Absence of Rejection in a Facial Allograft Recipient with a Positive Flow Crossmatch 24 Months after Induction with Rabbit Anti-Thymocyte Globulin and Anti-CD20 Monoclonal Antibody

Abstract

Background Donor-specific antibodies (DSA) to human leukocyte antigen increase the risk of accelerated rejection and allograft damage and reduce the likelihood of successful transplantation. Patients with full-thickness facial burns may benefit from facial allotransplantation. However, they are at a high risk of developing DSA due to standard features of their acute care. Case Presentation A 41-year-old male with severe disfigurement from facial burns consented to facial allotransplantation in 2014; panel reactive antibody score was 0%. In August of 2015, a suitable donor was found. Complement-dependent cytotoxicity crossmatch was negative; flow cytometry crossmatch was positive to donor B cells. An induction immunosuppression strategy consisting of rabbit antithymocyte globulin, rituximab, tacrolimus, mycophenolate mofetil (MMF), and methylprednisolone taper was designed. Total face, scalp, eyelid, ears, and skeletal subunit allotransplantation was performed without operative, immunological, or infectious complications. Maintenance immunosuppression consists of tacrolimus, MMF, and prednisone. As of posttransplant month 24, the patient has not developed acute rejection or metabolic or infectious complications. Conclusions To our knowledge, this is the first report of targeted B cell agents used for induction immunosuppression in skin-containing vascularized composite tissue allotransplantation. A cautious approach is warranted, but early results are promising for reconstructive transplant candidates given the exceptionally high rate of acute rejection episodes, particularly in the first year, in this patient population.

Anesthetic Considerations in Facial Transplantation: Experience at NYU Langone Health and Systematic Review

“…Both patients received induction and maintenance immunosuppression therapy as previously described. 16 , 25 , 27 Recipient characteristics and pre- and postoperative laboratory values are outlined in Table 4 . Intraoperative MAPs and UOPs are shown in Figure 3 , and the procedure summary and fluid requirements in Table 5 .…”

Total Eyelid Transplantation in a Face Transplant: Analysis of Postoperative Periorbital Function

“…Induction immunosuppression consisted of rabbit antithymocyte globulin, rituximab, tacrolimus, mycophenolate mofetil, and methylprednisolone, whereas maintenance immunosuppression consists of standard triple therapy with tacrolimus, mycophenolate mofetil, and prednisone. 10 To date, the recipient has not experienced any episodes of rejection. 10 Fig.…”

Reporting Practices on Immunosuppression and Rejection Management in Face Transplantation: A Systematic Review

“…Similar to prevention and surveillance of rejection, management of rejection in SOT is standardized, involving intravenous (IV) corticosteroid pulses for mild cases, monoclonal antibody therapy for severe cases, and IV immunoglobulins or sirolimus for resistant rejection episodes. 70,71 A standard protocol for rejection management in face VCA has yet to be clearly delineated. Protocols for the medical management of rejection were described for only 70% of face VCA patients in the reviewed literature.…”

“…22,72 Incidence of Acute and Chronic Rejection Seventy-three percent of face VCA patients are reported to have experienced at least one episode of acute rejection (AR) in peer-reviewed literature, all occurring within the first postoperative year. 73 In comparison, the 5-year incidence of acute rejection in kidney transplant recipients is 15% 71 and in liver transplant recipients is 7 to 23%. 74 Chronic rejection of the skin seems to be driven by the recipient's cellular immune effectors, which lead to the development of scleroderma-like features, resembling chronic graft versus host disease.…”

“…Eleven percent of face transplant patients reviewed in our study experienced chronic rejection. Comparatively, the 5-year incidence of chronic rejection in kidney transplant recipients is 13% 71 and in liver transplant recipients is 3 to 4%. 6 A low incidence of chronic rejection in face VCA may be explained by response to multiple treatments of acute rejection, early recognition, and reversal of rejection due to the visibility of the skin allograft, or the paucity of longterm follow-up resulting in underreporting of rejection episodes.…”