This retrospective review of the largest face transplant cohort aims to describe the evolution of immunosuppressive (IS) regimens used in face transplant recipients.

All face transplants performed between 2009 and 2016 were included. Review of patients' IS regimens, rates of rejections and infections, and its treatment was conducted utilizing institutional medical records.

Seven patients were transplanted and included. Patients were on average 41 years old, 5 (71%) were male and 4 (57%) received full facial allograft. All recipients were induced with rabbit antithymocyte globulin (rATG) 6 mg/kg in divided doses, and started on triple IS regimen with goal to be steroid free by third month. Tacrolimus target trough concentration was 10-15 ng/mL for the first 5 months, and 5-10 ng/mL thereafter. Mycophenolate mofetil was maintained at 2000 mg in divided daily doses, and prednisone was withdrawn in 6 (86%) recipients. Six patients developed acute cellular rejection (ACR) grade II or III within first 6 months. To date, all patients experienced at least one ACR. Early on, grade I and II rejection episodes were treated with intensification of maintenance IS and/or topical steroids and steroid boluses (750-1500 mg in divided doses). More recently, practice change lead to not requiring treatment for grade I rejections. Grade III ACR were treated with intensification of maintenance IS regimen and steroid boluses; steroid resistant rejection required treatment with rATG or alemtuzumab. Patient who required treatment with alemtuzumab was also diagnosed with antibody-mediated rejection (AMR) and required treatment with therapeutic plasmapheresis, IVIG, eculizumab, bortezomib and rituximab. Three patients (all CMV D+/R-) developed CMV viremia which was successfully treated with valganciclovir in two cases and foscarnet in the remaining case. All seven patients are alive with functioning graft; 4 (57%) resumed triple IS therapy and 1 (14%) recipient is on quadruple therapy including belatacept.

In conclusion, previously reported high rates of early rejection have been consistent with our cohort. As this field is still in its infancy, the diagnosis of graft rejection and determination of graft function is evolving as well as our choice of IS regimen and approach to treatment of rejections. This data will be used to guide our management and surveillance of future face transplant recipients.

CITATION INFORMATION: Klasek R., Kollar B., Tasigiorgos S., Pomahac B. Experience with Immunosuppressive Strategies in Vascularized Composite Allotransplantation of Face Am J Transplant. 2017;17 (suppl 3).

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