Chronic Rejection in Reconstructive Transplantation

Abstract

Clinical experience in vascularized composite allotransplantation (VCA) is accumulating, with about 25 % of the clinical cases now five or more years posttransplantation. To date, few centers have reported sequelae related to chronic rejection, and in fact, some centers have reported a clear lack of chronic rejection. Unfortunately, our center has had experience with graft vasculopathy in hand transplant recipients, and other characteristics of chronic rejection such as thinning of the skin and loss of adnexal structures have presented in one of our patients. In this chapter, we briefly review chronic rejection in solid organ transplantation and apply lessons learned to what is being presented by VCA recipients. The early experience suggests that VCA patients may be somewhat protected from chronic rejection, but that it can occur, and unlike solid organ transplants there may be multiple primary tissue targets. Like solid organ transplantation, the development of tolerance-inducing protocols with control of both acute and chronic rejection with reduced or no systemic immunosuppression is needed. It remains to be seen whether conventional immunosuppression will be any more effective in treating chronic rejection in VCA patients than it has been for solid organ recipients.