Such improvements in quality of life are evident in a patient transplanted in Louisville, Ky., who his surgeons said returned to work hanging gutters just two months after his single-hand transplant. According to the transplant team in Lyon, France, the world's first double-hand transplant patient is able to shave and take care of other personal hygiene tasks that he was unable to do before his transplant. Italian surgeons said that 22 years after one patient's hand was severed, the transplant has afforded nearly the same sense of touch in his transplanted hand as his other.
Today's discussion also included details of comprehensive, pathological studies conducted by French, British and Australian researchers on the first patient's hand, which was amputated at his request 28 months after transplantation. An outlier in a series of otherwise successful cases, the patient refused doctors' orders to take the required drugs to control rejection. Indeed, rejection resulted, manifested by painful lesions on his arm and hand. Studying the amputated graft indicated the rejection process was most prevalent in the outer layer of the skin but scant in the underlying tissues, such as bone and muscle. The researchers' conclusion: Monitoring changes on the skin is an effective way to recognize signs of rejection.
That case, performed in Lyon in 1998, grabbed international headlines and generated much debate, as did subsequent cases performed in the United States and elsewhere. One of the questions some critics continue to ask is whether it is ethical to subject a patient not undergoing an organ transplant to the inherent risks of immunosuppression, while others argue that treating hand recipients with these drugs is no different than treating patients with diseases like rheumatoid arthritis with the same agents. Like organ transplant patients and many patients with autoimmune diseases, hand transplant recipients must take powerful drugs that suppress their immune systems. But while protecting against rejection of the grafts, such drugs also can make patients susceptible to infections and tumor growth, calling into question whether the risks outweigh the benefits.
According to the studies presented today by the Italian, French and U.S. teams, none of these serious complications have yet to affect recipients of hand transplants. While patients have had some transient problems, such as high blood sugar, these were corrected by adjusting doses or treatments. Most importantly, the drugs thus far have been effective in preventing or reversing episodes of rejection, reported Dr. Bruno Gridelli of the Riuniti di Bergamo Hospital in Bergamo, Italy; Dr. Jean-Michel Dubernard of the Hopital Edouard Herriot in Lyon; and researchers from the University of Louisville and Kleinert, Kutz and Associates in Louisville. Three cases performed in China, to be reported Friday, indicate that exposing the donor grafts to radiation before transplantation may also help to prevent immune system attack.
Interestingly, unlike with organ transplants, even if mild or moderate rejection does occur in the transplanted hand it does not appear to affect its function, said Dr. Darla Granger from the University of Louisville. She cited one of her two patients who continued to work full time hanging gutters while his hand had visible signs of rejection. Apparently, he complied with taking his oral anti-rejection drugs but had stopped applying the topical ointment on his hand because its greasy consistency made it more difficult to perform his job.
There have been eight reported single-hand transplants. The world's first was performed in Lyon, France on Sept. 23, 1998. (The graft was amputated at the patient's request Feb. 2, 2001 in London.) The first case was followed by a transplant in Louisville on Jan. 24, 1999, and one in Guangzhou, China in September of that year. In 2000, teams in Kuala-Lumpur, Malaysia and Milan, Italy each performed transplants. In 2001, three transplants each were performed in Louisville, Harping, China, and in October of that year, in Milan.
Four double-hand transplants have been performed, according to reports. The world's first was Jan. 12, 2000 in Lyon. That same year, surgeons in Innsbruck, Austria and Guangzhou, China performed two cases, and the fourth transplant was performed in Harping, China in 2001.
According to the hand transplant teams represented at the International Congress of The Transplantation Society, hand transplantation and other types of composite tissue transplantation would benefit patients whose limbs have been severed or amputated or who require reconstructive surgery due to tumor resections or congenital deformities.
Held every two years, the International Congress of The Transplantation Society is recognized as the field's most important international scientific meeting. More than 1,600 abstracts covering basic and clinical science are being presented, and nearly 3,000 surgeons, physicians and researchers from 71 countries are in attendance. Co-chairs of the congress are Drs. Camillo Ricordi of the Diabetes Research Institute at the University of Miami School of Medicine and Domingo Casadei of the Instituto de Nefrologia in Buenos Aires.
Journal
Transplantation