Composite Tissue Allotransplantation (CTA) is the umbrella term for transplantations composed of multiple tissues like the hand or face. More than 32 patients have received hand transplants at institutions around the world. The longest surviving hand transplant patient is the first U.S. recipient at almost 10 years.
Rejection of the new hand following a transplant is a major concern for the team of specialists involved with a transplant. For this reason, an immunosuppression protocol is followed. Induction therapy with antibodies together with multi-drug maintenance therapy represents the standard employed around the world in human hand transplantation. Such drug regimens, while effective, have caused complications like infection and drug toxicity, among others, jeopardizing the benefits gained from otherwise successful hand transplantation.
McGowan Institute for Regenerative Medicine
faculty member Andrew Lee, M.D., director of the Division of Plastic Surgery and Reconstructive Surgery, and the other members of the UPMC Hand Transplant Team (McGowan Institute faculty member Stefan Schneeberger, M.D., director of the CTA Program; McGowan Institute faculty member Vijay Gorantla, M.D., Ph.D., administrative director of the CTA Program; and Gerald Brandacher, M.D., scientific director of the CTA Program) are proposing the use of the Pittsburgh Protocol for immunosuppression after hand transplant. It is composed of two elements: treating the patient with antibodies on the day of transplant, followed by a donor bone marrow infusion several days later. When used in solid organ transplants at UPMC, this protocol allows patients to be treated with low doses of a single maintenance drug.
Through this experimental program, Jessica Arrigo is in line to become the first woman in the United States to receive a hand transplant. In 2004, a norovirus attacked Ms. Arrigo’s body, sending her into septic shock. While spending 17 days in a medically induced coma, the lack of blood flowing to her limbs caused gangrene to set in. This then made it necessary to amputate her two legs below the knees, the four fingers and thumb on her right hand, and part of her left hand, which now has a reconstructed left thumb and parts of three fingers. Last year, Dr. Lee approached Ms. Arrigo about taking part in this new transplant program—the aim of which is to reduce the amount of potentially harmful post-operative drugs a patient must take to prevent his or her body from rejecting the transplanted hand. Ms. Arrigo currently awaits a donor.
In the last decade, around 80 different CTA surgeries have been performed with success. Since its inception, CTA has faced and endured much speculation, debate, controversy, and scrutiny. Early world outcomes have confirmed that satisfactory to excellent function can be achieved with these types of procedures.
The goal now is successful avoidance of the risks of high-dose multiple drug therapy to prevent rejection. Strategies like the Pittsburgh Protocol that aim to minimize maintenance immunosuppression have been studied in organ transplantation at UPMC. Realization of such protocols in clinical CTA will herald a new era of reconstructive transplant surgery to treat complex and major tissue defects.
Illustration: University of Louisville Health System, Harper Collins Illustrated Medical Dictionary
Press of Atlantic City (01/10/09)
The Daily Journal (01/13/09)
UPMC Hand Transplant Frequently Asked Questions
Bio: Dr. Vijay Gorantla
Bio: Dr. Andrew Lee
Bio: Dr. Stefan Schneeberger