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Home > Risks > Acute and Chronic Rejection

Acute and Chronic Rejection

 

Dr. Jaimie Shores, Hand/Arm Transplant Surgeon, talks about preventing transplant rejection.

 
 

What Is Rejection?

  • Rejection happens when a transplant recipient’s immune system thinks that the donated hand/arm is foreign to the recipient’s body and attempts to get rid of it.1
  • Rejection episodes are treatable in almost all cases for patients who get the necessary treatment.
  • Recipients can experience acute or chronic rejection, and the type of rejection a patient experiences will determine the symptoms, treatment, and prognosis of the rejection.2
  • To preserve your transplant, you will need to take anti-rejection medicines for the rest of your life (as long as you have your transplant).

What Is Acute Rejection?

  • Acute or short-term rejection occurs when a recipient’s body tries to attack the donated hand/arm soon after a transplant.
  • Acute rejection usually happens within weeks or months of a transplant but can also happen several years after transplantation.1,3
  • Acute rejection can occur multiple times.4-6
  • Acute rejection is treatable, and its effects are reversible when treated quickly.7
  • Hand/arm transplant recipients who follow their anti-rejection medicine regimen usually do not lose their transplant due to acute rejection, and acute rejection episodes are usually treated by increasing the dosage of anti-rejection medications.3
  • If acute rejection is left untreated, it can lead to chronic rejection.1,3

What Is Chronic Rejection?

  • Chronic or long-term rejection occurs over a longer time span than acute rejection, typically months to years after hand/arm transplantation.1
  • Compared to acute rejection, chronic rejection is typically harder to detect and may need to be confirmed with a skin biopsy.8
  • Factors that are associated with chronic rejection include: untreated acute rejection,8 organ donor’s age, recipient’s health conditions (e.g., high blood pressure, diabetes, obesity, high cholesterol), and recipients not taking their anti-rejection medicines.6
  • Unlike acute rejection, chronic rejection may not be reversible and can result in the loss of function, as well as the loss or the removal of the transplanted hand/arm.3,6,9-10
  • As of 2015, the rate of hand/arm transplant loss due to chronic rejection in Western Europe, Australia, and the U.S. was 9.5%.11

How Can Rejection Be Prevented?

  • To prevent rejection, hand/arm transplant recipients need to make a lifetime commitment to taking anti-rejection medicines (i.e., adhering to their anti-rejection medicine regimen) and monitoring the hand/arm.6,12
  • The recipient needs to routinely check their hand/arm for visible signs of rejection (for example, a rash in the transplanted area).
  • Recipients must notify their transplant team if they see any signs of rejection, which may require further medical tests (such as skin biopsies, standard vascular imaging, and antibody screening)3,6,13
  • If a hand/arm transplant recipient experiences a serious side effect or health complication from taking anti-rejection medicines, the removal of the hand/arm transplant may be recommended.14,15

How Can I Tell if My Body Is Attacking My New Hand?

  • Spotty, patchy, or blotchy rashes may begin to appear on the skin during a rejection episode.
  • Rejection may start in the palms of the hands or in the nail beds, but this is less common.
  • Recipients may experience a burning pain or no pain at all.
  • Recipients should tell their transplant team as soon as they start to experience symptoms of rejection so the team can treat the rejection episode as early as possible.
  • Rescue therapies to save the limb have been successful at treating and reversing common types of acute rejection. All hand/arm transplant recipients who have followed their anti-rejection medicine regimen as advised have been able to keep their transplanted hand(s)/arm(s).

How Can Rejection Be Detected?

  • Rejection episodes can be visibly identified and confirmed by medical tests.16
  • If recipients notice signs or symptoms of rejection (see below), they should contact their transplant team immediately.
  • In some cases, rejection episodes can be reversed by increasing the amount of anti-rejection medicines, and by using topical and/or steroid treatments.15,16
 

Dr. Jaimie Shores, Hand/Arm Transplant Surgeon, outlines how to recognize early signs of rejection.

 

Common Signs and Symptoms of Acute and Chronic Rejection Include:

  • A skin rash or discoloration of the skin, the palm, or nail bed⁷

  • Pain in the transplant area¹

  • Swelling¹

Patient-Reported Signs and Symptoms of Acute and Chronic Rejection Include¹:

  • Fever

  • Weight gain

  • Flu-like symptoms (e.g., nausea, headache, chills, vomiting, diarrhea, dizziness, body aches, tiredness)

  • Change in pulse rate

 

Mr. White, with unilateral, below-elbow limb loss (6 years after amputation), talks about his fear of transplant rejection.

 
 
 

Rejection Rates based on Social, Emotional, and Mental Health Factors:  An International Sample of n=43 Hand/Arm Transplant Recipients, 1998-2016

Condition Number and percent of recipients with
the condition		 Number and percent of recipients who rejected the hand/arm transplant by condition Statistical significance of the rejection rate condition comparison
Total recipients who completed the survey 43 5 (12% of total
respondents)		 Not applicable
Reported having intact upper extremity transplant(s) 38 (88%) Not applicable Not applicable
Reported having anxiety 29 (67%) 5 of 29 respondents
with anxiety (17%)
Significant
difference
Reported not having anxiety 14 (33%) 0 respondents
without anxiety (0%)
Reported being treated
for depression		 14 (33%) 2 of 14 respondents with depression (14%)
Not a significant
difference
Reported not having depression 29(67%) 3 of 29 respondents without depression (10%)
Reported having PTSD* 18 (42%) 4 of 18 respondents
with PTSD (22%)
Significant
difference
Reported not having PTSD* 25(58%) 1 of 25 respondents
without PTSD (4%)
Reported having realistic functional expectations 34 (79%) 2 of 34 respondents with realistic expectations (6%)
Significant
difference
Reported having unrealistic functional expectations 9 (21%) 3 of 9 respondents with unrealistic expectations (33%)
Reported having strong
family support		 33 (77%) 2 of 33 respondents with
strong family support (6%)
Not a significant
difference
Reported having poor or
fair family support		 10 (23%) 3 of 10 respondents with poor
or fair family support (30%)
Reported being actively engaged in Occupational Therapy (OT) and home exercises 28 (65%) 1 of 28 respondents
engaged in OT (7%)


Not a significant
difference
Reported not being actively engaged in Occupational Therapy (OT) and home exercises 15 (35%) 3 of 15 respondents
not actively engaged
in OT (20%)

Source: Kinsley SE, et al. Psychosocial Predictors of Upper Extremity Transplantation Outcomes: A Review of the International Registry 1998-2016. Plast Reconstr Surg Glob Open. 2020;8(9):e3133.
Context: De-identified survey data for 43 upper extremity transplant recipients were used from the International Registry on Hand and Composite Tissue Transplantation (IRHCTT) 1998-2016. The mean follow-up time from the date of upper extremity transplantation was 7 years.
*PTSD = Post-Traumatic Stress Disorder

 
 

Mr. Lund, bilateral upper limb transplant recipient (5 years after transplantation), talks about his experiences of rejection.

 

Click Below for More Videos

Videos of Health Care Professionals

Dr. Dumanian, Chief of Plastic Surgery, talks about the risk of limb rejection

Dr. Jaimie Shores, Hand/Arm Transplant Surgeon, describes what happens during an early rejection episode.

 

References

Sources

  1. Preventing Rejection. UNOS. Accessed September 14, 2022. https://transplantliving.org/after-the-transplant/preventing-rejection/.

  2. Park S, Eun S, Kwon ST. Hand Transplantation: Current status and immunologic obstacles. Experimental and Clinical Transplantation 2019;1:97-104.

  3. Kanitakis J, Petruzzo P, Badet L, et al. Chronic Rejection in Human Vascularized Composite Allotransplantation (Hand and Face Recipients): An Update. Transplantation 2016;100(10):2053-61. 

  4. Del Bene M, Di Caprio AP, Melzi ML, et al. Autologous Mesenchymal Stem Cells as a New Strategy in Immunosuppressant Therapy in Double Hand Allotransplantation. Plastic and Reconstructive Surgery 2013;131(2):305-307.

  5. Fischer S, Lian CG, Kueckelhaus M, et al. Acute Rejection in Vascularized Composite Allotransplantation. Current Opinion in Organ Transplantation 2014;19(6):531-544.

  6. Park S, Eun S, Kwon ST. Hand Transplantation: Current status and immunologic obstacles. Experimental and Clinical Transplantation 2019;1:97-104.

  7. Petruzzo P, Dubernard JM. The International Registry on Hand and Composite Tissue Allotransplantation. Clinical Transplants. 2011:247-253.

  8. Mundinger GS, Drachenberg CB. Chronic Rejection in Vascularized Composite Allografts. Curr Opin Organ Transplant 2014;19(3):309-14.

  9. Benedict JL, Barth RN. How to Help Patients Considering VCA. AMA Journal of Ethics. 2019; 21(11): 960-967.  

  10. Robbins NL, Wordsworth MJ, Parida BK, et al. A Flow Dynamic Rationale for Accelerated Vascularized Composite Allotransplantation Rejection. Plastic and Reconstructive Surgery. 2019;143(3):637-643.

  11. Shores JT, Brandacher G, Lee WPA. Hand and Upper Extremity Transplantation: An Update of Outcomes in the Worldwide Experience. Plast Reconstr Surg 2015;135(2):351e-360e.

  12. Barker JH, Allen F, Cunningham M, et al. Risk Assessment and Management in Hand and Facial Tissue Transplantation. European Journal of Trauma Emergency Surgery. 2011; 37(5):469-476.

  13. MacKay BJ, Nacke E, Posner M. Hand Transplantation--A Review. Bulletin of the Hospital for Joint Diseases 2014; 72(1):76-88.  

  14. Tintle, SM., Potter BK, Elliott RM, et al. Hand Transplantation. Journal of Bone and Joint Surgery. 2014;2(1):1-9.

  15. Levin LS, Cavadas PC. Reconstructive Surgery – The Evolution of VC. Chicago, IL: Symposium Session at the World Society for Reconstructive Microsurgery, July 2013.

  16. Petruzzo P, Lonzetta M, Dubernard JM et al. The International Registry on Hand and Composite Tissue Transplantation. Clinical and Translational Research 2010;90(12):1590-1594.