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Van Dieren L, Tawa P, Coppens M, Naenen L, Dogan O, Quisenaerts T, Lancia HH, Oubari H, Dabi Y, De Fré M, Thiessen Ef F, Cetrulo CL, Lellouch AG. Acute Rejection Rates in Vascularized Composite Allografts: A Systematic Review of Case Reports. J Surg Res 2024; 298:137-148. [PMID: 38603944 DOI: 10.1016/j.jss.2024.02.019] [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: 09/05/2023] [Revised: 01/20/2024] [Accepted: 02/29/2024] [Indexed: 04/13/2024]
Abstract
INTRODUCTION Vascularized Composite Allografts (VCA) are usually performed in a full major histocompatibility complex mismatch setting, with a risk of acute rejection depending on factors such as the type of immunosuppression therapy and the quality of graft preservation. In this systematic review, we present the different immunosuppression protocols used in VCA and point out relationships between acute rejection rates and possible factors that might influence it. METHODS This systematic review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. We systematically searched Medline (PubMed), Embase, and The Cochrane Library between November 2022 and February 2023, using following Mesh Terms: Transplant, Transplantation, Hand, Face, Uterus, Penis, Abdominal Wall, Larynx, and Composite Tissue Allografts. All VCA case reports and reviews describing multiple case reports were included. RESULTS We discovered 211 VCA cases reported. The preferred treatment was a combination of antithymocyte globulins, mycophenolate mofetil (MMF), tacrolimus, and steroids; and a combination of MMF, tacrolimus, and steroids for induction and maintenance treatment, respectively. Burn patients showed a higher acute rejection rate (P = 0.073) and were administered higher MMF doses (P = 0.020). CONCLUSIONS In contrast to previous statements, the field of VCA is not rapidly evolving, as it has encountered challenges in addressing immune-related concerns. This is highlighted by the absence of a standardized immunosuppression regimen. Consequently, more substantial data are required to draw more conclusive results regarding the immunogenicity of VCAs and the potential superiority of one immunosuppressive treatment over another. Future efforts should be made to report the VCA surgeries comprehensively, and muti-institutional long-term prospective follow-up studies should be performed to compare the number of acute rejections with influencing factors.
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Affiliation(s)
- Loïc Van Dieren
- Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Faculty of Medicine and Health Sciences, Antwerp, Belgium; Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Pierre Tawa
- Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Boston, Massachusetts; Shriners Hospitals for Children-Boston, Boston, Massachusetts
| | - Marie Coppens
- Faculty of Medicine and Health Sciences, Antwerp, Belgium
| | - Laura Naenen
- Faculty of Medicine and Health Sciences, Antwerp, Belgium
| | - Omer Dogan
- Faculty of Medicine and Health Sciences, Antwerp, Belgium
| | | | - Hyshem H Lancia
- Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Haïzam Oubari
- Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Yohann Dabi
- Department of Obstetrics, Gynecology and Reproductive Medicine, Sorbonne University, Tenon Hospital (AP-HP), Paris, France
| | - Maxime De Fré
- Department of Plastic, Reconstructive and Aesthetic Surgery, Antwerp University Hospital, Antwerp, Belgium
| | - Filip Thiessen Ef
- Department of Plastic, Reconstructive and Aesthetic Surgery, Antwerp University Hospital, Antwerp, Belgium
| | - Curtis L Cetrulo
- Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Boston, Massachusetts; Shriners Hospitals for Children-Boston, Boston, Massachusetts
| | - Alexandre G Lellouch
- Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Boston, Massachusetts; Shriners Hospitals for Children-Boston, Boston, Massachusetts.
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von Reiterdank IF, Tawa P, Berkane Y, de Clermont-Tonnerre E, Dinicu A, Pendexter C, Goutard M, Lellouch AG, van der Molen ABM, Coert JH, Cetrulo CL, Uygun K. Sub-Zero Non-Freezing of Vascularized Composite Allografts Preservation in Rodents. RESEARCH SQUARE 2023:rs.3.rs-3750450. [PMID: 38234765 PMCID: PMC10793490 DOI: 10.21203/rs.3.rs-3750450/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2024]
Abstract
Ischemia is a major limiting factor in Vascularized Composite Allotransplantation (VCA) as irreversible muscular injury can occur after as early as 4-6 hours of static cold storage (SCS). Organ preservation technologies have led to the development of storage protocols extending rat liver ex vivo preservation up to 4 days. Development of such a protocol for VCAs has the added challenge of inherent ice nucleating factors of the graft, therefore this study focused on developing a robust protocol for VCA supercooling. Rodent partial hindlimbs underwent subnormothermic machine perfusion (SNMP) with several loading solutions, followed by cryoprotective agent (CPA) cocktail developed for VCAs. Storage occurred in suspended animation for 24h and VCAs were recovered using SNMP with modified Steen. This study shows a robust VCA supercooling preservation protocol in a rodent model. Further optimization is expected to allow for its application in a transplantation model, which would be a breakthrough in the field of VCA preservation.
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Affiliation(s)
- Irina Filz von Reiterdank
- Center for Engineering in Medicine and Surgery, Derpartment of Surgery, Massachusetts General Hospital, Harvard Medical School
| | - Pierre Tawa
- Department of Plastic, Reconstructive and Aesthetic Surgery, Hôpital Paris Saint-Joseph
| | - Yanis Berkane
- Department of Plastic, Reconstructive and Aesthetic Surgery, Hôpital Sud, CHU Rennes, University of Rennes
| | | | - Antonia Dinicu
- Center for Engineering in Medicine and Surgery, Derpartment of Surgery, Massachusetts General Hospital, Harvard Medical School
| | - Casie Pendexter
- Center for Engineering in Medicine and Surgery, Derpartment of Surgery, Massachusetts General Hospital, Harvard Medical School
| | - Marion Goutard
- Department of Plastic, Reconstructive and Aesthetic Surgery, Hôpital Paris Saint-Joseph
| | - Alexandre G Lellouch
- Innovative Therapies in Haemostasis, INSERM UMR-S 1140, University of Paris, F-75006
| | - Aebele B Mink van der Molen
- Department of Plastic, Reconstructive and Hand Surgery, University Medical Center Utrecht, Utrecht University
| | - J Henk Coert
- Department of Plastic, Reconstructive and Hand Surgery, University Medical Center Utrecht, Utrecht University
| | - Curtis L Cetrulo
- Vascularized Composite Allotransplantation Laboratory, Massachusetts General Hospital, Harvard Medical School
| | - Korkut Uygun
- Center for Engineering in Medicine and Surgery, Derpartment of Surgery, Massachusetts General Hospital, Harvard Medical School
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Zhang L, Hoyos IA, Zubler C, Rieben R, Constantinescu M, Olariu R. Challenges and opportunities in vascularized composite allotransplantation of joints: a systematic literature review. Front Immunol 2023; 14:1179195. [PMID: 37275912 PMCID: PMC10235447 DOI: 10.3389/fimmu.2023.1179195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 05/08/2023] [Indexed: 06/07/2023] Open
Abstract
Background Joint allotransplantation (JA) within the field of vascularized composite allotransplantation (VCA) holds great potential for functional and non-prosthetic reconstruction of severely damaged joints. However, clinical use of JA remains limited due to the immune rejection associated with all forms of allotransplantation. In this study, we aim to provide a comprehensive overview of the current state of JA through a systematic review of clinical, animal, and immunological studies on this topic. Methods We conducted a systematic literature review in accordance with the PRISMA guidelines to identify relevant articles in PubMed, Cochrane Library, and Web of Science databases. The results were analyzed, and potential future prospects were discussed in detail. Results Our review included 14 articles describing relevant developments in JA. Currently, most JA-related research is being performed in small animal models, demonstrating graft survival and functional restoration with short-term immunosuppression. In human patients, only six knee allotransplantations have been performed to date, with all grafts ultimately failing and a maximum graft survival of 56 months. Conclusion Research on joint allotransplantation has been limited over the last 20 years due to the rarity of clinical applications, the complex nature of surgical procedures, and uncertain outcomes stemming from immune rejection. However, the key to overcoming these challenges lies in extending graft survival and minimizing immunosuppressive side effects. With the emergence of new immunosuppressive strategies, the feasibility and clinical potential of vascularized joint allotransplantation warrants further investigation.
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Affiliation(s)
- Lei Zhang
- Department of Plastic and Hand Surgery, Inselspital University Hospital Bern, University of Bern, Bern, Switzerland
- Department for BioMedical Research, University of Bern, Bern, Switzerland
- Department of Plastic and Reconstructive Surgery, Plastic and Reconstructive Surgery Center, Zhejiang Provincial People’s Hospital, Hangzhou, China
| | - Isabel Arenas Hoyos
- Department of Plastic and Hand Surgery, Inselspital University Hospital Bern, University of Bern, Bern, Switzerland
- Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - Cédric Zubler
- Department of Plastic and Hand Surgery, Inselspital University Hospital Bern, University of Bern, Bern, Switzerland
| | - Robert Rieben
- Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - Mihai Constantinescu
- Department of Plastic and Hand Surgery, Inselspital University Hospital Bern, University of Bern, Bern, Switzerland
| | - Radu Olariu
- Department of Plastic and Hand Surgery, Inselspital University Hospital Bern, University of Bern, Bern, Switzerland
- Department for BioMedical Research, University of Bern, Bern, Switzerland
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Lei B, Sleiman MM, Cheng Q, Tu Z, Zhu P, Goddard M, Martins PN, Langerude L, Nadig S, Tomlinson S, Atkinson C. In Situ Pre-Treatment of Vascularized Composite Allografts With a Targeted Complement Inhibitor Protects Against Brain Death and Ischemia Reperfusion Induced Injuries. Front Immunol 2021; 12:630581. [PMID: 34394069 PMCID: PMC8358649 DOI: 10.3389/fimmu.2021.630581] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 06/14/2021] [Indexed: 12/12/2022] Open
Abstract
Introduction Donor brain death (BD) is an unavoidable component of vascularized composite allograft (VCA) transplantation and a key contributor to ischemia-reperfusion injury (IRI). Complement is activated and deposited within solid organ grafts as a consequence of BD and has been shown to exacerbate IRI, although the role of BD and complement in VCA and the role it plays in IRI and VCA rejection has not been studied. Methods BD was induced in Balb/c donors, and the VCA perfused prior to graft procurement with UW solution supplemented with or without CR2-Crry, a C3 convertase complement inhibitor that binds at sites of complement activation, such as that induced on the endothelium by induction of BD. Following perfusion, donor VCAs were cold stored for 6 hours before transplantation into C57BL/6 recipients. Donor VCAs from living donors (LD) were also procured and stored. Analyses included CR2-Crry graft binding, complement activation, toxicity, injury/inflammation, graft gene expression and survival. Results Compared to LD VCAs, BD donor VCAs had exacerbated IRI and rejected earlier. Following pretransplant in-situ perfusion of the donor graft, CR2-Crry bound within the graft and was retained post-transplantation. CR2-Crry treatment significantly reduced complement deposition, inflammation and IRI as compared to vehicle-treated BD donors. Treatment of BD donor VCAs with CR2-Crry led to an injury profile not dissimilar to that seen in recipients of LD VCAs. Conclusion Pre-coating a VCA with CR2-Crry in a clinically relevant treatment paradigm provides localized, and therefore minimally immunosuppressive, protection from the complement-mediated effects of BD induced exacerbated IRI.
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Affiliation(s)
- Biao Lei
- Division of Hepatobiliary Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - M. Mahdi Sleiman
- Department of Microbiology and Immunology, Medical University of South Carolina, Charleston, SC, United States
| | - Qi Cheng
- Department of Microbiology and Immunology, Medical University of South Carolina, Charleston, SC, United States
- Department of Surgery, Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Institute of Organ Transplantation, Huazhong University of Science and Technology, Wuhan, China
| | - Zhenxiao Tu
- Department of Microbiology and Immunology, Medical University of South Carolina, Charleston, SC, United States
- Department of Surgery, Hepatic and Vascular Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Peng Zhu
- Department of Microbiology and Immunology, Medical University of South Carolina, Charleston, SC, United States
- Department of Surgery, Hepatic and Vascular Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Martin Goddard
- Pathology Department, Papworth Hospital NHS Trust, Cambridge, United Kingdom
| | - Paulo N. Martins
- UMass Memorial Medical Center, Department of Surgery, Transplant Division, University of Massachusetts, Worcester, MA, United States
| | - Logan Langerude
- Division of Pulmonary Medicine, University of Florida, Gainesville, FL, United States
| | - Satish Nadig
- Department of Microbiology and Immunology, Medical University of South Carolina, Charleston, SC, United States
- Department of Surgery, Lee Patterson Allen Transplant Immunobiology Laboratory, Medical University of South Carolina, Microbiology and Immunology, Charleston, SC, United States
| | - Stephen Tomlinson
- Department of Microbiology and Immunology, Medical University of South Carolina, Charleston, SC, United States
- Department of Surgery, Lee Patterson Allen Transplant Immunobiology Laboratory, Medical University of South Carolina, Microbiology and Immunology, Charleston, SC, United States
- Ralph H. Johnson VA Medical Center, Charleston, SC, United States
| | - Carl Atkinson
- Department of Microbiology and Immunology, Medical University of South Carolina, Charleston, SC, United States
- Division of Pulmonary Medicine, University of Florida, Gainesville, FL, United States
- Department of Surgery, Lee Patterson Allen Transplant Immunobiology Laboratory, Medical University of South Carolina, Microbiology and Immunology, Charleston, SC, United States
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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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Kaufman CL, Kanitakis J, Weissenbacher A, Brandacher G, Mehra MR, Amer H, Zelger BG, Zelger B, Pomahac B, McDiarmid S, Cendales L, Morelon E. Defining chronic rejection in vascularized composite allotransplantation-The American Society of Reconstructive Transplantation and International Society of Vascularized Composite Allotransplantation chronic rejection working group: 2018 American Society of Reconstructive Transplantation meeting report and white paper Research goals in defining chronic rejection in vascularized composite allotransplantation. SAGE Open Med 2020; 8:2050312120940421. [PMID: 32704373 PMCID: PMC7361482 DOI: 10.1177/2050312120940421] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Accepted: 09/20/2019] [Indexed: 12/12/2022] Open
Abstract
Objectives: This report summarizes a collaborative effort between the American Society of Reconstructive Transplantation and the International Society of Vascularized Composite Allotransplantation to establish what is known about chronic rejection in recipients of vascularized composite allografts, with an emphasis on upper extremity and face transplants. As a picture of chronic rejection in hand and face vascularized composite allografts emerges, the results will be applied to other types of vascularized composite allografts, such as uterine transplantation. Methods: The overall goal is to develop a definition of chronic rejection in vascularized composite allografts so that we can establish longitudinal correlates of factors such as acute rejection, immunosuppressive therapy, de novo donor-specific antibody and trauma/infection and other external factors on the development of chronic rejection. As Dr Kanitakis eloquently stated at the 2017 International Society of Vascularized Composite Allotransplantation meeting in Salzburg, “Before we can correlate causative factors of chronic rejection, we have to define what chronic rejection in VCA is.” Results: The first meeting report was presented at the sixth Biennial meeting of the American Society of Reconstructive Transplantation in November 2018. Based on collaborative efforts and descriptions of clinical cases of chronic rejection in vascularized composite allograft recipients, a working definition of chronic rejection in vascularized composite allografts with respect to overt functional decline, subclinical functional decline, histologic evidence without functional decline, and normal allograft function in the absence of histologic evidence of chronic rejection is proposed. Conclusions: It is the intent of this collaborative working group that these working definitions will help to focus ongoing research to define the incidence, risk factors and treatment regimens that will identify mechanisms of chronic rejection in vascularized composite allografts. As with all good research, our initial efforts have generated more questions than answers. We hope that this is the first of many updates.
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Affiliation(s)
| | - Jean Kanitakis
- Department of Dermatology, Ed. Herriot Hospital, Lyon, France
| | | | | | | | | | | | | | | | - Sue McDiarmid
- Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | | | - Emmanuel Morelon
- Department of Transplantation, Nephrology and Clinical Immunology, Ed. Herriot Hospital, Lyon, France
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8
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Fisher JD, Zhang W, Balmert SC, Aral AM, Acharya AP, Kulahci Y, Li J, Turnquist HR, Thomson AW, Solari MG, Gorantla VS, Little SR. In situ recruitment of regulatory T cells promotes donor-specific tolerance in vascularized composite allotransplantation. SCIENCE ADVANCES 2020; 6:eaax8429. [PMID: 32201714 PMCID: PMC7069700 DOI: 10.1126/sciadv.aax8429] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Accepted: 12/17/2019] [Indexed: 05/04/2023]
Abstract
Vascularized composite allotransplantation (VCA) encompasses face and limb transplantation, but as with organ transplantation, it requires lifelong regimens of immunosuppressive drugs to prevent rejection. To achieve donor-specific immune tolerance and reduce the need for systemic immunosuppression, we developed a synthetic drug delivery system that mimics a strategy our bodies naturally use to recruit regulatory T cells (Treg) to suppress inflammation. Specifically, a microparticle-based system engineered to release the Treg-recruiting chemokine CCL22 was used in a rodent hindlimb VCA model. These "Recruitment-MP" prolonged hindlimb allograft survival indefinitely (>200 days) and promoted donor-specific tolerance. Recruitment-MP treatment enriched Treg populations in allograft skin and draining lymph nodes and enhanced Treg function without affecting the proliferative capacity of conventional T cells. With implications for clinical translation, synthetic human CCL22 induced preferential migration of human Treg in vitro. Collectively, these results suggest that Recruitment-MP promote donor-specific immune tolerance via local enrichment of suppressive Treg.
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Affiliation(s)
- James D. Fisher
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA
- Medical Scientist Training Program, University of Pittsburgh, Pittsburgh, PA, USA
| | - Wensheng Zhang
- Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Stephen C. Balmert
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Dermatology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ali M. Aral
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Abhinav P. Acharya
- Department of Chemical Engineering, University of Pittsburgh, Pittsburgh, PA, USA
| | - Yalcin Kulahci
- Department of Chemical Engineering, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jingjing Li
- Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Heth R. Turnquist
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Immunology, University of Pittsburgh, Pittsburgh, PA, USA
- McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Angus W. Thomson
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Immunology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Mario G. Solari
- Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Vijay S. Gorantla
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
- Corresponding author. (S.R.L.); (V.S.G.)
| | - Steven R. Little
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Chemical Engineering, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Immunology, University of Pittsburgh, Pittsburgh, PA, USA
- McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Ophthalmology, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Pharmaceutical Sciences, University of Pittsburgh, Pittsburgh, PA, USA
- Corresponding author. (S.R.L.); (V.S.G.)
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9
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Treg-inducing microparticles promote donor-specific tolerance in experimental vascularized composite allotransplantation. Proc Natl Acad Sci U S A 2019; 116:25784-25789. [PMID: 31792185 DOI: 10.1073/pnas.1910701116] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
For individuals who sustain devastating composite tissue loss, vascularized composite allotransplantation (VCA; e.g., hand and face transplantation) has the potential to restore appearance and function of the damaged tissues. As with solid organ transplantation, however, rejection must be controlled by multidrug systemic immunosuppression with substantial side effects. As an alternative therapeutic approach inspired by natural mechanisms the body uses to control inflammation, we developed a system to enrich regulatory T cells (Tregs) in an allograft. Microparticles were engineered to sustainably release TGF-β1, IL-2, and rapamycin, to induce Treg differentiation from naïve T cells. In a rat hindlimb VCA model, local administration of this Treg-inducing system, referred to as TRI-MP, prolonged allograft survival indefinitely without long-term systemic immunosuppression. TRI-MP treatment reduced expression of inflammatory mediators and enhanced expression of Treg-associated cytokines in allograft tissue. TRI-MP also enriched Treg and reduced inflammatory Th1 populations in allograft draining lymph nodes. This local immunotherapy imparted systemic donor-specific tolerance in otherwise immunocompetent rats, as evidenced by acceptance of secondary skin grafts from the hindlimb donor strain and rejection of skin grafts from a third-party donor strain. Ultimately, this therapeutic approach may reduce, or even eliminate, the need for systemic immunosuppression in VCA or solid organ transplantation.
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10
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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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Robbins NL, Wordsworth MJ, Parida BK, Kaplan B, Gorantla VS, Weitzel CEK, Breidenbach WC. A Flow Dynamic Rationale for Accelerated Vascularized Composite Allotransplant Rejection. Plast Reconstr Surg 2019; 143:637e-643e. [PMID: 30624339 PMCID: PMC6400451 DOI: 10.1097/prs.0000000000005352] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 08/02/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND From 1996 to 2000, Diefenbeck et al. carried out six knee vascularized composite allotransplants. The allotransplants were composed of bone, soft tissue, and femoral vascular pedicle (25 to 40 cm). All rejected between 14 and 56 months. Failures were attributed to chronic rejection. In 2008, the Louisville team lost their fourth patient's hand transplant at 8 months. During the rejection workup, intraoperative findings noted a thickened arterial pedicle attributed to intimal hyperplasia with significant fibrotic perivascular tissue and a near "no-flow phenomenon." No cutaneous rejection was appreciated and failure was attributed to chronic rejection. METHODS Data were collected from two teams, one in Germany and the other in Louisville, Kentucky. The population under study consisted of the six knee and one hand transplants. The factor of interest was the long donor arterial pedicle. The outcome measurements were transplant survival time and histopathologic results. RESULTS There are only seven published vascularized composite allotransplant cases where a donor artery longer than 25 cm was used. This cohort represents a 100 percent accelerated failure rate. The cause of these losses remains unexplained. The donor arteries suffered from T-cell-mediated rejection and ischemia-induced media/adventitial necrosis. CONCLUSIONS We hypothesize that the donor artery rejected at an accelerated rate because of ischemia caused by disruption of the external vasa vasorum in conjunction with intimal hyperplasia induced by T-cell-mediated rejection that led to disruption of the Windkessel effect. Loss of this effect presented as intimal hyperplasia accelerated by ischemia causing an expedited transplant failure. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, V.
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Affiliation(s)
- Nicholas L. Robbins
- From the RESTOR Program, 59th Medical Wing, and the San Antonio Military Medical Center, Joint Base San Antonio; University of Texas Health at San Antonio; Baylor Scott & White Health; and the Wake Forest Institute for Regenerative Medicine
| | - Matthew J. Wordsworth
- From the RESTOR Program, 59th Medical Wing, and the San Antonio Military Medical Center, Joint Base San Antonio; University of Texas Health at San Antonio; Baylor Scott & White Health; and the Wake Forest Institute for Regenerative Medicine
| | - Bijaya K. Parida
- From the RESTOR Program, 59th Medical Wing, and the San Antonio Military Medical Center, Joint Base San Antonio; University of Texas Health at San Antonio; Baylor Scott & White Health; and the Wake Forest Institute for Regenerative Medicine
| | - Bruce Kaplan
- From the RESTOR Program, 59th Medical Wing, and the San Antonio Military Medical Center, Joint Base San Antonio; University of Texas Health at San Antonio; Baylor Scott & White Health; and the Wake Forest Institute for Regenerative Medicine
| | - Vijay S. Gorantla
- From the RESTOR Program, 59th Medical Wing, and the San Antonio Military Medical Center, Joint Base San Antonio; University of Texas Health at San Antonio; Baylor Scott & White Health; and the Wake Forest Institute for Regenerative Medicine
| | - Col Erik K. Weitzel
- From the RESTOR Program, 59th Medical Wing, and the San Antonio Military Medical Center, Joint Base San Antonio; University of Texas Health at San Antonio; Baylor Scott & White Health; and the Wake Forest Institute for Regenerative Medicine
| | - Warren C. Breidenbach
- From the RESTOR Program, 59th Medical Wing, and the San Antonio Military Medical Center, Joint Base San Antonio; University of Texas Health at San Antonio; Baylor Scott & White Health; and the Wake Forest Institute for Regenerative Medicine
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Novel targeted drug delivery systems to minimize systemic immunosuppression in vascularized composite allotransplantation. Curr Opin Organ Transplant 2018; 23:568-576. [DOI: 10.1097/mot.0000000000000564] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Yang JH, Eun SC. Therapeutic application of T regulatory cells in composite tissue allotransplantation. J Transl Med 2017; 15:218. [PMID: 29073905 PMCID: PMC5658973 DOI: 10.1186/s12967-017-1322-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2017] [Accepted: 10/20/2017] [Indexed: 12/21/2022] Open
Abstract
With growing number of cases in recent years, composite tissue allotransplantation (CTA) has been improving the quality of life of patient who seeks reconstruction and repair of damaged tissues. Composite tissue allografts are heterogeneous. They are composed of a variety of tissue types, including skin, muscle, vessel, bone, bone marrow, lymph nodes, nerve, and tendon. As a primary target of CTA, skin has high antigenicity with a rich repertoire of resident cells that play pivotal roles in immune surveillance. In this regard, understanding the molecular mechanisms involved in immune rejection in the skin would be essential to achieve successful CTA. Although scientific evidence has proved the necessity of immunosuppressive drugs to prevent rejection of allotransplanted tissues, there remains a lingering dilemma due to the lack of specificity of targeted immunosuppression and risks of side effects. A cumulative body of evidence has demonstrated T regulatory (Treg) cells have critical roles in induction of immune tolerance and immune homeostasis in preclinical and clinical studies. Presently, controlling immune susceptible characteristics of CTA with adoptive transfer of Treg cells is being considered promising and it has drawn great interests. This updated review will focus on a dominant form of Treg cells expressing CD4+CD25+ surface molecules and a forkhead box P3 transcription factor with immune tolerant and immune homeostasis activities. For future application of Treg cells as therapeutics in CTA, molecular and cellular characteristics of CTA and immune rejection, Treg cell development and phenotypes, Treg cell plasticity and stability, immune tolerant functions of Treg cells in CTA in preclinical studies, and protocols for therapeutic application of Treg cells in clinical settings are addressed in this review. Collectively, Treg cell therapy in CTA seems feasible with promising perspectives. However, the extreme high immunogenicity of CTA warrants caution.
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Affiliation(s)
- Jeong-Hee Yang
- Department of Plastic and Reconstructive Surgery, Composite Tissue Allotransplantation Immunology Laboratory, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Seok-Chan Eun
- Department of Plastic and Reconstructive Surgery, Composite Tissue Allotransplantation Immunology Laboratory, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
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Kaufman CL, Marvin MR, Chilton PM, Hoying JB, Williams SK, Tien H, Ozyurekoglu T, Ouseph R. Immunobiology in VCA. Transpl Int 2016; 29:644-54. [PMID: 26924305 DOI: 10.1111/tri.12764] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Revised: 09/23/2015] [Accepted: 02/23/2016] [Indexed: 01/09/2023]
Abstract
Transplantation of vascularized composite tissue is a relatively new field that is an amalgamation of experience in solid organ transplantation and reconstructive plastic and orthopedic surgery. What is novel about the immunobiology of VCA is the addition of tissues with unique immunologic characteristics such as skin and vascularized bone, and the nature of VCA grafts, with direct exposure to the environment, and external forces of trauma. VCAs are distinguished from solid organ transplants by the requirement of rigorous physical therapy for optimal outcomes and the fact that these procedures are not lifesaving in most cases. In this review, we will discuss the immunobiology of these systems and how the interplay can result in pathology unique to VCA as well as provide potential targets for therapy.
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Affiliation(s)
| | | | | | - James B Hoying
- Cardiovascular Innovation Institute, Louisville, KY, USA
| | | | - Huey Tien
- Christine M. Kleinert Institute, Louisville, KY, USA
| | | | - Rosemary Ouseph
- Kidney Disease Program, University of Louisville, Louisville, KY, USA
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Fryer M, Grahammer J, Khalifian S, Furtmüller GJ, Lee WPA, Raimondi G, Brandacher G. Exploring cell-based tolerance strategies for hand and face transplantation. Expert Rev Clin Immunol 2015; 11:1189-204. [DOI: 10.1586/1744666x.2015.1078729] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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