LeedsHAUL-VCA2017

Leeds UK hand transplant programme

simonkay

Leeds and Transplant Progress

• Firstapproaches2001• 2010agreedprincipleoffirsttwocases“atrisk”• 2010to2012wideconsultationwithstakeholdersincNHSBT• 2012Firsthandtransplantation• 2013March:commissioningchanges:representationtoHSSbegins• 2013-16protocols,costings,evidence,RDAG,consultationscontinue• 2015Leedscommissionedforfiveyears:estimateof2Txperannum• 2016Secondtransplant:bilateralhands• 2017Thirdtransplant(prev.abandonedNov’16)Biateralforearms

LeedsHAUL-VCA2017

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2012

2013

2014

2015

2016

2017

Single side

Wrist levelImmediate

2011

abandoned

Two sideMetacarpus level

Two sideProx 1/3 forearm

Surgery

Currently waiting

HAUL-VCA Leeds

Listed

LeedsHAUL-VCA2017

Enabling activity

• SNODtraining• OutreachtoSNODsandCLODsinitiallyYorkshire• ThenNWandNorthern• FrequentmeetingswithNHSEng• LoomingproblemwithCRGindisability:shouldreferralsonlybefromprostheticsandrehabilitation

LeedsHAUL-VCA2017

summary protocols

• Lossoneorbothlimbs• Trialprostheticscomplete• Psychologicalscreenover1yearforstabilityandsuitability• Notunder16(TBR)• Levels• Demandsandexpectations

LeedsHAUL-VCA2017

Support

• LargemultidisciplinaryTeam• Internationalmentorandliaison(Lyon,Pittsburgh)• ExistingcompetenciesinTx,immunology,microsurgery,prosthetics• Strongpsychologyteamwithintheunitalready• NHSBTfromthestart• Specialtysocieties(BSSHBTSBAPRAS)• LeedsTeachingHospitalsNHSTrust• OxfordUniversityHospitalsNHSTrust

LeedsHAUL-VCA2017

Results

• 3ex3Txsurvival.Mean24months(5-57)• Multipleepisodesacuterejection,espfirstyear• PromptdetectionAR,promptRxbysteroidpulse• 1xmucormycosisforearm:Rxwideexcison,cover6/12antifungals

LeedsHAUL-VCA2017

Contrast with SOT

• Smallnumbers• Notperceivedaslifepreserving• Prosthetic“solution”available(highrejectionrate).• Aestheticmatching• Mediarecognition• Emotionalcomplexity• Visiblerejection:skinrejection.• Slowtrecoverydictatedbynerveregeneration

LeedsHAUL-VCA2017

Common opposition attitudes

• Notlifesaving(nodata)• Immunomodulationsolelyforlethaldisease(cfotherconditions)• Trialofprosthetics:(protocol)• Psychologicalrejection(protocol)• Prostheticssafeandcheap(payforwhatyouget:mechanicalnotsensorynothuman)

• Nevergetnormalfunction(no,really?)

LeedsHAUL-VCA2017

Current status controversies and future opportunities• Proofofconceptwellestablished• Longtermsurvival:longest17years• Children?quadrimembral• Unilateral?• Veryproximal?

LeedsHAUL-VCA2017

Challenges in the year to come

• ResistCRGpressuretohandreferralcontroltorehabilitation• Freeupreferralprocess• Increasewaitinglistnumberstoallowdonoruptake• Increasedonoroutreachtoallowgreateroptions• Opennegotiationsonethicsofchildrecipients

LeedsHAUL-VCA2017

LeedsHAUL-VCA2017

Appendix

36 referrals into HAUL-VCA clinic Leeds

declinedmedically declinedpsychologicallyPacentwithdrew ListednotyettransplantedListedandtransplanted LeedsHAUL-VCA2017

Screening

Referral letter

First appointment

First psychology assessment

Final appointment

50% 30% 70% 50%

5%100%

LeedsHAUL-VCA2017

1

21

LeedsHAUL-VCA2017

Two Important Known Unknowns

• The effects of immunosuppression in healthy patients

• The natural history of handlessness

LeedsHAUL-VCA2017