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