Immunologic and Clinical Outcomes 20 Months after Full Face Transplant.

Long-term vascularized composite allograft (VCA) success will be determined by appearance, function, and complications. While standard tacrolimus based immunosuppression is associated with renal dysfunction, acceptable management strategies are available. We performed a full face transplant with large volume vascularized bone marrow in a patient with a large mid-face injury. Alemtuzumab induction therapy and tacrolimus, mycophenolate mofetil (MMF), and prednisone maintenance therapy was provided. Clinical laboratory and histologic analysis have been performed at defined intervals. The patient has excellent graft appearance with two mild episodes of BANFF grade I rejection on days 28 and 402 treated with steroids and taper with complete resolution. A right lower lip lesion was identified at 16 months revealed HPV positive cells without dysplasia that subsequently resolved. Renal function has demonstrated gradual decline over 12 months with current Cr of 1.88 mg/dL (eGFR 37 mL/min/BSA).Figure: No Caption available.Urine studies have not revealed significant proteinuria, polyoma virus studies have been negative, and renal ultrasound demonstrated lengths 9.9 cm and 10.0 cm consistent with loss of renal size. Tacrolimus level at 20 months was 5.0 ng/mL and the patient remains on low-dose steroid and mycophenolate mofetil therapy.Figure: No Caption available.20 month outcomes continue to demonstrate excellent cosmetic and functional outcomes of the facial allograft. Stage 3 chronic kidney disease has developed despite modest tacrolimus levels. Immunosuppressive strategies including more aggressive reduction in tacrolimus doses with substitution of mTOR inhibitors for mycophenolate mofetil are being implemented to preserve renal function.