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Barrow B, Diep GK, Berman ZP, Boczar D, Lee O, Salinero L, Howard R, Trilles J, Rodriguez Colon R, Rodriguez ED. Immunologic Outcomes in Cross-Sex Solid Organ Transplants: A Systematic Review and Meta-Analysis to Inform Vascularized Composite Allotransplantation. Plast Reconstr Surg 2024; 153:839-851. [PMID: 37224220 DOI: 10.1097/prs.0000000000010757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
BACKGROUND Of nearly 90 hand and 50 face transplant recipients, only five have received a cross-sex vascularized composite allotransplantation (CS-VCA). CS-VCA has the potential to expand the donor pool and has been proven anatomically feasible and ethically acceptable in previous studies. However, there is a lack of immunologic data. This study evaluated the immunologic feasibility of CS-VCA through analysis of the solid organ transplant literature, given the paucity of CS-VCA data. The authors hypothesize that rates of acute rejection (AR) and graft survival (GS) in CS versus same-sex (SS) solid organ transplantation are similar. METHODS A systematic review and meta-analysis were performed. Studies comparing GS or AR episodes in CS and SS adult kidney (KT) and liver transplant (LT) populations were included. Odds ratios were calculated for overall GS and AR for all SS and CS transplant combinations [male-to-female (MTF), female-to-male, and overall]. RESULTS A total of 693 articles were initially identified with 25 included in the meta-analysis. No significant difference in GS was noted between SS-KT versus CS-KT [OR, 1.04 (95% CI, 1.00 to 1.07); P = 0.07), SS-KT versus MTF-KT [OR, 0.97 (95% CI, 0.90 to 1.04); P = 0.41), and SS-LT versus MTF-LT [OR, 0.95 (95% CI, 0.91 to 1.00); P = 0.05). No significant difference in AR was noted between SS-KT versus MTF-KT [OR, 0.99 (95% CI, 0.96 to 1.02); P = 0.57), SS-LT versus CS-LT [OR, 0.78 (95% CI, 0.53 to 1.16); P = 0.22], or SS-LT versus female-to-male LT [OR, 1.03 (95% CI, 0.95 to 1.12); P = 0.47]. For the remaining pairings, GS was significantly increased and AR was significantly decreased in the SS transplants. CONCLUSIONS Published data suggest immunologic feasibility of CS-KT and CS-LT with the potential for generalization to the VCA population. CLINICAL RELEVANCE STATEMENT In theory, CS-VCA could expand the potential donor pool, ultimately leading to decreased wait times for recipients and improve the likelihood of establishing a immunologically favorable donor-recipient match.
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Affiliation(s)
- Brooke Barrow
- From the Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health
| | - Gustave K Diep
- From the Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health
| | - Zoe P Berman
- From the Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health
| | - Daniel Boczar
- From the Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health
| | - Olive Lee
- From the Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health
| | - Lauren Salinero
- From the Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health
| | - Rachel Howard
- From the Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health
| | - Jorge Trilles
- From the Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health
| | | | - Eduardo D Rodriguez
- From the Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health
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Perspectives et voies de recherche dans les allotransplantations composites vasculaires. BULLETIN DE L'ACADÉMIE NATIONALE DE MÉDECINE 2022. [DOI: 10.1016/j.banm.2022.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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3
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Duhamel P, Baus A, Bich C, Duhoux A, Brachet M, Ponsin P, Leclerc T, Verdaguer C, Rogez D, Annette S, Colas M, Lantiéri L, Bey E. Enjeux et perspectives des allotransplantations de tissus composites en chirurgie reconstructrice pour les très grands brûlés. BULLETIN DE L'ACADÉMIE NATIONALE DE MÉDECINE 2022. [DOI: 10.1016/j.banm.2022.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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4
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La Padula S, Pensato R, Pizza C, Coiante E, Roccaro G, Longo B, D’Andrea F, Wirz FS, Hersant B, Meningaud JP. Face Transplant: Indications, Outcomes, and Ethical Issues-Where Do We Stand? J Clin Med 2022; 11:jcm11195750. [PMID: 36233619 PMCID: PMC9571096 DOI: 10.3390/jcm11195750] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 09/13/2022] [Accepted: 09/26/2022] [Indexed: 11/21/2022] Open
Abstract
Background: The addition of face allotransplantation (FT) to the head and neck reconstructive surgery arsenal has started a true revolution. This study is aimed at providing an extensive analysis of the current practice of composite tissue allotransplantation. Moreover, a thorough description of pre-procedural, intra-operative, and post-procedural settings, indications, contraindications, outcomes, ethical considerations, and future perspectives is provided. Methods: The authors’ experience was supplemented with a literature review performed by using the PubMed, MEDLINE, and Embase databases on 21 February 2022. The search terms used were “face transplantation indications”, “face transplantation complications”, and “face transplantation ethical issues”. Results: The most recent achievements and long-term clinical sequelae of FT are classified and summarized. A large number of records (4435) were identified. Seventy-five articles were assessed for eligibility. Publications without new data and reports with a patient follow-up < 5 years were excluded. Nineteen articles met the criteria for inclusion. Conclusions: The most recent achievements in the field of FT may be combined with cutting-edge regenerative medicine procedures and innovative immunological processing. It is paramount to build strong international networks between the world FT experts in order to achieve higher-level outcomes and reduce the complication rate. Nevertheless, the utmost caution is required in patient selection, clinical assessment, strict follow-up, and rejection management.
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Affiliation(s)
- Simone La Padula
- Department of Plastic and Reconstructive Surgery, Università degli Studi di Napoli Federico II, Via Pansini 5, 80131 Napoli, Italy
- Department of Plastic, Reconstructive and Maxillo Facial Surgery, Henri Mondor Hospital, University Paris XII, 51 Avenue du Maréchal de Lattre de Tassigny, 94000 Créteil, France
- Correspondence:
| | - Rosita Pensato
- Department of Plastic and Reconstructive Surgery, Università degli Studi di Napoli Federico II, Via Pansini 5, 80131 Napoli, Italy
| | - Chiara Pizza
- Department of Plastic, Reconstructive and Maxillo Facial Surgery, Henri Mondor Hospital, University Paris XII, 51 Avenue du Maréchal de Lattre de Tassigny, 94000 Créteil, France
| | - Edoardo Coiante
- Department of Plastic, Reconstructive and Maxillo Facial Surgery, Henri Mondor Hospital, University Paris XII, 51 Avenue du Maréchal de Lattre de Tassigny, 94000 Créteil, France
| | - Giovanni Roccaro
- Department of Plastic, Reconstructive and Maxillo Facial Surgery, Henri Mondor Hospital, University Paris XII, 51 Avenue du Maréchal de Lattre de Tassigny, 94000 Créteil, France
| | - Benedetto Longo
- Department of Plastic and Reconstructive Surgery, Università di Roma Tor Vergata, Viale Oxford 81, 00133 Roma, Italy
| | - Francesco D’Andrea
- Department of Plastic and Reconstructive Surgery, Università degli Studi di Napoli Federico II, Via Pansini 5, 80131 Napoli, Italy
| | | | - Barbara Hersant
- Department of Plastic, Reconstructive and Maxillo Facial Surgery, Henri Mondor Hospital, University Paris XII, 51 Avenue du Maréchal de Lattre de Tassigny, 94000 Créteil, France
| | - Jean Paul Meningaud
- Department of Plastic, Reconstructive and Maxillo Facial Surgery, Henri Mondor Hospital, University Paris XII, 51 Avenue du Maréchal de Lattre de Tassigny, 94000 Créteil, France
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5
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The First Successful Combined Full Face and Bilateral Hand Transplant. Plast Reconstr Surg 2022; 150:414-428. [PMID: 35674521 DOI: 10.1097/prs.0000000000009369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Vascularized composite allotransplantation has redefined the frontiers of plastic and reconstructive surgery. At the cutting edge of this evolving paradigm, the authors present the first successful combined full face and bilateral hand transplant. METHODS A 21-year-old man presented for evaluation with sequelae of an 80 percent total body surface area burn injury sustained after a motor vehicle accident. The injury included full face and bilateral upper extremity composite tissue defects, resulting in reduced quality of life and loss of independence. Multidisciplinary evaluation confirmed eligibility for combined face and bilateral hand transplantation. The operative approach was validated through 11 cadaveric rehearsals utilizing computerized surgical planning. Institutional review board and organ procurement organization approvals were obtained. The recipient, his caregiver, and the donor family consented to the procedure. RESULTS Combined full face (i.e., eyelids, ears, nose, lips, and skeletal subunits) and bilateral hand transplantation (i.e., forearm level) was performed over 23 hours on August 12 to 13, 2020. Triple induction and maintenance immunosuppressive therapy and infection prophylaxis were administered. Plasmapheresis was necessary postoperatively. Minor revisions were performed over seven subsequent operations, including five left upper extremity, seven right upper extremity, and seven facial secondary procedures. At 8 months, the patient was approaching functional independence and remained free of acute rejection. He had significantly improved range of motion, motor power, and sensation of the face and hand allografts. CONCLUSIONS Combined face and bilateral hand transplantation is feasible. This was the most comprehensive vascularized composite allotransplantation procedure successfully performed to date, marking a new milestone in plastic and reconstructive surgery for patients with otherwise irremediable injuries.
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6
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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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7
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Gray KM, Peterson JM, Padilla PL, Smith JM, Zapata-Sirvent RL, Branski LK, Norbury WB, Dziewulski P. Vascularized Composite Allotransplantation in Burn Reconstruction: Systematic Review and Meta-analysis. J Burn Care Res 2021; 42:465-472. [PMID: 33091131 DOI: 10.1093/jbcr/iraa188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Vascularized composite allotransplantation has been successfully employed for burn reconstruction since 2003. However, its safety in this population has been questioned due to high levels of alloimmunization from burn care-related tissue exposures. To investigate this, a systematic review of vascularized composite allotransplantation employed for burn reconstruction was conducted, evaluating literature from January 2000 to September 2019. Articles containing vascularized composite allotransplantation, composite tissue allotransplantation, and burn reconstructive surgery were included; articles without published outcomes were excluded. Observational meta-analysis of pooled mortality and acute rejection episodes relative to allograft type (face vs extremity) and reconstruction type (burn vs non-burn) was performed. Twenty-four of the 63 identified articles met the criteria for inclusion, with 5 more articles added after secondary review. To date, 152 allotransplantations have been performed in 117 patients: 45 face transplants and 107 extremity transplants. Of these, 34 (22%) were performed for burn reconstruction in 25 patients (21%) with an overall higher 1-year mortality rate (12.0% vs 1.1%, P = .030). Of these deaths, 75% received three or more simultaneous allografts. Additionally, more episodes of acute rejection occurred compared to non-burn patients (4.4 vs 2.4, P = .035). Vascularized composite allotransplantation performed for burn reconstruction was found to be associated with a greater risk of 1-year mortality and nearly twice the number of episodes of acute rejection. Future studies should seek to identify unique risk factors of burn patients undergoing this operation and evaluate the relationship between antigenic burden and surgical outcomes.
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Affiliation(s)
- Kelsey M Gray
- School of Medicine, University of Texas Medical Branch, Galveston
| | - Joshua M Peterson
- Division of Plastic Surgery, Department of Surgery, University of Texas Medical Branch, Galveston
| | - Pablo L Padilla
- Division of Plastic Surgery, Department of Surgery, University of Texas Medical Branch, Galveston
| | - Jeffrey M Smith
- Division of Plastic Surgery, Department of Surgery, University of Texas Medical Branch, Galveston
| | - Ramón L Zapata-Sirvent
- Division of Plastic Surgery, Department of Surgery, University of Texas Medical Branch, Galveston.,Shriners Hospitals for Children, Galveston, Texas
| | - Ludwik K Branski
- Division of Plastic Surgery, Department of Surgery, University of Texas Medical Branch, Galveston.,Shriners Hospitals for Children, Galveston, Texas
| | - William B Norbury
- Division of Plastic Surgery, Department of Surgery, University of Texas Medical Branch, Galveston.,Shriners Hospitals for Children, Galveston, Texas
| | - Peter Dziewulski
- Division of Plastic Surgery, Department of Surgery, University of Texas Medical Branch, Galveston.,Shriners Hospitals for Children, Galveston, Texas
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8
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Gibson ALF, Holmes JH, Shupp JW, Smith D, Joe V, Carson J, Litt J, Kahn S, Short T, Cancio L, Rizzo J, Carter JE, Foster K, Lokuta MA, Comer AR, Smiell JM, Allen-Hoffmann BL. A phase 3, open-label, controlled, randomized, multicenter trial evaluating the efficacy and safety of StrataGraft® construct in patients with deep partial-thickness thermal burns. Burns 2021; 47:1024-1037. [PMID: 34099322 DOI: 10.1016/j.burns.2021.04.021] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 03/16/2021] [Accepted: 04/12/2021] [Indexed: 01/02/2023]
Abstract
OBJECTIVE This phase 3 study evaluated StrataGraft construct as a donor-site sparing alternative to autograft in patients with deep partial-thickness (DPT) burns. METHODS Patients aged ≥18 years with 3-49% total body surface area (TBSA) thermal burns were enrolled. In each patient, 2 DPT areas (≤2000cm2 total) of comparable depth after excision were randomized to either cryopreserved StrataGraft or autograft. Coprimary endpoints were: the difference in percent area of StrataGraft treatment site and autograft treatment site autografted at Month 3 (M3), and the proportion of patients achieving durable wound closure of the StrataGraft site without autograft at M3. Safety assessments were performed in all patients. Efficacy and safety follow-up continued to 1 year. RESULTS Seventy-one patients were enrolled. By M3, there was a 96% reduction in mean percent area of StrataGraft treatment sites that required autografting, compared with autograft treatment sites (4.3% vs 102.1%, respectively; P<.0001). StrataGraft treatment resulted in durable wound closure at M3 without autografting in 92% (95% CI: 85.6, 98.8; n/n 59/64) of patients for whom data were available. The most common StrataGraft-related adverse event was pruritus (15%). CONCLUSIONS Both coprimary endpoints were achieved. StrataGraft may offer a new treatment for DPT burns to reduce the need for autografting. CLINICAL TRIAL IDENTIFIER NCT03005106.
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Affiliation(s)
- Angela L F Gibson
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, Madison, WI 53792, United States.
| | - James H Holmes
- Department of Surgery, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157, United States
| | - Jeffrey W Shupp
- The Burn Center, Medstar Washington Hospital Center, 110 Irving Street Northwest, Washington, DC 20010, United States; Department of Surgery, Georgetown University School of Medicine, 3900 Reservoir Road NW, Washington, DC 20007, United States
| | - David Smith
- Department of Plastic Surgery, University of South Florida, 610 Tampa General Circle, Tampa, FL 33606, United States
| | - Victor Joe
- Department of Surgery, University of California at Irvine, 101 The City Drive South, Irvine, CA 92868, United States
| | - Joshua Carson
- Department of Surgery, University of Florida, 1600 SW Archer Road, Gainesville, FL 32610, United States
| | - Jeffrey Litt
- Department of Surgery, University of Missouri Health Care, 1 Hospital Dr, Columbia, MO 65201, United States
| | - Steven Kahn
- Department of Surgery, Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC 29425, United States
| | - Tracee Short
- Department of Surgery, Baton Rouge General Medical Center, 8595 Picardy Avenue, Suite 235, Baton Rouge, LA 70809, United States
| | - Leopoldo Cancio
- United States Army Institute of Surgical Research, 3851 Roger Brooke Dr #3600, Fort Sam Houston, TX 78234, United States
| | - Julie Rizzo
- United States Army Institute of Surgical Research, 3851 Roger Brooke Dr #3600, Fort Sam Houston, TX 78234, United States; Department of Surgery, United States University of Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, United States
| | - Jeffrey E Carter
- Department of Surgery, Louisiana State University School of Medicine, University Medical Center New Orleans, 2000 Canal Street, New Orleans, LA 70112, United States
| | - Kevin Foster
- Department of Surgery, The Arizona Burn Center at MIHS, 2601 E Roosevelt St, Phoenix, AZ 85008, United States
| | - Mary A Lokuta
- Stratatech, A Mallinckrodt Company, 510 Charmany Drive #169, Madison, WI 53719, United States
| | - Allen R Comer
- Stratatech, A Mallinckrodt Company, 510 Charmany Drive #169, Madison, WI 53719, United States
| | - Janice M Smiell
- Mallinckrodt Pharmaceuticals, 53 Frontage Road, Hampton, NJ 08827, United States
| | - B Lynn Allen-Hoffmann
- Department of Pathology and Department of Surgery, University of Wisconsin School of Medicine and Public Health, 5605 MSC 1300 University Avenue Madison, WI 53706, United States
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Abstract
Abstract
Purpose of Review
This article aims to review published outcomes associated with full-thickness vascularized abdominal wall transplantation, with particular emphasis on advances in the field in the last 3 years.
Recent Findings
Forty-six full-thickness vascularized abdominal wall transplants have been performed in 44 patients worldwide. Approximately 35% of abdominal wall transplant recipients will experience at least one episode of acute rejection in the first year after transplant, compared with rejection rates of 87.8% and 72.7% for hand and face transplant respectively. Recent evidence suggests that combining a skin containing abdominal wall transplant with an intestinal transplant does not appear to increase sensitization or de novo donor-specific antibody formation.
Summary
Published data suggests that abdominal wall transplantation is an effective safe solution to achieve primary closure of the abdomen after intestinal or multivisceral transplant. However, better data is needed to confirm observations made and to determine long-term outcomes, requiring standardized data collection and reporting and collaboration between the small number of active transplant centres around the world.
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10
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Kimberly LL, Ramly EP, Alfonso AR, Diep GK, Berman ZP, Rodriguez ED. Equity in access to facial transplantation. JOURNAL OF MEDICAL ETHICS 2020; 47:medethics-2020-106129. [PMID: 33060187 DOI: 10.1136/medethics-2020-106129] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 09/26/2020] [Accepted: 09/26/2020] [Indexed: 06/11/2023]
Abstract
We examine ethical considerations in access to facial transplantation (FT), with implications for promoting health equity. As a form of vascularised composite allotransplantation, FT is still considered innovative with a relatively low volume of procedures performed to date by a small number of active FT programmes worldwide. However, as numbers continue to increase and institutions look to establish new FT programmes, we anticipate that attention will shift from feasibility towards ensuring the benefits of FT are equitably available to those in need. This manuscript assesses barriers to care and their ethical implications across a number of considerations, with the intent of mapping various factors relating to health equity and fair access to FT. Evidence is drawn from an evolving clinical experience as well as published scholarship addressing several dimensions of access to FT. We also explore novel concerns that have yet to be mentioned in the literature.
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Affiliation(s)
- Laura L Kimberly
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY, United States
- Division of Medical Ethics, Department of Population Health, NYU Langone Health, New York, NY, United States
| | - Elie P Ramly
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY, United States
| | - Allyson R Alfonso
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY, United States
| | - Gustave K Diep
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY, United States
| | - Zoe P Berman
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY, United States
| | - Eduardo D Rodriguez
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY, United States
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11
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Tassin DH, Kemp Bohan PM, Cooper LE, Fletcher J, Hatem V, Caterson EJ, Cancio LC, Chan RK. Anti-human Leukocyte Antigen Immune Sensitization Effects of Cryopreserved Allograft and Blood Transfusion. J Burn Care Res 2020; 41:1216-1223. [PMID: 32725146 DOI: 10.1093/jbcr/iraa070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Vascularized composite allotransplantation (VCA) is the most advanced reconstructive technique available to patients who suffer devastating burns to the limbs or face. However, VCA requires donor-recipient matching. Burn patients have been reported to experience sensitization, or the development of anti-human leukocyte antigen antibodies, during resuscitation and wound coverage, potentially precluding them from future VCA. This study sought to investigate the contributions of both blood and allograft to sensitization in burn patients. Four groups were compared: burn patients who received blood products and allograft (group 1), burn patients who received blood products only (group 2), trauma patients who received blood products only (group 3), and healthy volunteer controls (group 4). The average calculated panel-reactive antibody (indicating sensitization) was higher in group 1 compared to group 4 (P = .035). Additionally, the incidence of severe sensitization was higher in group 1 relative to the other groups (P = .049). When comparing groups of patients who had no sensitization, mild sensitization, moderate sensitization, and severe sensitization, there were no significant differences in age, sex, blood products received, total body surface area burned, or allograft used between groups, though severely sensitized patients tended to have greater total body surface area involvement and received more units of packed red blood cells and allograft (P = .079, P = .196, and P = .072, respectively). We therefore conclude that while burn patients who received allograft and blood demonstrated a higher incidence of anti-human leukocyte antigen sensitization relative to healthy controls, this difference cannot solely be attributed to either allograft use or transfusion.
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Affiliation(s)
- David H Tassin
- Department of Surgery, Brooke Army Medical Center, Ft. Sam Houston, Texas
| | | | - Laura E Cooper
- U.S. Army Institute of Surgical Research, Ft. Sam Houston, Texas
| | - John Fletcher
- Department of Surgery, Brooke Army Medical Center, Ft. Sam Houston, Texas.,Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Victoria Hatem
- U.S. Army Institute of Surgical Research, Ft. Sam Houston, Texas
| | - E J Caterson
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Leopoldo C Cancio
- Department of Surgery, Brooke Army Medical Center, Ft. Sam Houston, Texas.,U.S. Army Institute of Surgical Research, Ft. Sam Houston, Texas
| | - Rodney K Chan
- Department of Surgery, Brooke Army Medical Center, Ft. Sam Houston, Texas.,U.S. Army Institute of Surgical Research, Ft. Sam Houston, Texas
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12
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Geoghegan L, Al-Khalil M, Scarborough A, Murray A, Issa F. Pre-transplant management and sensitisation in vascularised composite allotransplantation: A systematic review. J Plast Reconstr Aesthet Surg 2020; 73:1593-1603. [PMID: 32475735 DOI: 10.1016/j.bjps.2020.05.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 04/11/2020] [Accepted: 05/09/2020] [Indexed: 02/01/2023]
Abstract
INTRODUCTION Vascularised composite allotransplantation (VCA) permits like-for-like reconstruction following extensive soft tissue injuries. 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 formation and graft rejection in the context of VCA remains unclear. This systematic review aimed to determine whether pre-transplant management strategies influence immunological outcome following VCA. METHODS A systematic review of MEDLINE, EMBASE and CINAHL using a PRISMA-compliant methodology up to February 2019 was conducted. Pre-transplant, procedural and long-term outcome data were collected and recorded for all VCA recipients on an individual patient basis. RESULTS The search revealed 3,847 records of which 114 met inclusion criteria and reported clinical data related to 100 patients who underwent 129 VCA transplants. Trauma (50%) and burns (15%) were the most frequent indications for VCA. Of all 114 studies, only one reported acute resuscitative management. Fifteen patients were sensitised prior to reconstructive transplantation with an 80%%incidence of acute rejection in the first post-operative year. Seven patients demonstrated graft vasculopathy, only one of whom had demonstrated panel reactive antibodies. CONCLUSIONS Currently employed acute management strategies may predispose to the development of anti-HLA antibodies, adding to the already complex immunological challenge of VCA. To determine whether association between pre-transplant management and outcomes exists, further refinement of international registries is required.
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Affiliation(s)
- Luke Geoghegan
- Imperial College NHS Trust, London, UK; Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science (NDORMS), University of Oxford, Oxford, UK
| | | | | | - Alexandra Murray
- Department of Plastic and Reconstructive Surgery, Stoke Mandeville Hospital, Aylesbury, UK
| | - Fadi Issa
- Department of Plastic and Reconstructive Surgery, Stoke Mandeville Hospital, Aylesbury, UK; Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK.
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13
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Sullivan JV, Frew Q, Fox N, Dziewulski P. Letter to the editors in response to the article: Facial restoration by transplantation, B. Kolar, B Pomahac. The surgeon 16 (2018) 245-249. Surgeon 2019; 17:190-191. [PMID: 30772181 DOI: 10.1016/j.surge.2018.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 12/01/2018] [Indexed: 11/28/2022]
Affiliation(s)
- J V Sullivan
- The St Andrew's Centre for Plastic Surgery and Burns, Broomfield Hospital, Mid Essex Hospitals Trust, Chelmsford, Essex, UK.
| | - Q Frew
- The St Andrew's Centre for Plastic Surgery and Burns, Broomfield Hospital, Mid Essex Hospitals Trust, Chelmsford, Essex, UK
| | - N Fox
- The St Andrew's Centre for Plastic Surgery and Burns, Broomfield Hospital, Mid Essex Hospitals Trust, Chelmsford, Essex, UK
| | - P Dziewulski
- The St Andrew's Centre for Plastic Surgery and Burns, Broomfield Hospital, Mid Essex Hospitals Trust, Chelmsford, Essex, UK
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14
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Abstract
PURPOSE OF REVIEW For patients with devastating injuries in whom standard reconstruction is not an option, vascularized composite allotransplantation (VCA) has become a viable means of restoring form and function. However, immunological rejection continues to be a problem in VCA and has not yet been fully characterized. As the field is relatively new, much of the data on rejection and immunosuppression have been extrapolated from that of solid organ transplantation. In this review, we cover the basic mechanisms of rejection as they relate specifically to VCA with analysis of recent literature and future directions. RECENT FINDINGS Recent clinical studies have supported previously postulated T-cell-mediated mechanism of acute rejection and have also made strides in differentiating rejection from inflammation from other skin conditions and with different treatment regimens. Antibody-mediated rejection has been described in recent cases as well as treatment of presensitized patients receiving VCAs. With more long-term grafts, chronic changes, including vasculopathy, are being reported. SUMMARY Clinically observed types of rejection in VCA include mainly cell-mediated, antibody-mediated and chronic rejection. Advances in diagnosis and treatment of rejection have been made, but there is still much to be learned about VCA-specific rejection.
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15
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Burlage LC, Tessier SN, Etra JW, Uygun K, Brandacher G. Advances in machine perfusion, organ preservation, and cryobiology: potential impact on vascularized composite allotransplantation. Curr Opin Organ Transplant 2018; 23:561-567. [PMID: 30080697 PMCID: PMC6449688 DOI: 10.1097/mot.0000000000000567] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW In this review, we discuss novel strategies that allow for extended preservation of vascularized composite allografts and their potential future clinical implications for the field of vascularized composite allotransplantation (VCA). RECENT FINDINGS The current gold standard in tissue preservation - static cold preservation on ice - is insufficient to preserve VCA grafts for more than a few hours. Advancements in the field of VCA regarding matching and allocation, desensitization, and potential tolerance induction are all within reasonable reach to achieve; these are, however, constrained by limited preservation time of VCA grafts. Although machine perfusion holds many advantages over static cold preservation, it currently does not elongate the preservation time. More extreme preservation techniques, such as cryopreservation approaches, are, however, specifically difficult to apply to composite tissues as the susceptibility to ischemia and cryoprotectant agents varies greatly by tissue type. SUMMARY In the current scope of extended preservation protocols, high subzero approaches of VCA grafts will be particularly critical enabling technologies for the implementation of tolerance protocols clinically. Ultimately, advances in both preservation techniques and tolerance induction have the potential to transform the field of VCA and eventually lead to broad applications in reconstructive transplantation.
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Affiliation(s)
- Laura C. Burlage
- Center for Engineering in Medicine, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Surgery, Section Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University Medical Center Groningen, Groningen, The Netherlands
| | - Shannon N. Tessier
- Center for Engineering in Medicine, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Joanna W. Etra
- Department of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation (VCA) Laboratory, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Korkut Uygun
- Center for Engineering in Medicine, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Gerald Brandacher
- Department of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation (VCA) Laboratory, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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16
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Klein HJ, Lehner F, Schweizer R, Rüsi-Elsener B, Nilsson J, Plock JA. Screening of HLA sensitization during acute burn care. Burns 2018; 44:1330-1335. [DOI: 10.1016/j.burns.2018.01.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Revised: 01/11/2018] [Accepted: 01/12/2018] [Indexed: 12/12/2022]
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17
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Absence of Rejection in a Facial Allograft Recipient with a Positive Flow Crossmatch 24 Months after Induction with Rabbit Anti-Thymocyte Globulin and Anti-CD20 Monoclonal Antibody. Case Rep Transplant 2018; 2018:7691072. [PMID: 29888023 PMCID: PMC5985128 DOI: 10.1155/2018/7691072] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Revised: 03/15/2018] [Accepted: 03/21/2018] [Indexed: 11/18/2022] Open
Abstract
Background Donor-specific antibodies (DSA) to human leukocyte antigen increase the risk of accelerated rejection and allograft damage and reduce the likelihood of successful transplantation. Patients with full-thickness facial burns may benefit from facial allotransplantation. However, they are at a high risk of developing DSA due to standard features of their acute care. Case Presentation A 41-year-old male with severe disfigurement from facial burns consented to facial allotransplantation in 2014; panel reactive antibody score was 0%. In August of 2015, a suitable donor was found. Complement-dependent cytotoxicity crossmatch was negative; flow cytometry crossmatch was positive to donor B cells. An induction immunosuppression strategy consisting of rabbit antithymocyte globulin, rituximab, tacrolimus, mycophenolate mofetil (MMF), and methylprednisolone taper was designed. Total face, scalp, eyelid, ears, and skeletal subunit allotransplantation was performed without operative, immunological, or infectious complications. Maintenance immunosuppression consists of tacrolimus, MMF, and prednisone. As of posttransplant month 24, the patient has not developed acute rejection or metabolic or infectious complications. Conclusions To our knowledge, this is the first report of targeted B cell agents used for induction immunosuppression in skin-containing vascularized composite tissue allotransplantation. A cautious approach is warranted, but early results are promising for reconstructive transplant candidates given the exceptionally high rate of acute rejection episodes, particularly in the first year, in this patient population.
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18
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Desensitization and Prevention of Antibody-Mediated Rejection in Vascularized Composite Allotransplantation by Syngeneic Hematopoietic Stem Cell Transplantation. Transplantation 2018; 102:593-600. [DOI: 10.1097/tp.0000000000002070] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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19
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Tasigiorgos S, Kollar B, Krezdorn N, Bueno EM, Tullius SG, Pomahac B. Face transplantation-current status and future developments. Transpl Int 2018; 31:677-688. [DOI: 10.1111/tri.13130] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Revised: 12/21/2017] [Accepted: 02/02/2018] [Indexed: 01/01/2023]
Affiliation(s)
- Sotirios Tasigiorgos
- Division of Plastic Surgery; Department of Surgery; Brigham and Women's Hospital; Harvard Medical School; Boston MA USA
| | - Branislav Kollar
- Division of Plastic Surgery; Department of Surgery; Brigham and Women's Hospital; Harvard Medical School; Boston MA USA
| | - Nicco Krezdorn
- Department of Plastic, Aesthetic, Hand and Reconstructive Surgery; Hannover Medical School; Hannover Germany
| | - Ericka M. Bueno
- Division of Plastic Surgery; Department of Surgery; Brigham and Women's Hospital; Harvard Medical School; Boston MA USA
| | - Stefan G. Tullius
- Division of Transplant Surgery; Department of Surgery; Brigham and Women's Hospital; Harvard Medical School; Boston MA USA
| | - Bohdan Pomahac
- Division of Plastic Surgery; Department of Surgery; Brigham and Women's Hospital; Harvard Medical School; Boston MA USA
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20
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Abstract
PURPOSE OF REVIEW The outcome of vascularized composite allografts (VCA) often appear unrelated to the presence of donor-specific antibodies (DSA) in blood of the recipient or deposition of complement in the graft. The attenuation of injury and the absence of rejection in other types of grafts despite manifest donor-specific immunity have been explained by accommodation (acquired resistance to immune-mediated injury), adaptation (loss of graft antigen) and/or enhancement (antibody-mediated antigen blockade). Whether and how accommodation, adaptation and/or enhancement impact on the outcome of VCA is unknown. Here we consider how recent observations concerning accommodation in organ transplants might advance understanding and resolve uncertainties about the clinical course of VCA. RECENT FINDINGS Investigation of the mechanisms through which kidney allografts avert antibody-mediated injury and rejection provide insights potentially applicable to VCA. Interaction of DSA can facilitate replacement of donor by recipient endothelial cells, modulate or decrease synthesis of antigen, mobilize antigen that in turn blocks further immune recognition and limit the amount of bound antibody, allowing accommodation to ensue. These processes also can explain the apparent dissociation between the presence and levels of DSA in blood, deposition of C4d in grafts and antibody-mediated rejection. Over time the processes might also explain the inception of chronic graft changes. SUMMARY The disrupted tissue in VCA and potential for repopulation by endothelial cells of the recipient establish conditions that potentially decrease susceptibility to acute antibody-mediated rejection. These conditions include clonal suppression of donor-specific B cells, and adaptation, enhancement and accommodation. This setting also potentially highlights heretofore unrecognized interactions between these 'protective' processes.
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21
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Amini-Nik S, Yousuf Y, Jeschke MG. Scar management in burn injuries using drug delivery and molecular signaling: Current treatments and future directions. Adv Drug Deliv Rev 2018; 123:135-154. [PMID: 28757325 PMCID: PMC5742037 DOI: 10.1016/j.addr.2017.07.017] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 07/14/2017] [Accepted: 07/20/2017] [Indexed: 12/14/2022]
Abstract
In recent decades, there have been tremendous improvements in burn care that have allowed patients to survive severe burn injuries that were once fatal. However, a major limitation of burn care currently is the development of hypertrophic scars in approximately 70% of patients. This significantly decreases the quality of life for patients due to the physical and psychosocial symptoms associated with scarring. Current approaches to manage scarring include surgical techniques and non-surgical methods such as laser therapy, steroid injections, and compression therapy. These treatments are limited in their effectiveness and regularly fail to manage symptoms. As a result, the development of novel treatments that aim to improve outcomes and quality of life is imperative. Drug delivery that targets the molecular cascades of wound healing to attenuate or prevent hypertrophic scarring is a promising approach that has therapeutic potential. In this review, we discuss current treatments for scar management after burn injury, and how drug delivery targeting molecular signaling can lead to new therapeutic strategies.
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Affiliation(s)
- Saeid Amini-Nik
- Sunnybrook Research Institute, Toronto, Canada; Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada; Department of Surgery, Division of Plastic Surgery, University of Toronto, Toronto, Canada.
| | - Yusef Yousuf
- Institute of Medical Science, University of Toronto, Toronto, Canada; Sunnybrook Research Institute, Toronto, Canada
| | - Marc G Jeschke
- Institute of Medical Science, University of Toronto, Toronto, Canada; Sunnybrook Research Institute, Toronto, Canada; Department of Surgery, Division of Plastic Surgery, University of Toronto, Toronto, Canada; Department of Immunology, University of Toronto, Toronto, Canada; Ross-Tilley Burn Centre, Sunnybrook Health Sciences Centre, Toronto, Canada.
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22
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Win TS, Murakami N, Borges TJ, Chandraker A, Murphy G, Lian C, Barrera V, Ho Sui S, Schoenfeld D, Teague J, Bueno E, Tullius SG, Pomahac B, Clark RA, Riella LV. Longitudinal immunological characterization of the first presensitized recipient of a face transplant. JCI Insight 2017; 2:93894. [PMID: 28679959 DOI: 10.1172/jci.insight.93894] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 05/19/2017] [Indexed: 12/16/2022] Open
Abstract
Rejection affects greater than 80% of face transplants, yet no diagnostic criteria for antibody-mediated rejection (AMR) following face transplantation have been established. Given that different treatment strategies are required to address AMR and T cell-mediated rejection (TCMR), there is a critical need to delineate the features that can differentiate these two alloimmune responses. Here, we report the longitudinal immunological examination of what we believe to be the first and only highly sensitized recipient of a crossmatch-positive face transplant up to 4 years following transplantation. We conducted gene expression profiling on allograft biopsies collected during suspected AMR and TCMR episodes as well as during 5 nonrejection time points. Our data suggest that there are distinctive molecular features in AMR, characterized by overexpression of endothelial-associated genes, including ICAM1, VCAM1, and SELE. Although our findings are limited to a single patient, these findings highlight the potential importance of developing and implementing molecular markers to differentiate AMR from TCMR to guide clinical management. Furthermore, our case illustrates that molecular assessment of allograft biopsies offers the potential for new insights into the mechanisms underlying rejection. Finally, our medium-term outcomes demonstrate that face transplantation in a highly sensitized patient with a positive preoperative crossmatch is feasible and manageable.
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Affiliation(s)
- Thet Su Win
- Division of Plastic Surgery, Department of Surgery.,Department of Dermatology
| | - Naoka Murakami
- Schuster Transplantation Research Center, Renal Division, and
| | - Thiago J Borges
- Schuster Transplantation Research Center, Renal Division, and
| | - Anil Chandraker
- Schuster Transplantation Research Center, Renal Division, and
| | - George Murphy
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Christine Lian
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Victor Barrera
- Bioinformatics Core, Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Shannan Ho Sui
- Bioinformatics Core, Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - David Schoenfeld
- Department of Biostatistics, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Ericka Bueno
- Division of Plastic Surgery, Department of Surgery
| | - Stefan G Tullius
- Division of Transplant Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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23
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Lantieri L, Grimbert P, Ortonne N, Lemogne C, Wolkenstein P, Hivelin M. Facial transplantation: facing the limits, planning the future. Lancet 2017; 389:1293-1294. [PMID: 28379144 DOI: 10.1016/s0140-6736(17)30831-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2016] [Accepted: 10/26/2016] [Indexed: 10/19/2022]
Affiliation(s)
- Laurent Lantieri
- Service de Chirurgie Plastique, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris (APHP), Université Paris Descartes, Paris 75015, France
| | - Philippe Grimbert
- Service de Néphrologie et Transplantation, Hôpital Henri Mondor, APHP, Creteil, Université Paris Est Creteil, Paris, France
| | - Nicolas Ortonne
- Département de Pathologie, Hôpital Henri Mondor, APHP, Creteil, Université Paris Est Creteil, Paris, France
| | - Cédric Lemogne
- Service de Psychiatrie de l'adulte et du sujet âgé, Hôpital Européen Georges Pompidou, Université Paris Descartes, Paris, France
| | - Pierre Wolkenstein
- Service de Dermatologie, Hôpital Henri Mondor, Creteil, France; Université Paris Est Creteil, Paris, France
| | - Mikael Hivelin
- Service de Chirurgie Plastique, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris (APHP), Université Paris Descartes, Paris 75015, France.
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24
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Lindford AJ, Lauronen J, Juvonen E, Haimila K, Koljonen V. Evaluation of human leukocyte antigen sensitization in burn patients after treatment with skin allografts and transfusion of blood products. Transpl Int 2017; 30:320-322. [DOI: 10.1111/tri.12912] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Andrew J. Lindford
- Department of Plastic Surgery; University of Helsinki and Helsinki University Hospital; Helsinki Finland
| | | | - Eeva Juvonen
- Finnish Red Cross Blood Service; Helsinki Finland
| | | | - Virve Koljonen
- Department of Plastic Surgery; University of Helsinki and Helsinki University Hospital; Helsinki Finland
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25
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Vascularized Composite Allotransplantation—An Emerging Concept for Burn Reconstruction. J Burn Care Res 2017; 38:371-378. [DOI: 10.1097/bcr.0000000000000532] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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26
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27
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Finnerty CC, Jeschke MG, Branski LK, Barret JP, Dziewulski P, Herndon DN. Hypertrophic scarring: the greatest unmet challenge after burn injury. Lancet 2016; 388:1427-1436. [PMID: 27707499 PMCID: PMC5380137 DOI: 10.1016/s0140-6736(16)31406-4] [Citation(s) in RCA: 364] [Impact Index Per Article: 45.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Revised: 08/05/2016] [Accepted: 08/09/2016] [Indexed: 12/21/2022]
Abstract
Improvements in acute burn care have enabled patients to survive massive burns that would have once been fatal. Now up to 70% of patients develop hypertrophic scars after burns. The functional and psychosocial sequelae remain a major rehabilitative challenge, decreasing quality of life and delaying reintegration into society. Approaches to optimise healing potential of burn wounds use targeted wound care and surgery to minimise the development of hypertrophic scarring. Such approaches often fail, and modulation of the established scar is continued although the optimal indication, timing, and combination of therapies have yet to be established. The need for novel treatments is paramount, and future efforts to improve outcomes and quality of life should include optimisation of wound healing to attenuate or prevent hypertrophic scarring, well-designed trials to confirm treatment efficacy, and further elucidation of molecular mechanisms to allow development of new preventive and therapeutic strategies.
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Affiliation(s)
- Celeste C Finnerty
- Department of Surgery, The University of Texas Medical Branch, Galveston, TX, USA; The Institute for Translational Sciences, The University of Texas Medical Branch, Galveston, TX, USA; the Sealy Center for Molecular Medicine, The University of Texas Medical Branch, Galveston, TX, USA; Shriners Hospitals for Children, Galveston, TX, USA.
| | - Marc G Jeschke
- Sunnybrook Research Institute, Toronto, ON, Canada; Division of Plastic Surgery Department of Surgery and Immunology, University of Toronto, ON, Canada; Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Ludwik K Branski
- Department of Surgery, The University of Texas Medical Branch, Galveston, TX, USA; Shriners Hospitals for Children, Galveston, TX, USA
| | - Juan P Barret
- Department of Plastic Surgery and Burns, University Hospital Vall d'Hebron, Barcelona, Spain
| | - Peter Dziewulski
- St Andrew's Centre for Burns and Plastic Surgery, Broomfield Hospital, Chelmsford, UK; StAAR Research Unit, Faculty of Medical Sciences, Anglia Ruskin University, Chelmsford, UK
| | - David N Herndon
- Department of Surgery, The University of Texas Medical Branch, Galveston, TX, USA; The Institute for Translational Sciences, The University of Texas Medical Branch, Galveston, TX, USA; Shriners Hospitals for Children, Galveston, TX, USA
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28
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Lantieri L, Grimbert P, Ortonne N, Suberbielle C, Bories D, Gil-Vernet S, Lemogne C, Bellivier F, Lefaucheur JP, Schaffer N, Martin F, Meningaud JP, Wolkenstein P, Hivelin M. Face transplant: long-term follow-up and results of a prospective open study. Lancet 2016; 388:1398-1407. [PMID: 27567680 DOI: 10.1016/s0140-6736(16)31138-2] [Citation(s) in RCA: 100] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND More than 30 face transplantations have been done worldwide since 2005 but no documented long-term follow-up has been reported in the literature. We aimed to answer remaining question about the long-term risks and benefits of face transplant. METHODS In this single-centre, prospective, open study, we assessed 20 patients presenting with facial defects. Ten patients were selected, and, after three were secondarily excluded, seven were transplanted: two with neurofibromatosis 1, one with a burn, and four with self-inflicted facial gunshot injuries. We report the long-term outcomes of six face allotransplant recipients at an average of 6 years (range 3·4-9 years) after the transplantation. All admissions to hospital except for planned revisions and immunosuppressive follow-up therapy were reported as adverse events (safety endpoint). Predefined immunological, metabolic, surgical, and social integration endpoints were collected prospectively. Patients underwent quantitative health-related quality of life assessments through Short Form 36 health questionnaires. This study was registered with ClinicalTrials.gov, number NCT00527280. FINDINGS Two of seven patients died: one at 65 days due to transplant destruction with concomitant pseudomonas infection and the second at 3·4 years after transplantation by suicide. The six patients alive at long-term follow-up presented with functional transplants. Safety endpoints were related to infection in the first month, acute rejection from 1 day to 7 years after transplantation, or side-effects of immunosuppressive therapy. Recurrent rejection episodes justified maintenance therapy with high-dose steroids at high levels in all patients at last follow-up, yet none of the patients developed diabetes. Three patients were found to have hypertension with one requiring therapy. All patients had a noticeable reduction in glomerular filtration rate. All recipients and their families accepted their transplant. Improvements in social integration and quality of life were highly variable among the patients and depended on baseline levels and psychiatric comorbidities. INTERPRETATION These long-term results show the crucial effect of patients' social support and pre-existing psychiatric conditions on the risk-benefit ratio of facial transplantation. Careful preoperative patient selection and long-term postoperative follow-up programmes under strict institutional review board controls should be used for any future grafts of this type. FUNDING Protocole Hospitalier de Recherche Clinique (PHRC) National.
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Affiliation(s)
- Laurent Lantieri
- Service de Chirurgie Plastique, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris (APHP), Université Paris Descartes, Paris, France
| | - Philippe Grimbert
- Service de Néphrologie et Transplantation, Hôpital Henri Mondor, APHP, Creteil, France-Université Paris Est Creteil (UPEC), Paris France
| | - Nicolas Ortonne
- Département de Pathologie, Hôpital Henri Mondor, APHP, Creteil, France-Université Paris Est Creteil (UPEC), Paris France
| | - Caroline Suberbielle
- Laboratoire Régional d'Histocompatibilité «Jean Dausset», Hôpital Saint Louis, APHP, Paris, France; Université Paris Diderot, Paris, France
| | - Dominique Bories
- Laboratoire D'Hématologie Biologique et Moléculaire, Hôpital Henri Mondor, APHP, Creteil, France-Université Paris Est Creteil (UPEC), Paris France
| | - Salvador Gil-Vernet
- Unitat Assistencial de Trasplantament, Bellvitge Hospital Universitari, Barcelona, Spain
| | - Cédric Lemogne
- Service de Psychiatrie, Hôpital Européen Georges Pompidou, APHP-Université Paris Descartes, Paris, France
| | - Frank Bellivier
- Université Paris Diderot, Sorbonne Paris Cité, INSERM UMR-S 1144, Paris, France; APHP, GH Saint-Louis-Lariboisière-F Widal, Département de Psychiatrie et de Médecine Addictologique
| | - Jean Pascal Lefaucheur
- Service des Explorations Fonctionnelles, Hôpital Henri Mondor, APHP, Creteil, France-Université Paris Est Creteil (UPEC), Paris France
| | - Nathaniel Schaffer
- Service de Chirurgie Plastique, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris (APHP), Université Paris Descartes, Paris, France
| | | | - Jean Paul Meningaud
- Service de Chirurgie Plastique et Reconstructrice, Hôpital Henri Mondor, APHP, Creteil, France-Université Paris Est Creteil (UPEC), Paris France
| | - Pierre Wolkenstein
- Service de Dermatologie, Hôpital Henri Mondor, APHP, Creteil, France-Université Paris Est Creteil (UPEC), Paris France
| | - Mikael Hivelin
- Service de Chirurgie Plastique, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris (APHP), Université Paris Descartes, Paris, France.
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29
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30
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Hivelin M, Lantieri L, Suberbielle C, Jacquelinet C, Audry B, Grimbert P, Duhamel P. Extensively burns patients are not unsuitable candidates to vascularized composite allotransplantations but require optimization in access to suitable transplants. J Plast Reconstr Aesthet Surg 2015; 68:1763-4. [PMID: 26365149 DOI: 10.1016/j.bjps.2015.08.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Accepted: 08/23/2015] [Indexed: 10/23/2022]
Affiliation(s)
- Mikaël Hivelin
- Service de Chirurgie Plastique et Reconstructrice, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Université Paris Descartes, Paris, France.
| | - Laurent Lantieri
- Service de Chirurgie Plastique et Reconstructrice, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Université Paris Descartes, Paris, France
| | - Caroline Suberbielle
- Laboratoire Régional d'Histocompatibilité «Jean Dausset», CHU Saint Louis, Assistance Publique-Hôpitaux de Paris, Paris, France
| | | | | | - Philippe Grimbert
- Service de Néphrologie et Transplantation, CHU Mondor, Assistance Publique-Hôpitaux de Paris, Université Paris Est Creteil, Creteil, France
| | - Patrick Duhamel
- Service de Chirurgie Plastique, Centre de Traitement des Brûlés, Hôpital d'Instruction des Armées Percy, Clamart, France
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31
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Kueckelhaus M, Fischer S, Seyda M, Bueno EM, Aycart MA, Alhefzi M, ElKhal A, Pomahac B, Tullius SG. Vascularized composite allotransplantation: current standards and novel approaches to prevent acute rejection and chronic allograft deterioration. Transpl Int 2015; 29:655-62. [PMID: 26265179 DOI: 10.1111/tri.12652] [Citation(s) in RCA: 98] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Revised: 06/10/2015] [Accepted: 07/30/2015] [Indexed: 12/18/2022]
Abstract
The advent of more potent immunosuppressants led to the first successful human upper extremity transplantation in 1998. At this time, >100 upper extremity transplants, 30 face transplants, and a variety of other vascularized composite allotransplantation (VCA) procedures have been performed around the world. VCA recipients present unique challenges for transplantation. The incidence of acute rejection exceeds 80% in hand and face transplantation and is well documented, whereas reports about antibody-mediated rejection and chronic rejection remain scarce. Immunosuppression protocols commonly used at US centers are derived from solid organ transplantation protocols. Novel approaches to minimize rejections in VCA may include improved HLA matching and considerations toward cytomegalovirus infection status. New graft preservation techniques may decrease immunogenicity prior to transplant. Novel monitoring methods such as valid biomarkers, ultrasound biomicroscopy, and sentinel flaps may enable earlier diagnosis of rejection. Cell-based therapies are being explored to achieve immunosuppressive regimen minimization or even tolerance induction. The efficacy of local immunosuppression in clinical VCA remains controversial. In conclusion, although immunosuppressive strategies adapted from SOT have demonstrated good midterm results, focusing on the unique features of VCA grafts may enable additional, more specific treatment strategies in the future and improved long-term graft outcomes.
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Affiliation(s)
- Maximilian Kueckelhaus
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Department of Plastic Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, Germany
| | - Sebastian Fischer
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Department of Plastic Surgery, BG University Hospital Ludwigshafen, Heidelberg University, Ludwigshafen, Germany
| | - Midas Seyda
- Division of Transplant Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ericka M Bueno
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Mario A Aycart
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Muayyad Alhefzi
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Abdallah ElKhal
- Division of Transplant Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Bohdan Pomahac
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Stefan G Tullius
- Division of Transplant Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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