Are Clinical Outcomes of Vascularized Composite Allotransplantation Different from Solid Organ Transplants?

Kadiyala Ravindra¹, Detlev Erdmann¹, Scott Hollenbeck¹, Julie Hudson¹, Debra Sudan¹.

¹Department of Surgery, Duke University, Durham, NC, USA.

Introduction: VCA has been performed for life enhancing indications in a selected group of patients under institutional protocols. VCA was presumed to be different from solid organ transplants (SOT) in terms of immunosupprression need, lack of chronic rejection and significant long term morbidity. This paper is an attempt to audit the outcomes of VCA todate.

Patients and Methods: Analysis of major publications of hand and face allotransplantation was performed, including the biannual reports of the International registry on hand and composite tissue transplantation and presentations at the ASRT (American society of reconstructive transplantation). We tabulated and analyzed the incidence of infection, acute rejection, metabolic complications and neoplasia.

Results: A total of 50 hand and 11 face transplants have been performed worldwide. The patient and graft survival is 95% and 80%. The reasons for graft loss include lack of or non-compliance with immunosupprression in 8, chronic vascular rejection and bacterial infection in 1 each. Of the 11 face allotransplants done so far, 2 have died – one due to infection and the other from unclear causes. Acute rejection episodes are reported in 82% and 100% of hand and face recipients respectively. Half of them had multiple rejection events, despite the use of induction agents in 90% of cases. Chronic rejection has been demonstrated in 2 patients with graft loss and some evidence of vasculopathy was identified in 4 other recipients on deep biopsies and novel scanning methods. The incidence of opportunistic infections is 66.7% and has included CMV infections in 8. Metabolic complications are reported in 50% – including diabetes in 16% (8)and renal impairment in 5. Neoplasia has occurred in 2 – a skin cancer in 1 and lymphoma in another. One patient is reported to have renal failure on hemodialysis.

Conclusions: Current data from VCA patients shows that the incidence of acute rejection is far higher in these patients as compared to SOT. But the long term impact of these immunological events is far from clear as the entity of chronic rejection in VCA remains ill-defined. The problems of chronic immuosuppression parallel the results reported in solid organ transplantation. With time the incidence of metabolic, infection and neoplastic complications will rise. This has the potential to reignite the ethical debates about VCA.