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Knoedler L, Dean J, Diatta F, Thompson N, Knoedler S, Rhys R, Sherwani K, Ettl T, Mayer S, Falkner F, Kilian K, Panayi AC, Iske J, Safi AF, Tullius SG, Haykal S, Pomahac B, Kauke-Navarro M. Immune modulation in transplant medicine: a comprehensive review of cell therapy applications and future directions. Front Immunol 2024; 15:1372862. [PMID: 38650942 PMCID: PMC11033354 DOI: 10.3389/fimmu.2024.1372862] [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: 01/18/2024] [Accepted: 03/22/2024] [Indexed: 04/25/2024] Open
Abstract
Balancing the immune response after solid organ transplantation (SOT) and vascularized composite allotransplantation (VCA) remains an ongoing clinical challenge. While immunosuppressants can effectively reduce acute rejection rates following transplant surgery, some patients still experience recurrent acute rejection episodes, which in turn may progress to chronic rejection. Furthermore, these immunosuppressive regimens are associated with an increased risk of malignancies and metabolic disorders. Despite significant advancements in the field, these IS related side effects persist as clinical hurdles, emphasizing the need for innovative therapeutic strategies to improve transplant survival and longevity. Cellular therapy, a novel therapeutic approach, has emerged as a potential pathway to promote immune tolerance while minimizing systemic side-effects of standard IS regiments. Various cell types, including chimeric antigen receptor T cells (CAR-T), mesenchymal stromal cells (MSCs), regulatory myeloid cells (RMCs) and regulatory T cells (Tregs), offer unique immunomodulatory properties that may help achieve improved outcomes in transplant patients. This review aims to elucidate the role of cellular therapies, particularly MSCs, T cells, Tregs, RMCs, macrophages, and dendritic cells in SOT and VCA. We explore the immunological features of each cell type, their capacity for immune regulation, and the prospective advantages and obstacles linked to their application in transplant patients. An in-depth outline of the current state of the technology may help SOT and VCA providers refine their perioperative treatment strategies while laying the foundation for further trials that investigate cellular therapeutics in transplantation surgery.
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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
| | - Jillian Dean
- School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Fortunay Diatta
- Division of Plastic Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, United States
| | - Noelle Thompson
- University of Toledo College of Medicine and Life Sciences, Toledo, OH, United States
| | - Samuel Knoedler
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Richmond Rhys
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Khalil Sherwani
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, Berufsgenossenschaft (BG) Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Tobias Ettl
- Department of Dental, Oral and Maxillofacial Surgery, Regensburg, Germany
| | - Simon Mayer
- University of Toledo College of Medicine and Life Sciences, Toledo, OH, United States
| | - Florian Falkner
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, Berufsgenossenschaft (BG) Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Katja Kilian
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, Berufsgenossenschaft (BG) Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Adriana C. Panayi
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, Berufsgenossenschaft (BG) Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Jasper Iske
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité, Berlin, Germany
- Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Ali-Farid Safi
- Faculty of Medicine, University of Bern, Bern, Switzerland
- Craniologicum, Center for Cranio-Maxillo-Facial Surgery, Bern, Switzerland
| | - Stefan G. Tullius
- Division of Transplant Surgery, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Siba Haykal
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Bohdan Pomahac
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Martin Kauke-Navarro
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
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Ton C, Salehi S, Abasi S, Aggas JR, Liu R, Brandacher G, Guiseppi-Elie A, Grayson WL. Methods of ex vivo analysis of tissue status in vascularized composite allografts. J Transl Med 2023; 21:609. [PMID: 37684651 PMCID: PMC10492401 DOI: 10.1186/s12967-023-04379-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 07/21/2023] [Indexed: 09/10/2023] Open
Abstract
Vascularized composite allotransplantation can improve quality of life and restore functionality. However, the complex tissue composition of vascularized composite allografts (VCAs) presents unique clinical challenges that increase the likelihood of transplant rejection. Under prolonged static cold storage, highly damage-susceptible tissues such as muscle and nerve undergo irreversible degradation that may render allografts non-functional. Skin-containing VCA elicits an immunogenic response that increases the risk of recipient allograft rejection. The development of quantitative metrics to evaluate VCAs prior to and following transplantation are key to mitigating allograft rejection. Correspondingly, a broad range of bioanalytical methods have emerged to assess the progression of VCA rejection and characterize transplantation outcomes. To consolidate the current range of relevant technologies and expand on potential for development, methods to evaluate ex vivo VCA status are herein reviewed and comparatively assessed. The use of implantable physiological status monitoring biochips, non-invasive bioimpedance monitoring to assess edema, and deep learning algorithms to fuse disparate inputs to stratify VCAs are identified.
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Affiliation(s)
- Carolyn Ton
- Department of Biomedical Engineering, Johns Hopkins University, 400 North Broadway, Smith Building 5023, Baltimore, MD, 21231, USA
- Translational Tissue Engineering Center, Johns Hopkins University, 400 North Broadway, Smith Building 5023, Baltimore, MD, 21231, USA
| | - Sara Salehi
- Department of Biomedical Engineering, Johns Hopkins University, 400 North Broadway, Smith Building 5023, Baltimore, MD, 21231, USA
- Translational Tissue Engineering Center, Johns Hopkins University, 400 North Broadway, Smith Building 5023, Baltimore, MD, 21231, USA
| | - Sara Abasi
- Department of Biomedical Engineering, Center for Bioelectronics, Biosensors and Biochips (C3B®), Texas A&M University, Emerging Technologies Building 3120, 101 Bizzell St, College Station, TX, 77843, USA
- Department of Electrical and Computer Engineering, Center for Bioelectronics, Biosensors and Biochips (C3B®), Texas A&M University, Emerging Technologies Building 3120, 101 Bizzell St, College Station, TX, 77843, USA
- Media and Metabolism, Wildtype, Inc., 2325 3rd St., San Francisco, CA, 94107, USA
| | - John R Aggas
- Department of Biomedical Engineering, Center for Bioelectronics, Biosensors and Biochips (C3B®), Texas A&M University, Emerging Technologies Building 3120, 101 Bizzell St, College Station, TX, 77843, USA
- Department of Electrical and Computer Engineering, Center for Bioelectronics, Biosensors and Biochips (C3B®), Texas A&M University, Emerging Technologies Building 3120, 101 Bizzell St, College Station, TX, 77843, USA
- Test Development, Roche Diagnostics, 9115 Hague Road, Indianapolis, IN, 46256, USA
| | - Renee Liu
- Department of Biomedical Engineering, Johns Hopkins University, 400 North Broadway, Smith Building 5023, Baltimore, MD, 21231, USA
- Translational Tissue Engineering Center, Johns Hopkins University, 400 North Broadway, Smith Building 5023, Baltimore, MD, 21231, USA
| | - Gerald Brandacher
- Department of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation (VCA) Laboratory, Reconstructive Transplantation Program, Center for Advanced Physiologic Modeling (CAPM), Johns Hopkins University, Ross Research Building/Suite 749D, 720 Rutland Avenue, Baltimore, MD, 21205, USA.
| | - Anthony Guiseppi-Elie
- Department of Biomedical Engineering, Center for Bioelectronics, Biosensors and Biochips (C3B®), Texas A&M University, Emerging Technologies Building 3120, 101 Bizzell St, College Station, TX, 77843, USA.
- Department of Electrical and Computer Engineering, Center for Bioelectronics, Biosensors and Biochips (C3B®), Texas A&M University, Emerging Technologies Building 3120, 101 Bizzell St, College Station, TX, 77843, USA.
- Department of Cardiovascular Sciences, Houston Methodist Institute for Academic Medicine and Houston Methodist Research Institute, 6670 Bertner Ave., Houston, TX, USA.
- ABTECH Scientific, Inc., Biotechnology Research Park, 800 East Leigh Street, Richmond, VA, USA.
| | - Warren L Grayson
- Department of Biomedical Engineering, Johns Hopkins University, 400 North Broadway, Smith Building 5023, Baltimore, MD, 21231, USA.
- Translational Tissue Engineering Center, Johns Hopkins University, 400 North Broadway, Smith Building 5023, Baltimore, MD, 21231, USA.
- Department of Chemical and Biomolecular Engineering, Johns Hopkins University, Baltimore, MD, USA.
- Department of Materials Science and Engineering, Johns Hopkins University, Baltimore, MD, USA.
- Institute for Nanobiotechnology, Johns Hopkins University, Baltimore, MD, USA.
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Zhang L, Hoyos IA, Zubler C, Rieben R, Constantinescu M, Olariu R. Challenges and opportunities in vascularized composite allotransplantation of joints: a systematic literature review. Front Immunol 2023; 14:1179195. [PMID: 37275912 PMCID: PMC10235447 DOI: 10.3389/fimmu.2023.1179195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 05/08/2023] [Indexed: 06/07/2023] Open
Abstract
Background Joint allotransplantation (JA) within the field of vascularized composite allotransplantation (VCA) holds great potential for functional and non-prosthetic reconstruction of severely damaged joints. However, clinical use of JA remains limited due to the immune rejection associated with all forms of allotransplantation. In this study, we aim to provide a comprehensive overview of the current state of JA through a systematic review of clinical, animal, and immunological studies on this topic. Methods We conducted a systematic literature review in accordance with the PRISMA guidelines to identify relevant articles in PubMed, Cochrane Library, and Web of Science databases. The results were analyzed, and potential future prospects were discussed in detail. Results Our review included 14 articles describing relevant developments in JA. Currently, most JA-related research is being performed in small animal models, demonstrating graft survival and functional restoration with short-term immunosuppression. In human patients, only six knee allotransplantations have been performed to date, with all grafts ultimately failing and a maximum graft survival of 56 months. Conclusion Research on joint allotransplantation has been limited over the last 20 years due to the rarity of clinical applications, the complex nature of surgical procedures, and uncertain outcomes stemming from immune rejection. However, the key to overcoming these challenges lies in extending graft survival and minimizing immunosuppressive side effects. With the emergence of new immunosuppressive strategies, the feasibility and clinical potential of vascularized joint allotransplantation warrants further investigation.
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Affiliation(s)
- Lei Zhang
- Department of Plastic and Hand Surgery, Inselspital University Hospital Bern, University of Bern, Bern, Switzerland
- Department for BioMedical Research, University of Bern, Bern, Switzerland
- Department of Plastic and Reconstructive Surgery, Plastic and Reconstructive Surgery Center, Zhejiang Provincial People’s Hospital, Hangzhou, China
| | - Isabel Arenas Hoyos
- Department of Plastic and Hand Surgery, Inselspital University Hospital Bern, University of Bern, Bern, Switzerland
- Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - Cédric Zubler
- Department of Plastic and Hand Surgery, Inselspital University Hospital Bern, University of Bern, Bern, Switzerland
| | - Robert Rieben
- Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - Mihai Constantinescu
- Department of Plastic and Hand Surgery, Inselspital University Hospital Bern, University of Bern, Bern, Switzerland
| | - Radu Olariu
- Department of Plastic and Hand Surgery, Inselspital University Hospital Bern, University of Bern, Bern, Switzerland
- Department for BioMedical Research, University of Bern, Bern, Switzerland
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A Systematic Review of the Reported Complications Related to Facial and Upper Extremity Vascularized Composite Allotransplantation. J Surg Res 2023; 281:164-175. [PMID: 36162189 DOI: 10.1016/j.jss.2022.08.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 08/02/2022] [Accepted: 08/20/2022] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Twenty three years after the first successful upper extremity transplantation, the role of vascularized composite allotransplantation (VCA) in the world of transplantation remains controversial. Face and upper extremity reconstruction via transplantation have become successful options for highly selected patients with severe tissue and functional deficit when conventional reconstructive options are no longer available. Despite clear benefit in these situations, VCA has a significant potential for complications that are more frequent when compared to visceral organ transplantation. This study intended to perform an updated systematic review on such complications. MATERIALS AND METHODS MEDLINE database via PubMed, Embase and Cochrane Library were searched. Face and upper extremity VCA performed between 1998 and 2021 were included in the study. Relevant media and press conferences reports were also included. Complications related to face and upper extremity VCA were recorded and reviewed including their clinical characteristics and complications. RESULTS One hundred fifteen patients underwent facial (43%) or upper extremity (57%) transplantation. Overall, the surgical complication rate was 23%. Acute and chronic rejection was identified in 89% and 11% of patients, respectively. Fifty eight percent of patients experienced opportunistic infection. Impaired glucose metabolism was the most common immunosuppression-related complication other than infection. Nineteen percent of patients ultimately experienced partial or complete allograft loss. CONCLUSIONS Complications related to VCA are a significant source of morbidity and potential mortality. Incidence of such complications is higher than previously reported and should be strongly emphasized in patient consent process. Strict patient selection criteria, complex preoperative evaluation, consideration of alternatives, and thorough disclosure to patients should be routinely performed prior to VCA indication.
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Fortunato AC, Pinheiro RS, Matsumoto CS, Arantes RM, Rocha-Santos V, Nacif LS, Waisberg DR, Ducatti L, Martino RB, Carneiro-D’Albuquerque L, Andraus W. Techniques for Closing the Abdominal Wall in Intestinal and Multivisceral Transplantation: A Systematic Review. Ann Transplant 2022; 27:e934595. [PMID: 35228508 PMCID: PMC8897964 DOI: 10.12659/aot.934595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 01/13/2022] [Indexed: 11/09/2022] Open
Abstract
Short bowel syndrome is the most common etiology of intestinal failure, resulting from either resections of different intestinal segments or a congenital condition. Due to the absence or considerable reduction of intestinal loops in the abdominal cavity, patients with short bowel syndrome present with atrophy and muscle retraction of the abdominal wall, which leads to loss of abdominal domain and elasticity. This complication is an aggravating factor of intestinal transplantation since it can prevent the primary closure of the abdominal wall. A vast array of surgical techniques to overcome the challenges of the complexity of the abdominal wall have been described in the literature. The aim of our study was to review the modalities of abdominal wall closure in intestinal/multivisceral transplantation. Our study consisted of a systematic review following the methodological instructions described in the PRISMA guidelines. Duplicate studies and studies that did not meet the criteria for the systematic review were excluded, especially those without relevance and an explicit relationship with the investigated theme. After this step, 63 articles were included in our study. The results obtained with these techniques have been encouraging, but a high incidence of wound complications in some reports has raised concerns. There is no consensus among transplantation centers regarding which technique would be ideal and with higher success rates and lower rates of complications.
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Affiliation(s)
- Allana C. Fortunato
- Department of Gastroenterology, Clinics Hospital of the University of São Paulo, São Paulo, SP, Brazil
| | - Rafael S. Pinheiro
- Department of Gastroenterology, Clinics Hospital of the University of São Paulo, São Paulo, SP, Brazil
| | - Cal S. Matsumoto
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Rubens M. Arantes
- Department of Gastroenterology, Clinics Hospital of the University of São Paulo, São Paulo, SP, Brazil
| | - Vinicius Rocha-Santos
- Department of Gastroenterology, Clinics Hospital of the University of São Paulo, São Paulo, SP, Brazil
| | - Lucas S. Nacif
- Department of Gastroenterology, Clinics Hospital of the University of São Paulo, São Paulo, SP, Brazil
| | - Daniel R. Waisberg
- Department of Gastroenterology, Clinics Hospital of the University of São Paulo, São Paulo, SP, Brazil
| | - Liliana Ducatti
- Department of Gastroenterology, Clinics Hospital of the University of São Paulo, São Paulo, SP, Brazil
| | - Rodrigo B. Martino
- Department of Gastroenterology, Clinics Hospital of the University of São Paulo, São Paulo, SP, Brazil
| | | | - Wellington Andraus
- Department of Gastroenterology, Clinics Hospital of the University of São Paulo, São Paulo, SP, Brazil
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Successful transatlantic bilateral hand transplant in a young female highly sensitized to HLA class II antigens. Transpl Immunol 2021; 65:101377. [PMID: 33610677 DOI: 10.1016/j.trim.2021.101377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 02/14/2021] [Accepted: 02/14/2021] [Indexed: 11/21/2022]
Abstract
Vascularized composite allografts may be more susceptible to rejection than other types of organ transplants, particularly in sensitized recipients. We describe a successful transatlantic bilateral hand transplant in a 40-year old woman who was highly sensitized to class II HLA antigens including HLA-DPB1 (UNet CPRA = 86%). Prior to transplantation, we selected an upper limb donor based on HLA class II matching and absence of donor specific antibodies, given evidence that class II mismatches are associated with acute cellular rejection in hand transplants. The patient was conditioned using five doses of thymoglobulin, and her immunosuppression included tacrolimus, rapamycin, mycophenolate, and prednisone. Post-transplant, the patient non-DSA anti-HLA antibody levels drastically increased, but only transiently and weak DSAs developed, which became undetectable by two months posttransplant. Following transplantation, periodic biopsies over 6 months indicated no evidence of rejection except for transient Banff grade 1 and one sample with grade 2 acute rejection. There was no evidence of rejection on her recent 1-year follow-up. The patient is currently healthy, has recovered protective sensibility, and is regaining excellent function. This case highlights the importance of pre-transplantation planning, donor selection/compatibility, and ethical considerations in the ultimate success of VCA.
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Lymphocytic Vasculitis Associated With Mild Rejection in a Vascularized Composite Allograft Recipient: A Clinicopathological Study. Transplantation 2020; 104:e208-e213. [PMID: 32235257 DOI: 10.1097/tp.0000000000003241] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Histologic criteria for diagnosing acute rejection in vascularized composite tissue allograft (VCA) have been established by the Banff 2007 Working Classification of Skin-Containing Composite Tissue Allograft, but the role of early vascular lesions in graft rejection warrants additional analysis. METHODS We performed a retrospective study of 34 skin biopsies performed over 430 d for rejection surveillance, in Canada's first face allotransplant recipient. Three observers reviewed all biopsies to assess the nature and intensity of the inflammatory skin infiltrate. A complete histological and immunohistochemical review of the vascular components was performed with a focus on lymphocytic vasculitis, intravascular fibrin, vessel caliber, extent of injury, C4d positivity, and inflammatory cell phenotyping. We then correlated these data points to clinical and immunosuppression parameters. RESULTS Acute vascular damage in biopsies that would be classified as mild acute rejection correlates with troughs in immunosuppression and subsides when immunosuppressive tacrolimus doses are increased. Grade 0 Banff rejection and Grade I without lymphocytic vasculitis were almost indistinguishable, whereas Grade I with lymphocytic vasculitis was an easy and reproducible histologic finding. CONCLUSIONS Our results highlight the possible relevance of vascular injury in the context of VCA, as its presence might underlie a more aggressive form of immune rejection. If these findings are validated in other VCA patients, vascular injury in mild rejection might warrant a different clinical approach.
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Giannis D, Moris D, Cendales LC. Costimulation Blockade in Vascularized Composite Allotransplantation. Front Immunol 2020; 11:544186. [PMID: 33042138 PMCID: PMC7527523 DOI: 10.3389/fimmu.2020.544186] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 08/19/2020] [Indexed: 12/14/2022] Open
Abstract
Vascular composite allotransplantation (VCA) is a field under research and has emerged as an alternative option for the repair of severe disfiguring defects that result from infections or traumatic amputation in a selected group of patients. VCA is performed in centers with appropriate expertise, experience and adequate resources to effectively manage the complexity and complications of this treatment. Lifelong immunosuppressive therapy, immunosuppression associated complications, and the effects of the host immune response in the graft are major concerns in VCA. VCA is considered a quality of life transplant and the risk-benefit ratio is dissimilar to life saving transplants. Belatacept seems a promising drug that prolongs patient and graft survival in kidney transplantation and it could also be an alternative approach to VCA immunosuppression. In this review, we are summarizing current literature about the role of costimulation blockade, with a focus on belatacept in VCA.
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Affiliation(s)
- Dimitrios Giannis
- Institute of Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, NY, United States
| | - Dimitrios Moris
- Duke Surgery, Duke University Medical Center, Durham, NC, United States
| | - Linda C. Cendales
- Duke Surgery, Duke University Medical Center, Durham, NC, United States
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Di Stefano AB, Pappalardo M, Moschella F, Cordova A, Toia F. MicroRNAs in solid organ and vascularized composite allotransplantation: Potential biomarkers for diagnosis and therapeutic use. Transplant Rev (Orlando) 2020; 34:100566. [PMID: 32682704 DOI: 10.1016/j.trre.2020.100566] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 06/23/2020] [Accepted: 06/30/2020] [Indexed: 12/24/2022]
Abstract
Nowadays, solid organ transplantation (SOT) is an established treatment for patients with end-organ dysfunction, which dramatically improves the quality-of-life. Vascularized composite allotransplants (VCAs) including hand and face have been reported worldwide over the last 20 years. However, VCAs, differently to SOT, are life-enhancing instead of life-saving and are not routinely performed due to the risk of immune rejection and the adverse effects of immunosuppression. Over the past decade, although considerable improvements in short-term outcomes after allotransplantation have been registered, these results have not been translated into major progress in long-term allograft acceptance and patient survival. Recently active researches in the field of biomarker discovery have been conducted to develop individualized therapies for allograft recipients. MicroRNAs (miRNAs) are a small noncoding RNAs functioning as critical regulators of gene and protein expression by RNA interference. They have been connected in numerous biological processes and diseases. Due to their immunomodulatory functions, miRNAs have been amended as potential diagnostic and prognostic biomarker for the detection of rejection in allotransplantation. Due to their specific circulating expression profile, they could act as noninvasive predictive tools for rejection that may help clinicians in an early adjustment of the immunosuppression protocol during acute rejections episodes. Indeed, specific anti-sense oligonucleotides suppressing miRNAs expressed in rejection could reduce the rejection rate in allografts and decrease the use of immunosuppressants. We present a literature review of the immunomodulatory properties and characteristics of miRNAs. We will summarize the current knowledge on miRNAs as potential biomarkers for allograft rejection and possible application in allotransplantation monitoring. Finally, we will discuss the advances in preclinical miRNA-based therapies for immunosuppression.
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Affiliation(s)
- Anna Barbara Di Stefano
- BIOPLAST-Laboratory of BIOlogy and Regenerative Medicine-PLASTic Surgery, Plastic and Reconstructive Surgery Section, Department of Surgical, Oncological and Oral Sciences, University of Palermo, 90127 Palermo, Italy.
| | - Marco Pappalardo
- BIOPLAST-Laboratory of BIOlogy and Regenerative Medicine-PLASTic Surgery, Plastic and Reconstructive Surgery Section, Department of Surgical, Oncological and Oral Sciences, University of Palermo, 90127 Palermo, Italy.
| | - Francesco Moschella
- BIOPLAST-Laboratory of BIOlogy and Regenerative Medicine-PLASTic Surgery, Plastic and Reconstructive Surgery Section, Department of Surgical, Oncological and Oral Sciences, University of Palermo, 90127 Palermo, Italy.
| | - Adriana Cordova
- BIOPLAST-Laboratory of BIOlogy and Regenerative Medicine-PLASTic Surgery, Plastic and Reconstructive Surgery Section, Department of Surgical, Oncological and Oral Sciences, University of Palermo, 90127 Palermo, Italy; Plastic and Reconstructive Surgery Section, Department of Surgical, Oncological and Oral Sciences, University of Palermo, 90127 Palermo, Italy; Plastic and Reconstructive Unit, Department of Oncology, Azienda Ospedaliera Universitaria Policlinico "Paolo Giaccone", 90127 Palermo, Italy.
| | - Francesca Toia
- BIOPLAST-Laboratory of BIOlogy and Regenerative Medicine-PLASTic Surgery, Plastic and Reconstructive Surgery Section, Department of Surgical, Oncological and Oral Sciences, University of Palermo, 90127 Palermo, Italy; Plastic and Reconstructive Surgery Section, Department of Surgical, Oncological and Oral Sciences, University of Palermo, 90127 Palermo, Italy; Plastic and Reconstructive Unit, Department of Oncology, Azienda Ospedaliera Universitaria Policlinico "Paolo Giaccone", 90127 Palermo, Italy.
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10
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Abstract
: Vascularized composite allotransplantation (VCA) is a relatively new field in reconstructive medicine. Likely a result of the unique tissue composition of these allografts-including skin and often a bone marrow component-the immunology and rejection patterns do not always mimic those of the well-studied solid organ transplantations. While the number and type of VCAs performed is rapidly expanding, there is still much to be discovered and understood in the field. With more patients, new findings and patterns emerge and add to our understanding of VCA. Here, we present a case report of an upper extremity transplant recipient with trauma-induced rejection.
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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.
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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
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12
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Etra JW, Grzelak MJ, Fidder SA, Kolegraff K, Bonawitz S, Shores J, Oh B, Cooney DS, Beck SE, Brandacher G. A Skin Rejection Grading System for Vascularized Composite Allotransplantation in a Preclinical Large Animal Model. Transplantation 2019; 103:1385-1391. [PMID: 31241555 PMCID: PMC6613727 DOI: 10.1097/tp.0000000000002695] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 02/13/2019] [Accepted: 02/14/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND The Banff Criteria have been accepted as a system for grading histological rejection in graft skin in human vascularized composite allotransplantation (VCA). Preclinical swine hindlimb transplantation models have an important role in translational studies in VCA. However, unified grading criteria for rejection in swine skin have not yet been established. METHODS Two hundred fourteen swine skin biopsy specimens were reviewed, including 88 native skin biopsies and 126 specimens from the skin component of heterotopic swine hindlimb transplants. Thorough review was performed in a blinded fashion by an expert veterinary pathologist with attention paid to the applicability of the Banff criteria as well as specific histologic characteristics and trends. Clinical and histopathologic rejection scores were then directly compared. RESULTS Two hundred fourteen specimens reviewed showed significant similarities between swine and human skin, as previously published. Notable swine-specific characteristics, including paucicellular infiltration with rare epidermal cell infiltration or necrosis, were accounted for in a proposed grading system that parallels the Banff Criteria. CONCLUSIONS This comprehensive grading system, based on the Banff Classification for skin rejection in VCA, provides a standardized system for more accurate comparison of rejection in preclinical swine VCA models.
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Affiliation(s)
- Joanna W. Etra
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation (VCA) Laboratory, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Michael J. Grzelak
- Department of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation (VCA) Laboratory, Johns Hopkins University School of Medicine, Baltimore, MD
- Johns Hopkins University School of Medicine, Baltimore, MD
| | - Samuel A.J. Fidder
- Department of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation (VCA) Laboratory, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Keli Kolegraff
- Department of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation (VCA) Laboratory, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Steven Bonawitz
- Department of Surgery, Cooper Medical School of Rowan University, Camden, NJ
| | - Jaimie Shores
- Department of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation (VCA) Laboratory, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Byoungchol Oh
- Department of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation (VCA) Laboratory, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Damon S. Cooney
- Department of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation (VCA) Laboratory, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sarah E. Beck
- Department of Molecular and Comparative Pathobiology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Gerald Brandacher
- Department of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation (VCA) Laboratory, Johns Hopkins University School of Medicine, Baltimore, MD
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The Urogenital Epithelium and Corporal Tissues Are the Primary Targets of Rejection in Penile Vascularized Composite Allotransplantation: A New Real-Time Tissue-Based Monitoring System. Plast Reconstr Surg 2019; 143:534e-544e. [PMID: 30817651 DOI: 10.1097/prs.0000000000005377] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Although significant surgical advances have been made in the form of microvascular surgery and autologous free tissue transfer, penile reconstruction still poses several difficult challenges. Although interest in penile vascularized composite allotransplantation has grown since the first attempted transplant in 2006, little is known regarding the kinetics of rejection and subsequent function of penile allografts. The penis contains multiple tissue types that are not qualified by the Banff 2007 vascularized composite allotransplantation classification system, including urogenital mucosal epithelium and erectile tissues. In this study, the authors investigate the propagation of rejection and the resultant function following rejection in rat and human penile tissues. METHODS Rejected human and rat penile tissues were examined using an ex vivo real-time tissue-based derivative of the classic mixed lymphocyte reaction assay to determine the interactions occurring between en bloc penile tissues and peripheral blood mononuclear cells (autologous and allogeneic). Correlative in vivo heterotopic rat penile vascularized composite allotransplantation was used to correlate ex vivo findings. RESULTS In both human and rat ex vivo systems and in vivo rat vascularized composite allotransplantation, the urethral mucosa was the first to undergo rejection-associated apoptosis. The urethral mucosa was the most immunogenic and led to the highest level of peripheral blood mononuclear cell proliferative generations in all systems, whereas the neural tissues of the penis remained immune privileged. CONCLUSION These findings are the first to describe the kinetics of rejection in both human and rat penile vascularized composite allotransplantation and that the urethral mucosa is the most antigenic, suffering the highest level of rejection-associated apoptosis and peripheral blood mononuclear cell proliferative aggregation.
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14
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Abstract
PURPOSE OF REVIEW For patients with devastating injuries in whom standard reconstruction is not an option, vascularized composite allotransplantation (VCA) has become a viable means of restoring form and function. However, immunological rejection continues to be a problem in VCA and has not yet been fully characterized. As the field is relatively new, much of the data on rejection and immunosuppression have been extrapolated from that of solid organ transplantation. In this review, we cover the basic mechanisms of rejection as they relate specifically to VCA with analysis of recent literature and future directions. RECENT FINDINGS Recent clinical studies have supported previously postulated T-cell-mediated mechanism of acute rejection and have also made strides in differentiating rejection from inflammation from other skin conditions and with different treatment regimens. Antibody-mediated rejection has been described in recent cases as well as treatment of presensitized patients receiving VCAs. With more long-term grafts, chronic changes, including vasculopathy, are being reported. SUMMARY Clinically observed types of rejection in VCA include mainly cell-mediated, antibody-mediated and chronic rejection. Advances in diagnosis and treatment of rejection have been made, but there is still much to be learned about VCA-specific rejection.
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15
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Oda H, Ikeguchi R, Aoyama T, Ohta S, Noguchi T, Kaizawa Y, Yurie H, Takeuchi H, Mitsuzawa S, Yamamoto K, Matsuda S. Relative antigenicity of components in vascularized composite allotransplants: An experimental study of microRNAs expression in rat hind limb transplantation model. Microsurgery 2018; 39:340-348. [DOI: 10.1002/micr.30408] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 10/26/2018] [Accepted: 11/06/2018] [Indexed: 11/06/2022]
Affiliation(s)
- Hiroki Oda
- Department of Orthopaedic Surgery, Graduate School of Medicine; Kyoto University; Kyoto Japan
| | - Ryosuke Ikeguchi
- Department of Orthopaedic Surgery, Graduate School of Medicine; Kyoto University; Kyoto Japan
| | - Tomoki Aoyama
- Department of Physical Therapy, Human Health Sciences; Graduate School of Medicine, Kyoto University; Kyoto Japan
| | - Souichi Ohta
- Department of Orthopaedic Surgery, Graduate School of Medicine; Kyoto University; Kyoto Japan
| | - Takashi Noguchi
- Department of Orthopaedic Surgery; Tango Central Hospital; Kyotango Japan
| | - Yukitoshi Kaizawa
- Department of Orthopaedic Surgery, Graduate School of Medicine; Kyoto University; Kyoto Japan
| | - Hirofumi Yurie
- Department of Orthopaedic Surgery, Graduate School of Medicine; Kyoto University; Kyoto Japan
| | - Hisataka Takeuchi
- Department of Orthopaedic Surgery, Graduate School of Medicine; Kyoto University; Kyoto Japan
| | - Sadaki Mitsuzawa
- Department of Orthopaedic Surgery, Graduate School of Medicine; Kyoto University; Kyoto Japan
| | - Koji Yamamoto
- Department of Biomedical Engineering, Faculty of Life and Medical Sciences; Doshisha University; Kyotango Japan
| | - Shuichi Matsuda
- Department of Orthopaedic Surgery, Graduate School of Medicine; Kyoto University; Kyoto Japan
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16
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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.
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Wang AYL, Loh CYY, Chen SJ, Kao HK, Lin CH, Chuang SH, Lee CM, Sytwu HK, Wei FC. Blimp-1 prolongs allograft survival without regimen via influencing T cell development in favor of regulatory T cells while suppressing Th1. Mol Immunol 2018; 99:53-65. [PMID: 29698799 DOI: 10.1016/j.molimm.2018.04.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Revised: 03/16/2018] [Accepted: 04/05/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND B lymphocyte-induced maturation protein 1 (Blimp-1) transcription factor is expressed in multiple cell lineages and in particular, T cells. However, the role of Blimp-1 in T cell-mediated allograft tolerance is still unknown. METHODS This study is the first to investigate transplanted skin allograft survival using transgenic (Tg) mice with T cell overexpression of Blimp-1. RESULTS Without any immunosuppression, fully MHC-mismatched skin allografts on Tg(+) mice had a significantly prolonged survival rate and partial tolerance at 90 days. Allograft lymphocytic infiltration was decreased in Tg(+) mice and a dampened donor-stimulated alloimmune response was seen. An absolute cell number ratio of inflammatory Th1 and Th17 cells against anti-inflammatory regulatory T (Treg) and IL-10-producing T cells, as well as cytolytic proteins, were significantly decreased in lymphoid organs and allograft. Blimp-1 transgenic T cells displayed an increased Treg differentiation capability and enhanced suppression of T cell proliferation. Overexpression of Blimp-1 in T cells promoted the formation of an anti-inflammatory cell-cytokine composition, both systemically and locally via transcription factor modulation such as T-bet downregulation and FoxP3 upregulation. DISCUSSION As such, allograft survival was made possible due to Th1 suppression and Treg amplification with the creation of an 'allograft protective microenvironment'.
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Affiliation(s)
- Aline Yen Ling Wang
- Center for Vascularized Composite Allotransplantation, Chang Gung Memorial Hospital, Taoyuan, Taiwan.
| | - Charles Yuen Yung Loh
- Division of Surgery and Interventional Science, University College London, London, United Kingdom; St Andrew's Center for Burns and Plastic Surgery, Chelmsford, United Kingdom
| | - Shyi-Jou Chen
- Department of Pediatrics, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan; Department of Microbiology and Immunology, National Defense Medical Center, Taipei, Taiwan
| | - Huang-Kai Kao
- Department of Plastic Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Cheng-Hung Lin
- Center for Vascularized Composite Allotransplantation, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Department of Plastic Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Sheng-Hao Chuang
- Center for Vascularized Composite Allotransplantation, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chin-Ming Lee
- Department of General Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Huey-Kang Sytwu
- Department of Microbiology and Immunology, Graduate Institute of Life Sciences, National Defense Medical Center, Taipei, Taiwan
| | - Fu-Chan Wei
- Center for Vascularized Composite Allotransplantation, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Department of Plastic Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
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18
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Abstract
PURPOSE OF REVIEW Abdominal wall transplantation is a technique used to achieve abdominal closure after intestinal and multivisceral transplantation. This review focuses on whether there are additional benefits for the skin component as an immune-monitoring tool. RECENT FINDINGS The largest series of abdominal wall transplants has recently been published. Alongside the physiological advantage gained in abdominal closure, the authors describe the immunological insight that the skin component can provide and how this contributes to the management of patients. The skin appears to develop a rash with early rejection, which facilitates early systemic treatment before significant visceral rejection occurs. It can also help in cases in which there is diagnostic doubt regarding the cause of bowel dysfunction such as in instances of intestinal infection. Despite the additional immunological burden of donor tissue, there appears to be no requirement for increased immunosuppressive therapy. SUMMARY The technical and immunological feasibility of abdominal wall transplantation has now been demonstrated by several centres. Skin transplanted as part of the abdominal wall or as a separate vascularized sentinel skin flap may aid in the diagnosis of rejection. This has the potential to improve graft survival and reduce immunosuppressive morbidity.
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19
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Alhefzi M, Aycart MA, Bueno EM, Kiwanuka H, Krezdorn N, Pomahac B, Tullius SG. Treatment of Rejection in Vascularized Composite Allotransplantation. CURRENT TRANSPLANTATION REPORTS 2016. [DOI: 10.1007/s40472-016-0128-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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20
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Ikeguchi R, Kakinoki R, Ohta S, Oda H, Yurie H, Kaizawa Y, Mitsui H, Aoyama T, Toguchida J, Matsuda S. Recipient bone marrow-derived stromal cells prolong graft survival in a rat hind limb allotransplantation model. Microsurgery 2016; 37:632-640. [PMID: 27859595 DOI: 10.1002/micr.30128] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 10/02/2016] [Accepted: 10/27/2016] [Indexed: 01/14/2023]
Abstract
BACKGROUND Recent studies have indicated that bone marrow-derived stromal cells (BMSCs) have immunomodulatory properties that suppress the T cell responses that cause graft rejection. The purpose of this study is to evaluate the effect of recipient BMSCs intravenous infusion for immunomodulation in a rat vascularized composite allotransplantation model. METHODS A total of nine Wistar (WIS) rats and thirty Lewis (LEW) rats were used. BMSCs were harvested from three LEW rats. Twenty-four LEW rats were used as recipients and divided randomly into four groups: BMSC group, FK group, UT group, and Iso group. In the BMSC group, orthotopic rat hind limb transplantation was performed between WIS donor and LEW recipient rats. Recipient rats were injected intravenously with 2 × 106 recipient BMSCs on day 6, and with 0.2 mg/kg/day tacrolimus administered over 7 days (n = 6). In the FK group, recipient rats were treated with tacrolimus alone (n = 6). Rats in the UT group received no immunosuppressive treatment (n = 6). In the Iso group, transplantation was performed from three LEW donor rats to six LEW recipient rats without any immunosuppressive treatment (n = 6). Graft survival was assessed by daily inspection and histology. The immunological reactions of recipients were also evaluated. RESULTS The graft survival of recipient rats in the BMSC group (24.5 days) was significantly prolonged in comparison with that of the FK group (18 days) (P < .01). Cytokine expression analysis of the skin of grafted limbs showed that BMSCs treatment significantly decreased IFN-γ mRNA expression of the BMSC group (0.138 ± 0.045) in comparison with that of the FK group (1.049 ± 0.167) (P = .0001). Recipient rats in the BMSC group had significantly reduced serum IFN-γ cytokine levels (1.571 ± 0.779 pg/ml) in comparison with that of the FK group (7.059 ± 1.522 pg/ml) (P = .001). In in vitro study, BMSCs induce T cell hyporesponsiveness in a mixed lymphocyte reaction. CONCLUSION BMSCs induce T cell hyporesponsiveness and prolong graft survival in the rat vascularized composite allotransplantation model. BMSCs exhibit immunomodulatory properties against acute rejection that can be realized without the need for significant recipient immunosuppression.
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Affiliation(s)
- Ryosuke Ikeguchi
- Department of Orthopaedic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Ryosuke Kakinoki
- Department of Orthopaedic Surgery, Faculty of Medicine, Kindai University, Osaka, Japan
| | - Souichi Ohta
- Department of Orthopaedic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Hiroki Oda
- Department of Orthopaedic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Hirofumi Yurie
- Department of Orthopaedic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yukitoshi Kaizawa
- Department of Orthopaedic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Hiroto Mitsui
- Department of Orthopaedic Surgery, Nagoya City University Medical School, Nagoya, Japan
| | - Tomoki Aoyama
- Department of Orthopaedic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Junya Toguchida
- Department of Orthopaedic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Shuichi Matsuda
- Department of Orthopaedic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
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21
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Oda H, Ikeguchi R, Yurie H, Kaizawa Y, Ohta S, Yamamoto K, Aoyama T, Matsuda S. Plasma microRNAs Are Potential Biomarkers of Acute Rejection After Hindlimb Transplantation in Rats. Transplant Direct 2016; 2:e108. [PMID: 27826601 PMCID: PMC5096435 DOI: 10.1097/txd.0000000000000620] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Accepted: 08/09/2016] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND The development of effective immunosuppressive regimens has resulted in many cases of successful hand transplantation. Visual skin inspection and histological evaluation are used to assess the rejection of hand transplants, but these methods are largely subjective. In this study, we aimed to determine the potential of microRNAs (miRNAs) as biomarkers for acute rejection in vascularized composite allotransplants. METHODS In allograft group, 7 male Brown-Norway rats (RT1n) were used as donors and 13 male Lewis rats (RT1l) were used as recipients. In control group, 8 Lewis rats were used as donors and recipients. The hindlimbs of donor rats were transplanted orthotopically to recipient rats. Skin changes were noted daily. Skin biopsies were obtained from 5 recipients and evaluated histologically. Plasma samples were obtained from the other 8 recipients before transplant and 7, 10, and 14 days posttransplant and used to measure miRNA expression. RESULTS Skin changes occurred at a mean of 11.0 days posttransplant. Rejection in most skin biopsies taken 7 and 10 days posttransplant was histologically classified as grade 0, whereas that in most biopsies taken 14 days posttransplant was classified as grade 3. We found that expression of miRNA-146a and miRNA-155 was significantly upregulated at 10 and 14 days posttransplant compared with that at 7 days posttransplant. In control group, there were no significant changes in plasma miRNAs expressions. CONCLUSIONS The upregulation of plasma miRNA-146a and miRNA-155 was detected before the histological evaluation methods could diagnose complete rejection in the rat hindlimb transplantation model. Plasma miRNA-146a and miRNA-155 may be potential biomarkers of acute rejection after vascularized composite allotransplantation.
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Affiliation(s)
- Hiroki Oda
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Ryosuke Ikeguchi
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hirofumi Yurie
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yukitoshi Kaizawa
- Department of Orthopaedic Surgery, Yawata Central Hospital, Yawatagotanda, Japan
| | - Souichi Ohta
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Koji Yamamoto
- Research and Education Unit of Leaders for Integrated Medical System, Center for the Promotion of Interdisciplinary Education and Research, Kyoto University, Kyoto, Japan
| | - Tomoki Aoyama
- Department of Physical Therapy, Human Health Sciences, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shuichi Matsuda
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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22
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Gerlach UA, Vrakas G, Sawitzki B, Macedo R, Reddy S, Friend PJ, Giele H, Vaidya A. Abdominal Wall Transplantation: Skin as a Sentinel Marker for Rejection. Am J Transplant 2016; 16:1892-900. [PMID: 26713513 DOI: 10.1111/ajt.13693] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Revised: 11/24/2015] [Accepted: 12/20/2015] [Indexed: 01/25/2023]
Abstract
Abdominal wall transplantation (AWTX) has revolutionized difficult abdominal closure after intestinal transplantation (ITX). More important, the skin of the transplanted abdominal wall (AW) may serve as an immunological tool for differential diagnosis of bowel dysfunction after transplant. Between August 2008 and October 2014, 29 small bowel transplantations were performed in 28 patients (16 male, 12 female; aged 41 ± 13 years). Two groups were identified: the solid organ transplant (SOT) group (n = 15; 12 ITX and 3 modified multivisceral transplantation [MMVTX]) and the SOT-AWTX group (n = 14; 12 ITX and 2 MMVTX), with the latter including one ITX-AWTX retransplantation. Two doses of alemtuzumab were used for induction (30 mg, 6 and 24 h after reperfusion), and tacrolimus (trough levels 8-12 ng/mL) was used for maintenance immunosuppression. Patient survival was similar in both groups (67% vs. 61%); however, the SOT-AWTX group showed faster posttransplant recovery, better intestinal graft survival (79% vs. 60%), a lower intestinal rejection rate (7% vs. 27%) and a lower rate of misdiagnoses in which viral infection was mistaken and treated as rejection (14% vs. 33%). The skin component of the AW may serve as an immune modulator and sentinel marker for immunological activity in the host. This can be a vital tool for timely prevention of intestinal graft rejection and, more important, avoidance of overimmunosuppression in cases of bowel dysfunction not related to graft rejection.
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Affiliation(s)
- U A Gerlach
- Department of Transplant Surgery, Oxford University Hospitals and University of Oxford, Oxford, UK.,Department of General, Visceral and Transplantation Surgery, Charité-Universitaetsmedizin Berlin, Campus Virchow Klinikum, Berlin, Germany
| | - G Vrakas
- Department of Transplant Surgery, Oxford University Hospitals and University of Oxford, Oxford, UK
| | - B Sawitzki
- Institute for Medical Immunology, Charité-Universitaetsmedizin Berlin, Campus Virchow Klinikum, Berlin, Germany
| | - R Macedo
- Department of Transplant Surgery, Oxford University Hospitals and University of Oxford, Oxford, UK
| | - S Reddy
- Department of Transplant Surgery, Oxford University Hospitals and University of Oxford, Oxford, UK
| | - P J Friend
- Department of Transplant Surgery, Oxford University Hospitals and University of Oxford, Oxford, UK
| | - H Giele
- Department of Plastic and Reconstructive Surgery, Oxford University Hospitals and University of Oxford, Oxford, UK
| | - A Vaidya
- Department of Transplant Surgery, Oxford University Hospitals and University of Oxford, Oxford, UK
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23
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Schneider M, Cardones ARG, Selim MA, Cendales LC. Vascularized composite allotransplantation: a closer look at the banff working classification. Transpl Int 2016; 29:663-71. [DOI: 10.1111/tri.12750] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Revised: 06/15/2015] [Accepted: 01/22/2016] [Indexed: 11/26/2022]
Affiliation(s)
| | | | - M. Angelica Selim
- Pathology and Dermatology; Department of Pathology; Duke University Medical Center; Durham NC USA
| | - Linda C. Cendales
- Department of Surgery; Duke University Medical Center; Durham NC USA
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Emerging Implications for Extracellular Matrix-Based Technologies in Vascularized Composite Allotransplantation. Stem Cells Int 2016; 2016:1541823. [PMID: 26839554 PMCID: PMC4709778 DOI: 10.1155/2016/1541823] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 10/05/2015] [Indexed: 12/21/2022] Open
Abstract
Despite recent progress in vascularized composite allotransplantation (VCA), limitations including complex, high dose immunosuppression regimens, lifelong risk of toxicity from immunosuppressants, acute and most critically chronic graft rejection, and suboptimal nerve regeneration remain particularly challenging obstacles restricting clinical progress. When properly configured, customized, and implemented, biomaterials derived from the extracellular matrix (ECM) retain bioactive molecules and immunomodulatory properties that can promote stem cell migration, proliferation and differentiation, and constructive functional tissue remodeling. The present paper reviews the emerging implications of ECM-based technologies in VCA, including local immunomodulation, tissue repair, nerve regeneration, minimally invasive graft targeted drug delivery, stem cell transplantation, and other donor graft manipulation.
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25
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Abstract
PURPOSE OF REVIEW Acute rejection is the most common complication after vascularized composite allotransplantation (VCA). This review provides a state-of-the-art analysis of prevention, diagnosis and treatment of acute rejection episodes and highlights recent findings with the potential to improve patient care and enhance understanding of the underlying biologic processes. RECENT FINDINGS Recent reports suggest that maintenance immunosuppression dose reduction and steroid withdrawal are realistic goals in VCA, despite the known high immunogenicity of the skin component. It appears that utilization of sentinel flaps, in-depth histological analyses and application of novel biomarkers have facilitated early diagnosis and characterization of acute rejection episodes, leading to timely institution of appropriate therapy. The successful management of the first highly sensitized face transplant recipient suggests the possibility of carefully considering these high-risk VCA candidates for transplantation. SUMMARY Acute rejection is higher in VCA than in any other organ in the field of transplantation, although most episodes are controlled by high-dose steroids and optimization of maintenance immunosuppression. Because of limitations in patient number and the duration of follow-up, the long-term safety and effectiveness of VCA remain unclear. Moreover, the tests currently used to diagnose acute rejection are of limited value. Better diagnostic tools and a better understanding of the immunologic events during acute rejection are therefore needed to improve diagnosis, treatment and outcomes of this life-changing restorative surgery.
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Abstract
BACKGROUND Skin biopsies are critical for histologic evaluation of rejection and proper treatment after facial allotransplantation. Many facial allografts provide only limited skin area, and frequent biopsies may also compromise aesthetic outcome. Sentinel flaps, recovered as free fasciocutaneous radial forearm flaps, have been used for remote-site rejection monitoring. They maintain their axial blood supply, similar to facial allografts. The correlation between facial allografts and sentinel flaps in cases of rejection is presented. METHODS The authors analyzed the experience of the Boston team's use of four sentinel flaps. Rejection was evaluated and results were compared for each time point. Sentinel flaps were used as functional flaps whenever possible. RESULTS Results showed a reliable correlation between biopsy specimens taken from the facial allograft and sentinel flaps. During severe rejection episodes in 100 percent of biopsy pairs, both sites displayed a similar grade of rejection. In one case, clinical findings suggested rejection in the facial allograft but were unraveled as rosacea, because clinically there was no rejection displayed in the sentinel flap. CONCLUSIONS The sentinel flap shows a reliable correlation to the facial allograft in cases of severe rejection, therefore providing a valuable tool for rejection monitoring in facial allotransplantation. Advantages of using these flaps include the avoidance of further surgical procedures to the primary vascularized composite allotransplant, additional use of the sentinel flap to repair damaged nonfacial sites, and its utility as both a clinical and histopathologic barometer of rejection and predictor of the potential existence of facial dermatitis unrelated to rejection. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Davis TA, Anam K, Lazdun Y, Gimble JM, Elster EA. Adipose-derived stromal cells promote allograft tolerance induction. Stem Cells Transl Med 2014; 3:1444-50. [PMID: 25411475 DOI: 10.5966/sctm.2014-0131] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Amputations and unsalvageable injuries with devastating tissue loss are common in the combat wounded. Reconstructive transplantation in the civilian setting using vascular composite allotransplants (VCAs) with multiple tissues (skin, muscle, nerve, bone) combined with long-term multidrug immunosuppression has been encouraging. However, skin rejection remains a critical complication. Adipose-derived stromal/stem cells (ASCs) are easily obtained from normal individuals in high numbers, precluding ex vivo expansion. The reparative function and paracrine immunomodulatory capacity of ASCs has gained considerable attention. The present study investigated whether ASCs facilitate long-term skin allograft survival. ASCs were isolated from fresh human subcutaneous adipose lipoaspirate. Full-thickness skin grafts from BALB/c mice were transplanted onto the dorsal flanks of C57BL/6 mice treated with five doses of anti-CD4/CD8 monoclonal antibodies (10 mg/kg) on days 0, +2, +5, +7, and +14 relative to skin grafting. A single nonmyeloablative low dose of busulfan (5 mg/kg) was given on day +5. Seven days after skin transplantation, ASCs (3×10(6)) were infused i.v. with or without donor bone marrow cells (BMCs; 5×10(5)). ASC+BMC coinfusion with minimal conditioning led to stable lymphoid and myeloid macrochimerism, deletion of alloreactive T cells, expansion of regulatory T cells, and long-term allograft survival (>200 days). ASCs constitutively produced high levels of anti-inflammatory/immunoregulatory factors such as prostaglandin E2, indoleamine 2,3-dioxygenase, APO-1/Fas (CD95), and programmed cell death-1 ligand-2. These findings serve as a foundation for developing a translational advanced VCA protocol, embodying both ASCs and low-dose donor BMCs, in nonhuman primates, with the goal of enhancing functional outcomes and eliminating the complications associated with long-term immunosuppression.
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Affiliation(s)
- Thomas A Davis
- Regenerative Medicine Department, Operational and Undersea Medicine Directorate, Naval Medical Research Center, Silver Spring, Maryland, USA; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA; Department of Medicine and Surgery Center for Stem Cell Research & Regenerative Medicine, Tulane University School of Medicine, New Orleans, Louisiana, USA; LaCell, LLC, New Orleans, Louisiana, USA
| | - Khairul Anam
- Regenerative Medicine Department, Operational and Undersea Medicine Directorate, Naval Medical Research Center, Silver Spring, Maryland, USA; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA; Department of Medicine and Surgery Center for Stem Cell Research & Regenerative Medicine, Tulane University School of Medicine, New Orleans, Louisiana, USA; LaCell, LLC, New Orleans, Louisiana, USA
| | - Yelena Lazdun
- Regenerative Medicine Department, Operational and Undersea Medicine Directorate, Naval Medical Research Center, Silver Spring, Maryland, USA; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA; Department of Medicine and Surgery Center for Stem Cell Research & Regenerative Medicine, Tulane University School of Medicine, New Orleans, Louisiana, USA; LaCell, LLC, New Orleans, Louisiana, USA
| | - Jeffrey M Gimble
- Regenerative Medicine Department, Operational and Undersea Medicine Directorate, Naval Medical Research Center, Silver Spring, Maryland, USA; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA; Department of Medicine and Surgery Center for Stem Cell Research & Regenerative Medicine, Tulane University School of Medicine, New Orleans, Louisiana, USA; LaCell, LLC, New Orleans, Louisiana, USA
| | - Eric A Elster
- Regenerative Medicine Department, Operational and Undersea Medicine Directorate, Naval Medical Research Center, Silver Spring, Maryland, USA; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA; Department of Medicine and Surgery Center for Stem Cell Research & Regenerative Medicine, Tulane University School of Medicine, New Orleans, Louisiana, USA; LaCell, LLC, New Orleans, Louisiana, USA
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Banasik M, Jabłecki J, Boratyńska M, Kamińska D, Kościelska-Kasprzak K, Bartoszek D, Chełmoński A, Hałoń A, Baran W, Klinger M. Humoral immunity in hand transplantation: Anti-HLA and non-HLA response. Hum Immunol 2014; 75:859-62. [DOI: 10.1016/j.humimm.2014.06.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Revised: 06/10/2014] [Accepted: 06/10/2014] [Indexed: 10/25/2022]
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Edtinger K, Yang X, Uehara H, Tullius SG. Current status of vascularized composite tissue allotransplantation. BURNS & TRAUMA 2014; 2:53-60. [PMID: 27602363 PMCID: PMC5012023 DOI: 10.4103/2321-3868.130184] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Revised: 03/09/2014] [Indexed: 01/01/2023]
Abstract
Vascularized composite tissue allotransplantation (VCA) offers treatment options of complex functional deficiencies that cannot be repaired with conventional reconstructive methods. VCAs consist of blocks of functional units comprising different tissue types such as skin, bone, muscle, nerves, blood vessels, tendons, ligaments and others, and are thus substantially different from the composition of organ transplants. The field of VCA has made fascinating progresses in the recent past. Among other VCAs, numerous successful hand, face and limb transplants have been performed in the world. At the same time, specific questions in regard to innate and adaptive immunity, consequences of ischemia/reperfusion injury, immunosuppression, preservation, and regenerative capacity remain. In spite of this, the field is poised to make significant advances in the near future.
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Affiliation(s)
- Karoline Edtinger
- Division of Transplant Surgery and Laboratory of Transplant Surgery Research, Brigham and Women's Hospital and Harvard Medical School, 75 Francis St, Boston, Massachusetts 02115 USA ; Department of Surgery, University Hospital Regensburg, University of Regensburg, Regensburg, Germany
| | - Xiaoyong Yang
- Division of Transplant Surgery and Laboratory of Transplant Surgery Research, Brigham and Women's Hospital and Harvard Medical School, 75 Francis St, Boston, Massachusetts 02115 USA ; Division of Urology, Bejing Chao-Yang Hospital, Capital Medical University, Bejing, China
| | - Hanae Uehara
- Division of Transplant Surgery and Laboratory of Transplant Surgery Research, Brigham and Women's Hospital and Harvard Medical School, 75 Francis St, Boston, Massachusetts 02115 USA ; Department of Plastic and Reconstructive Surgery, Osaka Medical College, Takatsuki, Osaka, Japan
| | - Stefan G Tullius
- Division of Transplant Surgery and Laboratory of Transplant Surgery Research, Brigham and Women's Hospital and Harvard Medical School, 75 Francis St, Boston, Massachusetts 02115 USA
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Sarhane KA, Khalifian S, Ibrahim Z, Cooney DS, Hautz T, Lee WPA, Schneeberger S, Brandacher G. Diagnosing skin rejection in vascularized composite allotransplantation: advances and challenges. Clin Transplant 2014; 28:277-85. [DOI: 10.1111/ctr.12316] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/17/2013] [Indexed: 11/30/2022]
Affiliation(s)
- Karim A. Sarhane
- Department of Plastic and Reconstructive Surgery; Vascularized Composite Allotransplantation (VCA) Laboratory; Johns Hopkins University School of Medicine; Baltimore MD USA
| | - Saami Khalifian
- Department of Plastic and Reconstructive Surgery; Vascularized Composite Allotransplantation (VCA) Laboratory; Johns Hopkins University School of Medicine; Baltimore MD USA
| | - Zuhaib Ibrahim
- Department of Plastic and Reconstructive Surgery; Vascularized Composite Allotransplantation (VCA) Laboratory; Johns Hopkins University School of Medicine; Baltimore MD USA
| | - Damon S. Cooney
- Department of Plastic and Reconstructive Surgery; Vascularized Composite Allotransplantation (VCA) Laboratory; Johns Hopkins University School of Medicine; Baltimore MD USA
| | - Theresa Hautz
- Department of Visceral; Transplant, and Thoracic Surgery; Center of Operative Medicine, Innsbruck Medical University; Innsbruck Austria
| | - Wei-Ping Andrew Lee
- Department of Plastic and Reconstructive Surgery; Vascularized Composite Allotransplantation (VCA) Laboratory; Johns Hopkins University School of Medicine; Baltimore MD USA
| | - Stefan Schneeberger
- Department of Plastic and Reconstructive Surgery; Vascularized Composite Allotransplantation (VCA) Laboratory; Johns Hopkins University School of Medicine; Baltimore MD USA
- Department of Visceral; Transplant, and Thoracic Surgery; Center of Operative Medicine, Innsbruck Medical University; Innsbruck Austria
| | - Gerald Brandacher
- Department of Plastic and Reconstructive Surgery; Vascularized Composite Allotransplantation (VCA) Laboratory; Johns Hopkins University School of Medicine; Baltimore MD USA
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32
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Sarhane KA, Tuffaha SH, Broyles JM, Ibrahim AE, Khalifian S, Baltodano P, Santiago GF, Alrakan M, Ibrahim Z. A critical analysis of rejection in vascularized composite allotransplantation: clinical, cellular and molecular aspects, current challenges, and novel concepts. Front Immunol 2013; 4:406. [PMID: 24324470 PMCID: PMC3839257 DOI: 10.3389/fimmu.2013.00406] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2013] [Accepted: 11/08/2013] [Indexed: 12/17/2022] Open
Abstract
Advances in microsurgical techniques and immunomodulatory protocols have contributed to the expansion of vascularized composite allotransplantation (VCA) with very encouraging immunological, functional, and cosmetic results. Rejection remains however a major hurdle that portends serious threats to recipients. Rejection features in VCA have been described in a number of studies, and an international consensus on the classification of rejection was established. Unfortunately, current available diagnostic methods carry many shortcomings that, in certain cases, pose a great diagnostic challenge to physicians especially in borderline rejection cases. In this review, we revisit the features of acute skin rejection in hand and face transplantation at the clinical, cellular, and molecular levels. The multiple challenges in diagnosing rejection and in defining chronic and antibody-mediated rejection in VCA are then presented, and we finish by analyzing current research directions and novel concepts aiming at improving available diagnostic measures.
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Affiliation(s)
- Karim A Sarhane
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine , Baltimore, MD , USA
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Sinha I, Pomahac B. Split rejection in vascularized composite allotransplantation. EPLASTY 2013; 13:e53. [PMID: 24244785 PMCID: PMC3795428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Graft monitoring following vascularized composite allotransplantation (VCA) relies primarily on serial skin biopsy. However, given that VCA comprised multiple tissue types, skin biopsy may not accurately reflect rejection in other transplanted tissue. METHODS A review of the literature on episodes of both acute and chronic rejection following VCA was completed. Special attention was given to how these patients were monitored for rejection and whether skin biopsy accurately reflected the state of other tissue types within VCA. RESULTS Following VCA, skin biopsies accurately reflected episodes of acute rejection, but chronic rejection, resulting in both muscle fibrosis and graft vasculopathy, did not present with any ostensible skin changes. CONCLUSION Various tissue types within VCA can reject at different times and rates. We define this phenomenon as "split rejection." Split rejection has significant implications on flap monitoring, as it suggests that skin biopsy alone may not be sufficient in monitoring long-term graft rejection.
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Affiliation(s)
- Indranil Sinha
- Division of Plastic Surgery, Brigham and Women's Hospital, 75 Francis Street, Boston, Mass
| | - Bohdan Pomahac
- Division of Plastic Surgery, Brigham and Women's Hospital, 75 Francis Street, Boston, Mass,Correspondence:
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