Introduction: We describe here the outcome after two bilateral hand, one bilateral forearm and one unilateral hand transplantation at 12.5, 9.5, 6.5 and 3.5 years after transplantation.

Methods: Four patients received a bilateral hand (n=2), a bilateral forearm (n=1) or a unilateral hand transplantation between March 2000 and July 2009. Induction therapy with ATG (n=2) or alemtuzumab (n=2) was followed by tacrolimus, prednisolon MMF (n=3) or tacrolimus and MMF (n=1) maintenance IS. A mTor-Inhibitor was added under simultaneous withdrawal (n=2) or dose reduction (n=1) of tacrolimus (n=1) or MMF (n=3). Steroids were avoided in one and withdrawn in two patients.

Results: Hand function correlated well with time after transplant and amputation level. Intrinsic hand muscle function recovery and discriminative sensation were observed in all patients. Complications included CMV infection, fungal infection, hypertension, hyperglycemia, transient creatinine increase and headache and a bullous pemphigoid. Three, six, four, and one rejection episodes were successfully treated with steroids, anti-CD25, anti-CD52 antibodies and/or intensified maintenance IS. There have not been any donor specific antibodies (DSA) in our patients until 02/2012. The second patient developed a DSA-positive antibody mediated rejection 9 years after Tx which was treated successfully with a CD20-antibody. Skin histology at current shows no or mild perivascular lymphocytic infiltrates without signs of progression. Vessels are patent without signs for luminal narrowing or intimal proliferation.

Conclusion: The overall functional outcome and patient satisfaction are highly encouraging. All patients are now free of rejection with moderate levels of IS.

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