The United Kingdom Hand and Upper Limb Transplantation Service: A report on the first twelve years of a single-center, single-protocol clinical cohort.

BACKGROUND: Following the world's first case (1998), proof of concept was established for hand and upper limb transplantation (HAUL-T). By 2012, there was sufficient evidence for the United Kingdom HAUL-T service to be established on a standard of care basis. A commitment was made to report in detail on this prospective, single-center, single-protocol series. We provide the first comprehensive report on the procedures, surgical, functional, immunological and psychosocial outcomes of the United Kingdom (UK) HAUL-T service.

METHODS: Potentially suitable patients undergo sequential psychological and immunological evaluation over one year. Immunosuppression is induced with alemtuzumab, and maintained with tacrolimus, mycophenolate mofetil and prednisolone. Surgical techniques vary with the level of amputation. Rejection monitoring is clinical, with biopsy when indicated. Psychological follow-up is routine, immunosuppression monitoring and hand therapy delivery are shared with the teams local to the recipient. Annual review in Leeds includes SF-36 and patient satisfaction questionnaires, a suite of functional outcome measures, measurement of grip and pinch strength, Semmes-Weinstein monofilament testing, Sollerman Hand Function, and Box & Blocks Tests.

RESULTS: Ten patients have received 17 transplanted limbs, with follow-up between 6 months and 11 years. Graft survival is 100%. Five patients have produced donor-specific antibodies (DSA). All report overall psychosocial benefit. All demonstrate sensory and motor recovery at least sufficient for functional integration. Six patients have more than 4 years of follow-up, of which 4 demonstrate clinically significant improvements in composite functional scores. Nine have undergone secondary surgery. Post-transplant renal impairment is significantly more severe in patients with a prior history of dialysis.