Introduction: Since 2012, hand and upper limb (HAUL) vascularised composite allotransplantation has been available in the United Kingdom on a standard of care basis to select patients with upper limb loss who meet the stringent criteria and commitment for transplantation. Here, we report the functional and immunological outcomes of all patients who have had a HAUL transplant in the UK.   
Methods: This was a single centre retrospective study of prospectively collected data based at the UK centre for HAUL transplantation. All cases of HAUL transplant since the programme’s inception were included. Primary outcome measures were graft survival, episodes of rejection, episodes of infection, side effects of immunosuppressive medications, complications, and functional outcome measures. 
Results: The UK Hand Transplant service has performed 17 HAUL transplants in 10 patients; 7 male and 3 female. The mean age at time of transplant was 46.7 ± 11.8 years.  Aetiology of limb loss included sepsis, trauma (including blast and high tension electrical injury), and loss of function through disease. The later category included one patient with painful, total loss of hand function due to Systemic Sclerosis. Patient 10 was the world’s first to receive a HAUL transplant from a Donation after Circulatory Death (DCD) donor. The graft survival rate is 17/17. No patients have had chronic rejection. Five patients have generated de novo donor specific antibodies. The median number of acute rejection episodes was 3.5 (IQR 1.0-5.0). Three patients have had fungal infections post-transplant (one had mucormycosis). One patient had a peri-prosthetic fracture, osteomyelitis, and delayed union. Three patients have developed diabetes mellitus, controlled with oral medication. Patients with history of renal replacement (eg during severe sepsis) experience significantly greater renal impairment post-transplant and require careful assessment and management. For patients with at least 4 years follow up, Disabilities of Arm, Shoulder and Hand (DASH) scores improved in 5/6 patients. Canadian Occupational Performance Measure (COPM) scores improved in 6/6 patients. There were no psychological rejections, and all patients were happy to have had the transplant.
Conclusion: The UK’s HAUL transplant programme is amongst the most active in the Western Hemisphere. HAUL transplant has thus far proven to be a successful and a viable option for a select group of patients. As the transplant programme has matured, we have refined our processes in every aspect from patient selection and work-up for surgery, to donation, and post-operative care.  Novel indications are considered as they present. We continue to develop strategies to manage specific challenges, such as renal function post-transplant in patients that required renal replacement at the time of limb loss.