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Feturi FG, Zhang W, Erbas VE, Dong L, Sahin H, Zhang Z, Oksuz S, Spiess AM, Solari MG, Venkataramanan R, Gorantla VS. Topical Tacrolimus and Mycophenolic Acid Therapy Synergizes with Low Dose Systemic Immunosuppression to Sustain Vascularized Composite Allograft Survival. J Pharm Sci 2024; 113:1607-1615. [PMID: 38309457 DOI: 10.1016/j.xphs.2024.01.015] [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: 05/07/2023] [Revised: 01/23/2024] [Accepted: 01/24/2024] [Indexed: 02/05/2024]
Abstract
AIM The goal of this study was to evaluate whether topical administration of tacrolimus (TAC) and mycophenolic acid (MPA) at the transplant site enables vascularized composite allograft (VCA) survival with significant minimization of the dose and adverse effects of systemic TAC (STAC) immunosuppression. MATERIALS AND METHODS Lewis (Lew) rats received orthotopic hind limb allotransplants from fully mismatched Brown Norway (BN) donors. Group 1 (Controls) received no treatment. Other groups were treated with STAC at a dose of 1 mg/kg/day for 7 days. On post-operative day (POD) 8, the STAC dose was dropped to 0.1 mg/kg/day for Group 2 and maintained at 1 mg/kg for Group 3. Group 4 received topical application of TAC and MPA on the transplanted (Tx) limb starting POD 8 without STAC. Group 5 received topical TAC and MPA on the contralateral non-Tx limb and Group 6 received topical TAC and MPA on the Tx limb starting POD 8 along with low dose STAC (0.1 mg/kg/day). Treatment was continued until the study end point was reached, defined as either grade 3 rejection or allograft survival exceeding 100 days. .We conducted sequential LC-MS/MS measurements to assess TAC and MPA concentrations in both blood/plasma and allograft tissues. Additionally, we evaluated markers indicative of organ toxicity associated with STAC immunosuppression. RESULTS Compared to controls, topical therapy with TAC+MPA significantly prolonged allograft survival beyond 100 daysat very low dose STAC (0.1 mg/kg/day) (Group 6). The histopathological assessment of the grafts was consistent with the clinical outcomes. .Drug levels in blood/plasma remained low or undetectable, while allograft tissues showed higher drug concentrations compared to contralateral limb tissues (P<0.05). . Urinary creatinine clearance remained within the normal range at 2.5 mL/min. CONCLUSION Combination therapy with topical TAC and MPA synergizes with a very low dose, corticosteroid- free-STAC regimen and facilitates rejection-free, prolonged VCA survival without morbidity.
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Affiliation(s)
- Firuz G Feturi
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, 7220 Salk Hall, 3501 Terrace Street, Pittsburgh, PA, 15261 USA
| | - Wensheng Zhang
- Wilford Hall Ambulatory Surgical Center, 59th Medical Wing Office of Science and Technology, JBSA Lackland, TX, USA
| | - Vasil E Erbas
- Department of Plastic, Reconstructive and Aesthetic Surgery, Medical Park Gaziantep Hospital, Gaziantep, Turkey
| | - Liwei Dong
- Plastic and Aesthetic Surgery Department, XiJing Hospital, Xi'an, Shaanxi, China
| | - Huseyin Sahin
- Department of Plastic, Reconstructive and Aesthetic Surgery, Karadeniz Technical University, Trabzon, Turkey
| | | | - Sinan Oksuz
- Department of Plastic, Reconstructive and Aesthetic Surgery, School of Medicine, Gulhane Military Medical Academy, Ankara, Turkey
| | - Alexander M Spiess
- Department of Plastic and Reconstructive Surgery, University of Pittsburgh, Scaife Hall, Suite 6B, 3550 Terrace Street, Scaife Hall, Suite 6B, Pittsburgh, Pennsylvania, 15261 USA
| | - Mario G Solari
- Division of Plastic and Reconstructive Surgery, University of Colorado Hospital, Aurora, CO 80045, USA
| | - Raman Venkataramanan
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, 7220 Salk Hall, 3501 Terrace Street, Pittsburgh, PA, 15261 USA.
| | - Vijay S Gorantla
- Departments of Surgery, Ophthalmology and Bioengineering, Wake Forest School of Medicine, Wake Forest Institute of Regenerative Medicine, Winston Salem, NC, United States.
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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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Huelsboemer L, Boroumand S, Kochen A, Dony A, Moscarelli J, Hauc SC, Stögner VA, Formica RN, Pomahac B, Kauke-Navarro M. Immunosuppressive strategies in face and hand transplantation: a comprehensive systematic review of current therapy regimens and outcomes. FRONTIERS IN TRANSPLANTATION 2024; 3:1366243. [PMID: 38993787 PMCID: PMC11235358 DOI: 10.3389/frtra.2024.1366243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 02/21/2024] [Indexed: 07/13/2024]
Abstract
Background Recipients of Vascularized Composite Allotransplants require effective immunosuppressive therapy to prevent graft rejection. This systematic review summarizes the current body of literature on immunosuppressive regimens used in face and hand transplants while summarizing their outcome in terms of rejection, renal failure, and infections. Methods A systematic search of electronic databases was conducted to identify relevant studies from 1998 until July 1st, 2023. We included all studies that discussed immunosuppressive strategies in face and hand transplant recipients according to PRISMA. Results The standard triple maintenance therapy was mostly adjusted due to nephrotoxicity or high incidence of rejection. The most common alternative treatments utilized were sirolimus (25/91; 27.5%) or everolimus (9/91; 9.9%) following hand- and photophoresis (7/45; 15.6%), sirolimus (5/45; 11.1%) or belatacept (1/45; 2.2%) following face transplantation. Episodes of rejection were reported in 60 (65.9%) of hand- and 33 (73%) of face transplant patients respectively. Graft loss of 12 (13.2%) hand and 4 (8.9%) face transplants was reported. Clinical CMV infection was observed in 6 (6.6%) hand and 7 (15.5%) face transplant recipients. Conclusions Based on the herein presented data, facial grafts exhibited a heightened incidence of rejection episodes and CMV infections. Facial mucosa adds complexity to the immunological graft composition highlighting the need of individualized immunosuppressive regimens and further research.
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Affiliation(s)
- Lioba Huelsboemer
- Division of Reconstructive and Plastic Surgery, Yale School of Medicine, New Haven, CT, United States
| | - Sam Boroumand
- Division of Reconstructive and Plastic Surgery, Yale School of Medicine, New Haven, CT, United States
| | - Alejandro Kochen
- Division of Reconstructive and Plastic Surgery, Yale School of Medicine, New Haven, CT, United States
- Regenerative Wound Healing Center, Yale School of Medicine, New Haven, CT, United States
| | - Alna Dony
- Division of Reconstructive and Plastic Surgery, Yale School of Medicine, New Haven, CT, United States
- School of Medicine, University of Leeds, Leeds, United Kingdom
| | - Jake Moscarelli
- Division of Reconstructive and Plastic Surgery, Yale School of Medicine, New Haven, CT, United States
| | - Sacha C Hauc
- Division of Reconstructive and Plastic Surgery, Yale School of Medicine, New Haven, CT, United States
| | - Viola A Stögner
- Division of Reconstructive and Plastic Surgery, Yale School of Medicine, New Haven, CT, United States
| | - Richard N Formica
- Department of Medicine, Section of Nephrology and Transplantation, Yale School of Medicine, New Haven, CT, United States
| | - Bohdan Pomahac
- Division of Reconstructive and Plastic Surgery, Yale School of Medicine, New Haven, CT, United States
| | - Martin Kauke-Navarro
- Division of Reconstructive and Plastic Surgery, Yale School of Medicine, New Haven, CT, United States
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Ton C, Salehi S, Abasi S, Aggas JR, Liu R, Brandacher G, Guiseppi-Elie A, Grayson WL. Methods of ex vivo analysis of tissue status in vascularized composite allografts. J Transl Med 2023; 21:609. [PMID: 37684651 PMCID: PMC10492401 DOI: 10.1186/s12967-023-04379-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 07/21/2023] [Indexed: 09/10/2023] Open
Abstract
Vascularized composite allotransplantation can improve quality of life and restore functionality. However, the complex tissue composition of vascularized composite allografts (VCAs) presents unique clinical challenges that increase the likelihood of transplant rejection. Under prolonged static cold storage, highly damage-susceptible tissues such as muscle and nerve undergo irreversible degradation that may render allografts non-functional. Skin-containing VCA elicits an immunogenic response that increases the risk of recipient allograft rejection. The development of quantitative metrics to evaluate VCAs prior to and following transplantation are key to mitigating allograft rejection. Correspondingly, a broad range of bioanalytical methods have emerged to assess the progression of VCA rejection and characterize transplantation outcomes. To consolidate the current range of relevant technologies and expand on potential for development, methods to evaluate ex vivo VCA status are herein reviewed and comparatively assessed. The use of implantable physiological status monitoring biochips, non-invasive bioimpedance monitoring to assess edema, and deep learning algorithms to fuse disparate inputs to stratify VCAs are identified.
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Affiliation(s)
- Carolyn Ton
- Department of Biomedical Engineering, Johns Hopkins University, 400 North Broadway, Smith Building 5023, Baltimore, MD, 21231, USA
- Translational Tissue Engineering Center, Johns Hopkins University, 400 North Broadway, Smith Building 5023, Baltimore, MD, 21231, USA
| | - Sara Salehi
- Department of Biomedical Engineering, Johns Hopkins University, 400 North Broadway, Smith Building 5023, Baltimore, MD, 21231, USA
- Translational Tissue Engineering Center, Johns Hopkins University, 400 North Broadway, Smith Building 5023, Baltimore, MD, 21231, USA
| | - Sara Abasi
- Department of Biomedical Engineering, Center for Bioelectronics, Biosensors and Biochips (C3B®), Texas A&M University, Emerging Technologies Building 3120, 101 Bizzell St, College Station, TX, 77843, USA
- Department of Electrical and Computer Engineering, Center for Bioelectronics, Biosensors and Biochips (C3B®), Texas A&M University, Emerging Technologies Building 3120, 101 Bizzell St, College Station, TX, 77843, USA
- Media and Metabolism, Wildtype, Inc., 2325 3rd St., San Francisco, CA, 94107, USA
| | - John R Aggas
- Department of Biomedical Engineering, Center for Bioelectronics, Biosensors and Biochips (C3B®), Texas A&M University, Emerging Technologies Building 3120, 101 Bizzell St, College Station, TX, 77843, USA
- Department of Electrical and Computer Engineering, Center for Bioelectronics, Biosensors and Biochips (C3B®), Texas A&M University, Emerging Technologies Building 3120, 101 Bizzell St, College Station, TX, 77843, USA
- Test Development, Roche Diagnostics, 9115 Hague Road, Indianapolis, IN, 46256, USA
| | - Renee Liu
- Department of Biomedical Engineering, Johns Hopkins University, 400 North Broadway, Smith Building 5023, Baltimore, MD, 21231, USA
- Translational Tissue Engineering Center, Johns Hopkins University, 400 North Broadway, Smith Building 5023, Baltimore, MD, 21231, USA
| | - Gerald Brandacher
- Department of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation (VCA) Laboratory, Reconstructive Transplantation Program, Center for Advanced Physiologic Modeling (CAPM), Johns Hopkins University, Ross Research Building/Suite 749D, 720 Rutland Avenue, Baltimore, MD, 21205, USA.
| | - Anthony Guiseppi-Elie
- Department of Biomedical Engineering, Center for Bioelectronics, Biosensors and Biochips (C3B®), Texas A&M University, Emerging Technologies Building 3120, 101 Bizzell St, College Station, TX, 77843, USA.
- Department of Electrical and Computer Engineering, Center for Bioelectronics, Biosensors and Biochips (C3B®), Texas A&M University, Emerging Technologies Building 3120, 101 Bizzell St, College Station, TX, 77843, USA.
- Department of Cardiovascular Sciences, Houston Methodist Institute for Academic Medicine and Houston Methodist Research Institute, 6670 Bertner Ave., Houston, TX, USA.
- ABTECH Scientific, Inc., Biotechnology Research Park, 800 East Leigh Street, Richmond, VA, USA.
| | - Warren L Grayson
- Department of Biomedical Engineering, Johns Hopkins University, 400 North Broadway, Smith Building 5023, Baltimore, MD, 21231, USA.
- Translational Tissue Engineering Center, Johns Hopkins University, 400 North Broadway, Smith Building 5023, Baltimore, MD, 21231, USA.
- Department of Chemical and Biomolecular Engineering, Johns Hopkins University, Baltimore, MD, USA.
- Department of Materials Science and Engineering, Johns Hopkins University, Baltimore, MD, USA.
- Institute for Nanobiotechnology, Johns Hopkins University, Baltimore, MD, USA.
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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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Tacrolimus before CTLA4Ig and rapamycin promotes vascularized composite allograft survival in MGH miniature swine. Transpl Immunol 2022; 75:101696. [PMID: 35987329 DOI: 10.1016/j.trim.2022.101696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 08/11/2022] [Accepted: 08/11/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND We evaluated the outcome of vertical rectus abdominus myocutaneous flap (VRAM) allotransplantation in a mini-pig model, using a combined co-stimulation blockade (Co-SB) and mechanistic target of rapamycin inhibition (mTORi)-based regimen, with or without preceding calcineurin inhibition (CNI). MATERIALS AND METHODS VRAM allotransplants were performed between SLA-mismatched MGH miniature swine. Group A (n = 2) was treated continuously with the mTOR inhibitor rapamycin from day -1 in combination with the Co-SB agent cytotoxic T lymphocyte antigen 4-Ig (CTLA4-Ig) from post-operative day (POD) 0. In group B (n = 3), animals received tacrolimus daily from POD 0 to POD 13, followed by rapamycin daily from POD 7 and CTLA4-Ig weekly from POD 7-28. Graft rejection was determined by Banff criteria and host cellular and humoral immunity monitored. RESULTS In group A, allografts developed grade-I acute rejection by POD 2 and POD 7, and reached grade-IV by POD 17 and POD 20, respectively. By contrast, in group B, two allografts demonstrated grade-I rejection on POD 30 and grade-IV on POD 74, while the third exhibited grade-I rejection starting on POD 50, though this animal had to be euthanized on POD 58 due to Pneumocystis jirovecii infection. Time-to-event incidence of grade-I rejection was significantly lower in group A compared to group B. During the first 3 weeks post-transplant, no significant differences in anti-donor immunity were observed between the groups. CONCLUSION A short course of CNI, followed by combined Co-SB and mTORi significantly delays acute rejection of VRAM allografts in SLA-mismatched miniature swine.
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Tacrolimus-Eluting Disk within the Allograft Enables Vascularized Composite Allograft Survival with Site-Specific Immunosuppression without Systemic Toxicity. Pharm Res 2022; 39:2179-2190. [PMID: 35915321 DOI: 10.1007/s11095-022-03345-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 07/14/2022] [Indexed: 10/16/2022]
Abstract
AIM Widespread clinical application of vascularized composite allotransplantation (VCA) has been limited by the need for lifelong systemic immunosuppression to prevent rejection. Our goal was to develop a site-specific immunosuppressive strategy that promotes VCA allograft survival and minimizes the risk of systemic side effects. METHODS Tacrolimus loaded polycaprolactone (TAC-PCL) disks were prepared and tested for their efficacy in sustaining VCA allograft survival via site-specific immunosuppression. Brown Norway-to-Lewis rat hind limb transplantations were performed; animals received one TAC disk either in the transplanted (DTx) or in the contralateral non-transplanted (DnonTx) limbs. In another group, animals received DTx and lymphadenectomy on Tx side. Blood and allograft levels of TAC were measured using LC-MS/MS. Systemic toxicity was evaluated. RESULTS Animals that received DTx achieved long-term allograft survival (> 200 days) without signs of metabolic and infectious complications. In these animals, TAC blood levels were low but stable between 2 to 5 ng/mL for nearly 100 days. High concentrations of TAC were achieved in the allografts and the draining lymph nodes (DLN). Animals that underwent lymphadenectomy rejected their allograft by 175 days. Animals that received DnonTx rejected their allografts by day 70. CONCLUSION Controlled delivery of TAC directly within the allograft (with a single TAC disk) effectively inhibits rejection and prolongs VCA allograft survival, while mitigating the complications of systemic immunosuppression. There was a survival benefit of delivering TAC within the allograft as compared to a remote site. We believe this approach of local drug delivery has significant implications for drug administration in transplantation.
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Kim M, Fisher DT, Bogner PN, Sharma U, Yu H, Skitzki JJ, Repasky EA. Manipulating adrenergic stress receptor signalling to enhance immunosuppression and prolong survival of vascularized composite tissue transplants. Clin Transl Med 2022; 12:e996. [PMID: 35994413 PMCID: PMC9394753 DOI: 10.1002/ctm2.996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 07/05/2022] [Accepted: 07/11/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Vascularized composite tissue allotransplantation (VCA) to replace limbs or faces damaged beyond repair is now possible. The resulting clear benefit to quality of life is a compelling reason to attempt this complex procedure. Unfortunately, the high doses of immunosuppressive drugs required to protect this type of allograft result in significant morbidity and mortality giving rise to ethical concerns about performing this surgery in patients with non-life-threatening conditions. Here we tested whether we could suppress anti-graft immune activity by using a safe β2 -adrenergic receptor (AR) agonist, terbutaline, to mimic the natural immune suppression generated by nervous system-induced signalling through AR. METHODS A heterotopic hind limb transplantation model was used with C57BL/6 (H-2b) as recipients and BALB/c (H-2d) mice as donors. To test the modulation of the immune response, graft survival was investigated after daily intraperitoneal injection of β2 -AR agonist with and without tacrolimus. Analyses of immune compositions and quantification of pro-inflammatory cytokines were performed to gauge functional immunomodulation. The contributions to allograft survival of β2 -AR signalling in donor and recipient tissue were investigated with β2 -AR-/- strains. RESULTS Treatment with the β2 -AR agonist delayed VCA rejection, even with a subtherapeutic dose of tacrolimus. β2 -AR agonist decreased T-cell infiltration into the transplanted grafts and decreased memory T-cell populations in recipient's circulation. In addition, decreased levels of inflammatory cytokines (IFN-γ, IL-6, TNF-α, CXCL-1/10 and CCL3/4/5/7) were detected following β2 -AR agonist treatment, and there was a decreased expression of ICAM-1 and vascular cell adhesion molecule-1 in donor stromal cells. CONCLUSIONS β2 -AR agonist can be used safely to mimic the natural suppression of immune responses, which occurs during adrenergic stress-signalling and thereby can be used in combination regimens to reduce the dose needed of toxic immunosuppressive drugs such as tacrolimus. This strategy can be further evaluated for feasibility in the clinic.
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Affiliation(s)
- Minhyung Kim
- Department of Surgical OncologyRoswell Park Comprehensive Cancer CenterBuffaloNew YorkUSA
- Department of ImmunologyRoswell Park Comprehensive Cancer CenterBuffaloNew YorkUSA
| | - Daniel T. Fisher
- Department of Surgical OncologyRoswell Park Comprehensive Cancer CenterBuffaloNew YorkUSA
- Department of ImmunologyRoswell Park Comprehensive Cancer CenterBuffaloNew YorkUSA
| | - Paul N. Bogner
- Department of PathologyRoswell Park Comprehensive Cancer CenterBuffaloNew YorkUSA
| | - Umesh Sharma
- Department of Medicine, Division of CardiologyUniversity at BuffaloBuffaloNew YorkUSA
| | - Han Yu
- Department of Biostatistics and BioinformaticsRoswell Park Comprehensive Cancer CenterBuffaloNew YorkUSA
| | - Joseph J. Skitzki
- Department of Surgical OncologyRoswell Park Comprehensive Cancer CenterBuffaloNew YorkUSA
- Department of ImmunologyRoswell Park Comprehensive Cancer CenterBuffaloNew YorkUSA
| | - Elizabeth A. Repasky
- Department of ImmunologyRoswell Park Comprehensive Cancer CenterBuffaloNew YorkUSA
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Moris D, Cendales LC. Sensitization and Desensitization in Vascularized Composite Allotransplantation. Front Immunol 2021; 12:682180. [PMID: 34456906 PMCID: PMC8385557 DOI: 10.3389/fimmu.2021.682180] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 07/27/2021] [Indexed: 01/02/2023] Open
Abstract
Vascularized composite allotransplantation (VCA) is a field under research and has emerged as an alternative option for the repair of severe disfiguring defects that result from severe tissue loss in a selected group of patients. Lifelong immunosuppressive therapy, immunosuppression associated complications, and the effects of the host immune response in the graft are major concerns in this type of quality-of-life transplant. The initial management of extensive soft tissue injury can lead to the development of anti-HLA antibodies through injury-related factors, transfusion and cadaveric grafting. The role of antibody-mediated rejection, donor-specific antibody (DSA) formation and graft rejection in the context of VCA still remain poorly understood. The most common antigenic target of preexisting alloantibodies are MHC mismatches, though recognition of ABO incompatible antigens, minor histocompatibility complexes and endothelial cells has also been shown to contribute to rejection. Mechanistically, alloantibody-mediated tissue damage occurs primarily through complement fixation as well as through antibody-dependent cellular toxicity. If DSA exist, activation of complement and coagulation cascades can result in vascular thrombosis and infarction and thus rejection and graft loss. Both preexisting DSA but especially de-novo DSA are currently considered as main contributors to late allograft injury and graft failure. Desensitization protocols are currently being developed for VCA, mainly including removal of alloantibodies whereas treatment of established antibody-mediated rejection is achieved through high dose intravenous immunoglobulins. The long-term efficacy of such therapies in sensitized VCA recipients is currently unknown. The current evidence base for sensitizing events and outcomes in reconstructive transplantation is limited. However, current data show that VCA transplantation has been performed in the setting of HLA-sensitization.
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Affiliation(s)
| | - Linda C. Cendales
- Department of Surgery, Duke University Medical Center, Durham, NC, United States
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Lupon E, Lellouch AG, Acun A, Andrews AR, Oganesyan R, Goutard M, Taveau CB, Lantieri LA, Cetrulo CL, Uygun BE. Engineering Vascularized Composite Allografts Using Natural Scaffolds: A Systematic Review. TISSUE ENGINEERING PART B-REVIEWS 2021; 28:677-693. [PMID: 34238047 DOI: 10.1089/ten.teb.2021.0102] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
INTRODUCTION Vascularized Composite Allotransplantation refers to the transplantation of multiple tissues as a functional unit from a deceased donor to a recipient with a severe injury. These grafts serve as potential replacements for traumatic tissue losses. The main problems are the consequences of the long immunosuppressive drugs medications and the lake of compatible donor. To avoid these limitations, decellularization/recellularization constitute an attractive approach. The aim of decellularization/recellularization technology is to develop immunogenic free biological substitutes that will restore, maintain, or improve tissue and organ's function. METHODS A PubMed search was performed for articles on decellularization and recellularization of composite tissue allografts between March and February 2021, with no restrictions in publication year. The selected reports were evaluated in terms of decellularization protocols, assessment of decellularized grafts, and evaluation of their biocompatibility and repopulation with cells both in vitro and in vivo. RESULTS The search resulted in a total of 88 articles. Each article was reviewed, 77 were excluded and the remaining 11 articles reported decellularization of 12 different vascular composite allografts in humans (four), large animals (three), and small animals (rodents) (five). The decellularization protocol for vascularized composite allotransplantation varies slightly between studies, but majority of the reports employ 1% sodium dodecyl sulfate as the main reagent for decellularization. The immunological response of the decellularized scaffolds remains poorly evaluated. Few authors have been able to attempt the recellularization and transplantation of these scaffolds. Successful transplantation seems to require prior recellularization. CONCLUSION Decellularization/recellularization is a promising, growing, emerging developing research field in vascular composite allotransplantation.
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Affiliation(s)
- Elise Lupon
- University Toulouse III Paul Sabatier, Department of Plastic Surgery, Toulouse, Occitanie, France.,Massachusetts General Hospital, Harvard Medical School, Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Boston, Massachusetts, United States.,Shriners Hospitals for Children Boston, 24172, Boston, Massachusetts, United States.,Massachusetts General Hospital, 2348, Division of Plastic and Reconstructive Surgery, Boston, Massachusetts, United States;
| | - Alexandre G Lellouch
- Massachusetts General Hospital, Harvard Medical School, Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Boston, Massachusetts, United States.,Shriners Hospitals for Children Boston, 24172, Boston, Massachusetts, United States.,Hospital European George Pompidou, 55647, Department of Plastic Surgery, Paris, Île-de-France, France.,Massachusetts General Hospital, 2348, Division of Plastic and Reconstructive Surgery, Boston, Massachusetts, United States;
| | - Aylin Acun
- Shriners Hospitals for Children Boston, 24172, Boston, Massachusetts, United States.,Massachusetts General Hospital, Harvard Medical School, Center for Engineering in Medicine and Surgery, Boston, Massachusetts, United States;
| | - Alec R Andrews
- Massachusetts General Hospital, Harvard Medical School, Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Boston, Massachusetts, United States.,Shriners Hospitals for Children Boston, 24172, Boston, Massachusetts, United States.,Massachusetts General Hospital, 2348, Division of Plastic and Reconstructive Surgery, Boston, Massachusetts, United States;
| | - Ruben Oganesyan
- Shriners Hospitals for Children Boston, 24172, Boston, Massachusetts, United States.,Massachusetts General Hospital, Harvard Medical School, Center for Engineering in Medicine and Surgery, Boston, Massachusetts, United States;
| | - Marion Goutard
- Massachusetts General Hospital, Harvard Medical School, Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Boston, Massachusetts, United States.,Shriners Hospitals for Children Boston, 24172, Boston, Massachusetts, United States.,Hospital European George Pompidou, 55647, Department of Plastic Surgery, Paris, Île-de-France, France.,Massachusetts General Hospital, 2348, Division of Plastic and Reconstructive Surgery, Boston, Massachusetts, United States;
| | - Corentin B Taveau
- Hospital European George Pompidou, 55647, Department of Plastic Surgery, Paris, Île-de-France, France;
| | - Laurent A Lantieri
- Hospital European George Pompidou, 55647, Department of Plastic Surgery, Paris, Île-de-France, France;
| | - Curtis L Cetrulo
- Massachusetts General Hospital, Harvard Medical School, Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Boston, Massachusetts, United States.,Shriners Hospitals for Children Boston, 24172, Boston, Massachusetts, United States.,Massachusetts General Hospital, 2348, Division of Plastic and Reconstructive Surgery, Boston, Massachusetts, United States;
| | - Basak E Uygun
- Shriners Hospitals for Children Boston, 24172, Boston, Massachusetts, United States.,Massachusetts General Hospital, Harvard Medical School, Center for Engineering in Medicine and Surgery, Boston, Massachusetts, United States;
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11
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Chen Z, Xue S, Zhang S, Cheng K, Ye Q. Exosomes from donor-derived adipose mesenchymal stem cells prolong the survival of vascularized composite allografts. J Cell Physiol 2021; 236:5895-5905. [PMID: 33452713 DOI: 10.1002/jcp.30274] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 12/03/2020] [Accepted: 12/30/2020] [Indexed: 12/13/2022]
Abstract
Donor-derived adipose-derived mesenchymal stem cells (ADMSCs) dampen the alloimmune response and exosomes are reported to have biological activity similar to their parent cells. Here, we investigated the roles of exosomes from donor-derived ADMSCs (ADMSC-exo) in vascularized composite allotransplantation (VCA). Brown Norway-to-Lewis rat hindlimb transplantations were intravenously treated with either exosome from donor-derived ADMSCs or phosphate-buffered saline, combined with a short course of immunosuppression. We established that the treatment with ADMSC-exo prolongs the survival time of VCA grafts. Skin and muscle samples from ADMSC-exo-treated animals showed no histological signs of rejection, but samples from controls showed rejection of degree III. Comparing to the control group, a significant increase of donor cell chimerism, Tr1 and Treg, while a decrease of CD4+ T and Th1 cells were observed in the ADMSC-exo-treated group. Our findings imply that ADMSC-exo may be a valuable and safe treatment for extending VCA graft survival.
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Affiliation(s)
- Zhizhao Chen
- Hubei Key Laboratory of Medical Technology on Transplantation, Transplant Center of Wuhan University, Institute of Hepatobiliary Diseases of Wuhan University, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China.,Transplantation Center of the Third Xiangya Hospital of Central South University, Research Center of National Health Ministry on Transplantation Medicine Engineering and Technology, Changsha, China
| | - Shuai Xue
- Hubei Key Laboratory of Medical Technology on Transplantation, Transplant Center of Wuhan University, Institute of Hepatobiliary Diseases of Wuhan University, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
| | - Sheng Zhang
- Transplantation Center of the Third Xiangya Hospital of Central South University, Research Center of National Health Ministry on Transplantation Medicine Engineering and Technology, Changsha, China
| | - Ke Cheng
- Transplantation Center of the Third Xiangya Hospital of Central South University, Research Center of National Health Ministry on Transplantation Medicine Engineering and Technology, Changsha, China
| | - Qifa Ye
- Hubei Key Laboratory of Medical Technology on Transplantation, Transplant Center of Wuhan University, Institute of Hepatobiliary Diseases of Wuhan University, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China.,Transplantation Center of the Third Xiangya Hospital of Central South University, Research Center of National Health Ministry on Transplantation Medicine Engineering and Technology, Changsha, China
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12
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Rifkin WJ, Manjunath AK, Kantar RS, Jacoby A, Kimberly LL, Gelb BE, Diaz-Siso JR, Rodriguez ED. A Comparison of Immunosuppression Regimens in Hand, Face, and Kidney Transplantation. J Surg Res 2020; 258:17-22. [PMID: 32977237 DOI: 10.1016/j.jss.2020.08.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 07/12/2020] [Accepted: 08/02/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Authors have speculated that vascularized composite allotransplantation (VCA) recipients may require greater maintenance immunosuppression than solid organ transplant (SOT) recipients due to the higher antigenicity of skin. However, detailed comparisons of VCA and SOT immunosuppression regimens have been limited. METHODS Hand and face VCA recipient immunosuppression data were collected through a systematic literature review. Kidney recipient data were obtained through a retrospective chart review of the authors' institution. Prednisone and mycophenolate mofetil (MMF) doses were compared between VCA and kidney recipients at predefined follow-up intervals (<1, 1-5, and >5 y). Tacrolimus target trough levels (TTTL) were compared at follow-up intervals of 1-5 and >5 y, and stratified into our institution's kidney transplant risk-based target ranges (4-6 ng/mL, 6-8 ng/mL) or higher (>8 ng/mL). RESULTS Immunosuppression data were available for 57 VCA and 98 kidney recipients. There were no significant differences in prednisone doses between groups at all follow-up intervals. VCA recipient mean MMF dose was significantly greater at <1-y (1.71 ± 0.58 versus 1.16 ± 0.55 gm/d; P = 0.01). For VCA recipients, there was a significant difference (P = 0.02) in TTTL distribution over the three predefined therapeutic ranges (4-6 ng/mL, 6-8 ng/mL, and >8 ng/mL) between 1 and 5 y (24.0%, 20.0%, 56.0%, respectively) and >5 y (28.6%, 42.9%, 28.6%). CONCLUSIONS At longer follow-up, VCA and kidney recipients receive comparable MMF/prednisone doses, and most VCA recipients are treated with TTTL similar to kidney recipients. Further research may improve our understanding of VCA's complex risk/benefit ratio, and enhance informed consent.
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Affiliation(s)
- William J Rifkin
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, New York
| | - Amit K Manjunath
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, New York
| | - Rami S Kantar
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, New York
| | - Adam Jacoby
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, New York
| | - Laura L Kimberly
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, New York
| | - Bruce E Gelb
- Department of Surgery, NYU Langone Health, New York, New York
| | - J Rodrigo Diaz-Siso
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, New York
| | - Eduardo D Rodriguez
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, New York.
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Structure and Function of Porcine Arteries Are Preserved for up to 6 Days Using the HypoRP Cold-storage Solution. Transplantation 2020; 104:e125-e134. [PMID: 32000259 DOI: 10.1097/tp.0000000000003141] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Maintaining functional vessels during preservation of vascularized composite allografts (VCAs) remains a major challenge. The University of Wisconsin (UW) solution has demonstrated significant short-term benefits (4-6 h). Here we determined whether the new hypothermic resuscitation and preservation solution HypoRP improves both structure, survival, and function of pig arteries during storage for up to 6 days. METHODS Using porcine swine mesenteric arteries, the effects of up to 6-day incubation in a saline (PBS), UW, or HypoRP solution on the structure, cell viability, metabolism, and function were determined. RESULTS After incubation at 4°C, for up to 6 days, the structures of the arteries were significantly disrupted, especially the tunica media, following incubation in PBS, in contrast with incubation in the HypoRP solution and to a lesser extent, in UW solution. Those disruptions were associated with increased active caspase 3 indicative of apoptosis. Additionally, while incubation in PBS led to a significant decrease in the metabolic activity, UW and HypoRP solutions allowed a stable to increased metabolic activity following 6 days of cold storage. Functional responsiveness to phenylephrine (PE) and sodium nitroprusside (SNP) decreased over time for artery rings stored in PBS and UW solution but not for those stored in HypoRP solution. Moreover, artery rings cold-stored in HypoRP solution were more sensitive to ATP. CONCLUSIONS The HypoRP solution improved long-term cold storage of porcine arteries by limiting structural alterations, including the collagen matrix, reducing apoptosis, and maintaining artery contraction-relaxation functions for up to 6 days.
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Abstract
PURPOSE OF REVIEW Face transplantation is no longer a young field. Reported outcomes suggest that this life-enhancing transplantation is viable and ethically justified for appropriate patients. Given that pediatric hand transplantation has been performed with promising reported outcomes, it is time to consider how to properly expand the field of face transplantation into pediatric patients. RECENT FINDINGS Appropriate collaboration between adult and pediatric colleagues can mitigate risks associated with expanding surgical innovation between respective patient demographics. The reported outcomes of the first pediatric hand transplant question the appropriateness of increasing immunosuppression burden to a patient on an existing regimen for prior solid organ allotransplantion. Young donor allografts prove to be more resilient, however, implying that managing rejection episodes is key to long-term viability. Expanding face transplants into a younger population must consider the social functions of the face, and may facilitate healthy personal development given the cultural value appearance has in real life and in social media. SUMMARY We believe that pediatric face transplantation is not just a viable option, but an ethically reasonable one as long as the field proceeds with cautious optimism.
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Conrad A, Petruzzo P, Kanitakis J, Gazarian A, Badet L, Thaunat O, Vanhems P, Buron F, Morelon E, Sicard A. Infections after upper extremity allotransplantation: a worldwide population cohort study, 1998-2017. Transpl Int 2019; 32:693-701. [PMID: 30633815 DOI: 10.1111/tri.13399] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 11/05/2018] [Accepted: 01/04/2019] [Indexed: 12/15/2022]
Abstract
Risk-to-benefit analysis of upper extremity allotransplantation (UEA) warrants a careful assessment of immunosuppression-related complications. This first systematic report of infectious complications after UEA aimed to compare incidence and pattern of infections to that observed after kidney transplantation (KT). We conducted a matched cohort study among UEA and KT recipients from the International Registry on Hand and Composite Tissue Transplantation and the French transplant database DIVAT. All UEA recipients between 1998 and 2016 were matched with KT recipients (1:5) regarding age, sex, cytomegalovirus (CMV) serostatus and induction treatment. Infections were analyzed at three posttransplant periods (early: 0-6 months, intermediate: 7-12 months, late: >12 months). Sixty-one UEA recipients and 305 KT recipients were included. Incidence of infection was higher after UEA than after KT during the early period (3.27 vs. 1.95 per 1000 transplant-days, P = 0.01), but not statistically different during the intermediate (0.61 vs. 0.45/1000, P = 0.5) nor the late period (0.15 vs. 0.21/1000, P = 0.11). The distribution of infectious syndromes was significantly different, with mucocutaneous infections predominating after UEA, urinary tract infections and pneumonia predominating after KT. Incidence of infection is high during the first 6 months after UEA. After 1 year, the burden of infections is low, with favorable patterns.
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Affiliation(s)
- Anne Conrad
- Department of Transplantation, Nephrology and Clinical Immunology, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France.,Department of Infectious Diseases and Tropical Medicine, Croix-Rousse Hospital, Hospices Civils de Lyon, Lyon, France.,Claude Bernard Lyon 1 University, Villeurbanne, France
| | - Palmina Petruzzo
- Department of Transplantation, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France.,Department of Surgery, University of Cagliari, Cagliari, Italy
| | - Jean Kanitakis
- Department of Dermatology, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
| | | | - Lionel Badet
- Claude Bernard Lyon 1 University, Villeurbanne, France.,Department of Urology and Transplantation, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
| | - Olivier Thaunat
- Department of Transplantation, Nephrology and Clinical Immunology, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France.,Claude Bernard Lyon 1 University, Villeurbanne, France.,INSERM U1111, International Center for Infectiology Research, Lyon, France
| | - Philippe Vanhems
- Claude Bernard Lyon 1 University, Villeurbanne, France.,INSERM U1111, International Center for Infectiology Research, Lyon, France.,Infection Control and Epidemiology Unit, Edouard Herriot Hospital, Hospices Civils de Lyon, UMR CNRS 5558, Team Epidemiology and Public Health, Lyon, France
| | - Fanny Buron
- Department of Transplantation, Nephrology and Clinical Immunology, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
| | - Emmanuel Morelon
- Department of Transplantation, Nephrology and Clinical Immunology, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France.,Claude Bernard Lyon 1 University, Villeurbanne, France.,INSERM U1111, International Center for Infectiology Research, Lyon, France
| | - Antoine Sicard
- Department of Transplantation, Nephrology and Clinical Immunology, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France.,Claude Bernard Lyon 1 University, Villeurbanne, France
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16
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Honeyman C, Fries CA. Vascularised Composite Allotransplantation – Basic Science and Clinical Applications. ACTA ACUST UNITED AC 2019. [DOI: 10.29337/ijops.28] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Graft-implanted, enzyme responsive, tacrolimus-eluting hydrogel enables long-term survival of orthotopic porcine limb vascularized composite allografts: A proof of concept study. PLoS One 2019; 14:e0210914. [PMID: 30677062 PMCID: PMC6345449 DOI: 10.1371/journal.pone.0210914] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Accepted: 01/03/2019] [Indexed: 11/19/2022] Open
Abstract
Background Currently, patients receiving vascularized composite allotransplantation (VCA) grafts must take long-term systemic immunosuppressive therapy to prevent immunologic rejection. The morbidity and mortality associated with these medications is the single greatest barrier to more patients being able to receive these life-enhancing transplants. In contrast to solid organs, VCA, exemplified by hand or face transplants, allow visual diagnosis of clinical acute rejection (AR), directed biopsy and targeted graft therapies. Local immunosuppression in VCA could reduce systemic drug exposure and limit adverse effects. This proof of concept study evaluated, in a large animal forelimb VCA model, the efficacy and tolerability of a novel graft-implanted enzyme-responsive, tacrolimus (TAC)—eluting hydrogel platform, in achieving long-term graft survival. Methods Orthotopic forelimb VCA were performed in single haplotype mismatched mini-swine. Controls (n = 2) received no treatment. Two groups received TAC hydrogel: high dose (n = 4, 91 mg TAC) and low dose (n = 4, 49 mg TAC). The goal was to find a dose that was tolerable and resulted in long-term graft survival. Limbs were evaluated for clinical and histopathological signs of AR. TAC levels were measured in serial blood and skin tissue samples. Tolerability of the dose was evaluated by monitoring animal feeding behavior and weight. Results Control limbs underwent Banff Grade IV AR by post-operative day six. Low dose TAC hydrogel treatment resulted in long-term graft survival time to onset of Grade IV AR ranging from 56 days to 93 days. High dose TAC hydrogel also resulted in long-term graft survival (24 to 42 days), but was not well tolerated. Conclusion Graft-implanted TAC-loaded hydrogel delays the onset of Grade IV AR of mismatched porcine forelimb VCA grafts, resulting in long term graft survival and demonstrates dose-dependent tolerability.
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Local Injections of Tacrolimus-loaded Hydrogel Reduce Systemic Immunosuppression-related Toxicity in Vascularized Composite Allotransplantation. Transplantation 2018; 102:1684-1694. [DOI: 10.1097/tp.0000000000002283] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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19
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Petruzzo P, Sardu C, Lanzetta M, Dubernard JM. Report (2017) of the International Registry on Hand and Composite Tissue Allotransplantation (IRHCTT). CURRENT TRANSPLANTATION REPORTS 2017. [DOI: 10.1007/s40472-017-0168-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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