Publicado

2017-07-01

Hand Transplantation: Current concepts and management algorithm

Trasplante de mano: conceptos actuales y algoritmo de manejo

Palabras clave:

Hand Transplantation, Immunosuppression, Composite Tissue Allografts, Graft Rejection, Infection. (en)
Trasplante de mano, Inmunosupresión, Alotrasplante compuesto vascularizado, Rechazo de injerto, Infección (es)

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Autores/as

  • Carlos Ivan Carrillo-Moreno Universidad Nacional de Colombia - Faculty of Medicine - Department of Surgery - Human Organ and Tissue Transplantation Group - Bogotá D. C. - Colombia.
  • Diana Paola Escobar-Serna Universidad Nacional de Colombia - Faculty of Medicine - Department of Surgery - Human Organ and Tissue Transplantation Group - Bogotá D. C. - Colombia.
  • Samuel de Jesús González-Vélez Universidad Nacional de Colombia - Faculty of Medicine - Department of Surgery - Human Organ and Tissue Transplantation Group - Bogotá D. C. - Colombia.
  • Eyner Lozano-Marquez Universidad Nacional de Colombia - Faculty of Medicine - Department of Surgery - Human Organ and Tissue Transplantation Group - Bogotá D. C. - Colombia.

Introduction: Hand transplantation was first reported in 1964, and is currently one of the challenges that the 21st century poses to Medicine. Several related studies and advances have been achieved, thus allowing to explore new alternatives for patient management. Many reference centers have performed their own analyzes based on their experience, which has led to increase the viability of this type of transplant.

Objective: This review seeks to provide an overview of hand transplantation and to propose a management algorithm.

Materials and methods: Several criteria must be met to select candidates, including clinical, paraclinical and psychosocial assessment performed by a multidisciplinary team. Immunosuppression seeks to avoid rejection, while immunosuppressants must have appropriate serum levels to reduce adverse effects. Classical and atypical acute rejection cases have been reported, where the skin is the main target tissue. Chronic rejection cases are related to the blood vessels that become affected. Monitoring is performed using several tests, considering skin biopsy as the gold standard.

Results: Drug therapy complications derive from drug toxicity, which are manifested as metabolic disorders, development of opportunistic infections and neoplasms. Rehabilitation and social aspects, such as patient satisfaction, should be evaluated during recovery to ensure adherence to immunosuppressive therapy. In 2011, the international registry of hand and composite tissue transplantation reported 39 cases of upper limb transplantation with multiple results. All this proves that to achieve optimal and viable results, a multidisciplinary team must conduct proper follow-up, and that the patient should have a support and motivation network, and comply with pharmacological management.

Conclusion: Further research is expected to create strategies to develop tolerance and, thus, reduce management by immunosuppression.

Introducción. El trasplante de mano ha sido uno de los retos del siglo XXI, cuyo primer caso reportado ocurrió en 1964. En este campo se han hecho estudios y avances que permitieron explorar nuevas alternativas para el manejo del paciente con trasplante de mano, por lo que diversos centros de referencia han realizado análisis basados en sus experiencias, las cuales permitieron lograr la viabilidad de este tipo de trasplante.

Objetivo. Esta revisión busca dar una visión general sobre el trasplante de mano y proponer un algoritmo de manejo.

Materiales y métodos. La selección de candidatos requiere una serie de criterios, tales como evaluación clínica, paraclínica y psicosocial, desarrollados por un equipo multidisciplinario. La inmunosupresión busca evitar el rechazo y los inmunosupresores deben tener los niveles séricos apropiados para reducir sus efectos adversos. Se han reportado casos de rechazo agudo clásico y atípico, donde la piel es el principal tejido blanco, y rechazo crónico, en el cual se afectan los vasos sanguíneos. El seguimiento se realiza con varias pruebas, de modo que la de oro es la biopsia de piel.

Resultados. Las complicaciones del tratamiento farmacológico derivan de la toxicidad de los medicamentos y se manifiestan como alteraciones metabólicas, infecciones oportunistas y neoplasias. La rehabilitación y los aspectos sociales, como el grado de satisfacción del paciente, deben ser evaluados durante la recuperación para asegurar adherencia al tratamiento. En 2011 el registro internacional de alotransplante compuesto de mano reportó 39 casos de trasplante de extremidades superiores con resultados variables; todo esto evidencia que para lograr un resultado óptimo y viable del trasplante debe realizarse seguimiento por un equipo multidisciplinario, red de apoyo del paciente y motivación del mismo, junto con el cumplimiento del manejo farmacológico.

Conclusión. Se espera que nuevas investigaciones puedan crear estrategias para desarrollar tolerancia y, de esta forma, reducir el manejo mediante inmunosupresión.

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