Incidence of Successful Steroid Weaning in a Series of 8 Hand Transplant Recipients

Background

Immunosuppression regimens used in the field of VCA are commonly based on regimens used for kidney transplantation. Most programs, strive to use the least amount of immunosuppression that will protect the graft, while limiting complications. Our program has attempted to wean maintenance prednisone use in 7 of 8 hand transplant recipients.

Methods

Eight patients have received 9 hand transplants with a follow up of 9 months to 15 years (mean follow up 2003 days +/− 1918 days). Seven patients received a unilateral hand transplant and patient 6 received a bilateral hand transplant. Patient 4 lost his graft at 9 months due to ischemia secondary to vasculopathy, and patient 6 was lost to follow up at day 283. All recipients were male, (mean age of 50 +/− 8). All patients received induction and 5/8 were started on triple drug immunosuppression at the time of transplant.

Results

As shown in the table, the 6 hand recipients currently being followed at our program 4/6 have been weaned off steroids, and have never required treatment for rejection, or that steroids be restarted. In all 4 of these cases, weaning occurred one year post transplant or later. In 2 cases where prednisone was never started, or started late, significant rejection and vasculopathy was observed. However, patient 6 who was never weaned from steroids also had vasculopathy and rejection.

Table 1. Experience weaning maintenance steroids in hand transplant recipients

Patient	Induction	Start Pred	Day post Tx Pred stopped	Day restart pred	Solumedrol Bolus	Current days post tx	Current Daily Pred dose
1	simulect	post op	3166	Not done	Multiple	5597	none
2	simulect	post op	2355	3556	Multiple	4843	2.5mg
3	campath	day 958	1650	1794	Multiple	2731	5 mg
4	campath	Never	Never Started		None	271	n/a*
5	campath	day 196	1305	Not done	None	2005	none
6	campath	post op	Never stopped		Multiple	283	10 mg**
7	ATG	post op	390	Not done	Once	1047	none
8	ATG	post op	422	Not done	None	827	none

*Patient lost graft at day 271, due to vasculopathy, with minimal acute rejection

**Patient transferred care to another center on day 283, pred dose at time of transfer

Conclusion

In our experience, patients who have a relatively quiet clinical course for the first year post transplant can be weaned off prednisone, and have done well. Additionally, patients who are significantly farther than one year post transplant can be successfully weaned off prednisone and maintained on Prograf and Sirolimus or Prograf and MMF dual therapy.