Health Check: What price would you pay for a limb transplant?

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RIVALRY IN medicine is no different from that in any other field of human endeavour.

Who remembers the second person to climb Everest or walk on the moon - and who will bother to record the second transplant of a human hand? The race to be first involves risk but it is the driving force that brings scientific advance, social progress and, er, research grants.

Except that medical advances involve two people - and it is the patient, not the doctor, who takes the risk. Many men died trying to climb Everest but they were a danger only to themselves. The team that last week claimed the world's first transplant using a donor hand put their patient, Clint Hallam, a New Zealander, at risk.

The operation was clearly undertaken with his consent, and there is no reason to suppose that the risks were not fully explained to him. Mr Hallam, who lost his right hand in an accident with a chain saw nine years ago, was so keen to acquire a replacement that he had booked a consultation with a team in Kentucky in the US on the very day that he went under the knife in Paris. "We rang his wife in Australia who said: `He isn't going to meet you - he's got a new hand now'," said a miffed US researcher.

It is clear, too, that the international team that undertook the transplant was aware of the risk.

Professor Nadey Hakim, the British transplant expert from St Mary's hospital, London, said after the operation: "You have to dare in medicine or it does not advance." But was the risk justified? Some experts have their doubts. The risk derives not from the complexity of the surgery, which, while not routine, is certainly beyond the experimental stage - dozens of patients have had their own hands reattached after accidents, with varying degrees of success - but from the immune reaction that could be triggered by the foreign limb.

In immunological terms, transplanting a donor hand is much more difficult than transplanting a heart or kidney. The skin is the most antigenic organ in the body - provoking the strongest immune response - and Mr Hallam will have to take powerful immunosuppressant drugs to suppress the body's natural immune response, which will put him at risk of infection by any passing virus or bacterium, including those causing cancer.

In the case of a kidney or heart transplant, calculating the risks is straightforward. Not going ahead means almost certain death. But Mr Hallam and his doctors had to calculate the potential benefits of the new hand - not a vital organ - against the potential disaster of a severe immune reaction. The most serious risk is of graft-versus-host disease - rejection in reverse. Instead of the body rejecting the hand, the hand rejects the body; it could be fatal.

Mr Hallam will need close monitoring over the next weeks and months to ensure that his life is not in danger. Because of these risks the International Federation of Societies of Surgery of the Hand decided at its meeting in Vancouver earlier this year that a transplant of a donor hand should be carried out only on someone who had already had an organ transplant and was therefore already taking immunosuppressant drugs.

The French team, who are not among those at the forefront of this research, appear to have gone ahead despite this view. And in experiments on animals no donor graft has survived more than a year. I salute Mr Hallam's courage - but I fear for him.

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