Risks

Risks of Surgery

The surgical risks are similar to those for a replanted upper limb. These include risks of bleeding, scarring, nerve or vessel injury and vascular compromise. The risk of infection is higher in transplanted limbs than the replanted limb due to the necessity for immunosuppression.

There is a possibility of minor limb length discrepancy occurring in those receiving a single upper limb transplant.

Limb loss due to vascular occlusion may necessitate additional surgical procedures and potential further free tissue transfer.

Additional risks include those of an extended anaesthetic and invasive monitoring.

Risks Associated with Immunosuppression

The risks of immunosuppression are specific to the drugs required which may vary between individuals. Risks include hypertension, vomiting, diarrhoea, weight gain, hypercholesterolaemia, diabetes, cataracts, and impaired renal function.

Long term risks are common to all drugs used. It should be noted however, that the long-term sequelae of transplantation are specific to the organ transplanted. Currently long term data does not exist in a robust form for those having undergone hand transplantation as only small numbers have been performed and few individuals have been in receipt of their new limb for a time period long enough to display potential complications of sustained immunotherapeutic medication use.

Data is therefore extrapolated from that observed in solid organ transplant recipients. The frequency of long-term sequelae can however, vary by as much as 5 fold depending on which organ was transplanted. Hand transplant recipients will not have any additional co-morbidity. This may reduce the likelihood of sequelae, in contrast to solid organ recipients, who, by definition have at least one failing organ system.

Immunosuppression increases the chance of malignancy, organ failure and infection.

Malignancy

From renal data, those on long-term immunosuppression have an increased risk of cutaneous malignancy, lymphoma and Kaposi’s sarcoma. The risk of developing a skin malignancy is approximately 50% at 15 years, reaching 75% by 30 years of continual immunosuppression. To date only a single basal cell carcinoma and a single case of post transplant lymphoproliferative disorder (PTLD) have been reported amongst hand transplant recipients.

Organ Failure

Immunosuppression, when used long term also increases the chances of solid organ failure, particularly renal failure. From data available from solid organ transplants, between 5 and 25% of those immunosuppressed will develop renal failure after 10 years of continued therapy, depending on which organ has been transplanted.

It is expected that organ failure amongst hand transplant recipients will be less frequent than is seen in those having undergone solid organ transplantation.

Infection

Individuals will also be at a higher risk of infection, particularly from unusual organisms such as Cytomegalovirus (CMV), Human T-lymphotropic virus (HTLV), Epstein Barr Virus (EBV) as well as bacterial and fungal infections. Transplant recipients may require prophylactic therapy against such organisms.