Face and hand vascularized composite allografts (VCA) have demonstrated durable graft survivals with conventional immunosuppression but with the appearance of renal dysfunction. Management strategies that achieve VCA graft survivals of decades will require immunosuppressive strategies to protect against rejection while preserving renal function.

We performed a full face transplant with alemtuzumab induction therapy. Maintenance therapy was provided with tacrolimus and mycophenolate mofetil (MMF), and prednisone withdrawal was attempted over 21 days. Laboratory and histologic analysis have been performed at defined intervals and for indication.

The patient experienced a mild rejection episode (BANFF grade 1) on day 28 after steroid weaning and elimination was attempted. This responded immediately to steroid therapy and the patient was maintained with triple immunosuppressive therapy. A second mild rejection episode on day 402 (BANFF grade 1) was associated with low tacrolimus levels (<5 ng/mL) and was also quickly reversed with steroid therapy. Renal function demonstrated gradual decline over the next 12 months with eGFR <40 mL/min/BSA and imaging consistent with loss of renal size. Everolimus therapy (5-7 ng/mL) was initiated with tacrolimus (3-4 ng/mL) to preserve renal function at 22 months. Within 3 weeks the patient experience the most significant facial erythema and swelling to date with biopsy proven moderate rejection (BANFF grade 2). Rejection was not responsive to steroid therapy and required anti-thymocyte globulin therapy (5 mg/kg) for complete resolution. The patient is currently maintained on tacrolimus (levels 5-6 ng/mL), MMF and prednisone with acceptable renal function (creatinine 1.73 mg/dL and eGFR 49 ml/min/BSA).

The facial allograft at 30 months demonstrates excellent cosmetic and functional outcomes with stable renal function on tacrolimus/MMF/prednisone triple immunosuppression. Modification of the immunosuppressive strategy to include mTOR therapy did not provide adequate protection from rejection. Providing adequate immunosuppression to prevent skin rejection may present barriers to immunosuppression conversion strategies for VCA.

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