administered tacrolimus-loaded on-demand drug delivery system (TGMS-TAC) in a multiple MHC-mismatched porcine VCA model. Off-target toxicity was assessed in tissue and blood. Graft rejection was evaluated macroscopically while the complement system, T cells, neutrophils and NETs were analyzed in graft tissues by immunofluorescence and/or western blot. Plasmatic levels of inflammatory cytokines were measured using a Luminex magnetic-bead porcine panel, and NETs were measured in plasma and tissue using DNA-MPO ELISA. Lastly, to evaluate the effect of tacrolimus on NET formation, NETs were induced in-vitro in porcine and human peripheral neutrophils following incubation with tacrolimus. Results Repeated intra-graft administrations of TGMS-TAC minimized systemic toxicity and prolonged graft survival. Nevertheless, signs of rejection were observed at endpoint. Systemically, there were no increases in cytokine levels, complement anaphylatoxins, T-cell subpopulations, or neutrophils during rejection. Yet, tissue analysis showed local infiltration of T cells and neutrophils, together with neutrophil extracellular traps (NETs) in rejected grafts. Interestingly, intra-graft administration of tacrolimus contributed to a reduction in both T-cellular infiltration and NETs. In fact, in-vitro NETosis assessment showed a 62-84% reduction in NETs after stimulated neutrophils were treated with tacrolimus. Conclusion Our data indicate that the proposed local delivery of immunosuppression avoids off-target toxicity while prolonging graft survival in a multiple MHC-mismatch VCA model. Furthermore, NETs are found to play a role in graft rejection and could therefore be a potential innovative therapeutic target.
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Affiliation(s)
- Isabel Arenas Hoyos
- Department for BioMedical Research, University of Bern, Bern, Switzerland
- Department of Plastic and Hand Surgery, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Anja Helmer
- Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - Anaïs Yerly
- Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - Ioana Lese
- Department of Plastic and Hand Surgery, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Stefanie Hirsiger
- Department of Plastic and Hand Surgery, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Lei Zhang
- Department for BioMedical Research, University of Bern, Bern, Switzerland
- Department of Plastic and Hand Surgery, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Daniela Casoni
- Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - Luisana Garcia
- Department for BioMedical Research, University of Bern, Bern, Switzerland
| | | | - Sabine E. Hammer
- Institute of Immunology, University of Veterinary Medicine Vienna, City Bern, Austria
| | - Tereza Duckova
- Institute of Immunology, University of Veterinary Medicine Vienna, City Bern, Austria
| | - Yara Banz
- Institute of Pathology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Matteo Montani
- Institute of Pathology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Mihai Constantinescu
- Department of Plastic and Hand Surgery, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Esther Vögelin
- Department of Plastic and Hand Surgery, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Gregor Bordon
- Department of Chemistry, Biochemistry and Pharmaceutical Sciences, University of Bern, Bern, Switzerland
| | - Simone Aleandri
- Department of Chemistry, Biochemistry and Pharmaceutical Sciences, University of Bern, Bern, Switzerland
| | - Jean-Christophe Prost
- University Institute of Clinical Chemistry, Inselspital, Bern University Hospital, University of Bern, Vienna, Switzerland
| | - Adriano Taddeo
- Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - Paola Luciani
- Department of Chemistry, Biochemistry and Pharmaceutical Sciences, University of Bern, Bern, Switzerland
| | - Robert Rieben
- Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - Nicoletta Sorvillo
- Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - Radu Olariu
- Department of Plastic and Hand Surgery, Inselspital, Bern University Hospital, Bern, Switzerland
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2
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Amin KR, Fildes JE. The contribution of the donor vascularised hand and face allograft in transplant rejection: An immunological perspective. Transpl Immunol 2024; 84:102035. [PMID: 38518826 DOI: 10.1016/j.trim.2024.102035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 03/14/2024] [Accepted: 03/15/2024] [Indexed: 03/24/2024]
Abstract
Overcoming immunological rejection remains a barrier to the safe adoption of Vascularised Composite Allotransplantation (VCA). To mitigate this risk, clinical protocols have been derived from solid organ transplantation, targeting recipient immunomodulation, yet VCA is unique. Face and hand composite allografts are composed of multiple different tissues, each with their own immunological properties. Experimental work suggests that allografts carry variable numbers and populations of donor leukocytes in an organ specific manner. Ordinarily, these passenger leukocytes are transferred from the donor graft into the recipient circulation after transplantation. Whether alloantigen presentation manifests as acute allograft rejection or transplant tolerance is unknown. This review aims to characterise the immunological properties of the constituent parts of the donor face and hand, the potential fate of donor leukocytes and to consider theoretical graft specific interventions to mitigate early rejection.
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Affiliation(s)
- Kavit R Amin
- Department of Plastic Surgery, Manchester University NHS Foundation Trust, Manchester, UK; Division of Cell Matrix, Biology and Regenerative Medicine, University of Manchester, Manchester, UK; The Pebble Institute, Manchester, UK.
| | - James E Fildes
- The Pebble Institute, Manchester, UK; The Healthcare Technologies Institute, University of Birmingham, Birmingham, UK.
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3
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Ashraf MI, Mengwasser J, Reutzel-Selke A, Polenz D, Führer K, Lippert S, Tang P, Michaelis E, Catar R, Pratschke J, Witzel C, Sauer IM, Tullius SG, Kern B. Depletion of donor dendritic cells ameliorates immunogenicity of both skin and hind limb transplants. Front Immunol 2024; 15:1395945. [PMID: 38799435 PMCID: PMC11116604 DOI: 10.3389/fimmu.2024.1395945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 04/15/2024] [Indexed: 05/29/2024] Open
Abstract
Acute cellular rejection remains a significant obstacle affecting successful outcomes of organ transplantation including vascularized composite tissue allografts (VCA). Donor antigen presenting cells (APCs), particularly dendritic cells (DCs), orchestrate early alloimmune responses by activating recipient effector T cells. Employing a targeted approach, we investigated the impact of donor-derived conventional DCs (cDCs) and APCs on the immunogenicity of skin and skin-containing VCA grafts, using mouse models of skin and hind limb transplantation. By post-transplantation day 6, skin grafts demonstrated severe rejections, characterized by predominance of recipient CD4 T cells. In contrast, hind limb grafts showed moderate rejection, primarily infiltrated by CD8 T cells. Notably, the skin component exhibited heightened immunogenicity when compared to the entire VCA, evidenced by increased frequencies of pan (CD11b-CD11c+), mature (CD11b-CD11c+MHCII+) and active (CD11b-CD11c+CD40+) DCs and cDC2 subset (CD11b+CD11c+ MHCII+) in the lymphoid tissues and the blood of skin transplant recipients. While donor depletion of cDC and APC reduced frequencies, maturation and activation of DCs in all analyzed tissues of skin transplant recipients, reduction in DC activities was only observed in the spleen of hind limb recipients. Donor cDC and APC depletion did not impact all lymphocyte compartments but significantly affected CD8 T cells and activated CD4 T in lymph nodes of skin recipients. Moreover, both donor APC and cDC depletion attenuated the Th17 immune response, evident by significantly reduced Th17 (CD4+IL-17+) cells in the spleen of skin recipients and reduced levels of IL-17E and lymphotoxin-α in the serum samples of both skin and hind limb recipients. In conclusion, our findings underscore the highly immunogenic nature of skin component in VCA. The depletion of donor APCs and cDCs mitigates the immunogenicity of skin grafts while exerting minimal impact on VCA.
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Affiliation(s)
- Muhammad Imtiaz Ashraf
- Department of Surgery, Experimental Surgery, Charité – Universitätsmedizin Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Joerg Mengwasser
- Department of Surgery, Experimental Surgery, Charité – Universitätsmedizin Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Anja Reutzel-Selke
- Department of Surgery, Experimental Surgery, Charité – Universitätsmedizin Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Dietrich Polenz
- Department of Surgery, Experimental Surgery, Charité – Universitätsmedizin Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Kirsten Führer
- Department of Surgery, Experimental Surgery, Charité – Universitätsmedizin Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Steffen Lippert
- Department of Surgery, Experimental Surgery, Charité – Universitätsmedizin Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Peter Tang
- Department of Surgery, Experimental Surgery, Charité – Universitätsmedizin Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Edward Michaelis
- Department of Pathology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Rusan Catar
- Department of Nephrology and Internal Intensive Care Medicine, Charité Universitätsmedizin Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Healthy, Berlin, Germany
| | - Johann Pratschke
- Department of Surgery, Experimental Surgery, Charité – Universitätsmedizin Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Christian Witzel
- Department of Plastic Surgery, Charité – Universitätsmedizin Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Igor M. Sauer
- Department of Surgery, Experimental Surgery, Charité – Universitätsmedizin Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Stefan G. Tullius
- Division of Transplant Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
- Einstein Berlin Institute of Health Visiting Fellow, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Barbara Kern
- Department of Surgery, Experimental Surgery, Charité – Universitätsmedizin Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
- Department of Plastic Surgery, Charité – Universitätsmedizin Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
- Berlin Institute of Health at Charité – Universitätsmedizin Berlin, Berlin Institute of Health (BIH) Biomedical Innovation Academy, Berlin Institute of Health (BIH) Charité Clinician Scientist Program, Berlin, Germany
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4
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Regulatory T Cells: Liquid and Living Precision Medicine for the Future of VCA. Transplantation 2023; 107:86-97. [PMID: 36210500 DOI: 10.1097/tp.0000000000004342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Transplant rejection remains a challenge especially in the field of vascularized composite allotransplantation (VCA). To blunt the alloreactive immune response' stable levels of maintenance immunosupression are required. However' the need for lifelong immunosuppression poses the risk of severe side effects, such as increased risk of infection, metabolic complications, and malignancies. To balance therapeutic efficacy and medication side effects, immunotolerance promoting immune cells (especially regulatory T cells [Treg]) have become of great scientific interest. This approach leverages immune system mechanisms that usually ensure immunotolerance toward self-antigens and prevent autoimmunopathies. Treg can be bioengineered to express a chimeric antigen receptor or a T-cell receptor. Such bioengineered Treg can target specific antigens and thereby reduce unwanted off-target effects. Treg have demonstrated beneficial clinical effects in solid organ transplantation and promising in vivo data in VCAs. In this review, we summarize the functional, phenotypic, and immunometabolic characteristics of Treg and outline recent advancements and current developments regarding Treg in the field of VCA and solid organ transplantation.
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5
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A Systematic Review of the Reported Complications Related to Facial and Upper Extremity Vascularized Composite Allotransplantation. J Surg Res 2023; 281:164-175. [PMID: 36162189 DOI: 10.1016/j.jss.2022.08.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 08/02/2022] [Accepted: 08/20/2022] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Twenty three years after the first successful upper extremity transplantation, the role of vascularized composite allotransplantation (VCA) in the world of transplantation remains controversial. Face and upper extremity reconstruction via transplantation have become successful options for highly selected patients with severe tissue and functional deficit when conventional reconstructive options are no longer available. Despite clear benefit in these situations, VCA has a significant potential for complications that are more frequent when compared to visceral organ transplantation. This study intended to perform an updated systematic review on such complications. MATERIALS AND METHODS MEDLINE database via PubMed, Embase and Cochrane Library were searched. Face and upper extremity VCA performed between 1998 and 2021 were included in the study. Relevant media and press conferences reports were also included. Complications related to face and upper extremity VCA were recorded and reviewed including their clinical characteristics and complications. RESULTS One hundred fifteen patients underwent facial (43%) or upper extremity (57%) transplantation. Overall, the surgical complication rate was 23%. Acute and chronic rejection was identified in 89% and 11% of patients, respectively. Fifty eight percent of patients experienced opportunistic infection. Impaired glucose metabolism was the most common immunosuppression-related complication other than infection. Nineteen percent of patients ultimately experienced partial or complete allograft loss. CONCLUSIONS Complications related to VCA are a significant source of morbidity and potential mortality. Incidence of such complications is higher than previously reported and should be strongly emphasized in patient consent process. Strict patient selection criteria, complex preoperative evaluation, consideration of alternatives, and thorough disclosure to patients should be routinely performed prior to VCA indication.
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6
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Lee SJ, Kim HJ, Byun NR, Park CG. Donor-Specific Regulatory T Cell-Mediated Immune Tolerance in an Intrahepatic Murine Allogeneic Islet Transplantation Model with Short-Term Anti-CD154 mAb Single Treatment. Cell Transplant 2021; 29:963689720913876. [PMID: 32216448 PMCID: PMC7586274 DOI: 10.1177/0963689720913876] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Anti-CD154 blockade-based regimens remain unequaled in prolonging graft survival in various organ transplantation models. Several studies have focused on transplantation tolerance with the anti-CD154 blockade, but none of these studies has investigated the mechanisms associated with its use as the sole treatment in animal models, delaying our understanding of anti-CD154 blockade-mediated immune tolerance. The purpose of this study was to investigate the mechanism underlying the anti-CD154 monoclonal antibody (mAb) blockade in inducing immune tolerance using an intrahepatic murine allogeneic islet transplantation model. Allogeneic BALB/c AnHsd (BALB/c) islets were infused into the liver of diabetic C57BL/6 (B6) mice via the cecal vein. Anti-CD154 mAb (MR1) was administered on -1, 0, 1, 3, 5, and 7 d posttransplantation at 0.5 mg per mouse. We showed that short-term MR1 monotherapy could prolong the allogeneic islet grafts to more than 250 d in the murine intrahepatic islet transplantation model. The second islet grafts transplanted under the kidney capsule of the recipients were protected from rejection. We also found that rejection of same-donor skin grafts transplanted to the tolerant mice was modestly delayed. Using a DEREG mouse model, FoxP3+ regulatory T (Treg) cells were shown to play important roles in transplantation tolerance. In mixed lymphocyte reactions, Treg cells from the tolerant mice showed more potency in suppressing BALB/c splenocyte-stimulated Teff cell proliferation than those from naïve mice. In this study, we demonstrated for the first time that a short-term anti-CD154 mAb single treatment could induce FoxP3+ Treg cell-mediated immune tolerance in the intrahepatic murine allogeneic islet transplantation model.
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Affiliation(s)
- Seok-Joo Lee
- Department of Microbiology and Immunology, Seoul National University College of Medicine, Seoul, Korea
- Department of Biomedical Science, Seoul National University Graduate School, Seoul, Korea
- Xenotransplantation Research Center, Seoul National University College of Medicine, Seoul, Korea
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
- Department of Oral Microbiology and Immunology, Seoul National University School of Dentistry, Seoul, Korea
| | - Hyun-Je Kim
- Department of Microbiology and Immunology, Seoul National University College of Medicine, Seoul, Korea
- Department of Biomedical Science, Seoul National University Graduate School, Seoul, Korea
- Xenotransplantation Research Center, Seoul National University College of Medicine, Seoul, Korea
- Department of Dermatology, Samsung Medical Center, Seoul, Korea
| | - Na-ri Byun
- Department of Microbiology and Immunology, Seoul National University College of Medicine, Seoul, Korea
- Department of Biomedical Science, Seoul National University Graduate School, Seoul, Korea
- Xenotransplantation Research Center, Seoul National University College of Medicine, Seoul, Korea
- Byun is now with the Hanmi R&D center, Hwaseong-si, Gyeonggi-do18469, Korea
| | - Chung-Gyu Park
- Department of Microbiology and Immunology, Seoul National University College of Medicine, Seoul, Korea
- Department of Biomedical Science, Seoul National University Graduate School, Seoul, Korea
- Xenotransplantation Research Center, Seoul National University College of Medicine, Seoul, Korea
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
- Department of Dermatology, Samsung Medical Center, Seoul, Korea
- Institute of Endemic Diseases, Seoul National University College of Medicine, Seoul, Korea
- Biomedical Research Institute, Seoul National University Hospital, Seoul, Korea
- Chung-Gyu Park, MD, PhD, 103 Daehak-ro, Jongno-gu, 110-799 Seoul, South Korea. Emails: ;
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Leonard DA, Powell HR, Defazio MW, Shanmugarajah K, Mastroianni M, Rosales I, Farkash EA, Colvin RB, Randolph MA, Sachs DH, Kurtz JM, Cetrulo CL. Cutaneous leukocyte lineages in tolerant large animal and immunosuppressed clinical vascularized composite allograft recipients. Am J Transplant 2021; 21:582-592. [PMID: 32741100 PMCID: PMC7854956 DOI: 10.1111/ajt.16230] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 06/22/2020] [Accepted: 07/15/2020] [Indexed: 01/25/2023]
Abstract
Vascularized composite allografts (VCAs) can restore fully functional anatomic units in patients with limb amputations or severe facial tissue loss. However, acute rejection of the skin is frequently observed and underscores the importance of developing tolerance induction protocols. In this study, we have characterized the skin immune system in VCAs. We demonstrate infiltration of recipient leukocytes, regardless of rejection status, and in tolerant mixed hematopoietic chimeras, the co-existence of these cells with donor leukocytes in the absence of rejection. Here we characterize the dermal T cell and epidermal Langerhans cell components of the skin immune system in our porcine model of VCA tolerance, and the kinetics of cutaneous chimerism in both of these populations in VCAs transplanted to tolerant and nontolerant recipients, as well as in host skin. Furthermore, in biopsies from the first patient to receive a hand transplant in our program, we demonstrate the presence of recipient T cells in the skin of the transplanted limb in the absence of clinical or histological evidence of rejection.
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Affiliation(s)
- D. A. Leonard
- Center for Transplantation Sciences, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts,Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Boston, Massachusetts,Canniesburn Plastic Surgery Unit, Glasgow Royal Infirmary, Glasgow, Scotland
| | - H. R. Powell
- Center for Transplantation Sciences, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts
| | - M. W. Defazio
- Center for Transplantation Sciences, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts
| | - K. Shanmugarajah
- Center for Transplantation Sciences, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts,Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - M. Mastroianni
- Center for Transplantation Sciences, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts,Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - I. Rosales
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts
| | - E. A. Farkash
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts
| | - R. B. Colvin
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts
| | - M. A. Randolph
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - D. H. Sachs
- Center for Transplantation Sciences, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts,Columbia Center for Translational Immunology, Columbia University Medical Center, New York, New York
| | - J. M. Kurtz
- Center for Transplantation Sciences, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts,Department of Biology, Emmanuel College, Boston, Massachusetts
| | - C. L. Cetrulo
- Center for Transplantation Sciences, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts,Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Boston, Massachusetts,Shriners Hospital for Children, Boston, Massachusetts
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8
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Etra JW, Grzelak MJ, Fidder SA, Kolegraff K, Bonawitz S, Shores J, Oh B, Cooney DS, Beck SE, Brandacher G. A Skin Rejection Grading System for Vascularized Composite Allotransplantation in a Preclinical Large Animal Model. Transplantation 2019; 103:1385-1391. [PMID: 31241555 PMCID: PMC6613727 DOI: 10.1097/tp.0000000000002695] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 02/13/2019] [Accepted: 02/14/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND The Banff Criteria have been accepted as a system for grading histological rejection in graft skin in human vascularized composite allotransplantation (VCA). Preclinical swine hindlimb transplantation models have an important role in translational studies in VCA. However, unified grading criteria for rejection in swine skin have not yet been established. METHODS Two hundred fourteen swine skin biopsy specimens were reviewed, including 88 native skin biopsies and 126 specimens from the skin component of heterotopic swine hindlimb transplants. Thorough review was performed in a blinded fashion by an expert veterinary pathologist with attention paid to the applicability of the Banff criteria as well as specific histologic characteristics and trends. Clinical and histopathologic rejection scores were then directly compared. RESULTS Two hundred fourteen specimens reviewed showed significant similarities between swine and human skin, as previously published. Notable swine-specific characteristics, including paucicellular infiltration with rare epidermal cell infiltration or necrosis, were accounted for in a proposed grading system that parallels the Banff Criteria. CONCLUSIONS This comprehensive grading system, based on the Banff Classification for skin rejection in VCA, provides a standardized system for more accurate comparison of rejection in preclinical swine VCA models.
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Affiliation(s)
- Joanna W. Etra
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation (VCA) Laboratory, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Michael J. Grzelak
- Department of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation (VCA) Laboratory, Johns Hopkins University School of Medicine, Baltimore, MD
- Johns Hopkins University School of Medicine, Baltimore, MD
| | - Samuel A.J. Fidder
- Department of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation (VCA) Laboratory, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Keli Kolegraff
- Department of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation (VCA) Laboratory, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Steven Bonawitz
- Department of Surgery, Cooper Medical School of Rowan University, Camden, NJ
| | - Jaimie Shores
- Department of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation (VCA) Laboratory, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Byoungchol Oh
- Department of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation (VCA) Laboratory, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Damon S. Cooney
- Department of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation (VCA) Laboratory, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sarah E. Beck
- Department of Molecular and Comparative Pathobiology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Gerald Brandacher
- Department of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation (VCA) Laboratory, Johns Hopkins University School of Medicine, Baltimore, MD
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9
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Iske J, Nian Y, Maenosono R, Maurer M, Sauer IM, Tullius SG. Composite tissue allotransplantation: opportunities and challenges. Cell Mol Immunol 2019; 16:343-349. [PMID: 30842628 PMCID: PMC6462029 DOI: 10.1038/s41423-019-0215-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 02/04/2019] [Accepted: 02/05/2019] [Indexed: 12/24/2022] Open
Abstract
Vascularized composite allotransplants (VCAs) have unique properties because of diverse tissue components transplanted en mass as a single unit. In addition to surgery, this type of transplant also faces enormous immunological challenges that demand a detailed analysis of all aspects of alloimmune responses, organ preservation, and injury, as well as the immunogenicity of various tissues within the VCA grafts to further improve graft and patient outcomes. Moreover, the side effects of long-term immunosuppression for VCA patients need to be carefully balanced with the potential benefit of a non-life-saving procedure. In this review article, we provide a comprehensive update on limb and face transplantation, with a specific emphasis on the alloimmune responses to VCA, established and novel immunosuppressive treatments, and patient outcomes.
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Affiliation(s)
- Jasper Iske
- Division of Transplant Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Institute of Transplant Immunology, Integrated Research and Treatment Center Transplantation, Hannover Medical School, Hannover, Lower Saxony, Germany
| | - Yeqi Nian
- Division of Transplant Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ryoichi Maenosono
- Division of Transplant Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Max Maurer
- Department of Surgery, Charité - Universitätsmedizin Berlin, Campus Charité Mitte and Virchow-Klinikum, Berlin, Germany
| | - Igor M Sauer
- Department of Surgery, Charité - Universitätsmedizin Berlin, Campus Charité Mitte and Virchow-Klinikum, Berlin, Germany
| | - Stefan G Tullius
- Division of Transplant Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
- Einstein-BIH Visiting Fellow, Department of Surgery, Charité-Universitätsmedizin Berlin, Campus Charité Mitte and Virchow-Klinikumc, Berlin, Germany.
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10
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Abstract
PURPOSE OF REVIEW For patients with devastating injuries in whom standard reconstruction is not an option, vascularized composite allotransplantation (VCA) has become a viable means of restoring form and function. However, immunological rejection continues to be a problem in VCA and has not yet been fully characterized. As the field is relatively new, much of the data on rejection and immunosuppression have been extrapolated from that of solid organ transplantation. In this review, we cover the basic mechanisms of rejection as they relate specifically to VCA with analysis of recent literature and future directions. RECENT FINDINGS Recent clinical studies have supported previously postulated T-cell-mediated mechanism of acute rejection and have also made strides in differentiating rejection from inflammation from other skin conditions and with different treatment regimens. Antibody-mediated rejection has been described in recent cases as well as treatment of presensitized patients receiving VCAs. With more long-term grafts, chronic changes, including vasculopathy, are being reported. SUMMARY Clinically observed types of rejection in VCA include mainly cell-mediated, antibody-mediated and chronic rejection. Advances in diagnosis and treatment of rejection have been made, but there is still much to be learned about VCA-specific rejection.
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11
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Graves SS, Mathes DW, Storb R. Induction of Tolerance Towards Solid Organ Allografts Using Hematopoietic Cell Transplantation in Large Animal Models. ACTA ACUST UNITED AC 2019; 3. [PMID: 32944710 DOI: 10.21926/obm.transplant.1903080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background The application of hematopoietic cell transplantation for induction of immune tolerance has been limited by toxicities associated with conditioning regimens and to graft-versus-host disease (GVHD). Decades of animal studies have culminated into sufficient control of these two problems, making immune tolerance a viable alternative to life-long application of immunosuppressive drugs to prevent allograft rejection. Methods Studies in mice have paved the way for the application of HCT with limited toxicity in large animal models. Resultant studies in the pig, dog, and ultimately the nonhuman primate have led to appropriate methods for achieving nonmyeloablative irradiation protocols, dose, and timing of post-grafting immunosuppressive drugs, monoclonal antibody therapy, and biologicals for costimulatory molecule blockade. The genetics field has been extensively evaluated in appreciation of the ultimate need to obtain organs from MHC-mismatched unrelated donors. Results Nonmyeloablative conditioning regimens have been shown to be successful in inducing immune tolerance across all three animal models. Postgrafting immunosuppression is also important in assuring sustained donor hematopoiesis for tolerance. Donor chimerism need not be permanent to establish stable engraftment of donor organs, thereby essentially eliminating the risk of GVHD. Using nonmyeloablative HCT with monoclonal antibody immunosuppression, the kidney has been successfully transplanted in MHC-mismatched nonhuman primates. Conclusions Nonmyeloablative HCT for the establishment of temporary mixed chimerism has led to the establishment of stable tolerance against solid organ allografts in large animal models. The kidney, considered a tolerogenic organ, has been successfully transplanted in the clinic. Other organs such as heart, lung, and vascularized composite allografts (face and hands), remain distant possibilities. Further study in large animal models will be required to improve tolerance against these organs before success can be attained in the clinic.
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Affiliation(s)
- Scott S Graves
- Fred Hutchinson Cancer Research Center, 1100 Fairview Avenue N, D1-100, Seattle, WA, U.S.A
| | - David W Mathes
- Department of Plastic Surgery, University of Colorado, Aurora, CO.,Plastic Surgery Service VA, Eastern Care System, Denver, CO
| | - Rainer Storb
- Fred Hutchinson Cancer Research Center, 1100 Fairview Avenue N, D1-100, Seattle, WA, U.S.A.,University of Washington School of Medicine, Seattle, WA, U.S.A
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12
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Ozkan O, Ertosun MG, Ozkan O. Technical, Immunological, and Ethical Similarities and Differences Between Vascularized Composite Allotransplantation and Solid Organ Transplantation in Current Practice. Transplant Proc 2018; 50:3775-3782. [PMID: 30577269 DOI: 10.1016/j.transproceed.2018.06.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 06/19/2018] [Indexed: 12/12/2022]
Abstract
Solid organ transplantation (SOT) is a surgical method used as the gold standard in end-term organ failure. Following SOT, successful results have also been achieved in vascularized composite tissue transplantation, which improves the quality of life with the success of solid organ transplants and the development of modern immunosuppressive regimens. This review discusses the preoperative, operative, postoperative, and immunological differences between vascularized tissue transplantation and SOT.
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Affiliation(s)
- O Ozkan
- Akdeniz University School of Medicine, Department of Plastic and Reconstructive Surgery, Antalya, Turkey
| | - M G Ertosun
- Akdeniz University School of Medicine, Department of Plastic and Reconstructive Surgery, Antalya, Turkey
| | - O Ozkan
- Akdeniz University School of Medicine, Department of Plastic and Reconstructive Surgery, Antalya, Turkey.
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13
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Molitor M, Oliverius M, Sukop A. Abdominal wall allotransplantation. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2018; 162:184-189. [PMID: 30209436 DOI: 10.5507/bp.2018.038] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2018] [Accepted: 06/27/2018] [Indexed: 11/23/2022] Open
Abstract
Allotransplantation of vascularized composite tissue is a new field of transplantation surgery. One application of this technique is abdominal wall transplantation used as a supplementary procedure to the transplantation of visceral organs in patients with abdominal compartment deficits. As abdominal wall closure problems are experienced in around 30-40% of such patients, peer reviewed conclusions on the viability of various options, are important for an informed choice of possible procedures. This review focuses on the abdominal wall allotransplantion procedure. Our search provided 35 appropriate references which we used to support our findings as follows: abdominal wall transplantation was performed in 33 patients at seven centres. Of these, 30 had a full thickness abdominal wall transplanted from the same donor, 3 from a second donor. Three had visceral organ transplants and in addition, the posterior sheet of the rectus muscle fascia. In summary, our findings were that abdominal wall allotransplantation does not jeopardize the outcome of visceral organs transplantation. There is no higher risk of complications or rejection of the visceral organs. There have been no fatalities as a direct result of complications due to abdominal wall transplantation. Finally, the transplanted abdominal wall may provide an early warning of rejection before diagnostic tests on the bowel are symptomatic.
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Affiliation(s)
- Martin Molitor
- Department of Plastic Surgery Hospital na Bulovce and 1 st Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Martin Oliverius
- Department of General Surgery, 3 rd Faculty of Medicine, Charles University and Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Andrej Sukop
- Department of Plastic Surgery, 3 rd Faculty of Medicine, Charles University and Hospital Kralovske Vinohrady, Prague, Czech Republic
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14
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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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15
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Ding J, Liu S, Zhang D, Song Y, Ma X, Yi C, Song B, Xiao B, Su Y, Guo S. Transfusion of ethylene carbodiimide–fixed donor splenocytes prolongs survival of vascularized skin allografts. J Surg Res 2018; 221:343-352. [DOI: 10.1016/j.jss.2017.06.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Revised: 05/24/2017] [Accepted: 06/06/2017] [Indexed: 10/18/2022]
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16
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Abstract
PURPOSE OF REVIEW Abdominal wall transplantation is a technique used to achieve abdominal closure after intestinal and multivisceral transplantation. This review focuses on whether there are additional benefits for the skin component as an immune-monitoring tool. RECENT FINDINGS The largest series of abdominal wall transplants has recently been published. Alongside the physiological advantage gained in abdominal closure, the authors describe the immunological insight that the skin component can provide and how this contributes to the management of patients. The skin appears to develop a rash with early rejection, which facilitates early systemic treatment before significant visceral rejection occurs. It can also help in cases in which there is diagnostic doubt regarding the cause of bowel dysfunction such as in instances of intestinal infection. Despite the additional immunological burden of donor tissue, there appears to be no requirement for increased immunosuppressive therapy. SUMMARY The technical and immunological feasibility of abdominal wall transplantation has now been demonstrated by several centres. Skin transplanted as part of the abdominal wall or as a separate vascularized sentinel skin flap may aid in the diagnosis of rejection. This has the potential to improve graft survival and reduce immunosuppressive morbidity.
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Abstract
The field of vascularized composite allotransplantation-combining advances in reconstructive surgery, transplantation, and immunology-offers great promise for patients with heretofore unsolvable problems. In the last 30 years, hand transplantation has progressed through the phases of being a research subject, a controversial clinical procedure, a more widely accepted and expanding field, and now a promising endeavor undergoing refined indications. Although many lessons have been learned, few procedures in the author's experience have been as life-transformative in restoring the body image, motor and sensory functions, activities of daily living, and personal autonomy as successful hand transplantation.
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18
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Single Implantable FK506 Disk Prevents Rejection in Vascularized Composite Allotransplantation. Plast Reconstr Surg 2017; 139:403e-414e. [DOI: 10.1097/prs.0000000000002951] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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19
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Chang J, Graves SS, Butts-Miwongtum T, Sale GE, Storb R, Mathes DW. Long-term Tolerance Toward Haploidentical Vascularized Composite Allograft Transplantation in a Canine Model Using Bone Marrow or Mobilized Stem Cells. Transplantation 2016; 100:e120-e127. [PMID: 27861292 PMCID: PMC5453180 DOI: 10.1097/tp.0000000000001496] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND The development of safe and reliable protocols for the transplantation of the face and hands may be accomplished with animal modeling of transplantation of vascularized composite allografts (VCA). Previously, we demonstrated that tolerance to a VCA could be achieved after canine recipients were simultaneously given marrow from a dog leukocyte antigen-identical donor. In the present study, we extend those findings across a dog leukocyte antigen mismatched barrier. METHODS Eight recipient dogs received total body irradiation (4.5 cGy), hematopoietic cell transplantation (HCT), either marrow (n = 4) or granulocyte-colony stimulating factor mobilized peripheral blood stem cells (n = 4), and a VCA transplant from the HCT donor. Post grafting immunosuppression consisted of mycophenolate mofetil (28 days) and cyclosporine (35 days). RESULTS In 4 dogs receiving bone marrow, 1 accepted both its marrow transplant and demonstrated long-term tolerance to the donor VCA (>52 weeks). Three dogs rejected both their marrow transplants and VCA at 5 to 7 weeks posttransplant. Dogs receiving mobilized stem cells all accepted their stem cell transplant and became tolerant to the VCA. However, 3 dogs developed graft-versus-host disease, whereas 1 dog rejected its stem cell graft by week 15 but exhibited long-term tolerance toward its VCA (>90 weeks). CONCLUSIONS The data suggest that simultaneous transplantation of mobilized stem cells and a VCA is feasible and leads to tolerance toward the VCA in a haploidentical setting. However, there is a higher rate of donor stem cell engraftment compared with marrow HCT and an increase in the incidence of graft-versus-host disease.
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Affiliation(s)
- Jeff Chang
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
- Department of Surgery, University of Washington, Seattle, WA
| | - Scott S. Graves
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
- Department of Medicine, University of Washington, Seattle, WA
| | | | - George E. Sale
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
- Department of Pathology, University of Washington, Seattle, WA
| | - Rainer Storb
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
- Department of Medicine, University of Washington, Seattle, WA
| | - David W. Mathes
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
- Department of Surgery, University of Colorado, Aurora, CO
- Plastic Surgery Service, VA Eastern Colorado Care System, Denver, CO
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20
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Clinical Considerations for Vascularized Composite Allotransplantation of the Eye. J Craniofac Surg 2016; 27:1622-1628. [PMID: 27513765 DOI: 10.1097/scs.0000000000002985] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
Vascularized composite allotransplantation represents a potential shift in approaches to reconstruction of complex defects resulting from congenital differences as well as trauma and other acquired pathology. Given the highly specialized function of the eye and its unique anatomical components, vascularized composite allotransplantation of the eye is an appealing method for restoration, replacement, and reconstruction of the nonfunctioning eye. Herein, we describe conventional treatments for eye restoration and their shortcomings as well as recent research and events that have brought eye transplantation closer to a potential clinical reality. In this article, we outline some potential considerations in patient selection, donor facial tissue procurement, eye tissue implantation, surgical procedure, and potential for functional outcomes.
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21
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Issa F. Vascularized composite allograft-specific characteristics of immune responses. Transpl Int 2016; 29:672-81. [PMID: 26927941 DOI: 10.1111/tri.12765] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Revised: 07/03/2015] [Accepted: 02/24/2016] [Indexed: 01/31/2023]
Abstract
Vascularized composite allograft (VCA) transplantation, or reconstructive transplantation, has revolutionized the treatment of complex tissue and functional defects. Despite arriving during an age in which the immunology of solid organ transplant rejection has been investigated in much detail, these transplants have offered new perspectives from which to explore the immunobiology of transplantation. VCAs have a number of unique molecular, cellular, and architectural features which alter the character and intensity of the rejection response. While much is yet to be clarified, an understanding of these distinct mechanisms affords new possibilities for the control of immune responses in an effort to improve outcomes after VCA transplantation.
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Affiliation(s)
- Fadi Issa
- Transplantation Research Immunology Group, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
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22
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Tolerance induction via mixed chimerism in vascularized composite allotransplantation. Curr Opin Organ Transplant 2015; 20:602-7. [DOI: 10.1097/mot.0000000000000248] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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23
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Kueckelhaus M, Fischer S, Seyda M, Bueno EM, Aycart MA, Alhefzi M, ElKhal A, Pomahac B, Tullius SG. Vascularized composite allotransplantation: current standards and novel approaches to prevent acute rejection and chronic allograft deterioration. Transpl Int 2015; 29:655-62. [PMID: 26265179 DOI: 10.1111/tri.12652] [Citation(s) in RCA: 86] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Revised: 06/10/2015] [Accepted: 07/30/2015] [Indexed: 12/18/2022]
Abstract
The advent of more potent immunosuppressants led to the first successful human upper extremity transplantation in 1998. At this time, >100 upper extremity transplants, 30 face transplants, and a variety of other vascularized composite allotransplantation (VCA) procedures have been performed around the world. VCA recipients present unique challenges for transplantation. The incidence of acute rejection exceeds 80% in hand and face transplantation and is well documented, whereas reports about antibody-mediated rejection and chronic rejection remain scarce. Immunosuppression protocols commonly used at US centers are derived from solid organ transplantation protocols. Novel approaches to minimize rejections in VCA may include improved HLA matching and considerations toward cytomegalovirus infection status. New graft preservation techniques may decrease immunogenicity prior to transplant. Novel monitoring methods such as valid biomarkers, ultrasound biomicroscopy, and sentinel flaps may enable earlier diagnosis of rejection. Cell-based therapies are being explored to achieve immunosuppressive regimen minimization or even tolerance induction. The efficacy of local immunosuppression in clinical VCA remains controversial. In conclusion, although immunosuppressive strategies adapted from SOT have demonstrated good midterm results, focusing on the unique features of VCA grafts may enable additional, more specific treatment strategies in the future and improved long-term graft outcomes.
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Affiliation(s)
- Maximilian Kueckelhaus
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Department of Plastic Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, Germany
| | - Sebastian Fischer
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Department of Plastic Surgery, BG University Hospital Ludwigshafen, Heidelberg University, Ludwigshafen, Germany
| | - Midas Seyda
- Division of Transplant Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ericka M Bueno
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Mario A Aycart
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Muayyad Alhefzi
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Abdallah ElKhal
- Division of Transplant Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Bohdan Pomahac
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Stefan G Tullius
- Division of Transplant Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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24
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Zhu H, Xie F, Sheng L, Yu Q, Li Q. Rat model of heterotopic toe allotransplantation. J Surg Res 2015; 199:707-17. [PMID: 26081004 DOI: 10.1016/j.jss.2015.02.075] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Revised: 01/23/2015] [Accepted: 02/25/2015] [Indexed: 01/29/2023]
Abstract
BACKGROUND Finger allotransplantation is a promising treatment for severe finger destruction. However, more research is required to decrease the risks of this procedure to a level at which the clinical use of this non-life-saving procedure is justified. A proper animal model is essential for the required experiments. METHODS In this article, we established a toe transplantation model based on anatomic studies. A tapered dose of Cyclosporine A (CsA) was used as an immunosuppressive therapy in the Brown Norway-to-Lewis allotransplantation experimental group, whereas isotransplantation or allotransplantation without treatment or with ligated pedicles was performed on the control groups. Recipients were assessed daily after operation for any signs of rejection and complications. On postoperative day 90, skin graft test was used to test the level of donor-specific tolerance in the recipients. On postoperative day 120, x-rays and micro-computed tomographies were performed for bone morphology evaluation. The chimerism in the recipient peripheral blood, lymph node, spleen, and thymus was tested by flow cytometry and immunohistochemical staining. And histologic study of the toe grafts and skin grafts were carried out. RESULTS The blood supply of the toe graft was confirmed, and accordingly, transplantations were performed. The isografts survived indefinitely. The allografts with ligated pedicles experienced necrosis within 5 d. The allografts without treatment exhibited necrosis within 14 d. Forty percent, 20%, and 40% of the allografts associated with the CsA treatment experienced severe rejection, mild rejection, and nonrejection, according to gross graft appearance, respectively. Skin grafting tests showed three different types of results. X-rays and micro-computed tomographies reveal nearly normal bone morphologies in the bone structures of all surviving animals with grafts. Low levels of donor-specific chimerism were detected in the peripheral blood samples. Spleen, lymph node, and thymus chimerism were also confirmed in the long-term surviving animals with allografts. Histologic evaluation of the long-term survivals revealed similar graft morphologies in the isografts and the nonrejected allografts, inflammatory cell infiltration in the mildly rejected allografts, and degraded cutaneous appendages in the severely rejected allografts. CONCLUSIONS We established a toe allotransplantation model. Moreover, the low rate of chimerism did not introduce specific tolerance, which might explain the high rejection rate. This model might facilitate future research in finger allotransplantation.
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Affiliation(s)
- Hainan Zhu
- Department of Plastic and Reconstructive Surgery, Shanghai 9th People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, P.R. China
| | - Feng Xie
- Department of Plastic and Reconstructive Surgery, Shanghai 9th People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, P.R. China
| | - Lingling Sheng
- Department of Plastic and Reconstructive Surgery, Shanghai 9th People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, P.R. China
| | - Qingxiong Yu
- Department of Plastic and Reconstructive Surgery, Shanghai 9th People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, P.R. China
| | - Qingfeng Li
- Department of Plastic and Reconstructive Surgery, Shanghai 9th People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, P.R. China.
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Pilat N, Klaus C, Schwarz C, Hock K, Oberhuber R, Schwaiger E, Gattringer M, Ramsey H, Baranyi U, Zelger B, Brandacher G, Wrba F, Wekerle T. Rapamycin and CTLA4Ig synergize to induce stable mixed chimerism without the need for CD40 blockade. Am J Transplant 2015; 15:1568-79. [PMID: 25783859 DOI: 10.1111/ajt.13154] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Revised: 11/12/2014] [Accepted: 11/30/2014] [Indexed: 01/25/2023]
Abstract
The mixed chimerism approach achieves donor-specific tolerance in organ transplantation, but clinical use is inhibited by the toxicities of current bone marrow (BM) transplantation (BMT) protocols. Blocking the CD40:CD154 pathway with anti-CD154 monoclonal antibodies (mAbs) is exceptionally potent in inducing mixed chimerism, but these mAbs are clinically not available. Defining the roles of donor and recipient CD40 in a murine allogeneic BMT model, we show that CD4 or CD8 activation through an intact direct or CD4 T cell activation through the indirect pathway is sufficient to trigger BM rejection despite CTLA4Ig treatment. In the absence of CD4 T cells, CD8 T cell activation via the direct pathway, in contrast, leads to a state of split tolerance. Interruption of the CD40 signals in both the direct and indirect pathway of allorecognition or lack of recipient CD154 is required for the induction of chimerism and tolerance. We developed a novel BMT protocol that induces mixed chimerism and donor-specific tolerance to fully mismatched cardiac allografts relying on CD28 costimulation blockade and mTOR inhibition without targeting the CD40 pathway. Notably, MHC-mismatched/minor antigen-matched skin grafts survive indefinitely whereas fully mismatched grafts are rejected, suggesting that non-MHC antigens cause graft rejection and split tolerance.
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Affiliation(s)
- N Pilat
- Section of Transplantation Immunology, Department of Surgery, Medical University of Vienna, Austria
| | - C Klaus
- Section of Transplantation Immunology, Department of Surgery, Medical University of Vienna, Austria
| | - C Schwarz
- Section of Transplantation Immunology, Department of Surgery, Medical University of Vienna, Austria
| | - K Hock
- Section of Transplantation Immunology, Department of Surgery, Medical University of Vienna, Austria
| | - R Oberhuber
- Department of Visceral, Transplant, and Thoracic Surgery, Center of Operative Medicine, Innsbruck Medical University, Austria
| | - E Schwaiger
- Section of Transplantation Immunology, Department of Surgery, Medical University of Vienna, Austria
| | - M Gattringer
- Section of Transplantation Immunology, Department of Surgery, Medical University of Vienna, Austria
| | - H Ramsey
- Section of Transplantation Immunology, Department of Surgery, Medical University of Vienna, Austria
| | - U Baranyi
- Section of Transplantation Immunology, Department of Surgery, Medical University of Vienna, Austria
| | - B Zelger
- Institute of Pathology, Medical University of Innsbruck, Austria
| | - G Brandacher
- Department of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation (VCA) Laboratory, Johns Hopkins University School of Medicine, Baltimore, MD
| | - F Wrba
- Institute of Clinical Pathology, Medical University of Vienna, Austria
| | - T Wekerle
- Section of Transplantation Immunology, Department of Surgery, Medical University of Vienna, Austria
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The potential role for regulatory T-cell therapy in vascularized composite allograft transplantation. Curr Opin Organ Transplant 2015; 19:558-65. [PMID: 25333829 DOI: 10.1097/mot.0000000000000139] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
PURPOSE OF REVIEW Vascularized composite allograft (VCA) transplantation restores defects to a degree not possible by conventional techniques. However, it is limited by the need for long-term immunosuppression and high rates of acute rejection directed against skin. There is therefore a need for a therapy that may shift the risk-benefit ratio in favour of VCA transplantation. Regulatory T cells (Tregs) are a subset of T cells with potent immunoregulatory properties and the potential to promote immunosuppression-free allograft survival. In this review, we consider the evidence for Treg therapy in VCA transplantation. RECENT FINDINGS CD4 Tregs are the best-studied immunoregulatory cell type, and a large amount of experimental and clinical data is emerging to endorse their use in VCA transplantation. Data from animal and humanized models are particularly encouraging and demonstrate the potent efficacy of Treg at preventing skin allograft rejection. Moreover, central tolerance induction techniques in VCA transplantation models are demonstrating a dependence on Tregs for graft survival. SUMMARY An improvement in outcomes after VCA transplantation has the potential to revolutionize the field. Several effective therapeutic strategies have demonstrated great promise experimentally, and there is now a need to assess their safety and efficacy in a clinical setting.
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28
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Wachtman GS, Wimmers EG, Gorantla VS, Lin CH, Schneeberger S, Unadkat JV, Zheng XX, Brandacher G, Lee WPA. Biologics and donor bone marrow cells for targeted immunomodulation in vascularized composite allotransplantation: a translational trial in swine. Transplant Proc 2014; 43:3541-4. [PMID: 22099837 DOI: 10.1016/j.transproceed.2011.10.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Bone marrow (BM) infusion following organ transplantation is a prerequisite for potential donor-antigen-specific tolerance induction. We developed a preclinical swine model to determine the optimal dose of BM cells to achieve microchimerism. Furthermore, induction therapy was optimized by augmenting the BM infusion with biologics in the form of costimulatory blockade: cytotoxic T-lymphocyte antigen 4 immunoglobulin (CTLA4-Ig). MATERIALS AND METHODS Yucatan miniature swine (n = 12) underwent total body and thymic irradiation for cytodepletion. Animal groups received 15, 30, or 60 million cells per kilogram of whole unmodified BM. The optimal dose of BM cell infusion (BMT) was then applied to subsequent experiments evaluating the addition of CTLA4lg. Group 1 (control) received no treatment. Group 2 received FK506 only; group 3 received irradiation, BMT, and FK506; group 4 received FK506 and CTLA4-lg. RESULTS Microchimerism was established in all animals after BM cell infusion; at postoperative day 9, it was significantly increased for 60 million cells per kilogram (P = .0001). Transplanted animals in group 1 rejected the allograft 5 to 8 days after transplantation. Group 2 rejected the allograft (skin and muscle) 30 to 32 days after transplantation (2 days after cessation of immunosuppression). Group 3 rejected the skin portion of the allograft at 50, 52, and 53 days posttransplant. Remaining allograft components (muscle, bone, nerve, vessel) survived indefinitely. Group 4 animals demonstrated significantly prolonged muscle survival beyond 150 days posttransplant; the skin component survived past 150 days in two of three animals. Skin and muscle histology in all long-term surviving animals were normal. CONCLUSIONS BM cell infusion with 60 million cells per kilogram results in stable levels of microchimerism. The addition of costimulatory blockade (CTLA4lg) prolonged allograft skin survival and overall graft survival. Such targeted immunomodulatory protocols might facilitate immune tolerance and eliminate the need for multidrug immunosuppression to maintain graft survival after vascularized composite allotransplantation.
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Affiliation(s)
- G S Wachtman
- Division of Plastic and Reconstructive Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Simultaneous transplantation of hematopoietic stem cells and a vascularized composite allograft leads to tolerance. Transplantation 2014; 98:131-8. [PMID: 24918616 DOI: 10.1097/tp.0000000000000204] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND We have previously demonstrated that tolerance to a vascularized composite allograft (VCA) can be achieved after the establishment of mixed chimerism. We test the hypothesis that tolerance to a VCA in our dog leukocyte antigen-matched canine model is not dependent on the previous establishment of mixed chimerism and can be induced coincident with hematopoietic cell transplantation (HCT). METHODS Eight dog leukocyte antigen-matched, minor antigen mismatched dogs received 200 cGy of radiation and a VCA transplant. Four dogs received donor bone marrow at the time of VCA transplantation (group 1), whereas a second group of four dogs did not (group 2). All recipients received a limited course of postgrafting immunosuppression. All dogs that received HCT and VCA were given donor, third-party, and autologous skin grafts. RESULTS All group 1 recipients were tolerant to their VCA (>62 weeks). Three of the four dogs in group 2 rejected their VCA transplants after the cessation of immunosuppression. Biopsies obtained from the muscle and skin of VCA from group 1 showed few infiltrating cells compared with extensive infiltrates in biopsies of VCA from group 2. Compared with autologous skin and muscle, elevated levels of CD3+ FoxP3+ T-regulatory cells were found in the skin and muscle obtained from the VCA of HCT recipients. All group 1 animals were tolerant to their donor skin graft and promptly rejected the third-party skin grafts. CONCLUSION These data demonstrated that donor-specific tolerance to all components of the VCA can be established through simultaneous nonmyeloablative allogeneic HCT and VCA transplantation protocol.
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Mathes DW, Solari MG, Gazelle GS, Butler PEM, Wu A, Nazzal A, Nielsen GP, Huang CA, Sachs DH, Lee WPA, Randolph MA. Stable mixed hematopoietic chimerism permits tolerance of vascularized composite allografts across a full major histocompatibility mismatch in swine. Transpl Int 2014; 27:1086-96. [DOI: 10.1111/tri.12380] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Revised: 03/25/2014] [Accepted: 06/17/2014] [Indexed: 01/10/2023]
Affiliation(s)
- David W. Mathes
- Division of Plastic Surgery; University of Colorado, School of Medicine; Denver CO USA
| | - Mario G. Solari
- Division of Plastic Surgery; The University of Pittsburgh School of Medicine; Pittsburgh PA USA
| | - Guy Scott Gazelle
- Department of Radiology; Massachusetts General Hospital; Harvard Medical School; Boston MA USA
| | - Peter E. M. Butler
- Division of Plastic Surgery; Massachusetts General Hospital; Harvard Medical School; Boston MA USA
| | - Anette Wu
- Transplantation Biology Research Laboratory MGH-East; Massachusetts General Hospital; Harvard Medical School; Boston MA USA
| | - Adam Nazzal
- Division of Plastic Surgery; Massachusetts General Hospital; Harvard Medical School; Boston MA USA
| | - Gunnlauger P. Nielsen
- Department of Pathology; Massachusetts General Hospital; Harvard Medical School; Boston MA USA
| | - Christene A. Huang
- Transplantation Biology Research Laboratory MGH-East; Massachusetts General Hospital; Harvard Medical School; Boston MA USA
| | - David H. Sachs
- Transplantation Biology Research Laboratory MGH-East; Massachusetts General Hospital; Harvard Medical School; Boston MA USA
| | - Wei Ping Andrew Lee
- Department of Plastic Surgery; Johns Hopkins Medical Institutions; Baltimore MD USA
| | - Mark A. Randolph
- Division of Plastic Surgery; Massachusetts General Hospital; Harvard Medical School; Boston MA USA
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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.
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Leonard DA, Kurtz JM, Mallard C, Albritton A, Duran-Struuck R, Farkash EA, Crepeau R, Matar A, Horner BM, Randolph MA, Sachs DH, Huang CA, Cetrulo CL. Vascularized composite allograft tolerance across MHC barriers in a large animal model. Am J Transplant 2014; 14:343-55. [PMID: 24405666 PMCID: PMC3971524 DOI: 10.1111/ajt.12560] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2013] [Revised: 10/25/2013] [Accepted: 10/25/2013] [Indexed: 01/25/2023]
Abstract
Vascularized composite allograft (VCA) transplantation can restore form and function following severe craniofacial injuries, extremity amputations or massive tissue loss. The induction of transplant tolerance would eliminate the need for long-term immunosuppression, realigning the risk-benefit ratio for these life-enhancing procedures. Skin, a critical component of VCA, has consistently presented the most stringent challenge to transplant tolerance. Here, we demonstrate, in a clinically relevant miniature swine model, induction of immunologic tolerance of VCAs across MHC barriers by induction of stable hematopoietic mixed chimerism. Recipient conditioning consisted of T cell depletion with CD3-immunotoxin, and 100 cGy total body irradiation prior to hematopoietic cell transplantation (HCT) and a 45-day course of cyclosporine A. VCA transplantation was performed either simultaneously to induction of mixed chimerism or into established mixed chimeras 85-150 days later. Following withdrawal of immunosuppression both VCAs transplanted into stable chimeras (n=4), and those transplanted at the time of HCT (n=2) accepted all components, including skin, without evidence of rejection to the experimental end point 115-504 days posttransplant. These data demonstrate that tolerance across MHC mismatches can be induced in a clinically relevant VCA model, providing proof of concept for long-term immunosuppression-free survival.
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Affiliation(s)
- D. A. Leonard
- Transplantation Biology Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA,Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA,Department of Plastic and Reconstructive Surgery Research, University of Manchester, Manchester, UK
| | - J. M. Kurtz
- Transplantation Biology Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA,Department of Biology, Emmanuel College, Boston, MA
| | - C. Mallard
- Transplantation Biology Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - A. Albritton
- Transplantation Biology Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - R. Duran-Struuck
- Transplantation Biology Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - E. A. Farkash
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - R. Crepeau
- Transplantation Biology Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - A. Matar
- Transplantation Biology Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - B. M. Horner
- Transplantation Biology Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA,Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - M. A. Randolph
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - D. H. Sachs
- Transplantation Biology Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - C. A. Huang
- Transplantation Biology Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA,Corresponding authors: Curtis L. Cetrulo Jr, , and Christene A. Huang,
| | - C. L. Cetrulo
- Transplantation Biology Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA,Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA,Corresponding authors: Curtis L. Cetrulo Jr, , and Christene A. Huang,
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Kwak HH, Park KM, Nam HS, Park SM, Woo HM. Disparate hypervariable region-1 of mitochondrial DNA did not induce skin allograft rejection in cloned porcine models. Transplant Proc 2014; 45:1787-91. [PMID: 23769044 DOI: 10.1016/j.transproceed.2013.01.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2012] [Accepted: 01/15/2013] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Alloantigen recognition in skin transplantation is the bane for surgeons. Several studies have mainly focused on the immunogenicity of major histocompatibility (MHC) antigens and H-Y minor histocompatibility antigens. However, the roles of the mitochondrial DNA (mtDNA) encorded miHA have not been identified. Therefore, we sought to address the antigenicity of the hypervariable region 1 (HV-1) of mtDNA in skin transplantation using cloned pig models. METHODS Swine leukocyte antigen and HV-1 of mtDNA were analyzed using sequencing methods. Skin transplantation was performed between MHC-matched, mtDNA-mismatched cloned miniature pigs. Full-thickness skin was grafted between cloned pigs without any immunosuppressants. The grafted tissues were observed for 3 months and evaluated histologically. RESULTS The cloned pigs shared identical MHC but mtDNA mismatched at 9 positions. Skin grafts between the cloned pigs were accepted and hair growth maintained, whereas MHC-mismatched grafts showed acute rejection within 7 days after transplantation and were replaced by hairless scar tissue. CONCLUSIONS HV-1 disparate skin grafts were not recognized as alloantigenic by MHC-matched cloned pigs.
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Affiliation(s)
- H-H Kwak
- Stem Cell Institute, Kangwon National University, ChunCheon, Gangwon-do, Korea
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Ibrahim Z, Cooney DS, Shores JT, Sacks JM, Wimmers EG, Bonawitz SC, Gordon C, Ruben D, Schneeberger S, Lee WPA, Brandacher G. A modified heterotopic swine hind limb transplant model for translational vascularized composite allotransplantation (VCA) research. J Vis Exp 2013. [PMID: 24145603 DOI: 10.3791/50475] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Vascularized Composite Allotransplantation (VCA) such as hand and face transplants represent a viable treatment option for complex musculoskeletal trauma and devastating tissue loss. Despite favorable and highly encouraging early and intermediate functional outcomes, rejection of the highly immunogenic skin component of a VCA and potential adverse effects of chronic multi-drug immunosuppression continue to hamper widespread clinical application of VCA. Therefore, research in this novel field needs to focus on translational studies related to unique immunologic features of VCA and to develop novel immunomodulatory strategies for immunomodulation and tolerance induction following VCA without the need for long term immunosuppression. This article describes a reliable and reproducible translational large animal model of VCA that is comprised of an osteomyocutaneous flap in a MHC-defined swine heterotopic hind limb allotransplantation. Briefly, a well-vascularized skin paddle is identified in the anteromedial thigh region using near infrared laser angiography. The underlying muscles, knee joint, distal femur, and proximal tibia are harvested on a femoral vascular pedicle. This allograft can be considered both a VCA and a vascularized bone marrow transplant with its unique immune privileged features. The graft is transplanted to a subcutaneous abdominal pocket in the recipient animal with a skin component exteriorized to the dorsolateral region for immune monitoring. Three surgical teams work simultaneously in a well-coordinated manner to reduce anesthesia and ischemia times, thereby improving efficiency of this model and reducing potential confounders in experimental protocols. This model serves as the groundwork for future therapeutic strategies aimed at reducing and potentially eliminating the need for chronic multi-drug immunosuppression in VCA.
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Affiliation(s)
- Zuhaib Ibrahim
- Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine
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Bergfeld W, Klimczak A, Stratton JS, Siemionow MZ. A four-year pathology review of the near total face transplant. Am J Transplant 2013; 13:2750-64. [PMID: 23919328 DOI: 10.1111/ajt.12379] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2012] [Revised: 06/05/2013] [Accepted: 06/06/2013] [Indexed: 01/25/2023]
Abstract
In December of 2008, our institution performed a near total face transplant. The patient was monitored for signs of rejection assessed by paired skin and mucosa biopsies. The results of histological review of 120 biopsies collected during the first 4 years posttransplant are discussed. All biopsies were stained with hematoxylin and eosin, periodic acid-Schiff, immunohistochemical and TUNEL assays and graded using the Banff 2007 classification. Grade III rejection was diagnosed clinically at weeks 45 and 66, posttransplant; week 45 was determined as folliculitis while the erythema episode at week 66 confirmed an acute rejection (AR) that required hospitalization. The mucosa frequently showed interface inflammation without clinical signs of rejection and was not present in skin biopsies. In all, 34 of the 45 mucosal biopsies (75%) showed these interface changes. Clinical symptoms concurred with skin pathology in two grade III rejections. The mucosa showed histologic signs of rejection more frequently, which may indicate: increased mucosal sensitivity to rejection, a different type or subtype of AR that is specific to the mucosa, or a nonspecific process such as a drug effect. With more data and world experience, the diagnosis of face transplant rejection will be better defined and the Banff classification enhanced.
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Affiliation(s)
- W Bergfeld
- Department of Dermatology and Pathology, Cleveland Clinic, Cleveland, OH
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Abstract
Vascularized composite allotransplantation has become established as a clinical specialty since the first successful hand transplant was performed in 1998. Data now available indicate that hand and face transplants offer patients good functional outcomes and significant improvements in quality of life. Despite the debilitating nature of the injuries treated by such transplants, the defects are generally not life threatening, making it difficult for physicians to recommend life-long immunosuppression that can itself have grave consequences. One potential solution to this dilemma is the induction of immunologic tolerance of the tissue transplants because tolerance would eliminate the need for such immunosuppression. Transplant tolerance may also prevent chronic rejection, a significant source of late graft loss after organ transplantation.Induction of mixed hematopoietic chimerism is a robust approach to establishing such transplant tolerance, which recently led to the first clinical application of a tolerance induction protocol for kidney transplantation. In this manuscript, we review the current status of VCA and of research directed toward bringing a tolerance approach to the VCA field. We also discuss the potential clinical significance of these studies and outline the remaining obstacles to introduction of a tolerance induction protocol to clinical practice in hand or face transplantation.
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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
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Tolerogenicity of donor major histocompatibility complex-matched skin grafts in previously tolerant Massachusetts general hospital miniature swine. Transplantation 2013; 94:1192-9. [PMID: 23269447 DOI: 10.1097/tp.0b013e31827254f5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Long-term tolerance of class I disparate renal allografts in miniature swine can be induced by a short course of cyclosporine and persists for 3 to 4 months after grafts are removed. Donor class I peptide immunization 6 weeks after graftectomy of tolerated kidneys leads to sensitization, but donor skin grafts do not. Here, we tested the hypothesis that skin grafts prevent rejection after simultaneous peptide administration and skin grafting. METHODS Miniature swine underwent bilateral nephrectomy and class I-mismatched renal transplantation with a 12-day course of cyclosporine A to induce long-term tolerance. Tolerated allografts were then replaced with recipient-matched kidneys, and animals were challenged with simultaneous donor-type skin grafts and peptide. Six weeks later, second donor-matched kidneys were transplanted without immunosuppression, and immune responses were characterized. RESULTS Animals treated only with peptide (n=2) rejected subsequent renal transplants in 3 to 5 days with strong in vitro antidonor responses. Of five recipients of skin-plus-peptide regimen, two accepted kidneys long term, one demonstrated a modestly prolonged survival (11 days), and two rejected rapidly (5-7 days). The two long-term acceptors maintained donor-specific hyporesponsiveness in vitro. CONCLUSIONS Sensitization by class I peptide in previously tolerant swine could be prevented by simultaneous class I skin grafts. These data suggest that skin grafts may actually augment rather than abrogate downregulation in some cases. A mechanistic hypothesis for this surprising result is that recognition of class I antigens through the direct rather than the indirect pathway of antigen presentation promotes tolerance by expanding regulatory T cells.
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Site-specific immunosuppression in vascularized composite allotransplantation: prospects and potential. Clin Dev Immunol 2013; 2013:495212. [PMID: 23476677 PMCID: PMC3586464 DOI: 10.1155/2013/495212] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2012] [Accepted: 01/18/2013] [Indexed: 11/27/2022]
Abstract
Skin is the most immunogenic component of a vascularized composite allograft (VCA) and is the primary trigger and target of rejection.
The skin is directly accessible for visual monitoring of acute rejection (AR) and for directed biopsy, timely therapeutic intervention, and management of AR.
Logically, antirejection drugs, biologics, or other agents delivered locally to the VCA may reduce the need for systemic immunosuppression with its adverse effects.
Topical FK 506 (tacrolimus) and steroids have been used in clinical VCA as an adjunct to systemic therapy with unclear beneficial effects. However, there are no commercially available topical formulations for other widely used systemic immunosuppressive drugs such as mycophenolic acid, sirolimus, and everolimus. Investigating the site-specific therapeutic effects and efficacy of systemically active agents may enable optimizing the dosing, frequency, and duration of overall immunosuppression in VCA with minimization or elimination of long-term drug-related toxicity.
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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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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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Kiermeir DM, Meoli M, Müller S, Abderhalden S, Vögelin E, Constantinescu MA. Evaluation of a porcine whole-limb heterotopic autotransplantation model. Microsurgery 2012; 33:141-7. [DOI: 10.1002/micr.22038] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2012] [Revised: 07/12/2012] [Accepted: 07/13/2012] [Indexed: 11/07/2022]
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Brandacher G, Grahammer J, Sucher R, Lee WPA. Animal models for basic and translational research in reconstructive transplantation. ACTA ACUST UNITED AC 2012; 96:39-50. [PMID: 22457176 DOI: 10.1002/bdrc.21002] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Reconstructive transplantation represents a bona fide option for select patients with devastating tissue loss, which could better restore the appearance, anatomy, and function than any other conventional treatment currently available. Despite favorable outcomes, broad clinical application of reconstructive transplantation is limited by the potential side effects of chronic multidrug immunosuppression. Thus, any reconstructive measures to improve these non-life-threatening conditions must address a delicate balance of risks and benefits. Today, several exciting novel therapeutic strategies, such as the implementation of cellular therapies including bone marrow or stem cells that integrate the concepts of immune regulation with those of nerve regeneration, are on the horizon. The development of reliable and reproducible small and large animal models is essential for the study of the unique immunological and biological aspects of vascularized composite allografts and to translate such novel immunoregulatory and tolerance-inducing strategies and therapeutic concepts from the bench to bedside. This review provides an overview of the multitude of small and large animal models that have been particularly designed for basic and translational research related to reconstructive transplantation.
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Affiliation(s)
- Gerald Brandacher
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryand 21205, USA.
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Kuo YR, Chen CC, Goto S, Huang YT, Wang CT, Tsai CC, Chen CL. Immunomodulatory effects of bone marrow-derived mesenchymal stem cells in a swine hemi-facial allotransplantation model. PLoS One 2012; 7:e35459. [PMID: 22558153 PMCID: PMC3338845 DOI: 10.1371/journal.pone.0035459] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2011] [Accepted: 03/18/2012] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND In this study, we investigated whether the infusion of bone marrow-derived mesenchymal stem cells (MSCs), combined with transient immunosuppressant treatment, could suppress allograft rejection and modulate T-cell regulation in a swine orthotopic hemi-facial composite tissue allotransplantation (CTA) model. METHODOLOGY/PRINCIPAL FINDINGS Outbred miniature swine underwent hemi-facial allotransplantation (day 0). Group-I (n = 5) consisted of untreated control animals. Group-II (n = 3) animals received MSCs alone (given on days -1, +1, +3, +7, +14, and +21). Group-III (n = 3) animals received CsA (days 0 to +28). Group-IV (n = 5) animals received CsA (days 0 to +28) and MSCs (days -1, +1, +3, +7, +14, and +21). The transplanted face tissue was observed daily for signs of rejection. Biopsies of donor tissues and recipient blood sample were obtained at specified predetermined times (per 2 weeks post-transplant) or at the time of clinically evident rejection. Our results indicated that the MSC-CsA group had significantly prolonged allograft survival compared to the other groups (P<0.001). Histological examination of the MSC-CsA group displayed the lowest degree of rejection in alloskin and lymphoid gland tissues. TNF-α expression in circulating blood revealed significant suppression in the MSC and MSC-CsA treatment groups, as compared to that in controls. IHC staining showed CD45 and IL-6 expression were significantly decreased in MSC-CsA treatment groups compared to controls. The number of CD4+/CD25+ regulatory T-cells and IL-10 expressions in the circulating blood significantly increased in the MSC-CsA group compared to the other groups. IHC staining of alloskin tissue biopsies revealed a significant increase in the numbers of foxp3(+)T-cells and TGF-β1 positive cells in the MSC-CsA group compared to the other groups. CONCLUSIONS These results demonstrate that MSCs significantly prolong hemifacial CTA survival. Our data indicate the MSCs did not only suppress inflammation and acute rejection of CTA, but also modulate T-cell regulation and related cytokines expression.
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Affiliation(s)
- Yur-Ren Kuo
- Center for Composite Tissue Allotransplantation, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
- Department of Plastic and Reconstructive Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
- * E-mail:
| | - Chien-Chang Chen
- Center for Composite Tissue Allotransplantation, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
- Department of Plastic and Reconstructive Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Shigeru Goto
- Liver Transplantation Program and Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yu-Ting Huang
- Center for Composite Tissue Allotransplantation, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
- Department of Plastic and Reconstructive Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chun-Ting Wang
- Center for Composite Tissue Allotransplantation, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
- Department of Plastic and Reconstructive Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chia-Chun Tsai
- Center for Composite Tissue Allotransplantation, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
- Department of Plastic and Reconstructive Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chao-Long Chen
- Liver Transplantation Program and Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
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Abstract
BACKGROUND Mixed donor-host chimerism, established through hematopoietic cell transplantation (HCT), is a reproducible strategy for the induction of tolerance toward solid organs. Here, we ask whether a nonmyeloablative conditioning regimen establishing mixed donor-host chimerism leads to tolerance of antigenic vascularized composite allografts. METHODS Stable mixed chimerism was established in dogs given a sublethal dose (1-2 Gy) total body irradiation before and a short course of immunosuppression after dog leukocyte antigen-identical marrow transplantation. Vascularized composite allografts from marrow donors were performed after a median of 36 months (range, 4-54 months) after HCT. RESULTS All marrow recipients maintained mixed donor-host hematopoietic chimerism and accepted vascularized composite allografts for periods ranging between 52 and 90 weeks; in turn, marrow donors rejected vascularized composite allografts from their respective marrow recipients within 18 to 29 days. Biopsies of muscle and skin of vascularized composite allografts from mixed chimeras showed few infiltrating cells compared with extensive infiltrates in biopsies of vascularized composite allografts from marrow donors. Elevated levels of CD3+ FoxP3+ T-regulatory cells were found in skin and muscle of vascularized composite allografts of mixed chimeras compared with normal tissues. In mixed chimeras, increased numbers of T-regulatory cells were found in draining compared with nondraining lymph nodes of vascularized composite allografts. CONCLUSIONS These data suggest that nonmyeloablative HCT may form the basis for future clinical applications of solid organ transplantation and that T-regulatory cells may function toward maintenance of the vascularized composite allograft.
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Infrared Fluorescence Imaging of Lymphatic Regeneration in Nonhuman Primate Facial Vascularized Composite Allografts. Ann Plast Surg 2012; 68:314-9. [DOI: 10.1097/sap.0b013e31824671e5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Mundinger GS, Kelamis JA, Kim SH, Magarakis M, Jones LS, Ha JS, Rodriguez ED. Tunneled superficial inferior epigastric artery (SIEA) myocutaneous/vascularized femur chimeric flaps: A model to study the role of vascularized bone marrow in composite allografts. Microsurgery 2011; 32:128-35. [DOI: 10.1002/micr.20957] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2011] [Revised: 08/05/2011] [Accepted: 08/09/2011] [Indexed: 11/12/2022]
Affiliation(s)
- Gerhard S. Mundinger
- Division of Plastic, Reconstructive and Maxillofacial Surgery, R Adams Cowley Shock Trauma Center/University of Maryland Medical Center, 22 South Greene Street, Baltimore, MD 21201
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, MD
| | - Joseph A. Kelamis
- Division of Plastic, Reconstructive and Maxillofacial Surgery, R Adams Cowley Shock Trauma Center/University of Maryland Medical Center, 22 South Greene Street, Baltimore, MD 21201
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, MD
| | - Soon H. Kim
- Division of Plastic, Reconstructive and Maxillofacial Surgery, R Adams Cowley Shock Trauma Center/University of Maryland Medical Center, 22 South Greene Street, Baltimore, MD 21201
- Department of Plastic and Reconstructive Surgery, Konkuk University, Seoul, Korea
| | - Michael Magarakis
- Division of Plastic, Reconstructive and Maxillofacial Surgery, R Adams Cowley Shock Trauma Center/University of Maryland Medical Center, 22 South Greene Street, Baltimore, MD 21201
| | - Luke S. Jones
- Division of Plastic, Reconstructive and Maxillofacial Surgery, R Adams Cowley Shock Trauma Center/University of Maryland Medical Center, 22 South Greene Street, Baltimore, MD 21201
| | - Jinny S. Ha
- Division of Plastic, Reconstructive and Maxillofacial Surgery, R Adams Cowley Shock Trauma Center/University of Maryland Medical Center, 22 South Greene Street, Baltimore, MD 21201
| | - Eduardo D. Rodriguez
- Division of Plastic, Reconstructive and Maxillofacial Surgery, R Adams Cowley Shock Trauma Center/University of Maryland Medical Center, 22 South Greene Street, Baltimore, MD 21201
- Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, MD
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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.
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Affiliation(s)
- Jaimie T Shores
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21224, USA.
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Gorantla VS, Demetris AJ. Acute and chronic rejection in upper extremity transplantation: what have we learned? Hand Clin 2011; 27:481-93, ix. [PMID: 22051389 DOI: 10.1016/j.hcl.2011.08.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
To date, 78 upper extremity transplants have been performed in 55 recipients around the world. The purpose of this article is to provide an overview of acute and chronic rejection (CR) and to summarize collective insights in upper extremity transplantation. To date, almost all patients experienced AR that is pathophysiologically similar to that in solid organs. The spectre of chronic rejection is just emerging. Upper extremity transplantation has significant potential as a reconstructive option only if efforts are invested in strategies to reduce risks of prolonged immunosuppression and in approaches to better diagnose, monitor and treat AR and CR.
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Affiliation(s)
- Vijay S Gorantla
- Pittsburgh Reconstructive Transplantation Program, Division of Plastic Surgery, Department of Surgery, 3550 Terrace Street, Pittsburgh, PA 15261, USA
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