For Vascularized Composite Allografts: The Elephant in the Room

As we entertain increased use of vascularized composite allograft in treating our patients, we must be prepared for frank discussions regarding the risk of transplanting non–life-saving body parts requiring full immunosuppression. Today, a transplant patient will likely receive a calcineurin inhibitor, cyclosporine, or tacrolimus. Steroids are still commonly used in most centers. Mycophenolate mofetil has replaced azathioprine, with considerable benefit to patients. In some centers, single-drug immunosuppression suffices for many kidney and liver patients. The majority of centers, however, commit patients to triple-drug immunosuppression with prednisone, mycophenolate mofetil, and cyclosporine or tacrolimus. Although chronic immune-suppressive therapy ensures prevention of organ rejection, these medications place recipients at an increased risk for developing chronic renal failure, diabetes mellitus, and certain types of cancers. As clinicians, we should discuss not only the transplant process but also the long-term risks and complications of such an operation.