Outcomes after bilateral hand allotransplantation: a risk/benefit ration analysis

This is an interesting long term report of five patients who had bilateral hand allotransplants performed in the Lyon centre some years ago with a follow up ranging from three to 13 years. There were four men and one woman and all were young and the level of amputation was distal in three cases and mid forearm level in two patients. Patients essentially had the same immunosuppressive therapy with thymoglobulin induction and then tacrolimus, MMF and prednisone. Patient and graft survival was 100% and all recipients showed reasonable sensory motor recovery and partial recovery of intrinsic muscles in the hand and were able to perform a majority of activities of daily living. Most complications occurred in the first year after transplantation and all patients experienced at least one episode of acute rejection which was easily reversed with high dose steroids. One patient had six episodes of acute rejection. The risks associated with long term immunosuppression were studied and certainly appeared to be acceptable. The patients themselves found that the outcome was acceptable both socially and functionally. Regular angiograms failed to show any evidence of vasculopathy but the authors point out that this remains a continuing risk. This is in contrast to another study where evidence of vasculopathy was found. But the use of continuing triple therapy may have prevented the development of vasculopathy. This is an important long term follow up and as time goes by, far more information will be available about the long term function of hand transplants.