1
|
Scarabosio A, Surico PL, Tereshenko V, Singh RB, Salati C, Spadea L, Caputo G, Parodi PC, Gagliano C, Winograd JM, Zeppieri M. Whole-eye transplantation: Current challenges and future perspectives. World J Transplant 2024; 14:95009. [PMID: 38947970 PMCID: PMC11212585 DOI: 10.5500/wjt.v14.i2.95009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Revised: 04/24/2024] [Accepted: 05/15/2024] [Indexed: 06/13/2024] Open
Abstract
Whole-eye transplantation emerges as a frontier in ophthalmology, promising a transformative approach to irreversible blindness. Despite advancements, formidable challenges persist. Preservation of donor eye viability post-enucleation necessitates meticulous surgical techniques to optimize retinal integrity and ganglion cell survival. Overcoming the inhibitory milieu of the central nervous system for successful optic nerve regeneration remains elusive, prompting the exploration of neurotrophic support and immunomodulatory interventions. Immunological tolerance, paramount for graft acceptance, confronts the distinctive immunogenicity of ocular tissues, driving research into targeted immunosuppression strategies. Ethical and legal considerations underscore the necessity for stringent standards and ethical frameworks. Interdisciplinary collaboration and ongoing research endeavors are imperative to navigate these complexities. Biomaterials, stem cell therapies, and precision immunomodulation represent promising avenues in this pursuit. Ultimately, the aim of this review is to critically assess the current landscape of whole-eye transplantation, elucidating the challenges and advancements while delineating future directions for research and clinical practice. Through concerted efforts, whole-eye transplantation stands to revolutionize ophthalmic care, offering hope for restored vision and enhanced quality of life for those afflicted with blindness.
Collapse
Affiliation(s)
- Anna Scarabosio
- Department of Plastic Surgery, University Hospital of Udine, Udine 33100, Italy
- Department of Plastic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, United States
| | - Pier Luigi Surico
- Schepens Eye Research Institute of Mass Eye and Ear, Harvard Medical School, Boston, MA 02114, United States
| | - Vlad Tereshenko
- Department of Plastic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, United States
| | - Rohan Bir Singh
- Schepens Eye Research Institute of Mass Eye and Ear, Harvard Medical School, Boston, MA 02114, United States
| | - Carlo Salati
- Department of Ophthalmology, University Hospital of Udine, Udine 33100, Italy
| | - Leopoldo Spadea
- Eye Clinic, Policlinico Umberto I, "Sapienza" University of Rome, Rome 00142, Italy
| | - Glenda Caputo
- Department of Plastic Surgery, University Hospital of Udine, Udine 33100, Italy
| | - Pier Camillo Parodi
- Department of Plastic Surgery, University Hospital of Udine, Udine 33100, Italy
| | - Caterina Gagliano
- Department of Medicine and Surgery, University of Enna "Kore", Enna 94100, Italy
- Eye Clinic Catania University San Marco Hospital, Viale Carlo Azeglio Ciampi 95121 Catania, Italy
| | - Jonathan M Winograd
- Department of Plastic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, United States
| | - Marco Zeppieri
- Department of Ophthalmology, University Hospital of Udine, Udine 33100, Italy
| |
Collapse
|
2
|
Arenas Hoyos I, Helmer A, Yerly A, Lese I, Hirsiger S, Zhang L, Casoni D, Garcia L, Petrucci M, Hammer SE, Duckova T, Banz Y, Montani M, Constantinescu M, Vögelin E, Bordon G, Aleandri S, Prost JC, Taddeo A, Luciani P, Rieben R, Sorvillo N, Olariu R. A local drug delivery system prolongs graft survival by dampening T cell infiltration and neutrophil extracellular trap formation in vascularized composite allografts. Front Immunol 2024; 15:1387945. [PMID: 38887281 PMCID: PMC11180892 DOI: 10.3389/fimmu.2024.1387945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Accepted: 05/20/2024] [Indexed: 06/20/2024] Open
Abstract
Introduction The standard treatment for preventing rejection in vascularized composite allotransplantation (VCA) currently relies on systemic immunosuppression, which exposes the host to well-known side effects. Locally administered immunosuppression strategies have shown promising results to bypass this hurdle. Nevertheless, their progress has been slow, partially attributed to a limited understanding of the essential mechanisms underlying graft rejection. Recent discoveries highlight the crucial involvement of innate immune components, such as neutrophil extracellular traps (NETs), in organ transplantation. Here we aimed to prolong graft survival through a tacrolimus-based drug delivery system and to understand the role of NETs in VCA graft rejection. Methods To prevent off-target toxicity and promote graft survival, we tested a locally administered tacrolimus-loaded on-demand drug delivery system (TGMS-TAC) in a multiple MHC-mismatched porcine VCA model. Off-target toxicity was assessed in tissue and blood. Graft rejection was evaluated macroscopically while the complement system, T cells, neutrophils and NETs were analyzed in graft tissues by immunofluorescence and/or western blot. Plasmatic levels of inflammatory cytokines were measured using a Luminex magnetic-bead porcine panel, and NETs were measured in plasma and tissue using DNA-MPO ELISA. Lastly, to evaluate the effect of tacrolimus on NET formation, NETs were induced in-vitro in porcine and human peripheral neutrophils following incubation with tacrolimus. Results Repeated intra-graft administrations of TGMS-TAC minimized systemic toxicity and prolonged graft survival. Nevertheless, signs of rejection were observed at endpoint. Systemically, there were no increases in cytokine levels, complement anaphylatoxins, T-cell subpopulations, or neutrophils during rejection. Yet, tissue analysis showed local infiltration of T cells and neutrophils, together with neutrophil extracellular traps (NETs) in rejected grafts. Interestingly, intra-graft administration of tacrolimus contributed to a reduction in both T-cellular infiltration and NETs. In fact, in-vitro NETosis assessment showed a 62-84% reduction in NETs after stimulated neutrophils were treated with tacrolimus. Conclusion Our data indicate that the proposed local delivery of immunosuppression avoids off-target toxicity while prolonging graft survival in a multiple MHC-mismatch VCA model. Furthermore, NETs are found to play a role in graft rejection and could therefore be a potential innovative therapeutic target.
Collapse
Affiliation(s)
- Isabel Arenas Hoyos
- Department for BioMedical Research, University of Bern, Bern, Switzerland
- Department of Plastic and Hand Surgery, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Anja Helmer
- Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - Anaïs Yerly
- Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - Ioana Lese
- Department of Plastic and Hand Surgery, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Stefanie Hirsiger
- Department of Plastic and Hand Surgery, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Lei Zhang
- Department for BioMedical Research, University of Bern, Bern, Switzerland
- Department of Plastic and Hand Surgery, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Daniela Casoni
- Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - Luisana Garcia
- Department for BioMedical Research, University of Bern, Bern, Switzerland
| | | | - Sabine E. Hammer
- Institute of Immunology, University of Veterinary Medicine Vienna, City Bern, Austria
| | - Tereza Duckova
- Institute of Immunology, University of Veterinary Medicine Vienna, City Bern, Austria
| | - Yara Banz
- Institute of Pathology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Matteo Montani
- Institute of Pathology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Mihai Constantinescu
- Department of Plastic and Hand Surgery, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Esther Vögelin
- Department of Plastic and Hand Surgery, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Gregor Bordon
- Department of Chemistry, Biochemistry and Pharmaceutical Sciences, University of Bern, Bern, Switzerland
| | - Simone Aleandri
- Department of Chemistry, Biochemistry and Pharmaceutical Sciences, University of Bern, Bern, Switzerland
| | - Jean-Christophe Prost
- University Institute of Clinical Chemistry, Inselspital, Bern University Hospital, University of Bern, Vienna, Switzerland
| | - Adriano Taddeo
- Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - Paola Luciani
- Department of Chemistry, Biochemistry and Pharmaceutical Sciences, University of Bern, Bern, Switzerland
| | - Robert Rieben
- Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - Nicoletta Sorvillo
- Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - Radu Olariu
- Department of Plastic and Hand Surgery, Inselspital, Bern University Hospital, Bern, Switzerland
| |
Collapse
|
3
|
Amin KR, Fildes JE. The contribution of the donor vascularised hand and face allograft in transplant rejection: An immunological perspective. Transpl Immunol 2024; 84:102035. [PMID: 38518826 DOI: 10.1016/j.trim.2024.102035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 03/14/2024] [Accepted: 03/15/2024] [Indexed: 03/24/2024]
Abstract
Overcoming immunological rejection remains a barrier to the safe adoption of Vascularised Composite Allotransplantation (VCA). To mitigate this risk, clinical protocols have been derived from solid organ transplantation, targeting recipient immunomodulation, yet VCA is unique. Face and hand composite allografts are composed of multiple different tissues, each with their own immunological properties. Experimental work suggests that allografts carry variable numbers and populations of donor leukocytes in an organ specific manner. Ordinarily, these passenger leukocytes are transferred from the donor graft into the recipient circulation after transplantation. Whether alloantigen presentation manifests as acute allograft rejection or transplant tolerance is unknown. This review aims to characterise the immunological properties of the constituent parts of the donor face and hand, the potential fate of donor leukocytes and to consider theoretical graft specific interventions to mitigate early rejection.
Collapse
Affiliation(s)
- Kavit R Amin
- Department of Plastic Surgery, Manchester University NHS Foundation Trust, Manchester, UK; Division of Cell Matrix, Biology and Regenerative Medicine, University of Manchester, Manchester, UK; The Pebble Institute, Manchester, UK.
| | - James E Fildes
- The Pebble Institute, Manchester, UK; The Healthcare Technologies Institute, University of Birmingham, Birmingham, UK.
| |
Collapse
|
4
|
Ashraf MI, Mengwasser J, Reutzel-Selke A, Polenz D, Führer K, Lippert S, Tang P, Michaelis E, Catar R, Pratschke J, Witzel C, Sauer IM, Tullius SG, Kern B. Depletion of donor dendritic cells ameliorates immunogenicity of both skin and hind limb transplants. Front Immunol 2024; 15:1395945. [PMID: 38799435 PMCID: PMC11116604 DOI: 10.3389/fimmu.2024.1395945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 04/15/2024] [Indexed: 05/29/2024] Open
Abstract
Acute cellular rejection remains a significant obstacle affecting successful outcomes of organ transplantation including vascularized composite tissue allografts (VCA). Donor antigen presenting cells (APCs), particularly dendritic cells (DCs), orchestrate early alloimmune responses by activating recipient effector T cells. Employing a targeted approach, we investigated the impact of donor-derived conventional DCs (cDCs) and APCs on the immunogenicity of skin and skin-containing VCA grafts, using mouse models of skin and hind limb transplantation. By post-transplantation day 6, skin grafts demonstrated severe rejections, characterized by predominance of recipient CD4 T cells. In contrast, hind limb grafts showed moderate rejection, primarily infiltrated by CD8 T cells. Notably, the skin component exhibited heightened immunogenicity when compared to the entire VCA, evidenced by increased frequencies of pan (CD11b-CD11c+), mature (CD11b-CD11c+MHCII+) and active (CD11b-CD11c+CD40+) DCs and cDC2 subset (CD11b+CD11c+ MHCII+) in the lymphoid tissues and the blood of skin transplant recipients. While donor depletion of cDC and APC reduced frequencies, maturation and activation of DCs in all analyzed tissues of skin transplant recipients, reduction in DC activities was only observed in the spleen of hind limb recipients. Donor cDC and APC depletion did not impact all lymphocyte compartments but significantly affected CD8 T cells and activated CD4 T in lymph nodes of skin recipients. Moreover, both donor APC and cDC depletion attenuated the Th17 immune response, evident by significantly reduced Th17 (CD4+IL-17+) cells in the spleen of skin recipients and reduced levels of IL-17E and lymphotoxin-α in the serum samples of both skin and hind limb recipients. In conclusion, our findings underscore the highly immunogenic nature of skin component in VCA. The depletion of donor APCs and cDCs mitigates the immunogenicity of skin grafts while exerting minimal impact on VCA.
Collapse
Affiliation(s)
- Muhammad Imtiaz Ashraf
- Department of Surgery, Experimental Surgery, Charité – Universitätsmedizin Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Joerg Mengwasser
- Department of Surgery, Experimental Surgery, Charité – Universitätsmedizin Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Anja Reutzel-Selke
- Department of Surgery, Experimental Surgery, Charité – Universitätsmedizin Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Dietrich Polenz
- Department of Surgery, Experimental Surgery, Charité – Universitätsmedizin Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Kirsten Führer
- Department of Surgery, Experimental Surgery, Charité – Universitätsmedizin Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Steffen Lippert
- Department of Surgery, Experimental Surgery, Charité – Universitätsmedizin Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Peter Tang
- Department of Surgery, Experimental Surgery, Charité – Universitätsmedizin Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Edward Michaelis
- Department of Pathology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Rusan Catar
- Department of Nephrology and Internal Intensive Care Medicine, Charité Universitätsmedizin Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Healthy, Berlin, Germany
| | - Johann Pratschke
- Department of Surgery, Experimental Surgery, Charité – Universitätsmedizin Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Christian Witzel
- Department of Plastic Surgery, Charité – Universitätsmedizin Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Igor M. Sauer
- Department of Surgery, Experimental Surgery, Charité – Universitätsmedizin Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Stefan G. Tullius
- Division of Transplant Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
- Einstein Berlin Institute of Health Visiting Fellow, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Barbara Kern
- Department of Surgery, Experimental Surgery, Charité – Universitätsmedizin Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
- Department of Plastic Surgery, Charité – Universitätsmedizin Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
- Berlin Institute of Health at Charité – Universitätsmedizin Berlin, Berlin Institute of Health (BIH) Biomedical Innovation Academy, Berlin Institute of Health (BIH) Charité Clinician Scientist Program, Berlin, Germany
| |
Collapse
|
5
|
Beare JE, Fleissig Y, Kelm NQ, Reed RM, LeBlanc AJ, Hoying JB, Kaufman CL. Mimicking Clinical Rejection Patterns in a Rat Osteomyocutaneous Flap Model of Vascularized Composite Allotransplantation. J Surg Res 2024; 295:28-40. [PMID: 37979234 PMCID: PMC10922720 DOI: 10.1016/j.jss.2023.08.057] [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: 08/03/2022] [Revised: 08/09/2023] [Accepted: 08/30/2023] [Indexed: 11/20/2023]
Abstract
INTRODUCTION Graft loss in vascularized composite allotransplantation (VCA) is more often associated with vasculopathy and chronic rejection (CR) than acute cellular rejection (ACR). We present a rat osteomyocutaneous flap model using titrated tacrolimus administration that mimics the graft rejection patterns in our clinical hand transplant program. Comparison of outcomes in these models support a role for ischemia reperfusion injury (IRI) and microvascular changes in CR of skin and large-vessel vasculopathy. The potential of the surgical models for investigating mechanisms of rejection and vasculopathy in VCA and treatment interventions is presented. MATERIALS AND METHODS Four rodent groups were evaluated: syngeneic controls (Group 1), allogeneic transient immunosuppression (Group 2), allogeneic suboptimal immunosuppression (Group 3), and allogeneic standard immunosuppression (Group 4). Animals were monitored for ACR, vasculopathy, and CR of the skin. RESULTS Transient immunosuppression resulted in severe ACR within 2 wk of tacrolimus discontinuation. Standard immunosuppression resulted in minimal rejection but subclinical microvascular changes, including capillary thrombosis and luminal narrowing in arterioles in the donor skin. Further reduction in tacrolimus dose led to femoral vasculopathy and CR of the skin. Surprisingly, femoral vasculopathy was also observed in the syngeneic control group. CONCLUSIONS Titration of tacrolimus in the allogeneic VCA model resulted in presentations of rejection and vasculopathy similar to those in patients and suggests vasculopathy starts at the microvascular level. This adjustable experimental model will allow the study of variables and interventions, such as external trauma or complement blockade, that may initiate or mitigate vasculopathy and CR in VCA.
Collapse
Affiliation(s)
- Jason E Beare
- Cardiovascular Innovation Institute, University of Louisville, Louisville, Kentucky; Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, Kentucky
| | | | - Natia Q Kelm
- Cardiovascular Innovation Institute, University of Louisville, Louisville, Kentucky; Department of Physiology, University of Louisville, Louisville, Kentucky
| | - Robert M Reed
- Cardiovascular Innovation Institute, University of Louisville, Louisville, Kentucky
| | - Amanda J LeBlanc
- Cardiovascular Innovation Institute, University of Louisville, Louisville, Kentucky; Department of Cardiovascular and Thoracic Surgery, University of Louisville, Louisville, Kentucky
| | - James B Hoying
- Cardiovascular Innovation Institute, University of Louisville, Louisville, Kentucky; Department of Physiology, University of Louisville, Louisville, Kentucky
| | - Christina L Kaufman
- Cardiovascular Innovation Institute, University of Louisville, Louisville, Kentucky; Department of Cardiovascular and Thoracic Surgery, University of Louisville, Louisville, Kentucky; Trager Transplant Center, UofL Health/Jewish Hospital, Louisville, Kentucky.
| |
Collapse
|
6
|
Sun J(A, Adil A, Biniazan F, Haykal S. Immunogenicity and tolerance induction in vascularized composite allotransplantation. FRONTIERS IN TRANSPLANTATION 2024; 3:1350546. [PMID: 38993748 PMCID: PMC11235364 DOI: 10.3389/frtra.2024.1350546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 01/29/2024] [Indexed: 07/13/2024]
Abstract
Vascularized composite allotransplantation (VCA) is the transplantation of multiple tissues such as skin, muscle, bone, nerve, and vessels, as a functional unit (i.e., hand or face) to patients suffering from major tissue trauma and functional deficits. Though the surgical feasibility has been optimized, issues regarding graft rejection remains. VCA rejection involves a diverse population of cells but is primarily driven by both donor and recipient lymphocytes, antigen-presenting cells, macrophages, and other immune as well as donor-derived cells. In addition, it is commonly understood that different tissues within VCA, such as the skin, elicits a stronger rejection response. Currently, VCA recipients are required to follow potent and lifelong immunosuppressing regimens to maximize graft survival. This puts patients at risk for malignancies, opportunistic infections, and cancers, thereby posing a need for less perilous methods of inducing graft tolerance. This review will provide an overview of cell populations and mechanisms, specific tissue involved in VCA rejection, as well as an updated scope of current methods of tolerance induction.
Collapse
Affiliation(s)
- Jiahui (Angela) Sun
- Latner Thoracic Surgery Laboratories, University Health Network, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
- Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Aisha Adil
- Latner Thoracic Surgery Laboratories, University Health Network, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
- Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Felor Biniazan
- Latner Thoracic Surgery Laboratories, University Health Network, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
| | - Siba Haykal
- Latner Thoracic Surgery Laboratories, University Health Network, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
- Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Division of Plastic & Reconstructive Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| |
Collapse
|
7
|
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.
Collapse
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.
| |
Collapse
|
8
|
Zhang L, Hoyos IA, Zubler C, Rieben R, Constantinescu M, Olariu R. Challenges and opportunities in vascularized composite allotransplantation of joints: a systematic literature review. Front Immunol 2023; 14:1179195. [PMID: 37275912 PMCID: PMC10235447 DOI: 10.3389/fimmu.2023.1179195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 05/08/2023] [Indexed: 06/07/2023] Open
Abstract
Background Joint allotransplantation (JA) within the field of vascularized composite allotransplantation (VCA) holds great potential for functional and non-prosthetic reconstruction of severely damaged joints. However, clinical use of JA remains limited due to the immune rejection associated with all forms of allotransplantation. In this study, we aim to provide a comprehensive overview of the current state of JA through a systematic review of clinical, animal, and immunological studies on this topic. Methods We conducted a systematic literature review in accordance with the PRISMA guidelines to identify relevant articles in PubMed, Cochrane Library, and Web of Science databases. The results were analyzed, and potential future prospects were discussed in detail. Results Our review included 14 articles describing relevant developments in JA. Currently, most JA-related research is being performed in small animal models, demonstrating graft survival and functional restoration with short-term immunosuppression. In human patients, only six knee allotransplantations have been performed to date, with all grafts ultimately failing and a maximum graft survival of 56 months. Conclusion Research on joint allotransplantation has been limited over the last 20 years due to the rarity of clinical applications, the complex nature of surgical procedures, and uncertain outcomes stemming from immune rejection. However, the key to overcoming these challenges lies in extending graft survival and minimizing immunosuppressive side effects. With the emergence of new immunosuppressive strategies, the feasibility and clinical potential of vascularized joint allotransplantation warrants further investigation.
Collapse
Affiliation(s)
- Lei Zhang
- Department of Plastic and Hand Surgery, Inselspital University Hospital Bern, University of Bern, Bern, Switzerland
- Department for BioMedical Research, University of Bern, Bern, Switzerland
- Department of Plastic and Reconstructive Surgery, Plastic and Reconstructive Surgery Center, Zhejiang Provincial People’s Hospital, Hangzhou, China
| | - Isabel Arenas Hoyos
- Department of Plastic and Hand Surgery, Inselspital University Hospital Bern, University of Bern, Bern, Switzerland
- Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - Cédric Zubler
- Department of Plastic and Hand Surgery, Inselspital University Hospital Bern, University of Bern, Bern, Switzerland
| | - Robert Rieben
- Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - Mihai Constantinescu
- Department of Plastic and Hand Surgery, Inselspital University Hospital Bern, University of Bern, Bern, Switzerland
| | - Radu Olariu
- Department of Plastic and Hand Surgery, Inselspital University Hospital Bern, University of Bern, Bern, Switzerland
- Department for BioMedical Research, University of Bern, Bern, Switzerland
| |
Collapse
|
9
|
Knoedler L, Knoedler S, Panayi AC, Lee CAA, Sadigh S, Huelsboemer L, Stoegner VA, Schroeter A, Kern B, Mookerjee V, Lian CG, Tullius SG, Murphy GF, Pomahac B, Kauke-Navarro M. Cellular activation pathways and interaction networks in vascularized composite allotransplantation. Front Immunol 2023; 14:1179355. [PMID: 37266446 PMCID: PMC10230044 DOI: 10.3389/fimmu.2023.1179355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Accepted: 04/28/2023] [Indexed: 06/03/2023] Open
Abstract
Vascularized composite allotransplantation (VCA) is an evolving field of reconstructive surgery that has revolutionized the treatment of patients with devastating injuries, including those with limb losses or facial disfigurement. The transplanted units are typically comprised of different tissue types, including skin, mucosa, blood and lymphatic vasculature, muscle, and bone. It is widely accepted that the antigenicity of some VCA components, such as skin, is particularly potent in eliciting a strong recipient rejection response following transplantation. The fine line between tolerance and rejection of the graft is orchestrated by different cell types, including both donor and recipient-derived lymphocytes, macrophages, and other immune and donor-derived tissue cells (e.g., endothelium). Here, we delineate the role of different cell and tissue types during VCA rejection. Rejection of VCA grafts and the necessity of life-long multidrug immunosuppression remains one of the major challenges in this field. This review sheds light on recent developments in decoding the cellular signature of graft rejection in VCA and how these may, ultimately, influence the clinical management of VCA patients by way of novel therapies that target specific cellular processes.
Collapse
Affiliation(s)
- Leonard Knoedler
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
- Division of Plastic Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, United States
| | - Samuel Knoedler
- Division of Plastic Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, United States
- Department of Surgery, Division of Plastic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Adriana C. Panayi
- Department of Surgery, Division of Plastic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Catherine A. A. Lee
- Department of Pathology, Brigham and Women’s Hospital, Boston, MA, United States
| | - Sam Sadigh
- Department of Pathology, Brigham and Women’s Hospital, Boston, MA, United States
| | - Lioba Huelsboemer
- Division of Plastic Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, United States
| | - Viola A. Stoegner
- Division of Plastic Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, United States
- Department of Plastic, Aesthetic, Hand and Reconstructive Surgery, Burn Center, Hannover Medical School, Hannover, Germany
| | - Andreas Schroeter
- Department of Plastic, Aesthetic, Hand and Reconstructive Surgery, Burn Center, Hannover Medical School, Hannover, Germany
- Division of Transplant Surgery, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Barbara Kern
- Department of Plastic Surgery, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Vikram Mookerjee
- Division of Plastic Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, United States
| | - Christine G. Lian
- Department of Pathology, Brigham and Women’s Hospital, Boston, MA, United States
| | - Stefan G. Tullius
- Division of Transplant Surgery, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - George F. Murphy
- Department of Pathology, Brigham and Women’s Hospital, Boston, MA, United States
| | - Bohdan Pomahac
- Division of Plastic Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, United States
| | - Martin Kauke-Navarro
- Division of Plastic Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, United States
| |
Collapse
|
10
|
Quantification of Facial Allograft Edema During Acute Rejection: A Software-Based 3-Dimensional Analysis. Ann Plast Surg 2022; 89:326-330. [PMID: 35993687 DOI: 10.1097/sap.0000000000003274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Acute rejection (AR) is a common complication in facial transplant (FT) patients associated with allograft edema and erythema. Our study aims to demonstrate the feasibility of using software-based 3-dimensional (3D) facial analysis to quantify edema as it resolves during/after AR treatment in an FT patient. METHODS Our patient is a 23-year-old man who underwent a face and bilateral hand allotransplant in August 2020. The Vectra H1 (Canfield, Fairfield, NJ) portable scanner was used to capture 3D facial images at 8 time points between postoperative day (POD) 392 and 539. The images were analyzed with the Vectra Software using a rejection-free image (POD 539) as a control. RESULTS Edema increased in the periorbital, lower third, and submandibular regions before AR treatment (POD 392-415). At POD 448, total facial edema was reduced to near baseline values in response to plasmapheresis and thymoglobulin (+156.94 to +28.2 mL). The fastest and most notable response to treatment was seen in the periorbital region, while some edema remained in the submandibular (+19.79 mL) and right lower third (+8.65 mL) regions. On POD 465, after the initial improvement, the edema increased but was resolved with steroid use. Facial edema did not correlate with the histopathological evaluation in our patient. CONCLUSIONS We demonstrated the feasibility of analyzing 3D facial images to quantify edema during/after AR treatment in an FT patient. Our analysis detected edema changes consistent with AR followed by an improvement after treatment. This technology shows promise for noninvasive monitoring of FT patients.
Collapse
|
11
|
Burlage LC, Lellouch AG, Taveau CB, Tratnig-Frankl P, Pendexter CA, Randolph MA, Porte RJ, Lantieri LA, Tessier SN, Cetrulo CL, Uygun K. Optimization of Ex Vivo Machine Perfusion and Transplantation of Vascularized Composite Allografts. J Surg Res 2022; 270:151-161. [PMID: 34670191 PMCID: PMC8712379 DOI: 10.1016/j.jss.2021.09.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 08/30/2021] [Accepted: 09/16/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Machine perfusion is gaining interest as an efficient method of tissue preservation of Vascularized Composite Allografts (VCA). The aim of this study was to develop a protocol for ex vivo subnormothermic oxygenated machine perfusion (SNMP) on rodent hindlimbs and to validate our protocol in a heterotopic hindlimb transplant model. METHODS In this optimization study we compared three different solutions during 6 h of SNMP (n = 4 per group). Ten control limbs were stored in a preservation solution on Static Cold Storage [SCS]). During SNMP we monitored arterial flowrate, lactate levels, and edema. After SNMP, muscle biopsies were taken for histology examination, and energy charge analysis. We validated the best perfusion protocol in a heterotopic limb transplantation model with 30-d follow up (n = 13). As controls, we transplanted untreated limbs (n = 5) and hindlimbs preserved with either 6 or 24 h of SCS (n = 4 and n = 5). RESULTS During SNMP, arterial outflow increased, and lactate clearance decreased in all groups. Total edema was significantly lower in the HBOC-201 group compared to the BSA group (P = 0.005), 4.9 (4.3-6.1) versus 48.8 (39.1-53.2) percentage, but not to the BSA + PEG group (P = 0.19). Energy charge levels of SCS controls decreased 4-fold compared to limbs perfused with acellular oxygen carrier HBOC-201, 0.10 (0.07-0.17) versus 0.46 (0.42-0.49) respectively (P = 0.002). CONCLUSIONS Six hours ex vivo SNMP of rodent hindlimbs using an acellular oxygen carrier HBOC-201 results in superior tissue preservation compared to conventional SCS.
Collapse
Affiliation(s)
- Laura C. Burlage
- Center for Engineering in Medicine and Surgery, Department of Surgery, Massachusetts General Hospital/ Harvard Medical School, Boston, MA, USA,Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands,Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Boston, MA, USA,Division of Plastic and Reconstructive Surgery within the Department of Surgery, Massachusetts General Hospital/ Harvard Medical School, Boston, MA, USA,Shriners Hospitals for Children, Boston, MA USA,Corresponding author:
| | - Alexandre G. Lellouch
- Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Boston, MA, USA,Division of Plastic and Reconstructive Surgery within the Department of Surgery, Massachusetts General Hospital/ Harvard Medical School, Boston, MA, USA,Division of Plastic and Reconstructive Surgery within the Department of Surgery, European George Pompidou Hospital, University of Paris, Paris, France,Shriners Hospitals for Children, Boston, MA USA
| | - Corentin B. Taveau
- Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Boston, MA, USA,Division of Plastic and Reconstructive Surgery within the Department of Surgery, Massachusetts General Hospital/ Harvard Medical School, Boston, MA, USA,Division of Plastic and Reconstructive Surgery within the Department of Surgery, European George Pompidou Hospital, University of Paris, Paris, France,Shriners Hospitals for Children, Boston, MA USA
| | - Philipp Tratnig-Frankl
- Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Boston, MA, USA,Division of Plastic and Reconstructive Surgery within the Department of Surgery, Massachusetts General Hospital/ Harvard Medical School, Boston, MA, USA,Shriners Hospitals for Children, Boston, MA USA
| | - Casie A. Pendexter
- Center for Engineering in Medicine and Surgery, Department of Surgery, Massachusetts General Hospital/ Harvard Medical School, Boston, MA, USA,Shriners Hospitals for Children, Boston, MA USA
| | - Mark A. Randolph
- Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Boston, MA, USA,Division of Plastic and Reconstructive Surgery within the Department of Surgery, Massachusetts General Hospital/ Harvard Medical School, Boston, MA, USA,Shriners Hospitals for Children, Boston, MA USA
| | - Robert J. Porte
- Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands
| | - Laurent A. Lantieri
- Division of Plastic and Reconstructive Surgery within the Department of Surgery, European George Pompidou Hospital, University of Paris, Paris, France
| | - Shannon N. Tessier
- Center for Engineering in Medicine and Surgery, Department of Surgery, Massachusetts General Hospital/ Harvard Medical School, Boston, MA, USA,Shriners Hospitals for Children, Boston, MA USA
| | - Curtis L. Cetrulo
- Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Boston, MA, USA,Division of Plastic and Reconstructive Surgery within the Department of Surgery, Massachusetts General Hospital/ Harvard Medical School, Boston, MA, USA,Shriners Hospitals for Children, Boston, MA USA
| | - Korkut Uygun
- Center for Engineering in Medicine and Surgery, Department of Surgery, Massachusetts General Hospital/ Harvard Medical School, Boston, MA, USA,Shriners Hospitals for Children, Boston, MA USA
| |
Collapse
|
12
|
Valdivia E, Rother T, Yuzefovych Y, Hack F, Wenzel N, Blasczyk R, Krezdorn N, Figueiredo C. Genetic modification of limbs using ex vivo machine perfusion. Hum Gene Ther 2021; 33:460-471. [PMID: 34779223 DOI: 10.1089/hum.2021.199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Genetic engineering is a promising tool to repair genetic disorders, improve graft function or to reduce immune responses towards the allografts. Ex vivo organ perfusion systems have the potential to mitigate ischemic-reperfusion injury, prolong preservation time or even rescue organ function. We aim to combine both technologies to develop a modular platform allowing the genetic modification of vascularized composite (VC) allografts. Rat hind limbs were perfused ex vivo under subnormothermic conditions with lentiviral vectors. Specific perfusion conditions such as controlled pressure, temperature and flow rates were optimized to support the genetic modification of the limbs. Genetic modification was detected in vascular, muscular and dermal limb tissues. Remarkably, skin follicular and interfollicular keratinocytes as well as endothelial cells (ECs) showed stable transgene expression. Furthermore, levels of injury markers such as lactate, myoglobin and lactate dehydrogenase (LDH) as well as histological analyses showed that ex vivo limb perfusion with lentiviral vectors did not cause tissue damage and limb cytokine secretion signatures were not significantly affected. The use of ex vivo VC perfusion in combination with lentiviral vectors allows an efficient and stable genetic modification of limbs representing a robust platform to genetically engineer limbs towards increasing graft survival after transplantation.
Collapse
Affiliation(s)
- Emilio Valdivia
- Hannover Medical School, 9177, Institute of Transfusion Medicine and Transplant Engineering, Hannover, Niedersachsen, Germany;
| | - Tamina Rother
- Hannover Medical School, 9177, Institute of Transfusion Medicine and Transplant Engineering, Hannover, Niedersachsen, Germany;
| | - Yuliia Yuzefovych
- Hannover Medical School, 9177, Institute of Transfusion Medicine and Transplant Engineering, Hannover, Niedersachsen, Germany;
| | - Franziska Hack
- Hannover Medical School, 9177, Institute of Transfusion Medicine and Transplant Engineering, Hannover, Niedersachsen, Germany;
| | - Nadine Wenzel
- Hannover Medical School, 9177, Institute of Transfusion Medicine and Transplant Engineering, Hannover, Niedersachsen, Germany;
| | - Rainer Blasczyk
- Hannover Medical School, 9177, Institute of Transfusion Medicine and Transplant Engineering, Hannover, Niedersachsen, Germany;
| | - Nicco Krezdorn
- Hannover Medical School, 9177, Clinic for Plastic, Aesthetic, Hand and Reconstructive Surgery, Hannover, Niedersachsen, Germany;
| | - Constanca Figueiredo
- Hannover Medical School, 9177, Institute of Transfusion Medicine and Transplant Engineering, Hannover, Niedersachsen, Germany;
| |
Collapse
|
13
|
Stone JP, Amin KR, Geraghty A, Kerr J, Shaw M, Dabare D, Wong JK, Brough D, Entwistle TR, Montero-Fernandez A, Fildes JE. Renal hemofiltration prevents metabolic acidosis and reduces inflammation during normothermic machine perfusion of the vascularized composite allograft-A preclinical study. Artif Organs 2021; 46:259-272. [PMID: 34662442 DOI: 10.1111/aor.14089] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 09/16/2021] [Accepted: 09/24/2021] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Recent experimental evidence suggests normothermic machine perfusion of the vascularized composite allograft results in improved preservation compared to static cold storage, with less reperfusion injury in the immediate post-operative period. However, metabolic acidosis is a common feature of vascularized composite allograft perfusion, primarily due to the inability to process metabolic by-products. We evaluated the impact of combined limb-kidney perfusion on markers of metabolic acidosis and inflammation in a porcine model. METHODS Ten paired pig forelimbs were used for this study, grouped as either limb-only (LO, n = 5) perfusion, or limb-kidney (LK, n = 5) perfusion. Infrared thermal imaging was used to determine homogeneity of perfusion. Lactate, bicarbonate, base, pH, and electrolytes, along with an inflammatory profile generated via the quantification of cytokines and cell-free DNA in the perfusate were recorded. RESULTS The addition of a kidney to a limb perfusion circuit resulted in the rapid stabilization of lactate, bicarbonate, base, and pH. Conversely, the LO circuit became progressively acidotic, correlating in a significant increase in pro-inflammatory cytokines. Global perfusion across the limb was more homogenous with LK compared to LO. CONCLUSION The addition of a kidney during limb perfusion results in significant improvements in perfusate biochemistry, with no evidence of metabolic acidosis.
Collapse
Affiliation(s)
- John P Stone
- The Ex-Vivo Research Centre, Nether Alderley, UK.,The Ex-Vivo Lab, Division of Cell Matrix Biology and Regenerative Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Kavit R Amin
- The Ex-Vivo Research Centre, Nether Alderley, UK.,The Ex-Vivo Lab, Division of Cell Matrix Biology and Regenerative Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.,Blond McIndoe Laboratories, Division of Cell Matrix Biology and Regenerative Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.,Department of Plastic Surgery & Burns, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Abbey Geraghty
- The Ex-Vivo Lab, Division of Cell Matrix Biology and Regenerative Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Jak Kerr
- The Ex-Vivo Research Centre, Nether Alderley, UK.,The Ex-Vivo Lab, Division of Cell Matrix Biology and Regenerative Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Matthew Shaw
- The Ex-Vivo Lab, Division of Cell Matrix Biology and Regenerative Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Dilan Dabare
- Department of Nephrology and Transplantation, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Jason K Wong
- Blond McIndoe Laboratories, Division of Cell Matrix Biology and Regenerative Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.,Department of Plastic Surgery & Burns, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - David Brough
- Division of Neuroscience and Experimental Psychology, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Timothy R Entwistle
- The Ex-Vivo Research Centre, Nether Alderley, UK.,The Ex-Vivo Lab, Division of Cell Matrix Biology and Regenerative Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Angeles Montero-Fernandez
- The Ex-Vivo Lab, Division of Cell Matrix Biology and Regenerative Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.,Department of Pathology, Manchester Foundation Trust, Manchester, UK
| | - James E Fildes
- The Ex-Vivo Research Centre, Nether Alderley, UK.,The Ex-Vivo Lab, Division of Cell Matrix Biology and Regenerative Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| |
Collapse
|
14
|
Kiefer J, Diehm Y, Germann G, Kneser U, Terness P, Radu CA. [Immunosuppressive effect of mitomycin C-treated peripheral mononuclear blood cells (MICs) in vascularised composite allotransplantation]. HANDCHIR MIKROCHIR P 2021; 53:389-399. [PMID: 33412589 DOI: 10.1055/a-1261-3447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND Vascularized Composite Allotransplantation (VCA) enables the restoration of complex tissue defects. Since the first successful hand and face transplants were performed, clinical and experimental research has consistently improved immunosuppressive therapies. The incubation of peripheral blood mononuclear cells (PBMCs) with mitomycin C (MMC) results in immunomodulatory cells (MICs). In previous studies, the systemic application of MICs on the day of allogeneic hind limb transplantation led to a significant immunosuppression in rats. The aim of this study is to further investigate the optimal point in time of MIC application in a complex VCA model. MATERIAL AND METHODS In six groups, 60 allogeneic hind limb transplantations were performed. Fully mismatched rats were used as hind limb donors [Lewis (LEW)] and recipients [Brown-Norway (BN)]. Group A received donor-derived MICs seven days preoperatively. Group B received no immunosuppression; group C received untreated PBMCs seven days prior to transplantation. Animals in group D received cell culture media, whereas group E was treated with a standard immunosuppression consisting of tacrolimus and prednisolone. In group F, syngeneic hind limb transplantations (BN→BN) were performed. Transplant rejection was assessed clinically and histologically. RESULTS Group A showed a significantly earlier onset of allograft rejection after 3.5 ± 0.2 days (p < 0.01) when compared with control groups B, C and D (5.5 ± 0.7, 5.3 ± 0.7 und 5.7 ± 0.5). Groups E and F showedno allograft rejection. CONCLUSION This study shows that the time of application determines the immunomodulatory effects of MICs. Whereas the systemic application of MICs on the day of transplantation led to a significant immunosuppression in previous studies, this study demonstrates that preoperative injections of MICs lead to an acceleration of allotransplant rejection. Follow-up studies are necessary to investigate further modifications of application time as well as dose-effect relations and cell characteristics of these potential immunosuppressive cells.
Collapse
Affiliation(s)
- Jurij Kiefer
- BG Unfallklinik Ludwigshafen, Klinik f. Hand-, Plast. u. Rekonstr. Chirurgie, Schwerbrandverletztenzentrum
| | - Yannick Diehm
- BG Klinik Ludwigshafen, Klinik für Hand, Plastische und Rekonstruktive Chirurgie, Plastische Chirurgie der Universität Heidelberg, Schwerbrandverletztenzentrum
| | - Günter Germann
- ETHIANUM - Klinik für Plastische und Rekonstruktive Chirurgie Ästhetische Chirurgie
| | - Ulrich Kneser
- BG Unfallklinik Ludwigshafen und Ruprecht-Karls-Universität Heidelberg, Klinik für Hand, Plastische und Rekonstruktive Chirurgie, Schwerbrandverletztenzentrum, Klinik für Plastische Chirurgie
| | - Peter Terness
- UniversitätsKlinikum Heidelberg, Abteilung für Transplantationsimmunologie
| | - Christian Andreas Radu
- BG Unfallklinik Ludwigshafen, Klinik f. Hand-, Plast. u. Rekonstr. Chirurgie, Schwerbrandverletztenzentrum
| |
Collapse
|
15
|
Fleissig YY, Beare JE, LeBlanc AJ, Kaufman CL. Evolution of the rat hind limb transplant as an experimental model of vascularized composite allotransplantation: Approaches and advantages. SAGE Open Med 2020; 8:2050312120968721. [PMID: 33194200 PMCID: PMC7607771 DOI: 10.1177/2050312120968721] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 09/04/2020] [Indexed: 11/16/2022] Open
Abstract
As clinical experience with surgical techniques and immunosuppression in vascularized composite allotransplantation recipients has accumulated, vascularized composite allotransplantation for hand and face have become standard of care in some countries for select patients who have experienced catastrophic tissue loss. Experience to date suggests that clinical vascularized composite allotransplantation grafts undergo the same processes of allograft rejection as solid organ grafts. Nonetheless, there are some distinct differences, especially with respect to the immunologic influence of the skin and how the graft is affected by environmental and traumatic insults. Understanding the mechanisms around these similarities and differences has the potential to not only improve vascularized composite allotransplantation outcomes but also outcomes for all types of transplants and to contribute to our understanding of how complex systems of immunity and function work together. A distinct disadvantage in the study of upper extremity vascularized composite allotransplantation recipients is the low number of clinical transplants performed each year. As upper extremity transplantation is a quality of life rather than a lifesaving transplant, these numbers are not likely to increase significantly until the risks of systemic immunosuppression can be reduced. As such, experimental models of vascularized composite allotransplantation are essential to test hypotheses regarding unique characteristics of graft rejection and acceptance of vascularized composite allotransplantation allografts. Rat hind limb vascularized composite allotransplantation models have been widely used to address these questions and provide essential proof-of-concept findings which can then be extended to other experimental models, including mice and large animal models, as new concepts are translated to the clinic. Here, we review the large body of rat hind limb vascularized composite allotransplantation models in the literature, with a focus on the various surgical models that have been developed, contrasting the characteristics of the specific model and how they have been applied. We hope that this review will assist other researchers in choosing the most appropriate rat hind limb transplantation model for their scientific interests.
Collapse
Affiliation(s)
- Yoram Y Fleissig
- Christine M. Kleinert Institute for Hand and Microsurgery, Louisville, KY, USA
| | - Jason E Beare
- The Cardiovascular Innovation Institute, The University of Louisville, Louisville, KY, USA
| | - Amanda J LeBlanc
- The Cardiovascular Innovation Institute, The University of Louisville, Louisville, KY, USA
| | - Christina L Kaufman
- Department of Cardiovascular and Thoracic Surgery, The University of Louisville, Louisville, KY, USA
| |
Collapse
|
16
|
Mechanical Irritation in Vascularized Composite Tissue Allotransplantation Triggers Localized Skin Rejection. Transplantation 2020; 104:956-969. [PMID: 31929424 DOI: 10.1097/tp.0000000000003075] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Mechanical and thermal stress has been observed to trigger skin rejection in hand-transplanted patients. This study aims to investigate this phenomenon. METHODS Syngeneic and allogeneic orthotopic hindlimb transplantations were performed using male rats (Brown Norway to Lewis). Using a specially designed device, standardized mechanical skin irritation at a force of 5 N was applied to the planta pedis of the transplanted limb for 10 days, 4 times daily for 10 minutes. Biopsies, taken on day 10 and after a 5-day observational period, were assessed for macroscopic alterations using a standardized scale, by histopathology and immunohistochemistry, and for inflammatory protein expression using Luminex technology. RESULTS Allogeneic animals displayed significant aggravated macroscopic skin alterations compared with naive (P < 0.0001) and syngeneic controls (P = 0.0023). Histopathology showed a trend toward higher rejection/inflammation grades in allogeneic animals compared with syngeneic controls. Minor skin alterations in syngeneic limbs recovered quickly; however, in allogeneic limbs, macroscopic skin alterations were significantly more pronounced (P < 0.0001) 5 days after irritation. Interleukin-1b and interferon-γ levels were upregulated in skin of allogeneic limbs. CONCLUSIONS Mechanical skin irritation in vascularized composite allotransplantation can trigger localized skin inflammation consistent with rejection.
Collapse
|
17
|
Kaufman CL, Kanitakis J, Weissenbacher A, Brandacher G, Mehra MR, Amer H, Zelger BG, Zelger B, Pomahac B, McDiarmid S, Cendales L, Morelon E. Defining chronic rejection in vascularized composite allotransplantation-The American Society of Reconstructive Transplantation and International Society of Vascularized Composite Allotransplantation chronic rejection working group: 2018 American Society of Reconstructive Transplantation meeting report and white paper Research goals in defining chronic rejection in vascularized composite allotransplantation. SAGE Open Med 2020; 8:2050312120940421. [PMID: 32704373 PMCID: PMC7361482 DOI: 10.1177/2050312120940421] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Accepted: 09/20/2019] [Indexed: 12/12/2022] Open
Abstract
Objectives: This report summarizes a collaborative effort between the American Society of Reconstructive Transplantation and the International Society of Vascularized Composite Allotransplantation to establish what is known about chronic rejection in recipients of vascularized composite allografts, with an emphasis on upper extremity and face transplants. As a picture of chronic rejection in hand and face vascularized composite allografts emerges, the results will be applied to other types of vascularized composite allografts, such as uterine transplantation. Methods: The overall goal is to develop a definition of chronic rejection in vascularized composite allografts so that we can establish longitudinal correlates of factors such as acute rejection, immunosuppressive therapy, de novo donor-specific antibody and trauma/infection and other external factors on the development of chronic rejection. As Dr Kanitakis eloquently stated at the 2017 International Society of Vascularized Composite Allotransplantation meeting in Salzburg, “Before we can correlate causative factors of chronic rejection, we have to define what chronic rejection in VCA is.” Results: The first meeting report was presented at the sixth Biennial meeting of the American Society of Reconstructive Transplantation in November 2018. Based on collaborative efforts and descriptions of clinical cases of chronic rejection in vascularized composite allograft recipients, a working definition of chronic rejection in vascularized composite allografts with respect to overt functional decline, subclinical functional decline, histologic evidence without functional decline, and normal allograft function in the absence of histologic evidence of chronic rejection is proposed. Conclusions: It is the intent of this collaborative working group that these working definitions will help to focus ongoing research to define the incidence, risk factors and treatment regimens that will identify mechanisms of chronic rejection in vascularized composite allografts. As with all good research, our initial efforts have generated more questions than answers. We hope that this is the first of many updates.
Collapse
Affiliation(s)
| | - Jean Kanitakis
- Department of Dermatology, Ed. Herriot Hospital, Lyon, France
| | | | | | | | | | | | | | | | - Sue McDiarmid
- Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | | | - Emmanuel Morelon
- Department of Transplantation, Nephrology and Clinical Immunology, Ed. Herriot Hospital, Lyon, France
| |
Collapse
|
18
|
Colazo JM, Evans BC, Farinas AF, Al-Kassis S, Duvall CL, Thayer WP. Applied Bioengineering in Tissue Reconstruction, Replacement, and Regeneration. TISSUE ENGINEERING PART B-REVIEWS 2020; 25:259-290. [PMID: 30896342 DOI: 10.1089/ten.teb.2018.0325] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
IMPACT STATEMENT The use of autologous tissue in the reconstruction of tissue defects has been the gold standard. However, current standards still face many limitations and complications. Improving patient outcomes and quality of life by addressing these barriers remain imperative. This article provides historical perspective, covers the major limitations of current standards of care, and reviews recent advances and future prospects in applied bioengineering in the context of tissue reconstruction, replacement, and regeneration.
Collapse
Affiliation(s)
- Juan M Colazo
- 1Vanderbilt University School of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.,2Medical Scientist Training Program, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Brian C Evans
- 3Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee
| | - Angel F Farinas
- 4Department of Plastic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Salam Al-Kassis
- 4Department of Plastic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Craig L Duvall
- 3Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee
| | - Wesley P Thayer
- 3Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee.,4Department of Plastic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| |
Collapse
|
19
|
Guo Y, Messner F, Etra JW, Beck SE, Kalsi R, Furtmüller GJ, Schneeberger S, Chol Oh B, Brandacher G. Efficacy of single-agent immunosuppressive regimens in a murine model of vascularized composite allotransplantation. Transpl Int 2020; 33:948-957. [PMID: 32299127 DOI: 10.1111/tri.13618] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 01/24/2020] [Accepted: 04/10/2020] [Indexed: 01/18/2023]
Abstract
We herein investigate the safety and efficacy of single-agent anti-rejection regimens in a mouse vascularized composite allotransplantation (VCA) model. Orthotopic hind-limb transplantations (Balb/c → C57BL/6) were performed using 6- to 8-week-old mice. A thirty-day regimen of either rapamycin, tacrolimus (both 1, 3, 5 mg/kg/day) or cyclosporine (25, 35, 50 mg/kg/day) was used. Primary endpoints were animal and graft survival, and secondary chimerism and regulatory T-cell levels. For rapamycin and tacrolimus given at 1, 3, and 5 mg/kg/day, median graft survival time (MST) was 23 days (18-28 days), 30 days (23-30 days), and 30 d (30-30 days) and 14 days (13-18 days), 30 days (16-30 days), and 30 days (30-30 days), respectively. For cyclosporine dosed at 25 and 35 mg/kg/day, MST was 15 days (12-18 days) and 21 days (14-27 days). Toxicity from CsA 50 mg/kg led to 100% mortality. Mixed chimerism levels were higher in rapamycin-treated animals than in tacrolimus-treated recipients (P = 0.029). Tacrolimus was superior in preventing leukocyte recruitment to the allograft. In murine VCA, no standardized immunosuppressive regimen exists, limiting comparability of outcomes and survival. Our data demonstrate that rapamycin and tacrolimus maintenance treatment at 5 mg/kg/day both yielded allograft survival (<grade 3 rejection) in all animals. Rapamycin displayed less toxicity and maintained mixed chimerism but was not as potent in controlling leukocyte recruitment compared with tacrolimus.
Collapse
Affiliation(s)
- Yinan Guo
- Vascularized Composite Allotransplantation (VCA) Laboratory, Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Hand and Microsurgery, Xiangya Hospital, Central South University, Hunan, China
| | - Franka Messner
- Vascularized Composite Allotransplantation (VCA) Laboratory, Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Joanna W Etra
- Vascularized Composite Allotransplantation (VCA) Laboratory, Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sarah E Beck
- Department of Molecular and Comparative Pathobiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Richa Kalsi
- Vascularized Composite Allotransplantation (VCA) Laboratory, Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Surgery, University of Maryland Medical Center, Baltimore, MD, USA
| | - Georg J Furtmüller
- Vascularized Composite Allotransplantation (VCA) Laboratory, Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Stefan Schneeberger
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Byoung Chol Oh
- Vascularized Composite Allotransplantation (VCA) Laboratory, Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Gerald Brandacher
- Vascularized Composite Allotransplantation (VCA) Laboratory, Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| |
Collapse
|
20
|
Haug V, Kollar B, Obed D, Kiwanuka H, Turk M, Wo L, Tasigiorgos S, Kueckelhaus M, Riella LV, Pomahac B. The Evolving Clinical Presentation of Acute Rejection in Facial Transplantation. JAMA FACIAL PLAST SU 2020; 21:278-285. [PMID: 30998810 DOI: 10.1001/jamafacial.2019.0076] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Importance Acute rejection is one of the most frequent complications in facial transplantation, with potentially severe consequences for the recipient if overlooked. Clinical signs, such as erythema or edema, are helpful to diagnose acute rejection in the early follow-up stage; however, it is not well known whether these clinical signs remain reliable markers of acute rejection beyond the second posttransplant year. Objective To determine the diagnostic value of clinical signs of acute rejection after facial transplantation over time. Design, Setting, and Participants A retrospective, single-center cohort study was conducted of patients who underwent facial transplantation at Brigham and Women's Hospital between April 2009 and October 2014, with up to an 8-year follow-up. Medical records were reviewed until September 30, 2017. The medical records from 104 encounters with 7 patients who underwent partial or full facial transplantation were analyzed for symptoms of rejection, immunosuppressive therapy, and histopathologic findings. Main Outcomes and Measures The occurrence of 5 clinical signs of acute rejection were evaluated: erythema, edema, exanthema, suture line erythema, and mucosal lesions. Odds ratios (ORs) were calculated to determine the statistically significant association of these signs with the histopathologic diagnosis of rejection. In addition, tacrolimus blood levels, as a surrogate marker of immunosuppressive therapy, were evaluated. Results Of the 7 patients included in the study, 5 were men. The mean follow-up was 66 months (range, 35-101). Of 104 clinical encounters, 46 encounters (44.2%) represented rejection episodes and 58 encounters (55.8%) represented no-rejection episodes. Beyond 2 years posttransplantation, only erythema (OR, 6.53; 95% CI, 1.84-20.11; P = .004) and exanthema (OR, ∞; 95% CI, 2.2-∞; P = .004) were demonstrated to be reliable clinical signs of acute rejection in facial transplantation. There was also a statistically significant association of subtherapeutic tacrolimus levels with late rejection episodes (OR, 3.79; 95% CI, 1.25-12.88; P = .03). In addition, the occurrence of subclinical rejection was more frequent during later follow-up times (7 [24.1%] late rejections vs 1 [5.9%] early rejection). Five of 8 subclinical rejections (62.5%) were associated with subtherapeutic tacrolimus levels. Conclusions and Relevance Clinical signs of acute rejection in facial transplantation appear to be of limited diagnostic value, particularly after the second postoperative year. Until alternative biomarkers for rejection are identified, protocol skin biopsies will remain necessary for guiding assessments of allograft rejection. Level of Evidence 3.
Collapse
Affiliation(s)
- Valentin Haug
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Department of Hand, Plastic and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Branislav Kollar
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Doha Obed
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Harriet Kiwanuka
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Marvee Turk
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Luccie Wo
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sotirios Tasigiorgos
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Maximillian Kueckelhaus
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Leonardo V Riella
- Schuster Transplantation Research Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Bohdan Pomahac
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
21
|
Kollar B, Uffing A, Borges TJ, Shubin AV, Aoyama BT, Dagot C, Haug V, Kauke M, Safi AF, Talbot SG, Morelon E, Dakpe S, Pomahac B, Riella LV. MMP3 Is a Non-invasive Biomarker of Rejection in Skin-Bearing Vascularized Composite Allotransplantation: A Multicenter Validation Study. Front Immunol 2019; 10:2771. [PMID: 31849957 PMCID: PMC6897344 DOI: 10.3389/fimmu.2019.02771] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 11/12/2019] [Indexed: 12/17/2022] Open
Abstract
Background: There is unmet need for non-invasive immunomonitoring to improve diagnosis and treatment of acute rejection in vascularized composite allotransplantation (VCA). Circulating matrix metalloproteinase 3 (MMP3) was described as a candidate non-invasive biomarker to predict treatment response to acute rejection in clinical VCA. However, larger validation studies are yet to be reported to allow for more definitive conclusions. Methods: We retrospectively measured MMP3 levels using ELISA in a total of 140 longitudinal serum samples from six internal and three external face transplant recipients, as well as three internal and seven external upper extremity transplant recipients. The control groups comprised serum samples from 36 kidney transplant recipients, 14 healthy controls, and 38 patients with autoimmune skin disease. A linear mixed model was used to study the effect of rejection state (pre-transplant, no-rejection, non-severe rejection (NSR), and severe rejection) on MMP3 levels. Results: In VCA, MMP3 levels increased significantly (p < 0.001) between pre- and post-transplant no-rejection states. A further increase occurred during severe rejection (p < 0.001), while there was no difference in MMP3 levels between non-severe and no-rejection episodes. A threshold of 5-fold increase from pre-transplant levels could discriminate severe from NSR with 76% sensitivity and 81% specificity (AUC = 0.79, 95% CI = 0.65–0.92, p < 0.001). In kidney transplantation, the MMP3 levels were significantly (p < 0.001) elevated during antibody-mediated rejection but not during T-cell mediated rejection (TCMR) (p = 0.547). MMP3 levels in healthy controls and autoimmune skin disease patients were comparable with either pre-transplant or no-rejection/NSR episodes of VCA patients. Conclusion: The results of this study suggest that serum MMP3 protein is a promising marker for stratifying patients according to severity of rejection, complementary to biopsy findings.
Collapse
Affiliation(s)
- Branislav Kollar
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, United States
| | - Audrey Uffing
- Renal Division, Schuster Transplantation Research Center, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, United States
| | - Thiago J Borges
- Renal Division, Schuster Transplantation Research Center, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, United States
| | - Andrey V Shubin
- Department of Molecular and Cellular Biology, Harvard University, Cambridge, MA, United States
| | - Bruno T Aoyama
- Renal Division, Schuster Transplantation Research Center, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, United States
| | - Céline Dagot
- Department of Transplantation, Nephrology and Clinical Immunology, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
| | - Valentin Haug
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, United States.,Department of Hand, Plastic and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Martin Kauke
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, United States
| | - Ali-Farid Safi
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, United States
| | - Simon G Talbot
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, United States
| | - Emmanuel Morelon
- Department of Transplantation, Nephrology and Clinical Immunology, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
| | - Stéphanie Dakpe
- Department of Maxillo-Facial Surgery, Amiens University Hospital, Amiens, France
| | - Bohdan Pomahac
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, United States
| | - Leonardo V Riella
- Renal Division, Schuster Transplantation Research Center, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, United States
| |
Collapse
|
22
|
Farias-Cisneros E, Chilton PM, Palazzo MD, Ozyurekoglu T, Hoying JB, Williams SK, Baughman C, Jones CM, Kaufman CL. Infrared imaging of lymphatic function in the upper extremity of normal controls and hand transplant recipients via subcutaneous indocyanine green injection. SAGE Open Med 2019; 7:2050312119862670. [PMID: 31312452 PMCID: PMC6614946 DOI: 10.1177/2050312119862670] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Objectives: The goal of this study was to define the parameters of movement of indocyanine green in the upper extremity of normal control and hand transplant recipients. The purpose was to establish a non-invasive method of determining the level of lymphatic function in hand transplant recipients. In hand transplantation (and replantation), the deep lymphatic vessels are rarely repaired, resulting in altered lymphatic connections. In most cases, the relatively rapid inosculation of superficial lymphatic networks and drainage via the venous systems results in sufficient interstitial fluid and lymph drainage of the graft to prevent edema. However, our group and others have determined that some transplant recipients demonstrate chronic edema which is associated with lymphatic stasis. In one case, a patient with chronic edema has developed chronic rejection characterized by thinning of the skin, loss of adnexal structures, and fibrosis and contracture of the hand. Methods: Lymphatic function was evaluated by intradermal administration of near-infrared fluorescent dye, indocyanine green, and dynamic imaging with an infrared camera system (LUNA). To date, the assessment of lymphatic drainage in the upper extremity by clearance of indocyanine green dye has been studied primarily in oncology patients with abnormal lymphatic function, making assessment of normal drainage problematic. To establish normal parameters, indocyanine green lymphatic clearance functional tests were performed in a series of normal controls, and subsequently compared with indocyanine green clearance in hand transplant recipients. Results: The results demonstrate varied patterns of lymphatic drainage in the hand transplant patients that partially mimic normal hand lymphatic drainage, but also share characteristics of lymphedema patients defined in other studies. The study revealed significant deceleration of the dye drainage in the allograft of a patient with suspected chronic rejection and edema of the graft. Analysis of other hand transplant recipients revealed differing levels of dye deceleration, often localized at the level of surgical anastomosis. Conclusion: These studies suggest intradermal injection of indocyanine green and near-infrared imaging may be a useful clinical tool to assess adequacy of lymphatic function in hand transplant recipients.
Collapse
Affiliation(s)
| | - Paula M Chilton
- Christine M. Kleinert Institute for Hand and Microsurgery, Louisville, KY, USA
| | - Michelle D Palazzo
- Christine M. Kleinert Institute for Hand and Microsurgery, Louisville, KY, USA
| | - Tuna Ozyurekoglu
- Christine M. Kleinert Institute for Hand and Microsurgery, Louisville, KY, USA
| | - Jay B Hoying
- Cardiovascular Innovation Institute, Louisville, KY, USA
| | | | - Carter Baughman
- Christine M. Kleinert Institute for Hand and Microsurgery, Louisville, KY, USA
| | - Christopher M Jones
- Jewish Hospital Transplant Center, Jewish Hospital, KentuckyOne Health, Louisville, KY, USA
| | - Christina L Kaufman
- Christine M. Kleinert Institute for Hand and Microsurgery, Louisville, KY, USA
| |
Collapse
|
23
|
Kaufman CL, Bhutiani N, Ramirez A, Tien HY, Palazzo MD, Galvis E, Farner S, Ozyurekoglu T, Jones CM. Current Status of Vascularized Composite Allotransplantation. Am Surg 2019. [DOI: 10.1177/000313481908500628] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The field of vascularized composite allotransplantation (VCA) has moved from a highly experimental procedure to, at least for some patients, one of the best treatment alternatives for catastrophic tissue loss or dysfunction. Although the worldwide experience is still limited, progress has been made in translation to the clinic, and hand transplantation was recently designated standard of care and is now covered in full by the British Health System. This progress is tempered by the long-term challenges of systemic immunosuppression, and the rapidly evolving indications for VCA such as urogenital transplantation. This update will cover the state of and recent changes in the field, and an update of the Louisville VCA program as our initial recipient, the first person to receive a hand transplant in the United States celebrates the 20th anniversary of his transplant. The achievements and complications encountered over the last two decades will be reviewed. In addition, potential directions for research and collaboration as well as practical issues of how third party payers and funding are affecting growth of the field are presented.
Collapse
|
24
|
Iske J, Nian Y, Maenosono R, Maurer M, Sauer IM, Tullius SG. Composite tissue allotransplantation: opportunities and challenges. Cell Mol Immunol 2019; 16:343-349. [PMID: 30842628 PMCID: PMC6462029 DOI: 10.1038/s41423-019-0215-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 02/04/2019] [Accepted: 02/05/2019] [Indexed: 12/24/2022] Open
Abstract
Vascularized composite allotransplants (VCAs) have unique properties because of diverse tissue components transplanted en mass as a single unit. In addition to surgery, this type of transplant also faces enormous immunological challenges that demand a detailed analysis of all aspects of alloimmune responses, organ preservation, and injury, as well as the immunogenicity of various tissues within the VCA grafts to further improve graft and patient outcomes. Moreover, the side effects of long-term immunosuppression for VCA patients need to be carefully balanced with the potential benefit of a non-life-saving procedure. In this review article, we provide a comprehensive update on limb and face transplantation, with a specific emphasis on the alloimmune responses to VCA, established and novel immunosuppressive treatments, and patient outcomes.
Collapse
Affiliation(s)
- Jasper Iske
- Division of Transplant Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Institute of Transplant Immunology, Integrated Research and Treatment Center Transplantation, Hannover Medical School, Hannover, Lower Saxony, Germany
| | - Yeqi Nian
- Division of Transplant Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ryoichi Maenosono
- Division of Transplant Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Max Maurer
- Department of Surgery, Charité - Universitätsmedizin Berlin, Campus Charité Mitte and Virchow-Klinikum, Berlin, Germany
| | - Igor M Sauer
- Department of Surgery, Charité - Universitätsmedizin Berlin, Campus Charité Mitte and Virchow-Klinikum, Berlin, Germany
| | - Stefan G Tullius
- Division of Transplant Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
- Einstein-BIH Visiting Fellow, Department of Surgery, Charité-Universitätsmedizin Berlin, Campus Charité Mitte and Virchow-Klinikumc, Berlin, Germany.
| |
Collapse
|
25
|
Novel immunological and clinical insights in vascularized composite allotransplantation. Curr Opin Organ Transplant 2019; 24:42-48. [DOI: 10.1097/mot.0000000000000592] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
|
26
|
Increased levels of circulating MMP3 correlate with severe rejection in face transplantation. Sci Rep 2018; 8:14915. [PMID: 30297859 PMCID: PMC6175842 DOI: 10.1038/s41598-018-33272-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Accepted: 09/26/2018] [Indexed: 12/16/2022] Open
Abstract
Face transplantation is a viable treatment option for carefully selected patients with devastating injuries to the face. However, acute rejection episodes occur in more than 80% of recipients in the first postoperative year. Unfortunately, neither a correlation between histological grades of rejection and anti-rejection treatment nor systemic surrogate markers of rejection in face transplantation are established in clinical routine. Therefore, we utilized next generation aptamer-based SOMAscan proteomics platform for non-invasive rejection biomarker discovery. Longitudinal serum samples from face transplant recipients with long-term follow-up were included in this study. From the 1,310 proteins analyzed by SOMAscan, a 5-protein signature (MMP3, ACY1, IL1R2, SERPINA4, CPB2) was able to discriminate severe rejection from both no-rejection and nonsevere rejection samples. Technical validation on ELISA platform showed high correlation with the SOMAscan data for the MMP3 protein (rs = 0.99). Additionally, MMP3 levels were significantly increased during severe rejection as compared to no-rejection (p = 0.0009) and nonsevere rejection (p = 0.0173) episodes. Pathway analyses revealed significant activation of the metallopeptidase activity during severe face transplant rejection. This pilot study demonstrates the feasibility of SOMAscan to identify non-invasive candidate biomarkers of rejection in face transplantation. Further validation in a larger independent patient cohort is needed.
Collapse
|
27
|
Kollar B, Pomahac B. Facial restoration by transplantation. Surgeon 2018; 16:245-249. [PMID: 29490887 DOI: 10.1016/j.surge.2018.01.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 01/12/2018] [Indexed: 12/16/2022]
Abstract
Hundred years ago, Sir Harold Gillies laid a foundation to the modern plastic surgery trying to reconstruct facial defects of severely disfigured soldiers of World War I. Some years later, Joseph Murray experimented with rejection of skin grafts aimed for treatment of burned patients who sustained their injuries on battlefields of World War II. In 1954, the acquired expertise and intensive research allowed him to perform the first successful kidney transplantation in the world at Peter Bent Brigham Hospital in Boston. For his achievements in organ transplantation he was awarded Nobel Prize in 1990. The face transplantation appears to be a natural evolution of the work of these two extraordinary plastic surgeons. The first case of partial face transplant from 2005 in France revealed the world that facial restoration by transplantation is superior to conventional reconstruction methods. Since 2009, our team has performed 7 cases of face transplantation at Brigham and Women's Hospital, which is to our best knowledge the largest living single center face transplant cohort in the world. In this article, we want to reflect on the experience with face transplantation at our institution from the past years. We aim to briefly review the key points of the know-how which was given to us from the care of these unique patients.
Collapse
Affiliation(s)
- Branislav Kollar
- Department of Surgery, Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Bohdan Pomahac
- Department of Surgery, Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| |
Collapse
|
28
|
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.
Collapse
|
29
|
Donor-specific antibodies and antibody-mediated rejection in vascularized composite allotransplantation. Curr Opin Organ Transplant 2017; 21:510-5. [PMID: 27517505 DOI: 10.1097/mot.0000000000000349] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
PURPOSE OF REVIEW The presence of donor-specific antibodies (DSA) increases the risk of graft failure. Although DSA characteristics, human leukocyte antigen class specificity, mean fluorescence intensity and immunoglobulin G subclasses, and their impact on the graft are quite well studied in solid organ transplants, very little information is known about their impact on vascularized composite allotransplantation (VCA). The aim of this review is to highlight recent publications regarding occurrence and effects of DSA, their follow-up and treatment in the field of VCA. RECENT FINDINGS The latest publications dealing with antibody-mediated rejection in VCA are mainly case presentations and reports embedded in reviews. The most important findings shown were the demonstration of the severe clinical impact of de-novo DSA and the urgent need of finding a therapeutic strategy for patients with acute antibody-mediated rejection. Suggested protocols for desensitization of possible candidates for reconstructive transplantation have been published, as these individuals are often highly sensitized and not appropriate patients for a standard surgical procedure because of their major tissue defects. SUMMARY The functional outcome of reconstructive transplantation has clearly exceeded the results achieved with conventional surgical techniques. The recipients' immune response, particularly development of DSA and the long-term adherence, which is probably associated with the occurrence of chronic rejection, remain a challenge.
Collapse
|
30
|
Datta N, Devaney SG, Busuttil RW, Azari K, Kupiec-Weglinski JW. Prolonged Cold Ischemia Time Results in Local and Remote Organ Dysfunction in a Murine Model of Vascularized Composite Transplantation. Am J Transplant 2017; 17:2572-2579. [PMID: 28371289 DOI: 10.1111/ajt.14290] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Revised: 03/01/2017] [Accepted: 03/19/2017] [Indexed: 01/25/2023]
Abstract
Vascularized composite allotransplantation (VCA) is a viable reconstructive option for complex tissue defects. Although grafts with a large muscular component may be uniquely susceptible to ischemia-reperfusion (I/R) syndrome, the safe cold ischemia time in VCA has not been established. We investigated the effects of cold ischemia on innate immune response and recipient survival in a murine orthotopic hindlimb transplantation model. Surprisingly, mice receiving grafts exposed to 6 h or longer of cold storage demonstrated reduced survival and massive elevations in serum creatinine, blood urea nitrogen, and creatine kinase, compared with 1 h of cold storage recipients. This was accompanied by progressive increase in macrophage and neutrophil cell infiltration in muscle biopsy specimens, altered platelet endothelial cell adhesion molecule-1 expression, and ultimate renal injury. Multiplex immunoassay analysis identified 21 cytokines in serum and 18 cytokines in muscle biopsy specimens that are likely essential in the complex response to I/R-triggered injury in VCA. In conclusion, this study, in a mouse model of orthotopic hindlimb transplantation, is the first to document that prolonged cold ischemia triggers progressive I/R injury with vascular endothelial damage and may lead to irrecoverable local and remote organ damage. These experimental findings are important in guiding future therapies for human VCA recipients.
Collapse
Affiliation(s)
- Neha Datta
- The Dumont-UCLA Transplantation Center, Department of Surgery, Division of Liver and Pancreas Transplantation, David Geffen School of Medicine at University of California, Los Angeles, CA
| | - S G Devaney
- The Dumont-UCLA Transplantation Center, Department of Surgery, Division of Liver and Pancreas Transplantation, David Geffen School of Medicine at University of California, Los Angeles, CA
| | - R W Busuttil
- The Dumont-UCLA Transplantation Center, Department of Surgery, Division of Liver and Pancreas Transplantation, David Geffen School of Medicine at University of California, Los Angeles, CA
| | - K Azari
- The Dumont-UCLA Transplantation Center, Department of Surgery, Division of Liver and Pancreas Transplantation, David Geffen School of Medicine at University of California, Los Angeles, CA
| | - J W Kupiec-Weglinski
- The Dumont-UCLA Transplantation Center, Department of Surgery, Division of Liver and Pancreas Transplantation, David Geffen School of Medicine at University of California, Los Angeles, CA
| |
Collapse
|
31
|
|
32
|
Wekerle T, Oberbauer R. Never stand still. Transpl Int 2016; 30:5. [PMID: 28032406 DOI: 10.1111/tri.12908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
|
33
|
Kamińska D, Kościelska-Kasprzak K, Krajewska M, Chełmoński A, Jabłecki J, Żabińska M, Myszka M, Banasik M, Boratyńska M, Gomółkiewicz A, Dzięgiel P, Klinger M. Immune activation- and regulation-related patterns in stable hand transplant recipients. Transpl Int 2016; 30:144-152. [DOI: 10.1111/tri.12883] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Revised: 06/06/2016] [Accepted: 11/02/2016] [Indexed: 11/26/2022]
Affiliation(s)
- Dorota Kamińska
- Department of Nephrology and Transplantation Medicine; Wroclaw Medical University; Wroclaw Poland
| | | | - Magdalena Krajewska
- Department of Nephrology and Transplantation Medicine; Wroclaw Medical University; Wroclaw Poland
| | - Adam Chełmoński
- Subdepartment of Replantation of Limbs; St. Hedwig of Silesia Hospital; Trzebnica Poland
| | - Jerzy Jabłecki
- Subdepartment of Replantation of Limbs; St. Hedwig of Silesia Hospital; Trzebnica Poland
| | - Marcelina Żabińska
- Department of Nephrology and Transplantation Medicine; Wroclaw Medical University; Wroclaw Poland
| | - Marta Myszka
- Department of Nephrology and Transplantation Medicine; Wroclaw Medical University; Wroclaw Poland
| | - Mirosław Banasik
- Department of Nephrology and Transplantation Medicine; Wroclaw Medical University; Wroclaw Poland
| | - Maria Boratyńska
- Department of Nephrology and Transplantation Medicine; Wroclaw Medical University; Wroclaw Poland
| | | | - Piotr Dzięgiel
- Department of Histology and Embryology; Wroclaw Medical University; Wroclaw Poland
| | - Marian Klinger
- Department of Nephrology and Transplantation Medicine; Wroclaw Medical University; Wroclaw Poland
| |
Collapse
|