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Kiefer J, Zeller J, Schneider L, Thomé J, McFadyen JD, Hoerbrand IA, Lang F, Deiss E, Bogner B, Schaefer AL, Chevalier N, Horner VK, Kreuzaler S, Kneser U, Kauke-Navarro M, Braig D, Woollard KJ, Pomahac B, Peter K, Eisenhardt SU. C-reactive protein orchestrates acute allograft rejection in vascularized composite allotransplantation via selective activation of monocyte subsets. J Adv Res 2024:S2090-1232(24)00291-1. [PMID: 38992424 DOI: 10.1016/j.jare.2024.07.007] [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: 09/17/2023] [Revised: 01/24/2024] [Accepted: 07/08/2024] [Indexed: 07/13/2024] Open
Abstract
INTRODUCTION Despite advancements in transplant immunology and vascularized composite allotransplantation (VCA), the longevity of allografts remains hindered by the challenge of allograft rejection. The acute-phase response, an immune-inflammatory reaction to ischemia/reperfusion that occurs directly after allogeneic transplantation, serves as a catalyst for graft rejection. This immune response is orchestrated by acute-phase reactants through intricate crosstalk with the mononuclear phagocyte system. OBJECTIVE C-reactive protein (CRP), a well-known marker of inflammation, possesses pro-inflammatory properties and exacerbates ischemia/reperfusion injury. Thus, we investigated how CRP impacts acute allograft rejection. METHODS Prompted by clinical observations in facial VCAs, we employed a complex hindlimb transplantation model in rats to investigate the direct impact of CRP on transplant rejection. RESULTS Our findings demonstrate that CRP expedites allograft rejection and diminishes allograft survival by selectively activating non-classical monocytes. Therapeutic stabilization of CRP abrogates this activating effect on monocytes, thereby attenuating acute allograft rejection. Intravital imagining of graft-infiltrating, recipient-derived monocytes during the early phase of acute rejection corroborated their differential regulation by CRP and their pivotal role in driving the initial stages of graft rejection. CONCLUSION The differential activation of recipient-derived monocytes by CRP exacerbates the innate immune response and accelerates clinical allograft rejection. Thus, therapeutic targeting of CRP represents a novel and promising strategy for preventing acute allograft rejection and potentially mitigating chronic allograft rejection.
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Affiliation(s)
- Jurij Kiefer
- Department of Plastic and Hand Surgery, Medical Center - University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Johannes Zeller
- Department of Plastic and Hand Surgery, Medical Center - University of Freiburg, Faculty of Medicine, Freiburg, Germany; Atherothrombosis and Vascular Biology, Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
| | - Laura Schneider
- Department of Plastic and Hand Surgery, Medical Center - University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Julia Thomé
- Department of Plastic and Hand Surgery, Medical Center - University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - James D McFadyen
- Atherothrombosis and Vascular Biology, Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
| | - Isabel A Hoerbrand
- Department of Plastic and Hand Surgery, Medical Center - University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Friederike Lang
- Department of Plastic and Hand Surgery, Medical Center - University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Emil Deiss
- Department of Plastic and Hand Surgery, Medical Center - University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Balázs Bogner
- Department of Plastic and Hand Surgery, Medical Center - University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Anna-Lena Schaefer
- Department of Rheumatology and Clinical Immunology, Medical Center - University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Nina Chevalier
- Department of Rheumatology and Clinical Immunology, Medical Center - University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Verena K Horner
- Department of Plastic and Hand Surgery, Medical Center - University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Sheena Kreuzaler
- Department of Plastic and Hand Surgery, Medical Center - University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Ulrich Kneser
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg, Germany
| | - Martin Kauke-Navarro
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, USA
| | - David Braig
- Department of Plastic and Hand Surgery, Medical Center - University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Kevin J Woollard
- Centre for Inflammatory Disease, Imperial College London, London, UK
| | - Bohdan Pomahac
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, USA
| | - Karlheinz Peter
- Atherothrombosis and Vascular Biology, Baker Heart and Diabetes Institute, Melbourne, VIC, Australia; Baker Department of Cardiometabolic Health, University of Melbourne, Melbourne, Australia
| | - Steffen U Eisenhardt
- Department of Plastic and Hand Surgery, Medical Center - University of Freiburg, Faculty of Medicine, Freiburg, Germany.
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Egro FM, Schilling BK, Fisher JD, Saadoun R, Rubin JP, Marra KG, Solari MG. The Future of Microsurgery: Vascularized Composite Allotransplantation and Engineering Vascularized Tissue. J Hand Microsurg 2024; 16:100011. [PMID: 38854368 PMCID: PMC11127549 DOI: 10.1055/s-0042-1757182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Background Microsurgical techniques have revolutionized the field of reconstructive surgery and are the mainstay for complex soft tissue reconstruction. However, their limitations have promoted the development of viable alternatives. This article seeks to explore technologies that have the potential of revolutionizing microsurgical reconstruction as it is currently known, reflect on current and future vascularized composite allotransplantation (VCA) practices, as well as describe the basic science within emerging technologies and their potential translational applications. Methods A literature review was performed of the technologies that may represent the future of microsurgery: vascularized tissue engineering (VCA) and flap-specific tissue engineering. Results VCA has shown great promise and has already been employed in the clinical setting (especially in face and limb transplantation). Immunosuppression, logistics, cost, and regulatory pathways remain barriers to overcome to make it freely available. Vascularized and flap-specific tissue engineering remain a laboratory reality but have the potential to supersede VCA. The capability of creating an off-the-shelf free flap matching the required tissue, size, and shape is a significant advantage. However, these technologies are still at the early stage and require significant advancement before they can be translated into the clinical setting. Conclusion VCA, vascularized tissue engineering, and flap-specific bioengineering represent possible avenues for the evolution of current microsurgical techniques. The next decade will elucidate which of these three strategies will evolve into a tangible translational option and hopefully bring a paradigm shift of reconstructive surgery.
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Affiliation(s)
- Francesco M. Egro
- Department of Plastic Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
| | - Benjamin K. Schilling
- Department of Bioengineering, School of Engineering, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
| | - James D. Fisher
- Department of Plastic Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
- Department of Bioengineering, School of Engineering, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
| | - Rakan Saadoun
- Department of Plastic Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
| | - J. Peter Rubin
- Department of Plastic Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
- Department of Bioengineering, School of Engineering, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
- McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
| | - Kacey G. Marra
- Department of Plastic Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
- Department of Bioengineering, School of Engineering, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
- McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
| | - Mario G. Solari
- Department of Plastic Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
- McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States
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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.
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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.
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Noel OF, Dumbrava MG, Daoud D, Kammien AJ, Kauke-Navarro M, Pomahac B, Colen D. Vascularized Composite Allograft Versus Prosthetic for Reconstruction After Facial and Hand Trauma: Comparing Cost, Complications, and Long-term Outcome. Ann Plast Surg 2024; 92:100-105. [PMID: 37962243 DOI: 10.1097/sap.0000000000003731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
ABSTRACT In the past decade, vascularized composite allotransplantation (VCA) has become clinical reality for reconstruction after face and hand trauma. It offers patients the unique opportunity to regain form and function in a way that had only been achieved with traditional reconstruction or with the use of prostheses. On the other hand, prostheses for facial and hand reconstruction have continued to evolve over the years and, in many cases, represent the primary option for patients after hand and face trauma. We compared the cost, associated complications, and long-term outcomes of VCA with prostheses for reconstruction of the face and hand/upper extremity. Ultimately, VCA and prostheses represent 2 different reconstructive options with distinct benefit profiles and associated limitations and should ideally not be perceived as competing choices. Our work adds a valuable component to the general framework guiding the decision to offer VCA or prostheses for reconstruction after face and upper extremity trauma.
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Affiliation(s)
- Olivier F Noel
- From the Division of Plastic and Reconstructive Surgery, Yale-New Haven Hospital, Yale School of Medicine, New Haven, CT
| | | | - Deborah Daoud
- Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ
| | - Alexander J Kammien
- From the Division of Plastic and Reconstructive Surgery, Yale-New Haven Hospital, Yale School of Medicine, New Haven, CT
| | - Martin Kauke-Navarro
- From the Division of Plastic and Reconstructive Surgery, Yale-New Haven Hospital, Yale School of Medicine, New Haven, CT
| | - Bohdan Pomahac
- From the Division of Plastic and Reconstructive Surgery, Yale-New Haven Hospital, Yale School of Medicine, New Haven, CT
| | - David Colen
- From the Division of Plastic and Reconstructive Surgery, Yale-New Haven Hospital, Yale School of Medicine, New Haven, CT
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Toyoda Y, Levin LS. What is needed to ensure long-term sustainability for the field of vascularized composite allotransplantation? Curr Opin Organ Transplant 2023; 28:446-451. [PMID: 37767962 DOI: 10.1097/mot.0000000000001114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/29/2023]
Abstract
The field of vascularized composite allotransplantation (VCA) has demonstrated remarkable advances since its inception with some excellent long-term results in a variety of graft types. However, unlike solid organ transplantation, it has yet to become mainstream. We therefore discuss strategies on ensuring long-term sustainability by addressing continued clinical developments of VCA to improve the risk-to-benefit balance, importance of public support, improved policy and financial support, and need for a bridge to the future of transplant surgery. There has been headway on all fronts and collaboration among the VCA centers for centralization of data and incorporation of patient voices will be essential for continued progress.
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Affiliation(s)
| | - L Scott Levin
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Meyers A, Pandey S, Kopparthy V, Sadeghi P, Clark RC, Figueroa B, Dasarathy S, Brunengraber H, Papay F, Rampazzo A, Bassiri Gharb B. Weight gain is an early indicator of injury in ex vivo normothermic limb perfusion (EVNLP). Artif Organs 2023; 47:290-301. [PMID: 36305734 PMCID: PMC10100395 DOI: 10.1111/aor.14442] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 09/25/2022] [Accepted: 10/11/2022] [Indexed: 02/03/2023]
Abstract
PURPOSE There are no established criteria for discontinuing ex vivo normothermic limb perfusion (EVNLP) before irreversible damage occurs. This study evaluates weight gain as an indicator of injury during EVNLP. METHODS Sixteen Yorkshire pig forelimbs were procured and preserved using EVNLP with a hemoglobin-based oxygen carrier (HBOC-201) or static cold storage. EVNLP continued until termination criteria were met: arterial pressure ≥ 115 mm Hg, compartment pressure > 30 mm Hg, or 20% reduction of oxygen saturation. Limb weight, contractility, hemodynamics, perfusate electrolytes, metabolites and gases were recorded. Muscles were biopsied 6-h, and muscle injury scores (MIS) calculated. Forearm compartment pressures and indocyanine green (ICG) angiography were recorded at endpoint. Outcomes were compared at 2%, 5%, 10%, and 20% limb weight gain. RESULTS EVNLP lasted 20 ± 3 h. Weight gain was observed after 13 ± 5 h (2%), 15 ± 6 h (5%), 16 ± 6 h (10%), and 19 ± 4 h (20%). Weight correlated positively with MIS (ρ = 0.92, p < 0.0001), potassium (ρ = -1.00, p < 0.0001), pressure (ρ = 0.78, p < 0.0001), and negatively with contractility (ρ = -0.96, p = 0.011). At 5% weight gain, MIS (p < 0.0001), potassium (p = 0.03), and lactate (p < 0.0001) were significantly higher than baseline. Median muscle contractility was 5 [3-5] at 2% weight gain, 4 [1-5] at 5%, 3 [0-4] and 2 [0-2] at 10% and 20%, respectively. At 20% weight gain, contractility was significantly lower than baseline (p = 0.003). Percent weight gain correlated negatively with endpoint ICG hoof fluorescence (r = -0.712, p = 0.047). CONCLUSIONS Weight gain correlated with microscopic muscle injury and was the earliest evidence of limb dysfunction. Weight gain may serve as a criterion for discontinuation of EVNLP.
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Affiliation(s)
- Abigail Meyers
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Sonia Pandey
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Varun Kopparthy
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Payam Sadeghi
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Brian Figueroa
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Srinivasan Dasarathy
- Department of Gastroenterology, Hepatology, Pathobiology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Henri Brunengraber
- Department of Nutrition and Biochemistry, School of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Francis Papay
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Antonio Rampazzo
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
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Griffin JM, Kennedy CC, Boehmer KR, Hargraves IG, Amer H, Jowsey-Gregoire SG. Using team science in vascularized composite allotransplantation to improve team and patient outcomes. Front Psychol 2022; 13:935507. [PMID: 36148132 PMCID: PMC9486538 DOI: 10.3389/fpsyg.2022.935507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 08/16/2022] [Indexed: 11/13/2022] Open
Abstract
Reconstructive allografts using Vascularized Composite Allotransplantation (VCA) are providing individuals living with upper limb loss and facial disfigurement with new opportunities for a sensate, esthetically acceptable, and functional alternative to current treatment strategies. Important research attention is being paid to how best to assess and screen candidates for VCA, measure optimal patient outcomes, and support patient adherence to lifelong behaviors and medical regimens. Far less attention, however, has been dedicated to the team science required for these complex VCA teams to form, prepare, and provide the highest quality clinical and psychosocial care to those receiving VCA. VCA teams are unique in that they require specialized team members whose scope of practice may not otherwise overlap. The team also needs to constantly negotiate balancing patient safety with multiple risks throughout the transplant process. This study aimed to elucidate the team science needed for this highly innovative and complex area of medicine. Using in-depth qualitative interviews with 14 VCA team members and observations at team meetings, we found that careful consideration of team composition, team structure, and organizational commitment (e.g., local culture and team values; investment of resources) influences team performance and patient outcomes, but that to be efficient and truly effective, teams need to commit to developing processes that foster collaboration. These processes are action-oriented (e.g., communication, leadership), strategic (e.g., planning, training) and interpersonal (e.g., conflict management, trust building). Dedication and commitment to team science allows teams to manage conflict under stress and exercise ways to leverage strengths to provide optimal performance or patient psychosocial and clinical outcomes. This study can provide insight into quality improvement efforts for VCA teams and guidance for other transplant programs that wish to consider expansion into VCA.
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Affiliation(s)
- Joan M. Griffin
- Division of Health Care Delivery Research, Mayo Clinic, Rochester, MN, United States
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, United States
- *Correspondence: Joan M. Griffin,
| | - Cassie C. Kennedy
- Division of Health Care Delivery Research, Mayo Clinic, Rochester, MN, United States
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, United States
- Division of Pulmonary and Critical Care, Mayo Clinic, Rochester, MN, United States
- The William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN, United States
| | - Kasey R. Boehmer
- Division of Health Care Delivery Research, Mayo Clinic, Rochester, MN, United States
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, United States
| | - Ian G. Hargraves
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, United States
| | - Hatem Amer
- The William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN, United States
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, United States
- Essam and Dalal Obaid Center for Reconstructive Transplant Surgery, Mayo Clinic, Rochester, MN, United States
| | - Sheila G. Jowsey-Gregoire
- The William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN, United States
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, United States
- Department of Surgery, Mayo Clinic, Rochester, MN, United States
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Siminoff LA, Alolod GP, Davis EE, McGregor HR, Litsas DC, Sarwer DB, Mulvania PA, Hasz RD, Gardiner HM. Evaluation of an eLearning System to Train Health Professionals to Communicate about Vascularized Composite Allotransplantation with Donor Families. Prog Transplant 2022; 32:233-240. [PMID: 35686350 DOI: 10.1177/15269248221107040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Vascularized composite allotransplantation (VCA) donation relies on obtaining surrogate authorization. Yet, many donor professionals have limited experience discussing composite allograft donation. Using virtual and interactive elements, the eLearning program, Communicating Effectively about Donation for Vascularized Composite Allotransplantation (CEaD-VCA), was developed to enhance the quality of donor professionals' communication approach. RESEARCH QUESTIONS We tested the effectiveness of the eLearning program in improving donor professionals' knowledge, preparedness, and confidence leading discussions with families. DESIGN Donor professionals who primarily obtain family authorization for solid organ and tissue donation were recruited from 2 regional Organ Procurement Organizations. The training was evaluated using a nonrandomized pre-post design. Participants completed an online survey with items assessing their knowledge, preparedness, and confidence for donation discussions. Pre- and post-training responses were compared using paired sample t-tests. RESULTS The sample included 42 donor professionals. The majority (71.4%) had at least 3 years of work experience, and over half (52.4%) had no experience discussing VCA donation with families. Post-training, significant increases in mean knowledge scores (6.4 pre to 7.0 post, P < 0.01) and mean self-reported preparation (6.6 pre to 7.9 post, P < 0.0001) were observed. There were significant increases in mean confidence scores for discussing face (6.2 pre to 7.9 post, P < 0.0001) and hand (6.2 pre to 8.0 post, P < 0.0001) transplants. CONCLUSION The CEaD-VCA program was effective in increasing donor professionals' knowledge, preparation, and confidence when discussing donation, and holds potential for improving donor professional communication during donation discussions.
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Affiliation(s)
- Laura A Siminoff
- Department of Social and Behavioral Sciences, College of Public Health, 6558Temple University, Philadelphia, PA, USA
| | - Gerard P Alolod
- Department of Social and Behavioral Sciences, College of Public Health, 6558Temple University, Philadelphia, PA, USA
| | - Ellen E Davis
- Department of Social and Behavioral Sciences, College of Public Health, 6558Temple University, Philadelphia, PA, USA
| | - Hayley R McGregor
- Department of Social and Behavioral Sciences, College of Public Health, 6558Temple University, Philadelphia, PA, USA
| | - Diana C Litsas
- Department of Social and Behavioral Sciences, College of Public Health, 6558Temple University, Philadelphia, PA, USA
| | - David B Sarwer
- Department of Social and Behavioral Sciences, College of Public Health, 6558Temple University, Philadelphia, PA, USA
| | | | | | - Heather M Gardiner
- Department of Social and Behavioral Sciences, College of Public Health, 6558Temple University, Philadelphia, PA, USA
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Implantable Immunosuppressant Delivery to Prevent Rejection in Transplantation. Int J Mol Sci 2022; 23:ijms23031592. [PMID: 35163514 PMCID: PMC8835747 DOI: 10.3390/ijms23031592] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 01/26/2022] [Accepted: 01/27/2022] [Indexed: 02/04/2023] Open
Abstract
An innovative immunosuppressant with a minimally invasive delivery system has emerged in the biomedical field. The application of biodegradable and biocompatible polymer forms, such as hydrogels, scaffolds, microspheres, and nanoparticles, in transplant recipients to control the release of immunosuppressants can minimize the risk of developing unfavorable conditions. In this review, we summarized several studies that have used implantable immunosuppressant delivery to release therapeutic agents to prolong allograft survival. We also compared their applications, efficacy, efficiency, and safety/side effects with conventional therapeutic-agent administration. Finally, challenges and the future prospective were discussed. Collectively, this review will help relevant readers understand the different approaches to prevent transplant rejection in a new era of therapeutic agent delivery.
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75 Years of Excellence: The Story of Reconstructive Surgery. Plast Reconstr Surg 2021; 148:1423-1428. [PMID: 34847136 DOI: 10.1097/prs.0000000000008529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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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.
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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;
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Kim JY, Lei Z, Maienschein-Cline M, Chlipala GE, Balamurugan A, McDiarmid SV, Azari K, Yang OO. Longitudinal Analysis of the T-cell Receptor Repertoire in Graft-infiltrating Lymphocytes Following Hand Transplantation. Transplantation 2021; 105:1502-1509. [PMID: 33208695 PMCID: PMC8221714 DOI: 10.1097/tp.0000000000003535] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 10/02/2020] [Indexed: 01/23/2023]
Abstract
BACKGROUND T lymphocyte-mediated acute rejection is a significant complication following solid organ transplantation. Standard methods of monitoring for acute rejection rely on assessing histological tissue damage but do not define the immunopathogenesis. Additionally, current therapies for rejection broadly blunt cellular immunity, creating a high risk for opportunistic infections. There is, therefore, a need to better understand the process of acute cellular rejection to help develop improved prognostic tests and narrowly targeted therapies. METHODS Through next-generation sequencing, we characterized and compared the clonal T-cell receptor (TCR) repertoires of graft-infiltrating lymphocytes (GILs) and blood-derived lymphocytes from a hand transplant recipient over 420 days following transplantation. We also tracked the TCR clonal persistence and V beta (BV) gene usage, evaluating overlap between these 2 compartments. RESULTS TCR repertoires of blood and GIL populations remained distinct throughout the sampling period, and differential BV usage was consistently seen between these compartments. GIL TCR clones persisted over time and were seen in only limited frequency in the blood T-lymphocyte populations. CONCLUSIONS We demonstrate that blood monitoring of TCR clones does not reveal the pathogenic process of acute cellular rejection in transplanted tissue. GILs show clonal persistence with biased BV usage, suggesting that tissue TCR clonal monitoring could be useful, although a deeper understanding is necessary to prognosticate rejection based on TCR clonal repertoires. Finally, the distinct TCR BV usage bias in GILs raises the possibility for prevention and therapy of acute cellular rejection based on targeting of specific TCR clones.
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Affiliation(s)
- Joseph Y. Kim
- Division of Infectious Diseases, Department of Medicine, University of Illinois College of Medicine Peoria, Peoria, IL
| | - Zhengdeng Lei
- Research Informatics Core, Research Resources Center, University of Illinois at Chicago, Chicago, IL
| | - Mark Maienschein-Cline
- Research Informatics Core, Research Resources Center, University of Illinois at Chicago, Chicago, IL
| | - George E. Chlipala
- Research Informatics Core, Research Resources Center, University of Illinois at Chicago, Chicago, IL
| | - Arumugam Balamurugan
- Division of Infectious Diseases, Department of Medicine, Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
| | - Sue V. McDiarmid
- Department of Pediatrics, Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
- Department of Surgery, Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
| | - Kodi Azari
- Department of Surgery, Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
- Department of Orthopaedic Surgery, Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
| | - Otto O. Yang
- Division of Infectious Diseases, Department of Medicine, Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
- Department of Microbiology, Immunology, and Molecular Genetics, Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
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13
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Ward S, Boger M, Fleishman A, Shenkel J, Calvo A, Pomahac B, Zwolak R, Krishnan N, Rodrigue JR. Attitudes Toward Organ, Tissue, and Vascularized Composite Allograft (VCA) Donation and Transplantation: A Survey of United States Military Veterans. Transplantation 2021; 105:1116-1124. [PMID: 32639399 DOI: 10.1097/tp.0000000000003376] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND There are 20 million living US armed forces veterans; however, the organ donation attitudes of veterans have not been examined. METHODS Over a 17-month period, a convenience sample of 1517 veterans in New England completed a survey to assess attitudes about organ, tissue, and vascularized composite allograft (VCA) donation. RESULTS Most veterans (96%) supported the donation of organs and tissue for transplantation, and 59% were registered as an organ and tissue donor. Being younger (adjusted odds ratio [aOR]: 0.960.970.98; P = 0.01), female (aOR: 1.061.462.03; P = 0.02), non-Hispanic white (aOR: 1.302.073.30; P = 0.01), Hispanic (aOR: 1.282.434.61; P = 0.01), and having more trust that the transplant process is fair and equal (aOR: 1.191.401.65; P = 0.01) were predictive of donor registration. Also, most veterans were willing to donate their face (57%), hands/arms (81%), legs (81%), penis (men: 61%), and uterus (women: 76%) at time of death; donation willingness was higher for upper and lower limbs than for face or genitourinary organs (P < 0.001). Those unwilling to donate VCA organs expressed concerns about identity loss, psychological discomfort of self and others, body integrity, funeral presentation, and religious beliefs. Most (54%) felt that VCA donation should require permission of legal next-of-kin at the time of one's death, even if the decedent was a registered donor. CONCLUSIONS There is a high level of support for organ, tissue, and VCA transplantation and donation among veterans, despite limited educational campaigns targeting this population. There is high potential among veterans to further increase donor registry enrollment and raise awareness about VCA benefits for severely injured service members.
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Affiliation(s)
- Stephanie Ward
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | | | - Aaron Fleishman
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Jessica Shenkel
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Amanda Calvo
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Bohdan Pomahac
- Department of Surgery, Brigham and Women's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Robert Zwolak
- Department of Surgery, Veterans Affairs Medical Center, Manchester, NH
- Department of Surgery, Veterans Affairs Medical Center, White River Junction, VT
| | - Namrata Krishnan
- Department of Medicine, Veterans Affairs Medical Center, West Haven, CT
- Department of Medicine, Yale School of Medicine, New Haven, CT
| | - James R Rodrigue
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA
- Harvard Medical School, Boston, MA
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14
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Banerjee K, Madhyastha R, Nakajima Y, Maruyama M, Madhyastha H. Nanoceutical Adjuvants as Wound Healing Material: Precepts and Prospects. Int J Mol Sci 2021; 22:4748. [PMID: 33947121 PMCID: PMC8124138 DOI: 10.3390/ijms22094748] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 04/26/2021] [Accepted: 04/27/2021] [Indexed: 02/07/2023] Open
Abstract
Dermal wound healing describes the progressive repair and recalcitrant mechanism of 12 damaged skin, and eventually, reformatting and reshaping the skin. Many probiotics, nutritional supplements, metal nanoparticles, composites, skin constructs, polymers, and so forth have been associated with the improved healing process of wounds. The exact mechanism of material-cellular interaction is a point of immense importance, particularly in pathological conditions such as diabetes. Bioengineered alternative agents will likely continue to dominate the outpatient and perioperative management of chronic, recalcitrant wounds as new products continue to cut costs and improve the wound healing process. This review article provides an update on the various remedies with confirmed wound healing activities of metal-based nanoceutical adjuvanted agents and also other nano-based counterparts from previous experiments conducted by various researchers.
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Affiliation(s)
- Kaushita Banerjee
- Department of Biomedical Sciences, School of Biosciences and Technology, Vellore Institute of Technology, Vellore 632014, India;
| | - Radha Madhyastha
- Department of Applied Physiology, Faculty of Medicine, University of Miyazaki, Miyazaki 8891692, Japan; (R.M.); (Y.N.); (M.M.)
| | - Yuichi Nakajima
- Department of Applied Physiology, Faculty of Medicine, University of Miyazaki, Miyazaki 8891692, Japan; (R.M.); (Y.N.); (M.M.)
| | - Masugi Maruyama
- Department of Applied Physiology, Faculty of Medicine, University of Miyazaki, Miyazaki 8891692, Japan; (R.M.); (Y.N.); (M.M.)
| | - Harishkumar Madhyastha
- Department of Applied Physiology, Faculty of Medicine, University of Miyazaki, Miyazaki 8891692, Japan; (R.M.); (Y.N.); (M.M.)
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15
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Kohn TP, Peña V, Redett Iii RJ, Burnett AL. Penile allotransplantation: early outcomes from reported cases and survivorship considerations. Minerva Urol Nephrol 2021; 73:333-341. [PMID: 33781015 DOI: 10.23736/s2724-6051.21.04144-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Vascular composite allografts are at the forefront of medical and surgical innovation. With this new technique and the ability to transplant a face, hands, an abdominal wall, a uterus, or even a penis, patients can undergo operations that may drastically improve their quality of life. Although this process presents significant opportunities it is not always an easy road and requires significant upfront counseling and life-long immunosuppression. Often the recovery course is long, with functionality taking months to years to gain. Immunosuppression must be used to prevent rejection of the allograft although it has serious long-term side-effects. Only five patients have undergone penile allotransplantation but reported outcomes from these small numbers have nonetheless offered significant lessons with each patient. While the operation is still in its infancy, it is certain that shared experiences by surgical teams will yield improved outcomes in the future.
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Affiliation(s)
- Taylor P Kohn
- Johns Hopkins School of Medicine, Brady Urological Institute, Baltimore, MD, USA
| | - Vanessa Peña
- Johns Hopkins School of Medicine, Brady Urological Institute, Baltimore, MD, USA
| | - Richard J Redett Iii
- Vascularized Composite Allotransplantation (VCA) Laboratory, Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Arthur L Burnett
- Johns Hopkins School of Medicine, Brady Urological Institute, Baltimore, MD, USA -
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16
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Mt F, Sivakumar DK, Mohapatra D, Chittoria R. Intergender Hand Transplant: A Sex Congruent Hand Transformation. Ann Plast Surg 2021; 86:223-225. [PMID: 32756244 DOI: 10.1097/sap.0000000000002515] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT Hand and upper-extremity transplantation restore severely damaged limbs that cannot be repaired with conventional surgical techniques. Over the past 20 years, more than 200 vascularized composite allotransplantations have been performed worldwide, among them 7 were cases of sex unmatched hand transplants. The long term effects of recipient sex hormones and nerve regeneration on the sexually dimorphic physical features of donor upper extremity have not been described previously. We report a case of sex congruent transformation of hand morphology in an intergender hand transplant.
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Affiliation(s)
- Friji Mt
- From the Department of Plastic Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India
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17
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Woo SH, Kim YW, Cheon HJ, Jang S, Do JY, Choi JH, Kang DH, Nam HJ, Yoo MJ, Lee YS, Choi JH. Process of Obtaining Social Consensus and 3-Year Functional Outcomes of the First Hand Allotransplantation in Korea. J Korean Med Sci 2021; 36:e6. [PMID: 33429470 PMCID: PMC7801147 DOI: 10.3346/jkms.2021.36.e6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Accepted: 10/27/2020] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND On February 2, 2017, the surgical team of ten board-certified hand specialists of W Hospital in Korea successfully performed the nation's first hand transplantation at Yeungnam University Medical Center (YUMC). This paper reports on the legal, financial, and cultural hurdles that were overcome to open the way for hand transplantation and its functional outcomes at 36 months after the operation. METHODS W Hospital formed a memorandum of understanding with Daegu city and YUMC to comply with government regulations regarding hand transplantation. Campaigns were initiated in the media to increase public awareness and understanding. With the city's financial and legal support and the university's medical cooperation, a surgical team performed a left distal forearm hand transplantation from a brain-dead 48-year-old man to a 35-year-old left-handed man. RESULTS With this successful allotransplantation, the Korean Act on Organ Transplantation has now been amended to include hand transplantation. Korean national health insurance has also begun covering hand transplantation. Functional outcome at 36 months after the operation showed satisfactory progress in both motor and sensory functions. The disabilities of the arm, shoulder, and hand score were 23. The final Hand Transplantation Score was 90 points. Functional brain magnetic resonance imaging shows significant cortical reorganization of the corticospinal tract, and reinnervation of intrinsic muscle is observed. CONCLUSIONS Hand transplantation at the distal forearm shows very satisfactory outcomes in functional, aesthetical, and psychological aspects. Legal and financial barriers against hand transplantation have long been the most burdensome issues. Despite this momentous success, there have been no other clinical applications of vascularized composite allotransplantation due to the limited acceptance by Korean doctors and people. Further public education campaigns for vascularized composite allotransplantation are needed to increase awareness and acceptance.
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Affiliation(s)
- Sang Hyun Woo
- W Institute for Hand & Reconstructive Microsurgery, W General Hospital, Daegu, Korea.
| | - Young Woo Kim
- W Institute for Hand & Reconstructive Microsurgery, W General Hospital, Daegu, Korea
| | - Ho Jun Cheon
- W Institute for Hand & Reconstructive Microsurgery, W General Hospital, Daegu, Korea
| | - SungHo Jang
- Department of Physical Medicine and Rehabilitation, Yeungnam University College of Medicine, Daegu, Korea
| | - Jun Young Do
- Division of Nephrology, Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Joon Hyuk Choi
- Department of Pathology, Yeungnam University College of Medicine, Daegu, Korea
| | - Dong Ho Kang
- W Institute for Hand & Reconstructive Microsurgery, W General Hospital, Daegu, Korea
| | - Hyun Jae Nam
- W Institute for Hand & Reconstructive Microsurgery, W General Hospital, Daegu, Korea
| | - Myung Jae Yoo
- W Institute for Hand & Reconstructive Microsurgery, W General Hospital, Daegu, Korea
| | - Young Seok Lee
- W Institute for Hand & Reconstructive Microsurgery, W General Hospital, Daegu, Korea
| | - Jin Hee Choi
- W Institute for Hand & Reconstructive Microsurgery, W General Hospital, Daegu, Korea
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18
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Wang HY, Song JK, Shin S, Choi KM, Kim H. One-Tube Nested Real-Time PCR Assay for Rapid Screening of Porcine Cytomegalovirus in Clinical Samples. Front Vet Sci 2020; 7:586045. [PMID: 33195614 PMCID: PMC7656657 DOI: 10.3389/fvets.2020.586045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 09/30/2020] [Indexed: 11/16/2022] Open
Abstract
Porcine cytomegalovirus (PCMV) is a pathogen that must be removed from pigs for use as organ donors in xenotransplantation. Recently, it has been found that when donor pigs are infected with PCMV, a pig-to-non-human-primate xenotransplantation lower transplant survival by 2–3 times. Therefore, highly sensitive methods are needed to maintain designated pathogen free (DPF) pig and screen for xenografts. The purpose of this study was to evaluate the performance of commercially available method with one-tube nested real-time PCR assay to quickly detect PCMV infection in clinical samples and compare the results with those of sequence analysis. Molecular diagnostic methods were used to evaluate 127 samples, including tissues and blood samples from pigs suspected of PCMV infection. The detection rate for positive PCMV was 38.6% (n = 49), 23.6% (n = 30), and 12.6% (n = 16) in one-tube nested real-time PCR, nested PCR, and conventional PCR methods, respectively. All PCMV-positive samples in conventional PCR or nested PCR methods were also positive in the one-tube nested real-time PCR assay. All the PCR products in the three methods were checked for amplification of PCMV gene by PCR and subsequent direct sequencing. The results of one-tube nested real-time PCR were found to be consistent with those of sequence analysis for all the samples and showed good agreement (κ = 1). Our study found that the one-tube nested real-time PCR assay is more sensitive than the other two methods. This assay required approximately 1.5 h for completion. Therefore, we concluded that one-tube nested real-time PCR assay is a fast and reliable method for the characterizing pathogen responsible for PCMV infection.
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Affiliation(s)
| | - Joong Ki Song
- Optipharm Animal Disease Diagnostic Center, Cheongju, South Korea
| | - Seongho Shin
- Optipharm Animal Disease Diagnostic Center, Cheongju, South Korea
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19
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Zuo KJ, Gold A, Zlotnik Shaul R, Ho ES, Borschel GH, Zuker RM. Pediatric Upper Extremity Vascularized Composite Allotransplantation—Progress and Future. CURRENT TRANSPLANTATION REPORTS 2020. [DOI: 10.1007/s40472-020-00297-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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20
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Current and future regulatory and financial challenges in vascularized composite allotransplantation. Curr Opin Organ Transplant 2020; 25:615-619. [PMID: 33060543 DOI: 10.1097/mot.0000000000000813] [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
PURPOSE OF REVIEW To discuss current and future regulatory and financial issues affecting the field of vascularized composite allotransplantation (VCA). RECENT FINDINGS Vascularized composite allografts are regulated by the US Department of Health and Human Services Organ Procurement and Transplantation Network Final Rule (42 CFR part 121) in the United States and Directive 2010/53/EU of the European Parliament and the Council of 7 July 2010 in the European Union (EU). However, in the United States and most of the EU, VCA is not yet paid for by insurance or third-party payers and many centers depend upon grant funding, philanthropic gifts, and/or supplemental hospital/institutional funding strategies to pay for the transplants and postoperative care. SUMMARY In the absence of randomized clinical trial data, which is infeasible for studying VCA outcomes, consensus data sets are needed to document these procedures' value proposition and have them accepted as part of the standard of care. Procedure and immunosuppression protocol variability applied to a small patient cohort necessitates collaborative efforts by field experts to devise creative approaches, such as determining return-on-investment for anatomical subunits, to better understand these transplants' value and impact on patient quality-of-life.
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21
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Pharmacokinetics and Biodistribution of Tacrolimus after Topical Administration: Implications for Vascularized Composite Allotransplantation. Pharm Res 2020; 37:222. [PMID: 33067715 DOI: 10.1007/s11095-020-02921-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 09/01/2020] [Indexed: 12/13/2022]
Abstract
AIM The high doses of oral tacrolimus (TAC) (1,2) necessary to prevent acute rejection (AR) after vascularized composite allotransplantation (VCA) are associated with systemic adverse effects. The skin is the most antigenic tissue in VCA and the primary target of AR. However, the short-term use of topical TAC (Protopic®), as an off-label adjunct to oral TAC, to treat AR episodes pro re nata (PRN), has yielded inconsistent results. There is lack of data on the pharmacokinetics and tissue distribution of topical TAC in VCA, that hampers our understanding of the reasons for unreliable efficacy. Toward this goal, we evaluated the ability of topical TAC to achieve high local tissue concentrations at the site of application with low systemic concentrations. MATERIALS AND METHODS We assessed the pharmacokinetics and tissue distribution of topical TAC (Protopic®, 0.03%) after single or repeated topical application in comparison to those after systemic delivery in rats. Animals received a single topical application of TAC ointment (Group 1) or an intravenous (IV) injection of TAC (Group 2) at a dose of 0.5 mg/kg. In another experiment, animals received daily topical application of TAC ointment (Group 3), or daily intraperitoneal (IP) injection of TAC (Group 4) at a dose of 0.5 mg/kg for 7 days. TAC concentrations in blood and tissues were analyzed by Liquid Chromatography-Mass Spectrometry (LC/MS-MS). RESULTS Following single topical administration, TAC was absorbed slowly with a Tmax of 4 h and an absolute bioavailability of 11%. The concentrations of TAC in skin and muscle were several folds higher than whole blood concentrations. Systemic levels remained subtherapeutic (< 3 ng/ml) with repeated once daily applications. CONCLUSION Topical application of TAC ointment (Protopic®, 0.03%) at a dose of 0.5 mg/kg/day provided high concentrations in the local tissues with low systemic exposure. Repeated topical administration of TAC is well tolerated with no local or systemic adverse effects. This study confirms the feasibility of topical application of TAC for site specific graft immunosuppression and enables future applications in VCA.
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Guiding Strategies for the Future of Vascularized Composite Allotransplantation: A Systematic Review of Organ Donation Campaigns. Plast Reconstr Surg 2020; 146:922-934. [PMID: 32970015 DOI: 10.1097/prs.0000000000007187] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND Since the 1990s, the field of vascularized composite allotransplantation has gained momentum, offering unprecedented solutions for patients with defects not amenable to autologous reconstruction. As with solid organ donation, the vascularized composite allotransplant donor pool remains limited. This systematic review identifies past successes and failures in organ donation campaigns to guide future strategies for expanding vascularized composite allotransplant donation. METHODS A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Three databases (PubMed/MEDLINE, PsycINFO, and Embase) were searched through July 31, 2019. The study compiled solid organ and vascularized composite allotransplant campaigns that aimed to increase donor registration. Articles depicting the current state of vascularized composite allotransplant donation were also assessed. RESULTS Of an initial 3318 articles identified, 40 were included. Six articles described direct mail or print interventions, 10 depicted Web-based interventions, 13 dealt with interpersonal interventions, and seven used multimodal interventions. Four articles described the current state of vascularized composite allotransplant donation. A qualitative synthesis was conducted. The authors found that social media campaigns can have a robust but fleeting effect on registration trends and that interpersonal interventions are effective at increasing registration rates. In addition, the opportunity for participants to immediately register as organ donors, by means of either return mail, in-person, or online, is vital to campaign success. CONCLUSIONS Public organ donation campaigns have had success in increasing organ donor registration rates, particularly through the use of social media and interpersonal interventions that allow for immediate registration. Synthesizing this information, we propose a multimodal campaign to expand the vascularized composite allotransplant donor pool.
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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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24
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Xiao B, Zhang Y, Liu S, Ding J, Yu Z, Wang T, Song B. Nuclear Receptor Subfamily 4 Group A Member 1 Overexpression Prolongs Free Flap Allotransplant Graft Survival by Inducing T-Cell Anergy in the Rat. Transplant Proc 2020; 53:474-480. [PMID: 32919804 DOI: 10.1016/j.transproceed.2020.08.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 06/30/2020] [Accepted: 08/08/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND New strategies to inhibit acute rejection are needed for further applications of composite tissue allotransplantation. The nuclear receptor subfamily 4 group A member 1 (NR4A1) is considered a key controller of maintaining tolerance homeostasis. However, the effect of NR4A1 in suppressing rejection responses after allotransplantation remains unknown. METHODS Brown Norway rat groin flaps were transplanted into Lewis rat recipients. The recipients were administrated cytosporone B, an NR4A1 activator. NR4A1 expression and graft survival time were assessed. T helper type 1 and regulatory T cell populations in the second lymphoid organ were detected by flow cytometry. Furthermore, a retrovirus containing NR4A1 was constructed and transfected to T cells in vitro. After stimulation, interleukin 2 and interferon gamma secretions were detected in the T cells. RESULTS Administration of cytosporone B activated NR4A1 expression in allotransplant recipients and was associated with prolonged survival time of the vascularized free flap allograft. T helper type 1 cells in the recipient secondary lymphoid organs were decreased, whereas the population of regulatory T cells did not change. Interleukin 2 and interferon gamma were suppressed in vitro in the T cells overexpressing NR4A1. CONCLUSIONS We demonstrated that the overexpressed NR4A1 is associated with suppressed graft rejection response. The suppression effect may attribute to induction of T-cell anergy and blockade of key immunologic cytokines.
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Affiliation(s)
- Bo Xiao
- Department of Plastic Surgery, Xijing Hospital, Air Force Medical University, Xi'an, Shanxi Province, China.
| | - Yanqun Zhang
- Department of Emergency, Xijing Hospital, Air Force Medical University, Xi'an, Shanxi Province, China
| | - Shiqiang Liu
- Department of Plastic Surgery, Xijing Hospital, Air Force Medical University, Xi'an, Shanxi Province, China
| | - Jianke Ding
- Department of Plastic Surgery, Xijing Hospital, Air Force Medical University, Xi'an, Shanxi Province, China
| | - Zhou Yu
- Department of Plastic Surgery, Xijing Hospital, Air Force Medical University, Xi'an, Shanxi Province, China
| | - Tong Wang
- Department of Plastic Surgery, Xijing Hospital, Air Force Medical University, Xi'an, Shanxi Province, China
| | - Baoqiang Song
- Department of Plastic Surgery, Xijing Hospital, Air Force Medical University, Xi'an, Shanxi Province, China.
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25
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Van Pilsum Rasmussen SE, Uriarte J, Anderson N, Doby B, Ferzola A, Sung H, Cooney C, Brandacher G, Gordon E, Segev DL, Henderson ML. Public education materials about Vascular Composite Allotransplantation and donation in the United States: Current scope and limitations. Clin Transplant 2020; 34:e14066. [PMID: 32810365 DOI: 10.1111/ctr.14066] [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: 04/20/2020] [Revised: 07/28/2020] [Accepted: 08/11/2020] [Indexed: 11/27/2022]
Abstract
As the field of Vascular Composite Allotransplantation (VCA) grows, demand for VCA donations will increase. The public should be made aware of this treatment option to support patients' informed decision-making and authorization for deceased donation. We assessed the availability and quality of existing VCA public education materials from organ procurement organizations (OPOs), transplant centers, the Organ Procurement and Transplant Network, Veterans Affairs, and the Department of Defense. A content analysis was performed to identify topics covered and important gaps. In total, 1314 public education materials were analyzed, including OPO Facebook posts (61.6%), OPO Twitter posts (29.9%), websites (6.4%), and written documents (eg, fact sheets, research reports) (2.1%). Upper extremity (34.7%) and face (34.5%) transplants were more commonly covered than reproductive (6.4%) or other VCA types (2.8%). Most materials (76.6%) referenced a specific VCA story. However, few materials described which patient population could benefit from VCA (eg, Veterans, amputees, burn victims, 16.4%), the authorization requirements for VCA donation (6.6%), or the appearance of transplanted VCA organs (1.2%). Current VCA public education materials do not adequately educate the public. More comprehensive education materials are needed to prepare the public to authorize VCA donation, become potential donors, or learn about transplant options.
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Affiliation(s)
| | - Jefferson Uriarte
- Center for Health Services and Outcomes Research, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Naomi Anderson
- Center for Health Services and Outcomes Research, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Brianna Doby
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Alexander Ferzola
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Hannah Sung
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Carisa Cooney
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Gerald Brandacher
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Elisa Gordon
- Center for Health Services and Outcomes Research, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.,Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA.,Department of Acute and Chronic Care, Johns Hopkins University School of Nursing, Baltimore, Maryland, USA
| | - Macey L Henderson
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Acute and Chronic Care, Johns Hopkins University School of Nursing, Baltimore, Maryland, USA
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Fahradyan V, Said SAD, Ordenana C, Dalla Pozza E, Frautschi R, Duraes EFR, Madajka-Niemeyer M, Papay FA, Rampazzo A, Bassiri Gharb B. Extended ex vivo normothermic perfusion for preservation of vascularized composite allografts. Artif Organs 2020; 44:846-855. [PMID: 32133657 DOI: 10.1111/aor.13678] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 02/02/2020] [Accepted: 02/27/2020] [Indexed: 12/15/2022]
Abstract
Ischemia and reperfusion injury remains a significant limiting factor for the successful revascularization of amputated extremities. Ex vivo normothermic perfusion is a novel approach to prolong the viability of the amputated limbs by maintaining physiologic cellular metabolism. This study aimed to evaluate the outcomes of extended ex vivo normothermic limb perfusion (EVNLP) in preserving the viability of amputated limbs for over 24 hours. A total of 10 porcine forelimbs underwent EVNLP. Limbs were perfused using an oxygenated colloid solution at 38°C containing washed RBCs. Five forelimbs (Group A) were perfused for 12 hours and the following 5 (Group B) until the vascular resistance increased. Contralateral forelimbs in each group were preserved at 4°C as a cold storage control group. Limb viability was compared between the 2 groups through assessment of muscle contractility, compartment pressure, tissue oxygen saturation, indocyanine green (ICG) angiography and thermography. EVNLP was performed for 12 hours in group A and up to 44 hours (24-44 hours) in group B. The final weight increase (-1.28 ± 8.59% vs. 7.28 ± 15.05%, P = .548) and compartment pressure (16.50 ± 8.60 vs. 24.00 ± 9.10) (P = .151) were not significantly different between the two groups. Final myoglobin and CK mean values in group A and B were: 875.0 ± 325.8 ng/mL (A) versus 1133.8 ± 537.7 ng/mL (B) (P = .056) and 53 344.0 ± 16 603.0 U/L versus 64 333.3 ± 32 481.8 U/L (P = .286). Tissue oxygen saturation was stable until the end in both groups. Infra-red thermography and ICG-angiography detected variations of peripheral limb perfusion. Our results suggest that extended normothermic preservation of amputated limbs is feasible and that the outcomes of prolonged EVNLP (>24 hours) are not significantly different from short EVNLP (12 hours).
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Affiliation(s)
- Vahe Fahradyan
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | | | - Carlos Ordenana
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | | | | | | | | | - Frank A Papay
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Antonio Rampazzo
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, OH, USA
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27
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Wang S, Xiong Y, Wang Y, Chen J, Yang J, Sun B. Evaluation of PLGA microspheres with triple regimen on long-term survival of vascularized composite allograft - an experimental study. Transpl Int 2020; 33:450-461. [PMID: 31930539 DOI: 10.1111/tri.13574] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 09/23/2019] [Accepted: 01/08/2020] [Indexed: 02/06/2023]
Abstract
Systemic immunosuppression is indispensable for vascularized composite allotransplantation (VCA). Daily administration of standard triple therapy regimen of tacrolimus (FK506), mycophenolate mofetil (MMF), and steroid has severe side effects and reduces the compliance of VCA recipients. To overcome these hurdles, FK506/MMF/prednisolone (PDNN) was loaded into PLGA microspheres (PGLA MS). A single injection of FK506/MMF/PDNN-PLGA MS significantly prolonged the survival time of allograft in a rat hind limb transplantation model with a median survival time (MST) of more than 150 days compared to 34.5 days in the group treated orally with FK506/MMF/PDNN and 11 days in the nontreatment allograft and MS control groups. Analysis of showed that FK506/MMF/PDNN-PLGA MS could maintain relatively higher plasma and tissue drug concentrations for a long time. Moreover, histopathology and flow cytometry of circulating mononuclear cells revealed significantly prolonged immunosuppression by the FK506/MMF/PDNN-PLGA MS compared with the orally given FK506/MMF/PDNN. In conclusion, a single injection of FK506/MMF/PDNN-PLGA MS may provide a new approach for long-term prevention of immune rejection in VCA.
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Affiliation(s)
- Shoubao Wang
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yao Xiong
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yinmin Wang
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jingting Chen
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jun Yang
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Binbin Sun
- Department of Orthopaedics, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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28
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Wang H, Sobral MC, Snyder T, Brudno Y, Gorantla VS, Mooney DJ. Clickable, acid labile immunosuppressive prodrugs forin vivotargeting. Biomater Sci 2020; 8:266-277. [DOI: 10.1039/c9bm01487j] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Clickable immunosuppressive prodrugs enablein vivoreplenishment of drugs in biomaterial depots to maintain long-term immunosuppression in tissue/organ transplantation.
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Affiliation(s)
- Hua Wang
- Harvard John A. Paulson School of Engineering and Applied Sciences
- Harvard University
- Cambridge
- Massachusetts 02138
- USA
| | - Miguel C. Sobral
- Harvard John A. Paulson School of Engineering and Applied Sciences
- Harvard University
- Cambridge
- Massachusetts 02138
- USA
| | - Tracy Snyder
- Wyss Institute for Biologically Inspired Engineering
- Cambridge
- USA
| | - Yevgeny Brudno
- Harvard John A. Paulson School of Engineering and Applied Sciences
- Harvard University
- Cambridge
- Massachusetts 02138
- USA
| | - Vijay S. Gorantla
- Surgery
- Ophthalmology and Bioengineering
- Wake Forest School of Medicine
- Winston-Salem
- USA
| | - David J. Mooney
- Harvard John A. Paulson School of Engineering and Applied Sciences
- Harvard University
- Cambridge
- Massachusetts 02138
- USA
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29
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Rezaei M, Rampazzo A, Bassiri Gharb B. Machine preservation of extremities. Artif Organs 2019; 44:361-366. [DOI: 10.1111/aor.13615] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 11/29/2019] [Indexed: 12/21/2022]
Affiliation(s)
- Majid Rezaei
- Department of Plastic Surgery Cleveland Clinic Cleveland Ohio
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