Sunday, March 3, 2013

Face Transplant In A Sensitized Patient


Reading between the lines of the Feb. 27th Boston Globe article about the Brigham and Women's Hospital fifth transplant reveals an incredible accomplishment.  Not only was it yet another of a complex, still technically challenging transplants, but it helped a woman with a highly activated immune system that substantially raised the risk of rejection. We don't know exactly how far post-op the recipient, Carmen Blandin Tarleton, is. The date is not being publicized because it would allow determination of the donor's identity.

This type of discretion is highly appropriate and will help encourage additional donations. Continued sensitivity to the needs of the surviving families, and sharp focus on respect for the heroes, the donors, most of whom have remain publicly unidentified, is a crucial aspect of the field of organ donation. 

The extra concern about rejection is an addition to the factors that are becoming standardized with face transplantation - and how amazing that we can so quickly become accustomed to this incredible new quality of life transplant -  a mere eight years after the first one was performed in France by Dubernard and Devauchelle. Reports of this patient having received multiple prior blood transfusions explain why her immune system would have generated high levels of circulating antibodies primed to immediately recognize her new face as foreign (or not herself) and to attack and destroy it. Thousands of kidney failure patients seeking transplants confront the same problem with most never able to overcome it.

But the Brigham team was highly engaged and prepared to treat Tarleton's high antibody levels. She was treated pre-transplant with an experimental protocol. It sounds like she had a treatment called plasmapheresis which literally removes the antibodies from the blood, replacing that component of the blood with eithersaline,  albumin or plasma. Additionally she received an unidentified drug pre-transplant.

Of note, when she did have a post-transplant episode of rejection, she received another "special, expensive" drug that the hospital paid for. Such unique care is simply not available to kidney transplant candidates who might similarly benefit. In defense of hospitals, support of these expensive drugs (perhaps as much as $200,000 per patient per year) for a large number of patients would bankrupt the institutions.

According to the Globe, the patient is close to returning home to Vermont. She is a nurse with an apparently excellent ability to understand and consent to the experimental procedure and treatments. She is also quite capable of appreciating the remarkable outcome she has experienced to date. Her own blog is well worth reading.

Kudos to the Brigham team for their 5th face transplant, for development of an effective protocol for transplantation of a highly sensitized patient, for respect of the donor and family, and for appropriate patient selection.


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