Vascularized composite allotransplantation: current standards and novel approaches to prevent acute rejection and chronic allograft deterioration.
The advent of more potent immunosuppressants led to the first successful human upper extremity transplantation in 1998. At this time, >100 upper extremity transplants, 30 face transplants, and a variety of other vascularized composite allotransplantation (VCA) procedures have been performed around the world. VCA recipients present unique challenges for transplantation. The incidence of acute rejection exceeds 80% in hand and face transplantation and is well documented, whereas reports about antibody-mediated rejection and chronic rejection remain scarce. Immunosuppression protocols commonly used at US centers are derived from solid organ transplantation protocols. Novel approaches to minimize rejections in VCA may include improved HLA matching and considerations toward cytomegalovirus infection status. New graft preservation techniques may decrease immunogenicity prior to transplant. Novel monitoring methods such as valid biomarkers, ultrasound biomicroscopy, and sentinel flaps may enable earlier diagnosis of rejection. Cell-based therapies are being explored to achieve immunosuppressive regimen minimization or even tolerance induction. The efficacy of local immunosuppression in clinical VCA remains controversial. In conclusion, although immunosuppressive strategies adapted from SOT have demonstrated good midterm results, focusing on the unique features of VCA grafts may enable additional, more specific treatment strategies in the future and improved long-term graft outcomes.
Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.|Department of Plastic Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, Germany.
Maximilian
M
Kueckelhaus
Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.|Department of Plastic Surgery, BG University Hospital Ludwigshafen, Heidelberg University, Ludwigshafen, Germany.
Sebastian
S
Fischer
Division of Transplant Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
Midas
M
Seyda
Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
Ericka M
EM
Bueno
Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
Mario A
MA
Aycart
Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
Muayyad
M
Alhefzi
Division of Transplant Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
Abdallah
A
ElKhal
Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
Bohdan
B
Pomahac
Division of Transplant Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
Stefan G
SG
Tullius
D064591:Allografts; D000818:Animals; D000906:Antibodies / Q000276:immunology; D015415:Biomarkers / Q000378:metabolism; D006084:Graft Rejection / Q000209:etiology / Q000517:prevention & control; D006680:HLA Antigens / Q000276:immunology; D006801:Humans; D007108:Immune Tolerance; D007165:Immunosuppression Therapy / Q000379:methods*; D007166:Immunosuppressive Agents / Q000627:therapeutic use; D014184:Transplantation, Homologous; D063986:Vascularized Composite Allotransplantation / Q000379:methods* / Q000592:standards*
D000906:Antibodies; D015415:Biomarkers; D006680:HLA Antigens; D007166:Immunosuppressive Agents
acute rejection; antibody-mediated rejection; chronic rejection; composite tissue allotransplantation; immunosuppression; vascularized composite allotransplantation