Candidacy and waitlisting

All patients being considered for hand transplant candidacy will be evaluated by a multidisciplinary team prior to placement on the transplant waitlist. Multidisciplinary care planning will continue post-transplantation. In addition, all patients will undergo the testing detailed below. The pre-transplant evaluation is coordinated by the transplant coordinator and includes the following for all patients prior to waitlisting:

• Medical evaluation
• Financial counseling
• Nutrition/dietitian consultation
• Surgical consultation
• Orthopedic consultation
• Neurology consultation
• Physical therapy
• Occupational therapy
• Psychosocial evaluation
• Pharmacy
• Infectious disease
• Anesthesia Resource Center consultation
• Echocardiogram
• Pharmacy consultation
• Other imaging and studies as indicated
• Other medical subspecialty consultations as needed

Selection criteria

Appropriate patient selection is critical to safe and effective organ transplantation. Patient selection criteria are used to identify factors that may increase the risk of patient deaths or lead to foreshortened graft survival. These factors are assessed through a formal multidisciplinary evaluation process that is intended to provide a clear and consistent approach; adhere to all local, regional and national transplantation standards; and ensure that the process is consistent with the Hospital’s anti-discrimination policy.

Experts from the Hand Transplantation Program will perform the following routine patient assessments and apply the following criteria when evaluating potential transplant candidates and selecting patients for vascularized composite allotransplantation (VCA) hand transplantation. Potential transplant candidates will be provided with these criteria during their evaluation for transplant.

1. Referral and evaluation process. All patients referred to the Hand Transplantation Program for possible hand transplantation will be evaluated for transplant according to the framework described below (2-6). At the beginning of the evaluation process, families and patients are provided information about the evaluation process itself and about the potential benefits and harms of receiving a transplant, and their consent is obtained before proceeding with the evaluation. The transplant evaluation will be conducted by a designated multidisciplinary team of specialists. If conditions or factors that may be harmful to the surgical or patient outcome are identified by the team, the evaluation may be suspended or may result in a patient being ineligible as a transplant candidate at the current time.
2. Indications for VCA hand transplant. At this time, VCA hand transplantation will be considered for patients 6 to 17 years of age who have had bilateral hand amputation and a failed history of prosthetics that is likely to result in significantly diminished quality of life, and for whom there are no superior alternative therapies.
3. Routine patient assessments. Tests, studies and consultations are required prior to placement of a candidate on the transplant waitlist. The results of the tests, studies and consultations will be evaluated in the context of the Hand Transplant Program's absolute and relative contraindications listed below (4 and 5). Additionally, all results will be entered into the patient’s medical record.
4. Absolute contraindications to VCA hand transplantation. Absolute contraindications are medical conditions or factors that substantially diminish the likelihood of a successful transplant. The presence of an absolute contraindication excludes a patient from transplant candidacy at the current time. Absolute contraindications include active infection or malignancy, congenital lack of limbs, and/or unilateral limb loss.
5. Relative contraindications to VCA hand transplantation. Relative contraindications are medical conditions or factors that have the potential to significantly diminish the likelihood of a successful transplant. The presence of one or several relative contraindications may exclude a patient from transplant candidacy at the current time; however, each child will be assessed individually with regard to these concerns. Some relative contraindications are reversible or temporary, and may only affect candidacy for a limited period of time. Relative contraindications include: not currently being on immunosuppressive therapy, being less than 6 years of age at the time of evaluation, being unable to sit still unsedated for extended periods of time, and/or being unable to comply with rehabilitation therapy.
6. Patient participation and communication. Patients and their authorized decision-makers (such as parents or guardians) attend transplant education meetings during which the routine patient assessment data is reviewed and evaluated within the framework of the contraindications listed above (4 and 5) as part of the informed consent process.

At the conclusion of the evaluation process, patients and their families are provided in writing of the Hand Transplantation Program's decision regarding whether to list the patient and reasons for this decision. If the patient is declined transplant listing, the patient can continue to receive other forms of medical and surgical care at Children’s Hospital of Philadelphia. Patients, their families and referring physicians will be provided a copy of this selection criteria policy if requested.

If you believe your child is a candidate, please fill out our Patient Evaluation Form.