*Purpose: The purpose of this study is to evaluate histologic findings in a face and bilateral hand transplant recipient that was monitored with multi-site allograft biopsies during an episode of acute rejection, assessing the consistency of findings between allografts, based on the Banff Classification system.

*Methods: Skin biopsies were taken from both the facial and hand allografts, at the neck and forearms, respectively, at multiple timepoints over a 5-month period, during which there was ongoing clinical rejection which partially responded to pulse steroids and ultimately required lymphocyte depleting therapy. Histological assessment of biopsies was conducted according to the Banff Classification system by a single dermatopathologist. For each timepoint, we collected a biopsy from the facial allograft and at least one of the hand allografts. The results from each timepoint were evaluated in the context of the recipient’s clinical presentation and assessed for consistency of findings between the facial and hand allografts.

*Results: A total of 20 biopsies were collected at 8 separate time points. At 4 of the 8 (50.0%) timepoints, histological assessments revealed a discordance in Banff grade between the facial and hand allografts. Of these 4, the overall grade seen in the hand was higher by 1 level relative to the face at 3 (75%) timepoints, and this was due to the higher inflammatory infiltrate grading. Biopsies only showed concordant descriptions for all three sites at 50% of the time points. The patient was first admitted in May 2021 on clinical suspicion of rejection as manifested by allograft erythema and edema. He showed some improvement upon administration of pulse steroids. There was a subsequent admission in June following a similar protocol, but due to incomplete resolution of rejection, the patient required a longer admission for treatment with anti-thymocyte globulin and topical tacrolimus. Thereafter, we have not observed a recurrence of rejection.

*Conclusions: We found that the discordant histological findings seen during acute rejection in a face and bilateral hand transplant recipient warrant a rethinking of the utility of the Banff Classification system for clinical decision making in vascularized composite allotransplantation. Our findings revealed differing cross-sectional patterns of inflammatory infiltrates in the face and hand allografts at multiple timepoints. Additional factors, including differences in typical use of the transplanted subunits, may impact the degree of trauma and inflammation experienced by each allograft (e.g., hand and facial function and use are different). This may warrant reconsideration of the value of Banff grading, and necessitate more robust information to adequately characterize/diagnose rejection and guide medical management.

« Back to 2022 American Transplant Congress