Human Hand Transplantation Research Articles

Peripheral nerve repair is associated with augmented cross-tissue inflammation following vascularized composite allotransplantation.

Vascularized composite allotransplantation (VCA), with nerve repair/coaptation (NR) and tacrolimus (TAC) immunosuppressive therapy, is used to repair devastating traumatic injuries but is often complicated by inflammation spanning multiple tissues. We identified the parallel upregulation of transcriptional pathways involving chemokine signaling, T-cell receptor signaling, Th17, Th1, and Th2 pathways in skin and nerve tissue in complete VCA rejection compared to baseline in 7 human hand transplants and defined increasing complexity of protein-level dynamic networks involving chemokine, Th1, and Th17 pathways as a function of rejection severity in 5 of these patients. We next hypothesized that neural mechanisms may regulate the complex spatiotemporal evolution of rejection-associated inflammation post-VCA. For mechanistic and ethical reasons, protein-level inflammatory mediators in tissues from Lewis rats (8 per group) receiving either syngeneic (Lewis) or allogeneic (Brown-Norway) orthotopic hind limb transplants in combination with TAC, with and without sciatic NR, were compared to human hand transplant samples using computational methods. In cross-correlation analyses of these mediators, VCA tissues from human hand transplants (which included NR) were most similar to those from rats undergoing VCA + NR. Based on dynamic hypergraph analyses, NR following either syngeneic or allogeneic transplantation in rats was associated with greater trans-compartmental localization of early inflammatory mediators vs. no-NR, and impaired downregulation of mediators including IL-17A at later times. Thus, NR, while considered necessary for restoring graft function, may also result in dysregulated and mis-compartmentalized inflammation post-VCA and therefore necessitate mitigation strategies. Our novel computational pipeline may also yield translational, spatiotemporal insights in other contexts.

Hand Transplants, Daily Functioning, and the Human Capacity for Limb Regeneration.

Unlike some of our invertebrate and vertebrate cousins with the capacity to regenerate limbs after traumatic loss, humans do not have the ability to regrow arms or legs lost to injury or disease. For the millions of people worldwide who have lost a limb after birth, the primary route to regaining function and minimizing future complications is via rehabilitation, prosthetic devices, assistive aids, health system robustness, and social safety net structures. The majority of limbs lost are lower limbs (legs), with diabetes and vascular disorders being significant causal contributors. Upper limbs (arms) are lost primarily because of trauma; digits and hands are the most common levels of loss. Even if much of the arm remains intact, upper limb amputation significantly impacts function, largely due to the loss of the hand. Human hands are marvels of evolution and permit a dexterity that enables a wide variety of function not readily replaced by devices. It is not surprising, therefore, for some individuals, dissatisfaction with available prosthetic options coupled with remarkable advances in hand surgery techniques is resulting in patients undertaking the rigors of a hand transplantation. While not “regeneration” in the sense of the enviable ability with which Axolotls can replace a lost limb, hand transplants do require significant regeneration of tissues and nerves. Regaining sophisticated hand functions also depends on “reconnecting” the donated hand with the areas of the human brain responsible for the sensory and motor processing required for complex actions. Human hand transplants are not without controversy and raise interesting challenges regarding the human regenerative capacity and the status of transplants for enabling function. More investigation is needed to address medical and ethical questions prior to expansion of hand transplants to a wider patient population.

The Untold Story of the First Hand Transplant: Dedicated to the Memory of one of the Great Minds of the Ecuadorian Medical Community and the World.

In 1964, faced with the challenge of traumatic amputation, a team of surgeons at Clinica Guayaquil was convinced that the transplantation of a hand could significantly improve function and quality of life for the recipient. With a current but basic understanding of immunosuppression, the surgeons identified a recipient and waited for the correct donor. A human hand transplant had never been performed to date. The surgeons' criteria for the recipient included a young healthy individual who had sustained a traumatic amputation at the distal forearm level with full motion of the proximal joints. Communication with receiving hospitals and military facilities identified what they perceived to be a feasible donor for an allograft transplantation. Consent was obtained from the family in conjunction with the local military medical authorities and the clergy. Iced saline solution and Heparin irrigation were to be used to prepare the donor extremity. The immunosuppression regimen, limited at the time, consisted only of intravenous cortisone, Imuran, and a single dose of radiation. A member of the Ecuadorian marine sustained a limited blast injury that amputated his dominant hand but spared the forearm. He was transferred to the emergency department of Clinica Guayaquil. A donor who had recently died in a nearby hospital was identified not long after. A successful technical surgical transplantation was achieved. Consultants from major hospitals around the world (including Peter Bent Brigham Hospital) convened at the patient's bedside to observe the results. Despite all efforts, the patient suffered an irreversible rejection at 21 days post-transplant. This was the first allograft transplantation of a hand. The surgeons embarked on an intervention never tried before, firmly believing that better function and quality of life would result. The bravery of this surgical team was commendable. This early surgical endeavor opened the way for future successes in transplant surgery today.

A Lifesaving View of Vascularized Composite Allotransplantation: Patient Experience of Social Death Before and After Face, Hand, and Larynx Transplant.

Introduction:Most solid organ transplantation is viewed as lifesaving, whereas vascularized composite allotransplantation (VCA) has been viewed as life enhancing. This article challenges the latter and argues that “social death” evident in severe face, hand, and larynx disfigurement can be potentially treated via VCA. Social death (from a social science perspective) consists of a combination of 7 components: social isolation, loneliness, ostracism, loss of personhood, change of role and identity, harm, and disfigurement.Methods:In February 2016, PubMed and Google were searched for case reports of human face, hand, and larynx transplantation. Patient and team narratives were then coded for components of social death using social science and medical model criteria.Results:Eleven narratives were identified among 9 articles. The social science model (but not the medical model) described pretransplant social death and the resolution of social death by receiving VCA. Notably, the medical model of social death was deemed unsuitable for application to VCA. This is because case narratives consistently contradict elements of the medical model.Conclusions:By including social death as a patient inclusion criterion for face, hand, and larynx VCA, these transplants can be considered lifesaving. Additionally, because VCA requires lifelong immunosuppressant medication, considering VCA as a lifesaving intervention improves the technology’s risk–benefit analysis. Guidance for assessing social death is provided.

Lymphatic Clearance in the Hand/Forearm of Healthy Controls and Human Hand Transplant Recipients Using Infrared Imaging of Indocyanine Green

Objective: Abnormal lymphatic function defined by scintigraphy in hand transplant patients has been reported. In cases of chronic edema, it is not clear whether swelling is due to inadequate lymphatic function, vascular leakage, or both. In hand transplantation, deep lymphatic vessels are not anastomosed. Surface lymphatic drainage reestablishes spontaneously. Feasibility of upper limb lymphatic infrared imaging with indocyanine green (ICG) has been demonstrated in breast cancer patients. However, there is no body of information on objective measurement of lymphatic function with ICG using normal controls. During pilot scans of our transplant recipients, it became clear that we had to define normal subcutaneous ICG clearance before we could define abnormal function. The aim of this study is to establish parameters of lymphatic function defined by clearance of subcutaneous injection of ICG in normal controls. The ultimate goal is to noninvasively define adequate and inadequate lymphatic function in hand transplant and replant patients. Methods: After obtaining institutional review board approval (IRB) approval, we enrolled 10 (age range, 23-54; 5 males and 5 females) normal controls. Patients with a history of allergy to iodine or shellfish were excluded. Hand transplant recipients were imaged initially using a dose of 0.25 mg of ICG. Subsequently, dose titration studies were performed in normal controls. Doses ranged from 0.25 mg to 0.025 µg of dye per subcutaneous injection site on the volar or dorsal side of the hand in 100 µL of saline. The stock vial of ICG is reconstituted with sterile water per manufacturer’s (Novodaq, Novadaq Technologies Inc, Ontario, Canada) instructions. Subject hand and upper extremity was then imaged using the LUNA Florescence Angiography unit at 15 minutes to hourly intervals up to 6 hours postinjection. Selected patients were also imaged every 24 hours until dye cleared completely from the injection site. Images were analyzed using SPYi software. Results: Injection of 2 sites on the dorsal, but not volar side of the hand, allows clear visualization of drainage of ICG by both ulnar and radial lymphatic vessels from the hand to the antecubital fossa and the arm in the brachial veins. Relatively low doses of dye allow excellent visualization. In normal controls, ICG can be visualized in the antecubital fossa in a linear pattern by 15 minutes and in significant amounts by 30 minutes. Higher doses of dye were associated with excessive retention of dye at injection site with no improvement in vessel visualization. Hand transplant recipients demonstrated a mixture of linear and radial drainage, with more involvement of small superficial capillary-like networks. Conclusions: These pilot studies show that subcutaneous clearance of ICG as a targeted near-infrared (NIR) molecular imaging agent can be used to define lymphatic function. By combining subcutaneous injection with intravenous imaging of ICG, we hypothesize that the role of lymphatic function versus vessel leakage in chronic edema can be differentiated. Further studies are needed to identify whether this could be helpful in the evaluation/treatment of patients with lymphostasis related to burns, cellulitis, other infections, and compartment syndrome.

Chronic rejection in vascularized composite allografts.

To convey key issues surrounding chronic rejection in vascularized composite tissue allotransplantation (VCA), and to highlight pathologic features consistent with VCA chronic rejection. Features consistent with chronic rejection have been reported in three VCA animal models, and have been observed in a paucity of human knee and hand transplants. These features include transplant vasculopathy with intimal hyperplasia, tertiary lymphoid follicles, graft fibrosis, and graft edema. Transplant vasculopathy has been the most consistent finding across cases, and has resulted in graft dysfunction and loss. Antibody-mediated rejection has not been conclusively reported in animal models or human subjects, although some cases have demonstrated donor-specific antibody in conjunction with C4d deposition. Multiple immunologic and non-immunologic mechanisms of VCA chronic rejection have been proposed. As in solid organ transplantation, chronic rejection in VCA remains ill-defined. Transplant vasculopathy appears to be a key feature of chronic VCA rejection, whereas tertiary lymphoid follicles, graft fibrosis, and graft edema appear to be less-specific findings. Intimal hyperplasia can be detected with advanced imaging modalities.

Human hand transplants and challenges for adaptation in Japan

Human hand transplants and challenges for adaptation in Japan

Histopathology of Chronic Rejection in a Nonhuman Primate Model of Vascularized Composite Allotransplantation

Chronic rejection of vascularized composite allografts (VCA) is an emerging phenomenon that may decrease long-term allograft survival and impair allograft function. Although intimal hyperplasia has been reported in human hand transplants, chronic changes in VCAs remain poorly described. We developed a nonhuman primate model of face transplantation to evaluate the effect of various immunosuppressive regimens on allograft survival that we have previously reported. Nineteen grafts were successfully transplanted and serially biopsied to assess for rejection. Five VCA grafts with long-term survival (>200 days) were weaned off immunosuppression. We performed additional histologic and immunohistochemical studies on previously collected samples. All five grafts developed features consistent with chronic rejection, including neointimal proliferation, transplant vasculopathy, vessel wall fibrosis, progressive luminal occlusion, and tertiary lymphoid follicles. Review of 186 serial allograft skin and subcutaneous tissue biopsies revealed that tertiary follicles and vascular changes developed in the absence of acute skin rejection. No relationship was found between alloantibody production and these changes. Recognition of these characteristics of VCA chronic rejection is important for diagnosis in clinical hand and face transplantation. Studies directed towards minimizing VCA chronic rejection responses may be required to improve long-term outcomes.

Risk assessment and management in hand and facial tissue transplantation.

Since hand and facial tissue transplantation are new treatments, risk data must be derived from early reports of the few cases done to date combined with extrapolations from other procedures with similar risks. This manuscript summarizes data from both sources including eight separate studies that measure the real and perceived risks associated with hand and facial tissue transplantation. Real Risks: Several large clinical studies describing risk data from kidney transplant recipients (10-years experience) and risk data from 49 human hand transplants in 33 recipients (>10years experience) were reviewed. Perceived Risks: Over 500 subjects with different life experiences (facially disfigured, amputees, laryngectomees, kidney transplant recipients, transplant and reconstructive surgeons, and controls) were surveyed using a standardized and validated risk assessment instrument. Real Risks: Contrary to earlier estimates the risks of acute rejection are higher (80-85%) while the risks of chronic rejection (<5%) and other complications are lower than previously reported. Perceived Risks: Despite different life experiences, those questioned would accept similar amounts of risk to receive different types of transplant procedures (hand, foot, face, larynx, and kidney) but all would accept the most risk for a facial tissue transplant. Kidney transplant recipients, who live with the risks of immunosuppression, would accept the most risk while facially disfigured individuals and reconstructive surgeons, who have real-life experience with facial disfigurement, would accept the least. These studies contribute to the growing body of risk data necessary for moving hand and face transplantation into mainstream medicine.

Molecular Markers and Targeted Therapy of Skin Rejection in Composite Tissue Allotransplantation

Skin rejection remains a major hurdle in reconstructive transplantation. We investigated molecular markers of skin rejection with particular attention to lymphocyte trafficking. Skin biopsies (n = 174) from five human hand transplant recipients were analyzed for rejection, characteristics of the infiltrate and lymphocytic adhesion markers. The cellular infiltrate predominantly comprised CD3+ T cells. CD68, Foxp3 and indoleamine 2, 3-dioxygenase expression and the CD4/CD8 increased with severity of rejection. Lymphocyte adhesion markers were upregulated upon rejection, intercellular adhesion molecule-1 and E-selectin correlated best with severity of rejection. Guided by the findings, a specific E- and P-selectin inhibitor was investigated for its effect on skin rejection in a rat hind limb allotransplant model. While efomycine M (weekly s.c. injection into the graft) alone had no effect, long-term allograft survival was achieved when combined with antithymocyte globulin and tacrolimus (control group without efomycine M rejected at postoperative day [POD] 61 +/- 1). Upregulation of lymphocyte trafficking markers correlates with severity of skin rejection and time after transplantation in human hand transplantation. Blocking E- and P-selectin in the skin holds potential to significantly prolong limb allograft survival.

FK-506 ointment: an effective adjuvant therapy to treat a dramatic case of pyoderma gangrenosum of unilateral hand

Pyoderma gangrenosum (PG) is a cutaneous ulcer developing so rapidly that may mimic a fulminating infection. The correct treatment is nonsurgical, and surgery may get the condition worse.1 FK-506 ointment (0.1% Protopic, Astellas Pharma AG, Fribourg) is usually indicated for inflammatory skin diseases, such as atopic dermatitis and psoriasis2 or for acute rejection reversal of human hand transplantation 3. A few reports of PG affecting the functions of hands can be found in the scientific literature and this report describes the first case treated by FK-506 ointment as an adjuvant therapy.

Indoleamine 2,3-Dioxygenase and Foxp3 Expression in Skin Rejection of Human Hand Allografts

Human hand transplantation is complicated by skin rejection. To better define the characteristics of infiltrating cells, biopsies from human hand transplants have been investigated for expression of Foxp3 and indoleamine 2,3-dioxygenase (IDO), a key regulatory enzyme to induce T-lymphocyte unresponsiveness. A total of 104 skin biopsies taken from three bilateral hand transplant recipients over 6 years posttransplant were assessed by hematoxylin-eosin histology (graded 1–4b) and immunohistochemistry for IDO and Foxp3 according to a three-grade classification and correlated with the grade of rejection as well as time after transplantation. Overall, rejection ranged between grades 0 and 4a with an average score of 0.94. IDO was expressed in the endothelium independent of rejection. Upon rejection, IDO staining within the cellular infiltrate was significantly increased. Foxp3 in regulatory T cells was mainly found in samples undergoing severe rejection. Expression of IDO and Foxp3 compared well to each other, although the overall expression of Foxp3 was lower when compared to IDO. An increased expression of IDO as well as Foxp3 during rejection late after transplantation was observed. Characteristics of the cellular infiltrate indicate tolerogenic properties of a proportion of the cells and therefore a tendency toward self-limitation of the alloimmune response during skin rejection after hand transplantation.

Immunosuppression and Rejection in Human Hand Transplantation

Avoidance or at least minimization of maintenance immunosuppression represents the key step for promoting wider applicability of reconstructive transplantation. Understanding the mechanisms of composite tissue allograft rejection is essential in working toward that goal. We herein review the current knowledge on acute rejection in reconstructive transplantation and discuss findings in the light of novel immunosuppressive and immunomodulatory strategies.

Investigation of Risk Acceptance in Facial Transplantation

Background:The surgical techniques necessary to transplant a human face are well established, and the early success of human hand transplants suggests that the immunological hurdles of transplanting human facial tissues have largely been overcome. Therefore, it is the ethical barriers that pose the

Present technique and long-term results of toe-to-antebrachial stump transplantation

Complete hand amputation has been considered conventionally as an indication for the use of mechanical prosthetic devices in order to regain some hand like function. A microsurgical option to create a new pinching ability after wrist amputation has been used in a series of 13 patients. The actual operation technique is presented in detail. It was designed by the senior author in 1981 and applied into clinical use in 1983. In order to evaluate the functional results and patient satisfaction in long-term, a questionnaire was sent to 12 patients and 11 patients were interviewed, examined clinically and studied with a hand function scoring test according Sollerman. The operated series consist of 12 adults with posttraumatic distal antebrachial or wrist amputations and 1 adolescent boy with a congenital wrist level amputation. There were 3 females and 10 males in the series. The satisfaction to achieved result was generally good. The ADL section of Tamai score and the one we used correlated well with each other and patient satisfaction. Sollerman hand function test gave worse results in two blind patients and same occurred in two short antebrachial stump patients. However the satisfaction was much better in Tamai score among blind patients, with wrist amputation level amputations. In our opinion this single toe transfer method gives an acceptable pinch reconstruction for hand amputation patients. We measured pinch strength and total active motion. They averaged about half of the normal values. The reconstruction is suitable to the patients, who are not willing to donate multiple toes or who are aware and concerned about the risks of human hand transplantation, which necessarily will need a life-long immunosuppressive medication to prevent from rejection.

Investigation of Risk Acceptance in Facial Transplantation

The surgical techniques necessary to transplant a human face are well established, and the early success of human hand transplants suggests that the immunological hurdles of transplanting human facial tissues have largely been overcome. Therefore, it is the ethical barriers that pose the greatest challenge to performing facial transplantation. At the center of the ethical debate is the question, "Do the risks posed by the life-long immunosuppression that a recipient would have to take justify the benefits of receiving a face transplant?" In this study, the authors answer this question by assessing the degree of risk individuals would be willing to accept to receive a face transplant. To quantitatively assess risks versus benefits in facial transplantation, the authors developed the Louisville Instrument for Transplantation, or LIFT, which contains 237 standardized questions. Respondents in three study populations (healthy individuals, n = 150; organ transplant recipients, n = 42; and individuals with facial disfigurement, n = 34) were questioned about the extent to which they would trade off specific numbers of life-years, or sustain other costs, in exchange for receiving seven different transplant procedures. The authors found that the three populations would accept differing degrees of risk for the seven transplant procedures. Organ transplant recipients were the most risk-tolerant group, while facially disfigured individuals were the least risk tolerant. All groups questioned would accept the highest degree of risk to receive a face transplant compared with the six other procedures. This study presents an empirical basis for assessing risk versus benefit in facial transplantation. In doing so, it provides a more solid foundation upon which to introduce this exciting new reconstructive modality into the clinical arena.

Transmigration of donor cells involved in the sciatic nerve graft

Introduction Recently, human hand transplantation in Europe has shown that motor function may be recovered in some cases. However, little is known about cell trafficking involved the graft nerve. We have succeeded to use green fluorescent protein transgenic (GFP-Tg) rats with various cells strongly expressing GFP in a model a long-term survival of limb graft. In this model, we found retrograde migration of GFP-positive donor cells through the sclatic nerve anastomosis. It is well known that cellular components in the peripheral nerve graft especially Schwann cells, play an important role in the axonal regeneration promoted by nerve grafting. However, it was difficult to distinguish the cellular component of the nerve graft from recipient cells. The purpose of this study was to evaluate the migration of donor origin cells to the recipient's nerve and to examine the contribution of these cells in axonal regeneration using a simplified model of sciatic grafting. Methods Nerve defects were created in recipient rats, using three experimental combinations: group 1: wild-type rats from GFP Tg rats; group 2: GFP Tg rats from wild-type rats; group 3: wild-type rats from GFP Tg rats whose nerve grafts had been pretreated by freeze-thawing cycles (representing an acellular graft). The sciatic nerve specimens were examined under excitation light at 1, 2, and 3 weeks after transplantation. Results GFP-positive area expanded clearly beyond the anastomosis both proximally and distally in group 1 and infiltrated into the middle of the null graft in group 2. On the contrary, freeze-thawing grafts donated GFP Tg rats lost GFP expression completely. Columns of GFP-positive cells were formed in the degenerated graft migrated into the recipient's nerve both ante- and retrograde. The S100-positive GFP-positive cells were considered to be graft-origin Schwann cells. The regenerating axons were accompanied with these double-positive cells in the recipient nerve. In conclusion, we have visualized the contribution of graft cells to axonal regeneration beyond a peripheral nerve anastomosis.

Human hand transplantation: what have we learned?

Hand transplantation may become an important procedure for upper limb functional restoration. To date, 18 patients have been undergone 24 hand operations in the world. Initial results are extremely promising; the functional results are apparently superior to those obtained with prostheses. We report on the combined French and Italian experience of six patients (eight hands), which is based on a jointly devised protocol and represents the largest available clinical series. Six male patients aged 43, 33, 35, 32, 33, and 22 years received either a single right hand–dominant transplantation (four cases) or a simultaneous double hand transplantation (two cases). The time since the amputation ranged from 3 to 22 years. The level of transplantation was at the wrist in five cases (six hands) and at the distal forearm in two cases (two hands). Cold ischemia averaged 11.5 hours. Three patients simultaneously received additional full-thickness skin taken from the donor and transplanted onto their left hip area. This skin served as a source for biopsies and as an additional area to monitor rejection (distant sentinel skin graft). The immunosuppressive protocol included polyclonal antibodies (three patients) or monoclonal anti-CD 25 antibody (three patients), tacrolimus, mycophenolate mofetil, and prednisolone. No surgical complications occurred. Skin rejection occurred at least once in all patients at a mean of 40 days postoperatively. Three patients recovered protective and some discriminative sensation in their palm and fingers. Two patients are recovering sensation, but are still in the early phases of the regenerative process, due to the short time since the transplantation. One patient was not compliant with the immunosuppressive therapy, and underwent uncontrolled rejection and reamputation.

Serial monitoring of immunological parameters following human hand transplant.

Although early successes have been achieved in human hand transplant, the changes of immunological parameters in the recipients and their relations to clinical events were not yet known. In two patients undergoing hand transplantation, we prospectively determined lymphocyte subsets using flow cytometry as well as the serum levels of interleukin (IL)-2, IL-10, tumor necrosis factor (TNF)-alpha, and interferon (IFN)-gamma using enzyme linked immunosorbent assays during the first 6 months after transplantation. The decreases in CD, CD, CD T cell, the activated T cell (CD/CD, CD/HLA-DR(+)) as well as IL-2, IFN-gamma and corresponding significant peak in IL-10 in human hand transplant during the first post-transplant week were observed. Then these parameters recovered to the pre-transplant level except for an even higher level of CD T cell. The low CD/CD ratio was been maintained constantly. After 7 wk, IL-2, IFN-gamma, and IL-10 decreased to be maintained at a low or undetectable level except for slight increase in IL-10 at post-transplant month 5. There are no significant variation in TNF-alpha early after transplant. After 3 months, IL-10 was not detected again. The immunosuppressive agents had significantly effects on the immunological status in human hand transplant recipients. These profiles of immunological parameters would be useful data for the future immunomonitoring in human hand transplant recipients.

Facial transplantation: a working party report from the Royal College of Surgeons of England.

We are publishing this working party report on facial transplantation from the Royal College of Surgeons, England, in order to get opinions from the transplant community as to whether it is appropriate or not to perform this procedure at this point in time. There is no question that technically this can be done, but do the risks of failure, both technical and immunological, and the long-term risks of immunosuppression outweigh the potential benefits to the recipient who undoubtedly would be a severely burnt patient with a very scarred immobile face? The problems are not primarily technical but are immunological, psychological, and legal.