Clinical outcome following nerve allograft transplantation.

The clinical outcome of seven patients who underwent reconstruction of long upper- and lower-extremity peripheral nerve gaps with interposition peripheral nerve allografts is reported. Patients were selected for transplantation when the nerve gaps exceeded the length that could be reconstructed with available autograft tissue. Before transplantation, cadaveric allografts were harvested and preserved for 7 days in University of Wisconsin Cold Storage Solution at 5 degrees C. In the interim, patients were started on an immunosuppressive regimen consisting of either cyclosporin A or tacrolimus (FK506), azathioprine, and prednisone. Immunosuppression was discontinued 6 months after regeneration across the allograft(s) was evident. Six patients demonstrated return of motor function and sensation in the affected limb, and one patient experienced rejection of the allograft secondary to subtherapeutic immunosuppression. In addition to providing the ability to restore nerve continuity in severe extremity injuries, successful nerve allografting protocols have direct applicability to composite tissue transplantation.

Rat-strain differences in recovery following peripheral-nerve allotransplantation.

The rat model is commonly utilized in peripheral nerve research. Due to the short length of the rat limb and the animal's inherent neuroregenerative capacity, the timing of assessment of nerve regeneration is critical, and significant differences between groups can be lost if assessment is done too late. Additionally, the comparison of data from different rat-strain combinations has been questioned. This study better defines the time course of recovery after peripheral nerve grafting, and examines differences between Buffalo (BUF), Lewis (LEW), and ACI rats. Tibial-nerve isografts and allografts were performed and harvested at 6, 8, 10, or 14 weeks. Histomorphometry documented a statistically significant difference in the ACI/LEW and LEW/LEW combination at 10 weeks. No strain differences in graft rejection were noted. The optimal time to assess for histomorphometric differences in the ACI/LEW and LEW/LEW combination is at 10 weeks postoperatively.

Effects of FKBP-12 ligands following tibial nerve injury in rats.

The neuroregenerative properties of FK506, an FKBP-12 ligand that inhibits calcineurin, and V-10,367, an FKBP-12 ligand that does not inhibit calcineurin, were evaluated in crush and transection models. Rats were randomly assigned to one of seven groups, including untreated controls and FK506- or V-10,367-treated experimental groups. Following crush or transection nerve injury, animals were assessed with walking tracks, and histomorphometry. FK506-treated animals demonstrated significant functional recovery 11 days following crush and 18 days following transection injury. In untreated and V-10,367 treated animals, nerves recovered 13 days following crush injury, but did not improve significantly prior to sacrifice at 28 days in animals sustaining a transection injury. No statistically significant differences in histomorphometric parameters were identified between any of the groups. The study confirms that FK506 accelerates recovery from tibial nerve injury.

FK506 promotes functional recovery in crushed rat sciatic nerve.

In this study we examine whether the systemic administration of FK506 or Cyclosporin A (CsA) expedited functional recovery following an axonotmetic nerve injury, and compared their effects in a rat model. Seventy-five adult Buffalo rats received a crush injury to the right posterior tibial nerve and subsequently underwent either no treatment (group I), daily injections of FK506 (group II), or daily injections of CsA (group III). Walking track analysis demonstrated return of hindlimb function by 20 days postoperatively in group I, 14 days in group II, and 18 days in group III. The blood-nerve barrier (BNB) was reconstituted by postoperative day (POD) 7 in both FK506- and CsA-treated animals and by POD 13 in control animals. These results suggest that recovery of function is more rapid with daily administration of FK506 than with CsA or no treatment, perhaps because of earlier restoration of the blood-nerve barrier. Agents that facilitate nerve regeneration have the potential to limit the extent of motor endplate loss and muscle atrophy seen with prolonged denervation, thereby limiting permanent functional loss.

FK506 accelerates functional recovery following nerve grafting in a rat model.

The sometimes dramatic and permanent functional deficits that result from severe peripheral nerve injuries provide compelling incentives to identify exogenous agents that may expedite axonal regrowth and avoid prolonged denervation of end organs. The purpose of this study was to identify, whether the regular systemic administration of tacrolimus (FK506) or cyclosporin A (CsA) would influence the speed and efficiency of nerve regeneration through short nerve grafts. A total of 35 Buffalo rats each received a 2-cm posterior tibial nerve graft and were randomized to one of three experimental groups. Group I animals were left untreated, group II received daily CsA (5 mg/kg intraperitoneally), and group III received daily FK506 (1 mg/kg intraperitoneally). Walking tracks were obtained starting 3 weeks after graft placement and continuing biweekly for the next 7 weeks. FK506-treated animals fully recovered hindlimb function 7 days earlier than CsA-treated animals or untreated control animals. Regenerated nerves from one-half of each treatment group were harvested for histomorphometric analysis at 7 weeks, shortly after recovery was complete in the FK506-treatment group but not in the other two groups, and once again at 10.5 weeks when recovery of function had stabilized in all groups. At 7 weeks, FK506-treated animals had significantly greater fiber density and percentage of neural tissue per nerve and a significantly larger population of mature, myelinated fibers in comparison with either CsA-treated or untreated animals. The authors concluded that the daily, systemic administration of low-dose FK506 facilitates peripheral nerve recovery and regeneration after nerve grafting.

Regeneration through long nerve grafts in the swine model.

We investigated regeneration across a long nerve defect in the swine model to study extensive neural loss and long nerve gap. Most experiments have been conducted in the rodent model that, while an appropriate immunological model, only allows short nerve gaps to be studied. Twelve outbred swine received either an 8-cm ulnar nerve autograft or an allograft without immunosuppression. At 6 and 10 months, histomorphometry of the autografts demonstrated excellent nerve regeneration, while very poor regeneration was noted across the allografts. This confirmed that 8 cm are an adequate challenge independent of the spontaneous regeneration potential of axons seen in rodents. The swine ulnar nerve graft model causes minimal morbidity and will now be used with immunological manipulation of inbred animals.

Indefinite survival of peripheral nerve allografts after temporary Cyclosporine A immunosuppression.

It is hypothesized that unlike solid organ transplants immunosuppression of peripheral nerve allografts is needed only for the finite time period required for regeneration of proximal host nerve axons through the allograft and subsequent re-establishment of host end-organ connections. The aim of this study was to explore the consequences of temporary and continuous systemic Cyclosporine A (CsA) immunosuppression upon peripheral nerve allograft survival. Buffalo rats received Lewis nerve allografts under CsA immunosuppression (5 mg/kg/day) either continuously for 20 weeks, or for only 10 weeks followed by abrupt withdrawal. At 20 weeks, the nerve segments from both groups were regrafted into naïve Buffalo or Lewis recipients without further immunosuppression. These grafts were compared with isografts, unimmunosuppressed allografts and allografts immunosuppressed for 10 weeks in situ. By eight weeks following regrafting, the secondary Lewis recipients had rejected the temporarily immunosuppressed allografts and accepted the continuously immunosuppressed allograft, while the secondary Buffalo recipients accepted both the temporarily and continuously immunosuppressed allografts as assessed by histology and morphometry. Functional recovery was earlier in secondary recipient strain animals that received temporarily immunosuppressed allografts in comparison to those that received continuously immunosuppressed allografts. Analysis of secondary recipients of temporarily immunosuppressed allografts demonstrated greater in vitro MLR and LDA reactivity than did those receiving continuously immunosuppressed allografts. These findings support the hypothesis that donor alloantigens are lost or replaced by the recipient after immunosuppression withdrawal. Moreover, the change to recipient antigenicity in the nerve allograft is retarded and incomplete under continuous CsA immunosuppression, resulting in acceptance by both secondary donor and recipient strains upon regraftment.

The role of conduits in nerve repair: a review.

The restoration of effective and meaningful axonal function following peripheral nerve injury continues to be a considerable clinical challenge. The use of conduits to bridge the gap between severed ends is a contemporary experimental maneuver that isolates the microenvironment of regenerating axons. Entubulation has allowed analysis and manipulation of putative influences upon nerve regeneration. A review is provided of the research efforts that have explored the neurobiological and mechanical factors that guide nerve regeneration within conduits. Levels of specificity, from tissue specific growth to end-organ specific growth, are outlined within the framework of the theories of Neurotropism, Contact Guidance and Neurotrophism. Included are investigations utilizing different conduit materials and the few clinical applications of these conduits. A number of chamber manipulations, extra-cellular matrix substrates and growth factors and their molecular receptors have been implicated in enhanced regeneration specificity. This information has been extended to the conduit model. The interposition of healthy nerve segments into conduits is proposed as a means of extending the length of successful nerve regeneration.