Background: In July 2015, our center successfully performed the first bilateral hand transplant in a pediatric patient in the United States. The recipient was an 8 year old male quadramembranal amputee secondary to septicemia. He was amputated at 2 years of age and received a kidney transplant at 4 years of age.

Methods: A matched size and color donor was identified by UNOS. Following successful surgery, a multi-disciplinary team of experts in orthopedic, vascular, plastic and transplant surgery, nephrology and transplant medicine, occupation/rehabilitation medicine and neurology have worked together to optimize medical management and therapies. The patient has strong social support, augmented by ongoing social work and psychology services.

Results: The patient received thymoglobulin induction and was initially maintained on tacrolimus, mycophenolate mofetil and prednisone. Due to tacrolimus nephrotoxicity with creatinine elevation, sirolimus was added to the immunosuppressive regimen to enable tacrolimus dose reduction. Over the first four months post-transplant, the patient has experienced multiple episodes of rejection, mostly grade 1 and responsive to topical tacrolimus and steroids. The patient continues intensive daily occupational and physical therapy. He is able to grasp, pinch and release. Active wrist flexion is progressing. He is incorporating his hands into his sense of body. Functional motor mapping of the cerebral cortex with right and left elbow flexion correlate with demonstrated clinical functional changes and have highlighted underlying cortical deficits likely related to the initial timing of amputation.

Conclusions: Short-term management of the first pediatric bilateral hand transplantation has included frequent episodes of low-grade rejection and tacrolimus toxicity, however these issues have been responsive to treatment. Neurological and functional progress requires long-term monitoring, but short-term results are promising. In future pediatric candidates, pre-transplant cortical functional mapping should be considered to inform rehabilitation expectations and help target physical therapies. Additionally, consistent social and psychological support are crucial for children and their caregivers undergoing this novel treatment which demands long-term commitment to rigorous therapies.

CITATION INFORMATION: Amaral S, Levine M, Chang B, Lopez S, McAndrew C, Kessler S, Shaked A, Levin L. First Bilateral Hand Transplant in a Child: Short-Term Medical Outcomes and Challenges. Am J Transplant. 2016;16 (suppl 3).

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