title: Face Transplantation in a Highly Sensitized Recipient.
abstract: Face transplantation was performed in a highly sensitized recipient with positive preoperative crossmatch and subsequent antibody-mediated rejection. The recipient was a 45-year-old female with extensive conventional reconstructions after chemical burns over the majority of the body. Residual quality of life and facial functions were poor. Levels of circulating anti-human leukocyte antigen (HLA) antibodies were high, and panel reactive antibody score was 98%. A potential donor was identified; however, with positive T and B cell flow crossmatches. The transplant team proceeded with face transplantation from this donor, under tailored immune suppression and with available salvage options. The operation was successful. Plasmapheresis and induction immune suppression (i.e., thymoglobulin followed by mycophenolate mofetil, tacrolimus, and steroids) were provided. Five days later, there was significant facial swelling, rising anti-HLA antibody titers, and unprecedented evidence of C4d deposits on skin. High doses of steroids and thymoglobulin were provided; however, rejection increased such that by day 19 it was diagnosed grade III in the BANFF scale. After stopping thymoglobulin because of serum sickness, combination therapy of plasmapheresis, eculizumab, bortezomib, and alemtuzumab was provided. HLA antibody levels decreased while swelling and redness improved. At 3 months, there were no longer signs of rejection on biopsy.
authors.affiliation: Renal Division, Schuster Family Transplantation Research Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
authors.forename: Anil
authors.initials: A
authors.lastname: Chandraker
authors.affiliation: Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
authors.forename: Ramon
authors.initials: R
authors.lastname: Arscott
authors.affiliation: Division of Dermatopathology, Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
authors.forename: George
authors.initials: G
authors.lastname: Murphy
authors.affiliation: Division of Dermatopathology, Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
authors.forename: Christine
authors.initials: C
authors.lastname: Lian
authors.affiliation: Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
authors.forename: Ericka
authors.initials: E
authors.lastname: Bueno
authors.affiliation: Division of Infectious Diseases, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
authors.forename: Francisco
authors.initials: F
authors.lastname: Marty
authors.affiliation: Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
authors.forename: Helmut
authors.initials: H
authors.lastname: Rennke
authors.affiliation: Division of Nephrology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
authors.forename: Edgar
authors.initials: E
authors.lastname: Milford
authors.affiliation: Division of Transplant Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
authors.forename: Stefan
authors.initials: S
authors.lastname: Tullius
authors.affiliation: Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
authors.forename: Bodhan
authors.initials: B
authors.lastname: Pomahac
mesh_terms: D054445:Facial Transplantation / Q000379:methods*; D005260:Female; D006084:Graft Rejection / Q000276:immunology*; D006680:HLA Antigens; D006650:Histocompatibility Testing / Q000379:methods*; D006801:Humans; D007166:Immunosuppressive Agents / Q000494:pharmacology / Q000627:therapeutic use; D008875:Middle Aged
chemical_list: D006680:HLA Antigens; D007166:Immunosuppressive Agents