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We herein provide an update on two bilateral hand and one bilateral forearm transplants with emphasis on immunosuppression (IS), function, morphology, and graft vascular changes at 8 years and 2 years after bilateral hand and 5 years after bilateral forearm transplantation. Between March 2000 and May 2006, three patients underwent bilateral hand or forearm transplantation at our institution. Following induction therapy with antithymocyte globulin (ATG) (n = 2) or alemtuzumab (n = 1), tacrolimus, prednisolone +/- mycophenolate mofetil (MMF) were given for maintenance IS. Later, tacrolimus (n = 1) or MMF (n = 1) was replaced by sirolimus/everolimus for long-term IS. Clinical follow-ups with evaluation of hand function, skin biopsies, X-ray, ultrasound, angiography, computed tomography angiography, electrophysiological studies, and somatosensory evoked potentials were performed at regular intervals. Three, six, and three rejection episodes were successfully treated with bolused steroids, anti-CD25 or anti-CD52 antibodies. Subsequently, skin histology remained normal without any evidence of chronic rejection. Hand function continuously improved during the first 3 years and since then remained stable with minor improvements. Investigation of hand arteries revealed no signs of occlusion or stenosis. Motor and intrinsic hand muscle function continues to improve in all patients. Protective sensation was observed in all patients; however, discriminative sensation was only accomplished after hand but not forearm transplantation. No life-threatening adverse events occurred. Despite immunologic challenging postoperative courses, patients are now free of rejection with moderate levels of IS and good functional results. No signs indicating chronic rejection have been encountered.

Background: Human herpes virus (HHV8) is associated with Castleman's disease, primary effusion lymphoma, and the Kaposi's sarcoma (KS)., Patients and Methods: Among 3815 solid organ transplants performed at our center between 1977 and 2003, five patients (0.1%) were identified with KS., Results: There were one cardiac, one liver, and three renal allograft recipients of median age of 52 (range 38 to 60) years, three of whom were females. Three patients were of Italian and one of Turkish descent; only one patient was a native Austrian. The onset of the disease was 2.0, 7.5, 7.8, 9.4 months, and 22 years posttransplant. Diagnosis of KS was based in all cases on histology. The heart recipient developed a tumor on the planta pedis; one renal recipient, on both legs. The liver and the two remaining renal recipients presented with disseminated disease. Treatment in all cases consisted of reduction in immunosuppression, together with surgery (n = 1), chemotherapy (n = 1), or irradiation (n = 2). Furthermore, immunosuppression was switched in two cases from Tacrolimus to Sirolimus. In the liver recipient a complete response was achieved; he died, however, due to noncompliance followed by graft failure. One renal recipient died without evidence of recurrent disease from myocardial infarction. The cardiac and two renal recipients are alive between 4 months and 17 years with well-functioning grafts and no evidence of recurrent disease., Discussion: HHV8-associated lesions seem to be extremely rare in the Central European transplant population. Nevertheless, awareness of KS is important for early diagnosis and optimal treatment.

The Organ shortage has caused an accumulation of acutely decompensated patients listed as medical urgency code 2 (MUC 2) (United network for Organ Sharing 2) while awaiting liver transplantation. Between June 1997 and June 2003, 22 of 360 liver transplantation patients (6%) were listed as MUC 2. Prophylactic immunosuppression consisted of calcineurin inhibitor-based drug therapy, using antithymocyte globulin or interleukin-2 receptor antagonist induction in 64%. The overall perioperative infection rate was 50%, and the rejection rate was 23%. We observed 7 episodes of oral or genital herpes simplex virus lesions; 2 patients (both with cytomegalovirus-mismatched transplants) developed cytomegalovirus disease, and another 5 patients received ganciclovir for preemptive therapy or prophylaxis. Two patients developed pneumonia: 5, sepsis that originated in 4 cases from a contaminated central venous line; and 1 methicillin-resistant endocarditis, which resulted in Staphylococcus aureus lethal outcome. After a median follow up of 3 years, 1 patient underwent a repeat transplantation procedure and 6 patients had died, 4 of them from infectious complications. Liver transplantation of MUC 2-listed patients may result in acceptable results similar to those of MUC 3 and MUC 4 categories.

One major cause of graft loss after kidney transplantation or simultaneous kidney and pancreas transplantation is death of the recipient due to cardiac events. Records of 261 patients who underwent sole kidney (group A) or combined kidney-pancreas transplantation (group B) were retrospectively analyzed. Patients were divided into groups with basic cardiac evaluation (chest X-ray, electrocardiogram) and patients with additional diagnostics [echocardiography, exercise stress test, myocardial perfusion test, and coronary angiography (CAG)]. The results of the performed CAGs were as follows: proven coronary artery disease (CAD) in 22 patients (12.43%) in group A and 37 patients (44.05%) in group B; stenosis of one main coronary artery of 70% or greater in 8.47% (group A) and 16.67% (group B) of the patients. Subsequent revascularization procedures were performed in 15 candidates (8.47%) of group A and 11 (13.10%) of group B. The incidence of posttransplant cardiac events (PCE) was lower in recipients in both groups who underwent additional cardiac evaluation. Late postoperative deaths were reported in 3.45% of kidney recipients with no additional evaluation (group A), in 2.06% of patients with further diagnostics (group A), and in only 1.19% of patients with invasive pretransplant evaluation (group B). Patients with known CAD and no further invasive diagnostics or subsequent revascularization are at great risk. PCE were observed in three of seven patients in this subgroup. Careful cardiac evaluation including echocardiography, exercise stress test, myocardial perfusion test, and CAG is associated with a low incidence of PCE.