Australia's First Hand Transplant: Outcome at 1 year

Abstract

Background: The first Australian hand transplant procedure was performed on 22nd March 2011. The 65 year old male recipient suffered overwhelming pneumoccoal sepsis in 2006 following a splenectomy resulting in quadrimembral amputation. The left hand was amputated to the mid-metacarpal level and a faux thumb fashioned with minimal residual function. The right hand was amputated to the level of the carpal bones. The upper extremity functional index (UEFI) score for his right hand was 8/80. A right unilateral hand transplant was performed. The peri-operative course is detailed. The patient received a blood group compatible but complete HLA mismatched limb. A number of anti-HLA antibodies were detected by Luminex: A*24:02 (MFI 974) and Cw2 (MFI 528) were donor specific. The patient was CMV and EBV positive. Induction therapy with basiliximab was followed by tacrolimus (levels 7-10), mycophenolic acid (720mg bd) and prednisolone (weaned to 5mg d) maintenance immunsuppression. Cold ischemic time was 3 hours; total surgical time 8 hours 50 minutes. The post-operative course was complicated by cellular rejection (Banff II with adenexal involvement) detected on surveillance biopsy at Day 10. Treatment with pulse methylprednisolone and topical tacrolimus and corticosteroid resulted in complete resolution. Therapy with insulin was commenced on Day 7, but subsequently ceased on day 70; treatment with metformin continued (HbA1c 6.3%). Hypercholesterolemia (total cholesterol 6.4mmol/L) has required pharmacotherapy. There was no evidence of renal dysfunction or microalbuminuria. No anti-HLA antibodies are currently detectable by Luminex testing. Hand function has improved in keeping with the time post surgery. Grip strength progressively increased to 20kg; lateral grasp to 2kg and pincer grasp to 1.5kg. The UEFI score 7 months post-op was 47/80. Intrinsic muscle recovery was documented at 10 months post transplantation. Protective sensation over the entire hand to hot and cold and partial return of light touch and proprioception was evident by 10 months. Functional activities included writing, attending to personal care, dressing, use of cutlery and managing his prosthetic legs. Conclusion(s): Hand transplantation has been successfully performed in Australia on a 65 yo male quadrimembral amputee with standard immunosuppression. One early episode of cell mediated rejection was successfully treated. The recipient has integrated his transplanted hand into functional activities which have greatly enhanced his quality of life.