First Pediatric Double Hand Transplant Successful

Troy Brown, RN

July 18, 2017

The world's first pediatric double hand transplant was performed on an 8-year-old boy and, after 18 months of follow-up, physicians are cautiously optimistic about the boy's prognosis, according to an article published online today in The Lancet Child & Adolescent Health.

"Our study shows that hand transplant surgery is possible when carefully managed and supported by a team of surgeons, transplant specialists, occupational therapists, rehabilitation teams, social workers and psychologists," Sandra Amaral, MD, from the division of nephrology at Children's Hospital of Philadelphia, Pennsylvania, said in a Lancet news release. "18 months after the surgery, the child is more independent and able to complete day-to-day activities. He continues to improve as he undergoes daily therapy to increase his hand function, and psychosocial support to help deal with the ongoing demands of his surgery."

The boy, Zion Harvey, from Baltimore, Maryland, had contracted staphylococcal sepsis with systemic ischemic injury at age 2, and subsequently underwent quadrimembral amputation and developed kidney failure. He received a kidney allograft from his mother, Pattie Ray, at age 4. The surgeons selected him for the hand procedure, as he was already receiving immunosuppressive therapy to prevent rejection of the kidney.

"A child psychologist, [pediatric] transplantation pharmacist, and social worker assessed psychosocial readiness to undertake surgery and a prolonged rehabilitation period, history of medical adherence, and the family's ability to provide social and logistical support," Dr Amaral and colleagues write. "The child and his mother, his primary caregiver, had shown resilience through his initial critical illness, peritoneal dialysis, and kidney transplantation, and no psychosocial contraindications to transplantation were identified."

Before the surgery, the child had limited ability to dress, feed, and bathe himself, and required specialized equipment. His mother's goals for him after surgery were that he would be able to dress himself, brush his teeth, and cut food independently. The child hoped to be able to climb monkey bars and use a baseball bat.

Suitable donor organs became available in July 2015 and four medical teams worked simultaneously on the donor hands and the little boy for 10 ½ hours.

Within hours after surgery, the child required vascular revision of the ulnar artery. He experienced no further immediate postoperative vascular complications.

He began daily occupational therapy 6 days after the transplant; therapy included video games and engaging exercises using finger lights and puppets as well as writing and activities of daily living. He and his mother received regular emotional support from a psychologist and social worker, who also helped them plan for his return to school.

"The patient's course was complicated by multiple episodes of graft rejection, minor systemic infections, moderate renal transplant functional impairment, [hyperlipidemia], the need for chronic anticoagulation with low-dose aspirin, the need for more immunosuppression than he required before hand transplantation, months of intensive rehabilitation, and a prolonged period of time until functional recovery to a pretransplantation level," the researchers write.

The child was able to use the ligaments from his residual limbs to move his fingers within days of the transplant and the nerves of his hands had regrown enough that he could move his hands and feel touch within approximately 6 months. Functional brain imaging showed that his brain developed pathways for controlling hand movement and feeling touch.

He was able to feed himself and grip a pen within the first 6 months, use scissors and crayons by 8 months, and swing a baseball bat with both hands within a year of the surgery.

Hand transplantation is not life-saving, thus the decision to subject a child to a lifetime of antirejection medications, including steroids, cannot be undertaken lightly, Marco Lanzetta, PhD, MD, from Italian Institute of Hand Surgery, Monza, Italy; the department of orthopaedics and microsurgery, University of Canberra, New South Wales, Australia; and the department of orthopaedics, Ludes University, Lugano, Switzerland, writes in an accompanying Comment.

"After kidney transplantation…this child was on a steroid free antirejection protocol, which included mycophenolate mofetil and tacrolimus, with normal renal function (serumcreatinine 0.4 mg/dL). Not taking steroids is an enormous advantage to avoid common side-effects such as bone necrosis and growth retardation in post-transplantation," Dr Lanzetta writes.

"At the time of the hand allograft, the patient had no medical problems. After the second allograft, because of the necessary increase in immunosuppressive therapy, which included steroids, the creatinine concentration in his blood had more than doubled. He is now on a quadruple therapy which includes sirolimus in an attempt to limit nephrotoxicity," he explains.

Advances in prosthetic technology complicate the picture, Dr Lanzetta says.

"We now have an availability of different so-called bionic prostheses, for which movement is much less mechanical and more controllable, with independent smooth finger flexion and extension. They are very light, aesthetically appealing, and can be equipped with sensibility. In view of these developments, one might argue that it is too late to attempt [pediatric] heterologous hand transplantation, since prosthetics are now very sophisticated. Equally, it could be argued that it is too early for such procedures to go ahead without much needed new immunosuppression drugs."

One coauthor reports receiving investigator-initiated research funding from Eisai outside the submitted work. One coauthor reports nonfinancial support from Pfizer outside the submitted work. One coauthor reports grants from Hansjörg Wyss and the US Department of Defense during the completion of the study. The remaining coauthors and Dr Lanzetta report no relevant financial relationships.

Lancet Child & Adolescent Health. Published online July 18, 2017. Full text; Comment

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