Need for kidney transplantation following vascularized composite allotransplantation: an international, multi-center case series

Introduction: Vascularized composite allotransplantation (VCA) is a powerful restorative tool for patients with severe soft tissue loss. The long-term implications of immunosuppression following VCA on renal function remain uncertain. Methods: A retrospective review of patients undergoing VCA and requiring renal transplant at three global centers was performed. Renal and VCA graft function were monitored over time. Causes of renal failure and time to renal transplant following VCA were determined. Results: Three patients were included. Patient A underwent face transplantation, and patients B and C underwent bilateral hand transplantations. All patients were on tacrolimus therapy following VCA. Renal failure occurred in all patients: secondary to tacrolimus toxicity in patient A; on the grounds of biopsy proven pre-existing renal damage in patient B; and secondary to prior septic acute tubular necrosis plus tacrolimus toxicity in patient C. Living/deceased donor renal transplant was performed at 87, 7, and 107 months, respectively. Patient A has had progressive recipient kidney impairment (creatinine at last follow-up: 2.26 mg/dL). Patients B and C have had stable recipient kidney function (creatinine 0.89 mg/dL and 1.20 mg/dL). VCA graft function in the setting of renal failure was not altered. Conclusions: Nephrotoxicity and potential renal failure remain major issues following VCA, as demonstrated in this cohort of patients requiring renal replacement therapy and transplant. VCA graft function and survival in the setting of renal failure was not altered. Patients undergoing VCA should be appropriately counseled on the long-term renal implications of immunosuppression.