1
|
Gao Q, Cai JZ, Dong H. A Review of the Risk Factors and Approaches to Prevention of Post-Reperfusion Syndrome During Liver Transplantation. Organogenesis 2024; 20:2386730. [PMID: 39097866 PMCID: PMC11299628 DOI: 10.1080/15476278.2024.2386730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Revised: 06/22/2024] [Accepted: 07/26/2024] [Indexed: 08/05/2024] Open
Abstract
Post-reperfusion syndrome (PRS) is a severe and highly lethal syndrome that occurs after declamping the portal vein forceps during liver transplantation. It is marked by severe hemodynamic disturbances manifested by decreased mean arterial pressure, increased heart rate and elevated pulmonary artery pressure. The complex pathogenesis of PRS remains understudied. It is generally believed to be related to the large amount of acidic, cold blood that enters the circulation after release of the portal clamp. This blood is rich in oxygen-free radicals and metabolic toxins, which not only aggravate the ischemia-reperfusion injury of the liver but also further attack the systemic organs indiscriminately. Considering the range of possible adverse prognoses including acute kidney injury, delirium and graft nonfunction, it is imperative that clinicians increase their awareness and prevention of PRS. The aim of this article is to review the current risk factors, pathophysiological mechanisms and prevention strategies for PRS.
Collapse
Affiliation(s)
- Qian Gao
- Department of Anesthesiology, Affiliated Hospital of Qingdao University, Qingdao University, Qingdao, China
| | - Jin-Zhen Cai
- Organ Transplant Center, Affiliated Hospital of Qingdao University, Qingdao University, Qingdao, China
| | - He Dong
- Department of Anesthesiology, Affiliated Hospital of Qingdao University, Qingdao University, Qingdao, China
| |
Collapse
|
2
|
Nie Y, Huang JB, He SJ, Chen HD, Jia JJ, Li JJ, He XS, Zhao Q. Validation and performance of three scoring systems for predicting primary non-function and early allograft failure after liver transplantation. Hepatobiliary Pancreat Dis Int 2024; 23:463-471. [PMID: 37661517 DOI: 10.1016/j.hbpd.2023.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 08/21/2023] [Indexed: 09/05/2023]
Abstract
BACKGROUND Primary non-function (PNF) and early allograft failure (EAF) after liver transplantation (LT) seriously affect patient outcomes. In clinical practice, effective prognostic tools for early identifying recipients at high risk of PNF and EAF were urgently needed. Recently, the Model for Early Allograft Function (MEAF), PNF score by King's College (King-PNF) and Balance-and-Risk-Lactate (BAR-Lac) score were developed to assess the risks of PNF and EAF. This study aimed to externally validate and compare the prognostic performance of these three scores for predicting PNF and EAF. METHODS A retrospective study included 720 patients with primary LT between January 2015 and December 2020. MEAF, King-PNF and BAR-Lac scores were compared using receiver operating characteristic (ROC) and the net reclassification improvement (NRI) and integrated discrimination improvement (IDI) analyses. RESULTS Of all 720 patients, 28 (3.9%) developed PNF and 67 (9.3%) developed EAF in 3 months. The overall early allograft dysfunction (EAD) rate was 39.0%. The 3-month patient mortality was 8.6% while 1-year graft-failure-free survival was 89.2%. The median MEAF, King-PNF and BAR-Lac scores were 5.0 (3.5-6.3), -2.1 (-2.6 to -1.2), and 5.0 (2.0-11.0), respectively. For predicting PNF, MEAF and King-PNF scores had excellent area under curves (AUCs) of 0.872 and 0.891, superior to BAR-Lac (AUC = 0.830). The NRI and IDI analyses confirmed that King-PNF score had the best performance in predicting PNF while MEAF served as a better predictor of EAD. The EAF risk curve and 1-year graft-failure-free survival curve showed that King-PNF was superior to MEAF and BAR-Lac scores for stratifying the risk of EAF. CONCLUSIONS MEAF, King-PNF and BAR-Lac were validated as practical and effective risk assessment tools of PNF. King-PNF score outperformed MEAF and BAR-Lac in predicting PNF and EAF within 6 months. BAR-Lac score had a huge advantage in the prediction for PNF without post-transplant variables. Proper use of these scores will help early identify PNF, standardize grading of EAF and reasonably select clinical endpoints in relative studies.
Collapse
Affiliation(s)
- Yu Nie
- General Surgery Center, Department of Hepatobiliary Surgery II, Research Center for Artificial Organ and Tissue Engineering, Guangzhou Clinical Research and Transformation Center for Artificial Liver, Institute of Regenerative Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Jin-Bo Huang
- Organ Transplant Center, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou 510080, China; Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou 510080, China
| | - Shu-Jiao He
- General Surgery Center, Department of Hepatobiliary Surgery II, Research Center for Artificial Organ and Tissue Engineering, Guangzhou Clinical Research and Transformation Center for Artificial Liver, Institute of Regenerative Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Hua-Di Chen
- Organ Transplant Center, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou 510080, China; Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou 510080, China
| | - Jun-Jun Jia
- Division of Hepatobiliary Pancreatic Surgery, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Jing-Jing Li
- Organ Transplant Center, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou 510080, China; Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou 510080, China
| | - Xiao-Shun He
- Organ Transplant Center, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou 510080, China; Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou 510080, China
| | - Qiang Zhao
- Organ Transplant Center, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou 510080, China; Guangdong Provincial International Cooperation Base of Science and Technology, Guangzhou 510080, China.
| |
Collapse
|
3
|
Broere R, Luijmes SH, de Jonge J, Porte RJ. Graft repair during machine perfusion: a current overview of strategies. Curr Opin Organ Transplant 2024; 29:248-254. [PMID: 38726753 PMCID: PMC11224572 DOI: 10.1097/mot.0000000000001151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/03/2024]
Abstract
PURPOSE OF REVIEW With changing donor characteristics (advanced age, obesity), an increase in the use of extended criteria donor (ECD) livers in liver transplantation is seen. Machine perfusion allows graft viability assessment, but still many donor livers are considered nontransplantable. Besides being used as graft viability assessment tool, ex situ machine perfusion offers a platform for therapeutic strategies to ameliorate grafts prior to transplantation. This review describes the current landscape of graft repair during machine perfusion. RECENT FINDINGS Explored anti-inflammatory therapies, including inflammasome inhibitors, hemoabsorption, and cellular therapies mitigate the inflammatory response and improve hepatic function. Cholangiocyte organoids show promise in repairing the damaged biliary tree. Defatting during normothermic machine perfusion shows a reduction of steatosis and improved hepatobiliary function compared to nontreated livers. Uptake of RNA interference therapies during machine perfusion paves the way for an additional treatment modality. SUMMARY The possibility to repair injured donor livers during ex situ machine perfusion might increase the utilization of ECD-livers. Application of defatting agents is currently explored in clinical trials, whereas other therapeutics require further research or optimization before entering clinical research.
Collapse
Affiliation(s)
- Roberto Broere
- Department of Surgery, Division of Hepato-Pancreato- Biliary and Transplant Surgery, Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | | | | | | |
Collapse
|
4
|
Müller PC, Müller BP, Dutkowski P. [Organ donation and organ assessment after primary circulatory death and secondary brain death]. CHIRURGIE (HEIDELBERG, GERMANY) 2024; 95:618-626. [PMID: 38750373 PMCID: PMC11286625 DOI: 10.1007/s00104-024-02094-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/16/2024] [Indexed: 07/26/2024]
Abstract
BACKGROUND The global organ shortage is the biggest obstacle to expand urgently needed liver transplantation activities. In addition to donation after brain death (DBD), donation after primary circulatory death (DCD) has also been introduced in many European countries to increase the number of donated organs. OBJECTIVE This article summarizes the legal and ethical aspects of DCD, the practical donation process of DCD, the clinical results of DCD liver transplantation with a special focus on organ assessment before a planned DCD liver transplantation. RESULTS In Europe 11 countries have active DCD liver transplantation programs and a total of 1230 DCD liver transplantations were performed in Europe in 2023. The highest proportion of DCD liver transplantations were recorded in Belgium (52.8%), the Netherlands (42.8%) and Switzerland (32.1%). The adequate selection of donors and recipients is crucial in DCD transplantation and the use of DCD livers particularly depends on the preparedness of the healthcare system for routine machine perfusion. The leaders are Belgium, France and Italy which implant around 68-74% of DCD organs. With an adequate organ assessment, the long-term results of DBD and DCD liver transplantations are comparable. To assess mitochondrial damage and thus organ quality, hypothermic oxygenated machine perfusion (HOPE) was introduced and has the secondary benefit of mitochondrial protection through oxygenation. The establishment of aerobic metabolism in mitochondria under hypothermia leads to a reduction of toxic metabolites and the restoration of ATP storage, which subsequently leads to a reperfusion light during implantation. CONCLUSION Expanding the donor pool with DCD donors can counteract the global organ shortage. With adequate patient selection and routine organ assessment short-term and also long-term outcomes of DBD and DCD liver transplantation are comparable.
Collapse
Affiliation(s)
- Philip C Müller
- Klinik für Viszeralchirugie, Clarunis - Universitäres Bauchzentrum, Universitätsspital Basel, Basel, Schweiz
| | - Beat P Müller
- Klinik für Viszeralchirugie, Clarunis - Universitäres Bauchzentrum, Universitätsspital Basel, Basel, Schweiz
| | - Philipp Dutkowski
- Klinik für Viszeralchirugie, Clarunis - Universitäres Bauchzentrum, Universitätsspital Basel, Basel, Schweiz.
- Department of Surgery, Clarunis - University Digestive Health Care Centre Basel, Spitalstr. 21, 4031, Basel, Schweiz.
| |
Collapse
|
5
|
Wehrle CJ, Zhang M, Khalil M, Pita A, Modaresi Esfeh J, Diago-Uso T, Kim J, Aucejo F, Kwon DCH, Ali K, Cazzaniga B, Miyazaki Y, Liu Q, Fares S, Hong H, Tuul M, Jiao C, Sun K, Fairchild RL, Quintini C, Fujiki M, Pinna AD, Miller C, Hashimoto K, Schlegel A. Impact of Back-to-Base Normothermic Machine Perfusion on Complications and Costs: A Multicenter, Real-World Risk-Matched Analysis. Ann Surg 2024; 280:300-310. [PMID: 38557793 DOI: 10.1097/sla.0000000000006291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
OBJECTIVE Assess cost and complication outcomes after liver transplantation (LT) using normothermic machine perfusion (NMP). BACKGROUND End-ischemic NMP is often used to aid logistics, yet its impact on outcomes after LT remains unclear, as does its true impact on costs associated with transplantation. METHODS Deceased donor liver recipients at 2 centers (January 1, 2019, to June 30, 2023) were included. Retransplants, splits, and combined grafts were excluded. End-ischemic NMP (OrganOx-Metra) was implemented in October 2022 for extended-criteria donation after brain death (DBDs), all donations after circulatory deaths (DCDs), and logistics. NMP cases were matched 1:2 with static cold storage controls (SCS) using the Balance-of-Risk [donation after brain death (DBD)-grafts] and UK-DCD Score (DCD-grafts). RESULTS Overall, 803 transplantations were included, 174 (21.7%) receiving NMP. Matching was achieved between 118 NMP-DBDs with 236 SCS; and 37 NMP-DCD with 74 corresponding SCS. For both graft types, median inpatient comprehensive complications index values were comparable between groups. DCD-NMP grafts experienced reduced cumulative 90-day comprehensive complications index (27.6 vs 41.9, P =0.028). NMP also reduced the need for early relaparotomy and renal replacement therapy, with subsequently less frequent major complications (Clavien-Dindo ≥IVa). This effect was more pronounced in DCD transplants. NMP had no protective effect on early biliary complications. Organ acquisition/preservation costs were higher with NMP, yet NMP-treated grafts had lower 90-day pretransplant costs in the context of shorter waiting list times. Overall costs were comparable for both cohorts. CONCLUSIONS This is the first risk-adjusted outcome and cost analysis comparing NMP and SCS. In addition to logistical benefits, NMP was associated with a reduction in relaparotomy and bleeding in DBD grafts, and overall complications and post-LT renal replacement for DCDs. While organ acquisition/preservation was more costly with NMP, overall 90-day health care costs-per-transplantation were comparable.
Collapse
Affiliation(s)
| | | | | | | | - Jamak Modaresi Esfeh
- Department of Gastroenterology and Transplant Hepatology, Cleveland Clinic, Cleveland, OH
| | - Teresa Diago-Uso
- Department of Liver Transplantation, Cleveland Clinic Abu Dhabi, Cleveland, OH
| | - Jaekeun Kim
- Transplantation Center, Cleveland Clinic, OH
| | | | | | - Khaled Ali
- Transplantation Center, Cleveland Clinic, OH
| | | | | | - Qiang Liu
- Transplantation Center, Cleveland Clinic, OH
| | - Sami Fares
- Transplantation Center, Cleveland Clinic, OH
| | - Hanna Hong
- Transplantation Center, Cleveland Clinic, OH
| | | | - Chunbao Jiao
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland, OH
| | - Keyue Sun
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland, OH
| | - Robert L Fairchild
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland, OH
| | - Cristiano Quintini
- Department of Liver Transplantation, Cleveland Clinic Abu Dhabi, Cleveland, OH
| | | | | | | | - Koji Hashimoto
- Transplantation Center, Cleveland Clinic, OH
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland, OH
| | - Andrea Schlegel
- Transplantation Center, Cleveland Clinic, OH
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland, OH
| |
Collapse
|
6
|
Kneifel F, Vondran F, Vogel T. [Machine perfusion in transplantation surgery]. CHIRURGIE (HEIDELBERG, GERMANY) 2024; 95:610-617. [PMID: 39052038 DOI: 10.1007/s00104-024-02122-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/04/2024] [Indexed: 07/27/2024]
Abstract
The use of machine perfusion in solid organ transplantation has developed tremendously worldwide in recent years. Although the number of randomized controlled trials in the field of organ preservation is still limited, machine perfusion has been shown to be superior to static cold storage of donor organs. Various devices for clinical use with hypothermia or normothermia are already available for most organs. Whether and which perfusion strategy is superior to the others is the subject of current clinical research. This also applies to the further evaluation of possible synergistic effects in the sequential use of the various protocols. The common goal of all dynamic perfusion technologies is to optimize organ preservation between removal and transplantation. By testing the quality of marginal donor organs prior to transplantation, it should also be possible to use these organs without exposing the patient to increased risk. This can lead to a significant expansion of the donor pool. This is particularly important in Germany, where there is an ongoing shortage of organs and restrictive legislation regarding the expansion of the donor pool. Furthermore, the perfusion technology offers the possibility to serve as a platform for other ex situ and in situ therapies on isolated organs. In addition to the conditioning of pre-damaged organs for transplantation, this could lead to further applications in the context of targeted organ therapies and also to improved transplant logistics in the future.
Collapse
Affiliation(s)
- Felicia Kneifel
- Klinik für Allgemein‑, Viszeral- und Transplantationschirurgie, Universitätsklinikum Münster, Münster, Deutschland
| | - Florian Vondran
- Klinik für Allgemein‑, Viszeral‑, Kinder- und Transplantationschirurgie, RWTH Universitätsklinikum Aachen, Pauwelsstr. 30, 52074, Aachen, Deutschland
| | - Thomas Vogel
- Klinik für Allgemein‑, Viszeral‑, Kinder- und Transplantationschirurgie, RWTH Universitätsklinikum Aachen, Pauwelsstr. 30, 52074, Aachen, Deutschland.
| |
Collapse
|
7
|
Groen PC, van Leeuwen OB, de Jonge J, Porte RJ. Viability assessment of the liver during ex-situ machine perfusion prior to transplantation. Curr Opin Organ Transplant 2024; 29:239-247. [PMID: 38764406 PMCID: PMC11224566 DOI: 10.1097/mot.0000000000001152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/21/2024]
Abstract
PURPOSE OF REVIEW In an attempt to reduce waiting list mortality in liver transplantation, less-than-ideal quality donor livers from extended criteria donors are increasingly accepted. Predicting the outcome of these organs remains a challenge. Machine perfusion provides the unique possibility to assess donor liver viability pretransplantation and predict postreperfusion organ function. RECENT FINDINGS Assessing liver viability during hypothermic machine perfusion remains challenging, as the liver is not metabolically active. Nevertheless, the levels of flavin mononucleotide, transaminases, lactate dehydrogenase, glucose and pH in the perfusate have proven to be predictors of liver viability. During normothermic machine perfusion, the liver is metabolically active and in addition to the perfusate levels of pH, transaminases, glucose and lactate, the production of bile is a crucial criterion for hepatocyte viability. Cholangiocyte viability can be determined by analyzing bile composition. The differences between perfusate and bile levels of pH, bicarbonate and glucose are good predictors of freedom from ischemic cholangiopathy. SUMMARY Although consensus is lacking regarding precise cut-off values during machine perfusion, there is general consensus on the importance of evaluating both hepatocyte and cholangiocyte compartments. The challenge is to reach consensus for increased organ utilization, while at the same time pushing the boundaries by expanding the possibilities for viability testing.
Collapse
Affiliation(s)
- Puck C Groen
- Department of Surgery, Division of Hepato-Pancreato- Biliary and Transplant Surgery, Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | | | | | | |
Collapse
|
8
|
Scatton O, Turco C, Savier E, Pelissié J, Legallais C, Sakka M, Aoudjehane L, Wendum D, Migliazza J, Spiritelli S, Conti F, Goumard C. Preclinical validation of a customized circuit for ex situ uninterrupted cold-to-warm prolonged perfusion of the liver. Artif Organs 2024; 48:876-890. [PMID: 38553992 DOI: 10.1111/aor.14743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 01/15/2024] [Accepted: 02/26/2024] [Indexed: 07/23/2024]
Abstract
CONTEXT Clinical adoption of ex situ liver perfusion is growing. While hypothermic perfusion protects against ischemia-reperfusion injury in marginal grafts, normothermic perfusion enables organ viability assessment and therefore selection of borderline grafts. The combination of hypothermic and normothermic perfusion, known as "cold-to-warm," may be the optimal sequence for organ preservation, but is difficult to achieve with most commercial perfusion systems. We developed an adaptable customized circuit allowing uninterrupted "cold-to-warm" perfusion and conducted preclinical studies on healthy porcine livers and discarded human livers to demonstrate the circuit's efficacy. METHODS In collaboration with bioengineers, we developed a customized circuit that adapts to extracorporeal circulation consoles used in cardiovascular surgery and includes a proprietary reservoir enabling easy perfusate change without interrupting perfusion. This preclinical study was conducted on porcine and human livers. Perfusion parameters (pressures, flows, oxygenation) and organ viability were monitored. RESULTS The customized circuit was adapted to a LivaNova S5® console, and the perfusions were flow-driven with real-time pressure monitoring. Ten porcine liver and 12 discarded human liver perfusions were performed during 14 to 18 h and 7 to 25 h, respectively. No hyperpressure was observed (porcine and human portal pressure 2-6 and 2-8 mm Hg; arterial pressure 10-65 and 20-65 mm Hg, respectively). No severe histological tissue injury was observed (Suzuki score ≤ 3 at the end of perfusion). Seven (70%) porcine livers and five (42%) human livers met the UK viability criteria. CONCLUSION The customized circuit and system design enables smooth uninterrupted "cold-to-warm" perfusion not present in current commercial perfusion systems.
Collapse
Affiliation(s)
- Olivier Scatton
- Department of Hepatobiliary Surgery and Liver Transplantation, Sorbonne Université, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
- INSERM UMRS-938, Centre de Recherche Saint-Antoine (CRSA), Sorbonne Université, Paris, France
| | - Célia Turco
- INSERM UMRS-938, Centre de Recherche Saint-Antoine (CRSA), Sorbonne Université, Paris, France
- Liver Transplantation Unit, Department of Digestive and Oncologic Surgery, University Hospital of Besançon, Besançon, France
| | - Eric Savier
- Department of Hepatobiliary Surgery and Liver Transplantation, Sorbonne Université, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
- INSERM UMRS-938, Centre de Recherche Saint-Antoine (CRSA), Sorbonne Université, Paris, France
| | - Jérôme Pelissié
- Department of Extracorporeal Perfusion and Vascular Surgery, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Cécile Legallais
- Department of Metabolic Biochemistry, Sorbonne Université, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Medhi Sakka
- Department of Metabolic Biochemistry, Sorbonne Université, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Lynda Aoudjehane
- INSERM UMRS-938, Centre de Recherche Saint-Antoine (CRSA), Sorbonne Université, Paris, France
- INSERM, Institute of Cardiometabolism and Nutrition (ICAN), Sorbonne Université, Paris, France
| | - Dominique Wendum
- Department of Pathology, Saint-Antoine Hospital (AP-HP), Paris, France
| | - John Migliazza
- Department of Discovery, Research and Development, LivaNova PLC, London, UK
| | - Sandra Spiritelli
- Department of Discovery, Research and Development, LivaNova PLC, London, UK
| | - Filomena Conti
- INSERM UMRS-938, Centre de Recherche Saint-Antoine (CRSA), Sorbonne Université, Paris, France
- Department of Medical Liver Transplantation, Assistance Publique-Hôpitaux de Paris (AP-HP), Pitié-Salpêtrière Hospital, Paris, France
| | - Claire Goumard
- Department of Hepatobiliary Surgery and Liver Transplantation, Sorbonne Université, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
- INSERM UMRS-938, Centre de Recherche Saint-Antoine (CRSA), Sorbonne Université, Paris, France
| |
Collapse
|
9
|
Li PJ, Shah S, Mehta N. Recent Advances in Liver Transplantation for Hepatocellular Carcinoma. Curr Treat Options Oncol 2024:10.1007/s11864-024-01247-8. [PMID: 39085572 DOI: 10.1007/s11864-024-01247-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/08/2024] [Indexed: 08/02/2024]
Abstract
OPINION STATEMENT Liver transplantation for hepatocellular carcinoma (HCC) remains an evolving field. Major challenges HCC transplant patients face today include liver organ donor shortages and the need for both better pre-transplant bridging/downstaging therapies and post-transplant HCC recurrence treatment options. The advent of immunotherapy and the demonstrated efficacy of immune checkpoint inhibitors in multiple solid tumors including advanced/unresectable HCC hold promise in expanding both the neoadjuvant and adjuvant HCC transplant treatment regimen, though caution is needed with these immune modulating agents leading up to and following transplant. New options for pre-transplant HCC management will expand access to this curative option as well as ensure patients have adequate control of their HCC prior to transplant to maximize the utility of a liver donor. Machine perfusion has been an active area of investigation in recent years and could expand the organ donor pool, helping address current liver donor shortages. Finally, additional HCC biomarkers such as AFP-L3 and DCP have shown promise in improving risk stratification of HCC patients. Together, these three recent advancements will likely alter HCC transplant guidelines in the coming years.
Collapse
Affiliation(s)
- P Jonathan Li
- University of California San Francisco School of Medicine, 533 Parnassus Avenue, San Francisco, CA, 94143, USA.
| | - Sachin Shah
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Neil Mehta
- Division of Gastroenterology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| |
Collapse
|
10
|
Wehrle CJ, Jiao C, Sun K, Zhang M, Fairchild RL, Miller C, Hashimoto K, Schlegel A. Machine perfusion in liver transplantation: recent advances and coming challenges. Curr Opin Organ Transplant 2024; 29:228-238. [PMID: 38726745 DOI: 10.1097/mot.0000000000001150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/03/2024]
Abstract
PURPOSE OF REVIEW Machine perfusion has been adopted into clinical practice in Europe since the mid-2010s and, more recently, in the United States (US) following approval of normothermic machine perfusion (NMP). We aim to review recent advances, provide discussion of potential future directions, and summarize challenges currently facing the field. RECENT FINDINGS Both NMP and hypothermic-oxygenated perfusion (HOPE) improve overall outcomes after liver transplantation versus traditional static cold storage (SCS) and offer improved logistical flexibility. HOPE offers additional protection to the biliary system stemming from its' protection of mitochondria and lessening of ischemia-reperfusion injury. Normothermic regional perfusion (NRP) is touted to offer similar protective effects on the biliary system, though this has not been studied prospectively.The most critical question remaining is the optimal use cases for each of the three techniques (NMP, HOPE, and NRP), particularly as HOPE and NRP become more available in the US. There are additional questions regarding the most effective criteria for viability assessment and the true economic impact of these techniques. Finally, with each technique purported to allow well tolerated use of riskier grafts, there is an urgent need to define terminology for graft risk, as baseline population differences make comparison of current data challenging. SUMMARY Machine perfusion is now widely available in all western countries and has become an essential tool in liver transplantation. Identification of the ideal technique for each graft, optimization of viability assessment, cost-effectiveness analyses, and proper definition of graft risk are the next steps to maximizing the utility of these powerful tools.
Collapse
Affiliation(s)
| | - Chunbao Jiao
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland, Ohio, USA
| | - Keyue Sun
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland, Ohio, USA
| | - Mingyi Zhang
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland, Ohio, USA
| | - Robert L Fairchild
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland, Ohio, USA
| | | | - Koji Hashimoto
- Transplantation Center, Cleveland Clinic
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland, Ohio, USA
| | - Andrea Schlegel
- Transplantation Center, Cleveland Clinic
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland, Ohio, USA
| |
Collapse
|
11
|
Okumura K, Dhand A, Misawa R, Sogawa H, Veillette G, Nishida S. Normothermic Machine Perfusion Is Associated With Improvement in Mortality and Graft Failure in Donation After Cardiac Death Liver Transplant Recipients in the United States. Transplant Direct 2024; 10:e1679. [PMID: 38988687 PMCID: PMC11230788 DOI: 10.1097/txd.0000000000001679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Revised: 05/07/2024] [Indexed: 07/12/2024] Open
Abstract
Background Use of normothermic machine perfusion (NMP) may help to expand the liver transplantation (LT) donor pool by potentially increasing the utilization of donation after circulatory death (DCD) organs. The aim of this study was to assess the impact of NMP on LT from DCD organs. Methods Data among DCD adult LT recipients in the United Network for Organ Sharing between January 2016 and December 2022 were analyzed. Outcomes were compared between 2 groups: NMP versus non-MP using propensity score matching. Results During the study period, 4217 DCD LT recipients (NMP: 257 and non-MP: 3960) were identified. compared with non-MP, DCD LT recipients in NMP group were older (median recipient age: 61 versus 59 y, P = 0.013), had lower model for the end-stage liver disease score, longer wait time (126 versus 107 d, P = 0.028), and received organs from older donors (median age: 42 versus 38 y, P < 0.01) with longer preservation time (9.9 versus 5.3 h, P < 0.001). Two-year overall survival (NMP 94.4% versus non-MP 89.7%, P = 0.040) and 2-y graft survival (NMP 91.3% versus non-MP 84.6%, P = 0.017) were better in the NMP group. After propensity score matching, 2-y overall survival (NMP 94.2% versus non-MP 88.0%, P = 0.023) and graft survival (NMP 91.3% versus non-MP 81.6%, P = 0.004) were better in the NMP group. On multivariable cox regression analysis, NMP was an independent factor of protection against mortality (hazard ratio, 0.43; 95% confidence interval: 0.20-0.91; P = 0.029) and against graft failure (hazard ratio, 0.26; 95% confidence interval: 0.11-0.61; P = 0.002). Conclusions Use of NMP for LT from DCD donors was associated with improved posttransplant patient and graft survival.
Collapse
Affiliation(s)
- Kenji Okumura
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Abhay Dhand
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Ryosuke Misawa
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Hiroshi Sogawa
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Gregory Veillette
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Seigo Nishida
- Department of Surgery, Westchester Medical Center and New York Medical College, Valhalla, NY
| |
Collapse
|
12
|
van Furth LA, Huijink TM, van Leeuwen LL, Maassen H, Lantinga VA, Ogurlu B, Hamelink TL, Pool MBF, Schutter R, Veldhuis SZJ, Ottens PJ, Moers C, Berger SP, Leuvenink HGD, Posma RA, Venema LH. The association between hemoglobin levels and renal function parameters during normothermic machine perfusion: A retrospective cohort study using porcine kidneys. Artif Organs 2024; 48:862-875. [PMID: 38546373 DOI: 10.1111/aor.14750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 03/07/2024] [Accepted: 03/13/2024] [Indexed: 07/23/2024]
Abstract
BACKGROUND Ex vivo normothermic machine perfusion (NMP) is a promising tool for assessing an isolated kidney prior to transplantation. However, there is no consensus on the perfusate's optimal oxygen-carrying capacity to support renal function. To investigate the association of hemoglobin levels with renal function parameters, a retrospective analysis of isolated, normothermically, perfused porcine kidneys was performed. METHODS Between 2015 and 2021, a total of 228 kidneys underwent 4 h of NMP with perfusates that varied in hemoglobin levels. A generalized linear model was used to determine the association of hemoglobin levels with time-weighted means of renal function markers, such as fractional sodium excretion (FENa) and creatinine clearance (CrCl). Stratified by baseline hemoglobin level (<4.5, 4.5-6, or >6 mmol/L), these markers were modeled over time using a generalized linear mixed-effects model. All models were adjusted for potential confounders. RESULTS Until a hemoglobin level of around 5 mmol/L was reached, increasing hemoglobin levels were associated with superior FENa and CrCl. Thereafter, this association plateaued. When hemoglobin levels were categorized, hemoglobin <4.5 mmol/L was associated with worse renal function. Hemoglobin levels were neither significantly associated with proteinuria during NMP nor with ATP levels at the end of NMP. Hemoglobin levels >6 mmol/L showed no additional benefits in renal function. CONCLUSION In conclusion, we found an association between baseline hemoglobin levels and superior renal function parameters, but not injury, during NMP of porcine kidneys. Furthermore, we show that performing a retrospective cohort study of preclinical data is feasible and able to answer additional questions, reducing the potential use of laboratory animals.
Collapse
Affiliation(s)
- L Annick van Furth
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Tobias M Huijink
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - L Leonie van Leeuwen
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
- Recanati/Miller Transplantation Institute, Mt. Sinai, New York City, New York, USA
| | - Hanno Maassen
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Veerle A Lantinga
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Baran Ogurlu
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Tim L Hamelink
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Merel B F Pool
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Rianne Schutter
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Susanne Z J Veldhuis
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Petra J Ottens
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Cyril Moers
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Stefan P Berger
- Department of Nephrology, University Medical Center Groningen, Groningen, The Netherlands
| | - Henri G D Leuvenink
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Rene A Posma
- Department of Critical Care, University Medical Center Groningen, Groningen, The Netherlands
| | - Leonie H Venema
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| |
Collapse
|
13
|
van Leeuwen LL, Irizar H, Kim-Schluger L, Florman S, Akhtar MZ. The Potential of Machine Learning to Predict Early Allograft Dysfunction after Normothermic Machine Perfusion in Liver transplantation. J Hepatol 2024:S0168-8278(24)02438-3. [PMID: 39094744 DOI: 10.1016/j.jhep.2024.07.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2024] [Accepted: 07/27/2024] [Indexed: 08/04/2024]
Affiliation(s)
- L Leonie van Leeuwen
- Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York City, New York, USA.
| | - Haritz Irizar
- Center for Biostatistics, Department of Population Health Science & Policy, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Leona Kim-Schluger
- Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Sander Florman
- Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - M Zeeshan Akhtar
- Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| |
Collapse
|
14
|
Purssell A, Kumar D. Impact of machine perfusion on transplant infectious diseases: New challenges and opportunities. Transpl Infect Dis 2024:e14348. [PMID: 39078339 DOI: 10.1111/tid.14348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 06/30/2024] [Accepted: 07/09/2024] [Indexed: 07/31/2024]
Abstract
Preservation techniques that maintain the viability of an organ graft between retrieval from the donor and implantation into the recipient remain a critical aspect of solid organ transplantation. While traditionally preservation is accomplished with static cold storage, advances in ex vivo dynamic machine perfusion, both hypothermic and normothermic, have allowed for prolongation of organ viability and recovery of marginal organs effectively increasing the usable donor pool. However, the use of these novel machine perfusion technologies likely exposes the recipient to additional infectious risk either through clonal expansion of pathogens derived during organ recovery or de novo exogenous acquisition of pathogens while the organ remains on the machine perfusion circuit. There is a paucity of high-quality studies that have attempted to quantify infection risk, although it appears that prolonging the time on the machine perfusion circuit and normothermic parameters increases the risk of infection. Conversely, the use of ex vivo machine perfusion unlocks new opportunities to detect and treat donor-derived infections before implantation into the recipient. This review seeks to reveal how the use of ex vivo machine perfusion strategies may augment the risk of infection in the organ recipient as well as outline ways that this technology could be leveraged to enhance our ability to manage donor-derived infections.
Collapse
Affiliation(s)
- Andrew Purssell
- Ajmera Transplant Centre, University Health Network, Toronto, Canada
| | - Deepali Kumar
- Ajmera Transplant Centre, University Health Network, Toronto, Canada
| |
Collapse
|
15
|
Zhang IW, Lurje I, Lurje G, Knosalla C, Schoenrath F, Tacke F, Engelmann C. Combined Organ Transplantation in Patients with Advanced Liver Disease. Semin Liver Dis 2024. [PMID: 39053507 DOI: 10.1055/s-0044-1788674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/27/2024]
Abstract
Transplantation of the liver in combination with other organs is an increasingly performed procedure. Over the years, continuous improvement in survival could be realized through careful patient selection and refined organ preservation techniques, in spite of the challenges posed by aging recipients and donors, as well as the increased use of steatotic liver grafts. Herein, we revisit the epidemiology, allocation policies in different transplant zones, indications, and outcomes with regard to simultaneous organ transplants involving the liver, that is combined heart-liver, liver-lung, liver-kidney, and multivisceral transplantation. We address challenges surrounding combined organ transplantation such as equity, utility, and logistics of dual organ implantation, but also advantages that come along with combined transplantation, thereby focusing on molecular mechanisms underlying immunoprotection provided by the liver to the other allografts. In addition, the current standing and knowledge of machine perfusion in combined organ transplantation, mostly based on center experience, will be reviewed. Notwithstanding all the technical advances, shortage of organs, and the lack of universal eligibility criteria for certain multi-organ combinations are hurdles that need to be tackled in the future.
Collapse
Affiliation(s)
- Ingrid Wei Zhang
- Department of Hepatology and Gastroenterology, Charité Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health (BIH) at Charité - Universitätsmedizin, Berlin, Germany
- European Foundation for the Study of Chronic Liver Failure (EF CLIF) and Grifols Chair, Barcelona, Spain
| | - Isabella Lurje
- Department of Hepatology and Gastroenterology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Georg Lurje
- Department of Surgery, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Christoph Knosalla
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Felix Schoenrath
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Frank Tacke
- Department of Hepatology and Gastroenterology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Cornelius Engelmann
- Department of Hepatology and Gastroenterology, Charité Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health (BIH) at Charité - Universitätsmedizin, Berlin, Germany
| |
Collapse
|
16
|
Robinson T, Vargas PA, Yemini R, Goldaracena N, Pelletier S. Are we on track to increase organ utilization? An analysis of machine perfusion preservation for liver transplantation in the United States. Artif Organs 2024. [PMID: 39034871 DOI: 10.1111/aor.14812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 05/17/2024] [Accepted: 06/11/2024] [Indexed: 07/23/2024]
Abstract
BACKGROUND Efforts to improve the quality of marginal grafts for transplantation are essential. Machine perfusion preservation appears as a promising solution. METHODS The United Network for Organ Sharing (UNOS) database was queried for deceased liver donor records between 2016 and 2022. The primary outcome of interest was the organ nonutilization rate. Long-term graft and patient survival among extended criteria donors (ECDs) were also analyzed. RESULTS During the study period, out of 54 578 liver grafts recovered for transplant, 5085 (9.3%) were nonutilized. Multivariable analysis identified normothermic machine perfusion (NMP) preservation as the only predictor associated with a reduction in graft nonutilization (OR = 0.12; 95% CI = 0.06-0.023, p < 0.001). Further analysis of ECD grafts that were transplanted revealed comparable 1-,2- and 3-years graft survival (89%/88%/82% vs. 90%/85%/81%, p = 0.60), and patient survival (92%/91%/84% vs. 92%/88%/84%, p = 0.65) between grafts that underwent MP vs. those who did not, respectively. CONCLUSIONS Liver nonutilization rates in the United States are at an all-time high. Available data, most likely including cases from clinical trials, showed that NMP reduced the odds of organ nonutilization by 12% among the entire deceased donor pool and by 16% among grafts from ECD. Collective efforts and further evidence reflecting day-to-day clinical practice are needed to fully reach the potential of MP for liver transplant.
Collapse
Affiliation(s)
- Todd Robinson
- Division of Transplant Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Paola A Vargas
- Division of Transplant Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Renana Yemini
- Division of Transplant Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Nicolas Goldaracena
- Division of Transplant Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Shawn Pelletier
- Division of Transplant Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| |
Collapse
|
17
|
Rejas C, Junger H. Cholangiocyte Organoids in Liver Transplantation; a Comprehensive Review. Transpl Int 2024; 37:12708. [PMID: 39100755 PMCID: PMC11294148 DOI: 10.3389/ti.2024.12708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 06/17/2024] [Indexed: 08/06/2024]
Abstract
Liver transplantation is the only curative option for many liver diseases that end up in liver failure, and cholangiopathy remains a challenging complication post-liver transplant, associated with significant morbidity and potential graft loss. The low availability of organs and high demand for transplantation motivate scientists to find novel interventions. Organoids, as three-dimensional cell cultures derived from adult cells or induced pluripotent cells, may help to address this problem. Different types of organoids have been described, from which cholangiocyte organoids offer a high level of versatility and plasticity for a deeper study of liver disease mechanisms. Cholangiocytes can be obtained from different segments of the biliary tree and have shown a remarkable capacity to adapt to new environments, presenting an effective system for studying cholangiopathies. Studies using cholangiocyte organoids show promising results for disease modeling, where organoids offer fundamental features to recapitulate the complexities of tissues in vitro and uncover fundamental pathological pathways to potentially reveal therapeutic strategies for personalized medicine. Organoids could hold the potential for regeneration of injured livers, representing tools of clinical impact in regenerative medicine when tissue damage is already present.
Collapse
Affiliation(s)
| | - H. Junger
- Department of Surgery, University Hospital Regensburg, Regensburg, Germany
| |
Collapse
|
18
|
Zimmer M, Hillebrandt KH, Roschke NN, Lippert S, Klein O, Nebrich G, Gassner JMGV, Strobl F, Pratschke J, Krenzien F, Sauer IM, Raschzok N, Moosburner S. Distinctive protein expression in elderly livers in a Sprague-Dawley rat model of normothermic ex vivo liver machine perfusion. Eur J Med Res 2024; 29:361. [PMID: 38992689 PMCID: PMC11238374 DOI: 10.1186/s40001-024-01961-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Accepted: 07/04/2024] [Indexed: 07/13/2024] Open
Abstract
BACKGROUND Liver grafts are frequently declined due to high donor age or age mismatch with the recipient. To improve the outcome of marginal grafts, we aimed to characterize the performance of elderly vs. young liver grafts in a standardized rat model of normothermic ex vivo liver machine perfusion (NMP). METHODS Livers from Sprague-Dawley rats aged 3 or 12 months were procured and perfused for 6 h using a rat NMP system or collected as a reference group (n = 6/group). Tissue, bile, and perfusate samples were used for biochemical, and proteomic analyses. RESULTS All livers cleared lactate during perfusion and continued to produce bile after 6 h of perfusion (614 mg/h). Peak urea levels in 12-month-old animals were higher than in younger animals. Arterial and portal venous pressure, bile production and pH did not differ between groups. Proteomic analysis identified a total of 1477 proteins with oxidoreductase and catalytic activity dominating the gene ontology analysis. Proteins such as aldehyde dehydrogenase 1A1 and 2-Hydroxyacid oxidase 2 were significantly more present in livers of older age. CONCLUSIONS Young and elderly liver grafts exhibited similar viability during NMP, though proteomic analyses indicated that older grafts are less resilient to oxidative stress. Our study is limited by the elderly animal age, which corresponds to mature but not elderly human age typically seen in marginal human livers. Nevertheless, reducing oxidative stress could be a promising therapeutic target in the future.
Collapse
Affiliation(s)
- Maximilian Zimmer
- Department of Surgery, Experimental Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany
| | - Karl Herbert Hillebrandt
- Department of Surgery, Experimental Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany
- BIH Academy, Clinician Scientist Program, Berlin Institute of Health at Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Nathalie Nora Roschke
- Department of Surgery, Experimental Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany
| | - Steffen Lippert
- Department of Surgery, Experimental Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany
| | - Oliver Klein
- Center for Regenerative Therapies, Core Unit Imaging Mass Spectrometry, Berlin Institute of Health at Charité, Berlin, Germany
| | - Grit Nebrich
- Center for Regenerative Therapies, Core Unit Imaging Mass Spectrometry, Berlin Institute of Health at Charité, Berlin, Germany
| | - Joseph Maria George Vernon Gassner
- Department of Surgery, Experimental Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany
- BIH Academy, Clinician Scientist Program, Berlin Institute of Health at Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Felix Strobl
- Department of Surgery, Experimental Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany
| | - Johann Pratschke
- Department of Surgery, Experimental Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany
| | - Felix Krenzien
- Department of Surgery, Experimental Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany
- BIH Academy, Clinician Scientist Program, Berlin Institute of Health at Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Igor Maximilian Sauer
- Department of Surgery, Experimental Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany
| | - Nathanael Raschzok
- Department of Surgery, Experimental Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany
- BIH Academy, Clinician Scientist Program, Berlin Institute of Health at Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Simon Moosburner
- Department of Surgery, Experimental Surgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany.
- BIH Academy, Clinician Scientist Program, Berlin Institute of Health at Charité-Universitätsmedizin Berlin, Berlin, Germany.
| |
Collapse
|
19
|
Nguyen MC, Li X, Reddy KS, Mathur AK. Commentary: DCD liver transplant in patients with a MELD over 35. Front Immunol 2024; 15:1404948. [PMID: 39055702 PMCID: PMC11269119 DOI: 10.3389/fimmu.2024.1404948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Accepted: 06/24/2024] [Indexed: 07/27/2024] Open
Affiliation(s)
- Michelle C. Nguyen
- Department of Surgery, Division of Transplant Surgery, Mayo Clinic Arizona, Scottsdale, AZ, United States
| | | | | | | |
Collapse
|
20
|
Tran MH, Gao J, Wang X, Liu R, Parris CL, Esquivel C, Fan Y, Wang L. Enhancing Liver Transplant Outcomes through Liver Precooling to Mitigate Inflammatory Response and Protect Mitochondrial Function. Biomedicines 2024; 12:1475. [PMID: 39062048 PMCID: PMC11275024 DOI: 10.3390/biomedicines12071475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Revised: 06/26/2024] [Accepted: 07/02/2024] [Indexed: 07/28/2024] Open
Abstract
Transplanted organs experience several episodes of ischemia and ischemia-reperfusion. The graft injury resulting from ischemia-reperfusion (IRI) remains a significant obstacle to the successful survival of transplanted grafts. Temperature significantly influences cellular metabolic rates because biochemical reactions are highly sensitive to temperature changes. Consequently, lowering the temperature could reduce the degradative reactions triggered by ischemia. In mitigating IRI in liver grafts, the potential protective effect of localized hypothermia on the liver prior to blood flow obstruction has yet to be explored. In this study, we applied local hypothermia to mouse donor livers for a specific duration before stopping blood flow to liver lobes, a procedure called "liver precooling". Mouse donor liver temperature in control groups was controlled at 37 °C. Subsequently, the liver donors were preserved in cold University of Wisconsin solution for various durations followed by orthotopic liver transplantation. Liver graft injury, function and inflammation were assessed at 1 and 2 days post-transplantation. Liver precooling exhibited a significant improvement in graft function, revealing more than a 47% decrease in plasma aspartate transaminase (AST) and alanine aminotransferase (ALT) levels, coupled with a remarkable reduction of approximately 50% in liver graft histological damage compared to the control group. The protective effects of liver precooling were associated with the preservation of mitochondrial function, a substantial reduction in hepatocyte cell death, and a significantly attenuated inflammatory response. Taken together, reducing the cellular metabolism and enzymatic activity to a minimum level before ischemia protects against IRI during transplantation.
Collapse
Affiliation(s)
- Minh H. Tran
- Department of Molecular Pharmacology and Physiology, University of South Florida College of Medicine, Tampa, FL 33612, USA
| | - Jie Gao
- School of Health Professions, The University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | - Xinzhe Wang
- Department of Molecular Pharmacology and Physiology, University of South Florida College of Medicine, Tampa, FL 33612, USA
| | - Ruisheng Liu
- Department of Molecular Pharmacology and Physiology, University of South Florida College of Medicine, Tampa, FL 33612, USA
| | - Colby L. Parris
- Department of Molecular Pharmacology and Physiology, University of South Florida College of Medicine, Tampa, FL 33612, USA
| | - Carlos Esquivel
- Department of Molecular Pharmacology and Physiology, University of South Florida College of Medicine, Tampa, FL 33612, USA
| | - Yingxiang Fan
- Department of Molecular Pharmacology and Physiology, University of South Florida College of Medicine, Tampa, FL 33612, USA
| | - Lei Wang
- Department of Molecular Pharmacology and Physiology, University of South Florida College of Medicine, Tampa, FL 33612, USA
| |
Collapse
|
21
|
Muth V, Stobl F, Michelotto J, Gilles L, Kirwan JA, Eisenberger A, Marchand J, Roschke NN, Moosburner S, Pratschke J, Sauer IM, Raschzok N, Gassner JM. Quality Assessment by Bile Composition in Normothermic Machine Perfusion of Rat Livers. Tissue Eng Part A 2024. [PMID: 38832856 DOI: 10.1089/ten.tea.2024.0048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2024] Open
Abstract
Background: The persistent challenge of organ scarcity in liver transplantation leads to an escalating dependence on organs obtained from extended criteria donors (ECD). Normothermic machine perfusion (NMP) is used for improved preservation. Due to the mimicked in vivo conditions during normothermic machine perfusion, the liver is metabolically active, which allows quality assessment during perfusion. Bile seems to be of rising interest in clinical studies, as it is easily collectible for analysis. As there are currently no data on biliary bile acids during NMP, the primary objective of this study was to use our experimental rodent NMP model to assess changes in bile composition through organ damage during perfusion to inform clinical evaluation of donor organs during NMP. Methods: Thirty livers from male Sprague-Dawley rats in five groups underwent 6 h of NMP using either erythrocyte-supplemented DMEM or Steen solution, with or without 30 min of warm ischemia time (WIT). We conducted regular measurements of AST, ALT, LDH, and urea levels in the perfusate at 3-hour intervals. Bile samples were analyzed for biliary pH, LDH, and gamma glutamyltransferase, as well as biliary bile acids via mass spectrometry and UHPLC. Results: Compared with regular livers, liver injury parameters were significantly higher in our donation after circulatory death (DCD) model. Bile production was significantly reduced in livers exposed to WIT, and the bile showed a significantly more alkaline pH. This correlated with the concentration of total bile acids, which was significantly higher in livers experiencing WIT. However, regular livers produced a higher total amount of biliary bile acids during perfusion. Taurocholic acid and its metabolites were most prominent. Secondary bile acids were significantly reduced during perfusion due to the missing enterohepatic circulation. Conclusions: WIT-induced liver injury affects bile composition within our small-animal NMP model. We hypothesize this phenomenon to be attributed to the energy-driven nature of bile secretion, potentially explaining why DCD livers produce less, yet more concentrated, bile. Our results may inform clinical studies, in which biliary bile acids might have a potential as a quantifiable viability marker in human NMP liver transplantation studies.
Collapse
Affiliation(s)
- Vanessa Muth
- Department of Surgery CCM|CVK, Experimental Surgery, Charité -;Universitätsmedizin;Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität;zu;Berlin, Berlin, Germany
| | - Felix Stobl
- Department of Surgery CCM|CVK, Experimental Surgery, Charité -;Universitätsmedizin;Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität;zu;Berlin, Berlin, Germany
| | - Julian Michelotto
- Department of Surgery CCM|CVK, Experimental Surgery, Charité -;Universitätsmedizin;Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität;zu;Berlin, Berlin, Germany
| | - Linda Gilles
- Department of Surgery CCM|CVK, Experimental Surgery, Charité -;Universitätsmedizin;Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität;zu;Berlin, Berlin, Germany
| | - Jennifer A Kirwan
- Metabolomics Platform, Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany
- Max Delbrück Center, Berlin, Germany
| | - Alina Eisenberger
- Metabolomics Platform, Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany
- Max Delbrück Center, Berlin, Germany
| | - Jeremy Marchand
- Metabolomics Platform, Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany
- Max Delbrück Center, Berlin, Germany
| | - Nathalie N Roschke
- Department of Surgery CCM|CVK, Experimental Surgery, Charité -;Universitätsmedizin;Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität;zu;Berlin, Berlin, Germany
| | - Simon Moosburner
- Department of Surgery CCM|CVK, Experimental Surgery, Charité -;Universitätsmedizin;Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität;zu;Berlin, Berlin, Germany
- Clinician Scientist Program, Berlin Institute of Health at Charité -;Universitätsmedizin;Berlin, BIH Academy, Berlin, Germany
| | - Johann Pratschke
- Department of Surgery CCM|CVK, Experimental Surgery, Charité -;Universitätsmedizin;Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität;zu;Berlin, Berlin, Germany
| | - Igor M Sauer
- Department of Surgery CCM|CVK, Experimental Surgery, Charité -;Universitätsmedizin;Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität;zu;Berlin, Berlin, Germany
| | - Nathanael Raschzok
- Department of Surgery CCM|CVK, Experimental Surgery, Charité -;Universitätsmedizin;Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität;zu;Berlin, Berlin, Germany
- Clinician Scientist Program, Berlin Institute of Health at Charité -;Universitätsmedizin;Berlin, BIH Academy, Berlin, Germany
| | - Joseph Mgv Gassner
- Department of Surgery CCM|CVK, Experimental Surgery, Charité -;Universitätsmedizin;Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität;zu;Berlin, Berlin, Germany
- Clinician Scientist Program, Berlin Institute of Health at Charité -;Universitätsmedizin;Berlin, BIH Academy, Berlin, Germany
| |
Collapse
|
22
|
Croome KP. Should advanced perfusion be the standard of care for donation after circulatory death liver transplant? Am J Transplant 2024; 24:1127-1131. [PMID: 38514015 DOI: 10.1016/j.ajt.2024.03.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 03/06/2024] [Accepted: 03/14/2024] [Indexed: 03/23/2024]
Abstract
As an alternative to static cold storage (SCS), advanced perfusion techniques such as normothermic regional perfusion and ex-situ perfusion (normothermic or hypothermic) have emerged as a way to improve the ischemic injury suffered by donation after circulatory death (DCD) livers. Multiple studies have been published that have demonstrated superior post-DCD liver transplant outcomes when using advanced perfusion compared with SCS. In particular, these studies have shown lower rates of ischemic cholangiopathy with advanced perfusion. In addition to the improved post-liver transplant outcomes, studies have also demonstrated higher rates of liver utilization from DCD donors when advanced perfusion is used compared with SCS. Given the high rates of graft loss in patients who develop ischemic cholangiopathy, the significant reduction seen in DCD donor livers that have undergone advanced perfusion represents a key step in more broad utilization of these livers. With such compelling evidence from multiple trials, it seems reasonable to ask the question: should advanced perfusion be the standard of care for DCD liver transplant?
Collapse
|
23
|
Malik AK, Tingle SJ, Chung N, Owen R, Mahendran B, Counter C, Sinha S, Muthasamy A, Sutherland A, Casey J, Drage M, van Dellen D, Callaghan CJ, Elker D, Manas DM, Pettigrew GJ, Wilson CH, White SA. The impact of time to death in donors after circulatory death on recipient outcome in simultaneous pancreas-kidney transplantation. Am J Transplant 2024; 24:1247-1256. [PMID: 38360185 DOI: 10.1016/j.ajt.2024.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 01/27/2024] [Accepted: 02/07/2024] [Indexed: 02/17/2024]
Abstract
The time to arrest donors after circulatory death is unpredictable and can vary. This leads to variable periods of warm ischemic damage prior to pancreas transplantation. There is little evidence supporting procurement team stand-down times based on donor time to death (TTD). We examined what impact TTD had on pancreas graft outcomes following donors after circulatory death (DCD) simultaneous pancreas-kidney transplantation. Data were extracted from the UK transplant registry from 2014 to 2022. Predictors of graft loss were evaluated using a Cox proportional hazards model. Adjusted restricted cubic spline models were generated to further delineate the relationship between TTD and outcome. Three-hundred-and-seventy-five DCD simultaneous kidney-pancreas transplant recipients were included. Increasing TTD was not associated with graft survival (adjusted hazard ratio HR 0.98, 95% confidence interval 0.68-1.41, P = .901). Increasing asystolic time worsened graft survival (adjusted hazard ratio 2.51, 95% confidence interval 1.16-5.43, P = .020). Restricted cubic spline modeling revealed a nonlinear relationship between asystolic time and graft survival and no relationship between TTD and graft survival. We found no evidence that TTD impacts pancreas graft survival after DCD simultaneous pancreas-kidney transplantation; however, increasing asystolic time was a significant predictor of graft loss. Procurement teams should attempt to minimize asystolic time to optimize pancreas graft survival rather than focus on the duration of TTD.
Collapse
Affiliation(s)
- Abdullah K Malik
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK; NIHR Blood and Transplant Research Unit, Newcastle University and Cambridge University, Newcastle upon Tyne, Cambridge, UK.
| | - Samuel J Tingle
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK; NIHR Blood and Transplant Research Unit, Newcastle University and Cambridge University, Newcastle upon Tyne, Cambridge, UK
| | - Nicholas Chung
- Northumbria Healthcare NHS Foundation Trust, Cramlington, UK
| | - Ruth Owen
- Manchester University NHS Foundation Trust, Manchester, UK
| | - Balaji Mahendran
- NIHR Blood and Transplant Research Unit, Newcastle University and Cambridge University, Newcastle upon Tyne, Cambridge, UK
| | | | - Sanjay Sinha
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | | | - John Casey
- Edinburgh Royal Infirmary, Edinburgh, UK
| | - Martin Drage
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Chris J Callaghan
- NHS Blood and Transplant, Bristol, UK; Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Doruk Elker
- Cardiff and Vale University Health Board, Cardiff, UK
| | - Derek M Manas
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK; NIHR Blood and Transplant Research Unit, Newcastle University and Cambridge University, Newcastle upon Tyne, Cambridge, UK; NHS Blood and Transplant, Bristol, UK
| | - Gavin J Pettigrew
- NIHR Blood and Transplant Research Unit, Newcastle University and Cambridge University, Newcastle upon Tyne, Cambridge, UK; Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Colin H Wilson
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK; NIHR Blood and Transplant Research Unit, Newcastle University and Cambridge University, Newcastle upon Tyne, Cambridge, UK
| | - Steven A White
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK; NIHR Blood and Transplant Research Unit, Newcastle University and Cambridge University, Newcastle upon Tyne, Cambridge, UK; NHS Blood and Transplant, Bristol, UK
| |
Collapse
|
24
|
Wang S, Lin X, Tang Y, Liang Y, Zhang M, Xie Z, Guo Y, Dong Y, Zhao Q, Guo Z, Wang D, He X, Ju W, Chen M. Ischemia-free liver transplantation improves the prognosis of recipients using functionally marginal liver grafts. Clin Mol Hepatol 2024; 30:421-435. [PMID: 38600871 PMCID: PMC11261232 DOI: 10.3350/cmh.2024.0139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 03/23/2024] [Accepted: 04/11/2024] [Indexed: 04/12/2024] Open
Abstract
BACKGROUND/AIMS The shortage of donor liver hinders the development of liver transplantation. This study aimed to clarify the poor outcomes of functionally marginal liver grafts (FMLs) and provide evidence for the improvement of ischemia-free liver transplantation (IFLT) after FML transplantation. METHODS Propensity score matching was used to control for confounding factors. The outcomes of the control group and FML group were compared to demonstrate the negative impact of FMLs on liver transplantation patients. We compared the clinical improvements of the different surgical types. To elucidate the underlying mechanism, we conducted bioinformatic analysis based on transcriptome and single-cell profiles. RESULTS FMLs had a significantly greater hazard ratio (HR: 1.969, P=0.018) than did other marginal livers. A worse 90-day survival (Mortality: 12.3% vs. 5.0%, P=0.007) was observed in patients who underwent FML transplantation. Patients who received FMLs had a significant improvement in overall survival after IFLT (Mortality: 10.4% vs 31.3%, P=0.006). Pyroptosis and inflammation were inhibited in patients who underwent IFLT. The infiltration of natural killer cells was lower in liver grafts from these patients. Bulk transcriptome profiles revealed a positive relationship between IL-32 and Caspase 1 (R=0.73, P=0.01) and between IL-32 and Gasdermin D (R=0.84, P=0.0012). CONCLUSION FML is a more important negative prognostic parameter than other marginal liver parameters. IFLT might ameliorate liver injury in FMLs by inhibiting the infiltration of NK cells, consequently leading to the abortion of IL-32, which drives pyroptosis in monocytes and macrophages.
Collapse
Affiliation(s)
- Shuai Wang
- Organ Transplant Center, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People’s Republic of China
- Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, People’s Republic of China
- Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, People’s Republic of China
| | - Xiaohong Lin
- Department of Thyroid and Breast Surgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People’s Republic of China
| | - Yunhua Tang
- Organ Transplant Center, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People’s Republic of China
- Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, People’s Republic of China
- Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, People’s Republic of China
| | - Yichen Liang
- Organ Transplant Center, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People’s Republic of China
- Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, People’s Republic of China
- Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, People’s Republic of China
| | - Min Zhang
- Organ Transplant Center, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People’s Republic of China
- Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, People’s Republic of China
- Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, People’s Republic of China
| | - Zhonghao Xie
- Organ Transplant Center, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People’s Republic of China
- Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, People’s Republic of China
- Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, People’s Republic of China
| | - Yiwen Guo
- Organ Transplant Center, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People’s Republic of China
- Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, People’s Republic of China
- Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, People’s Republic of China
| | - Yuqi Dong
- Organ Transplant Center, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People’s Republic of China
- Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, People’s Republic of China
- Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, People’s Republic of China
| | - Qiang Zhao
- Organ Transplant Center, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People’s Republic of China
- Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, People’s Republic of China
- Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, People’s Republic of China
| | - Zhiyong Guo
- Organ Transplant Center, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People’s Republic of China
- Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, People’s Republic of China
- Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, People’s Republic of China
| | - Dongping Wang
- Organ Transplant Center, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People’s Republic of China
- Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, People’s Republic of China
- Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, People’s Republic of China
| | - Xiaoshun He
- Organ Transplant Center, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People’s Republic of China
- Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, People’s Republic of China
- Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, People’s Republic of China
| | - Weiqiang Ju
- Organ Transplant Center, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People’s Republic of China
- Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, People’s Republic of China
- Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, People’s Republic of China
| | - Maogen Chen
- Organ Transplant Center, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People’s Republic of China
- Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou, People’s Republic of China
- Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, People’s Republic of China
| |
Collapse
|
25
|
Mahboub P, Aburawi M, Ozgur OS, Pendexter C, Cronin S, Lin FM, Jain R, Karabacak MN, Karimian N, Tessier SN, Markmann JF, Yeh H, Uygun K. Gradual rewarming with a hemoglobin-based oxygen carrier improves viability of donation after circulatory death in rat livers. FRONTIERS IN TRANSPLANTATION 2024; 3:1353124. [PMID: 38993754 PMCID: PMC11235298 DOI: 10.3389/frtra.2024.1353124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Accepted: 06/10/2024] [Indexed: 07/13/2024]
Abstract
Background Donation after circulatory death (DCD) grafts are vital for increasing available donor organs. Gradual rewarming during machine perfusion has proven effective in mitigating reperfusion injury and enhancing graft quality. Limited data exist on artificial oxygen carriers as an effective solution to meet the increasing metabolic demand with temperature changes. The aim of the present study was to assess the efficacy and safety of utilizing a hemoglobin-based oxygen carrier (HBOC) during the gradual rewarming of DCD rat livers. Methods Liver grafts were procured after 30 min of warm ischemia. The effect of 90 min of oxygenated rewarming perfusion from ice cold temperatures (4 °C) to 37 °C with HBOC after cold storage was evaluated and the results were compared with cold storage alone. Reperfusion at 37 °C was performed to assess the post-preservation recovery. Results Gradual rewarming with HBOC significantly enhanced recovery, demonstrated by markedly lower lactate levels and reduced vascular resistance compared to cold-stored liver grafts. Increased bile production in the HBOC group was noted, indicating improved liver function and bile synthesis capacity. Histological examination showed reduced cellular damage and better tissue preservation in the HBOC-treated livers compared to those subjected to cold storage alone. Conclusion This study suggests the safety of using HBOC during rewarming perfusion of rat livers as no harmful effect was detected. Furthermore, the viability assessment indicated improvement in graft function.
Collapse
Affiliation(s)
- Paria Mahboub
- Department of Surgery, University Medical Center Groningen, Groningen, Netherlands
- Center for Engineering in Medicine and Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
- Department of Research, Shriners Hospitals for Children, Boston, MA, United States
| | - Mohamed Aburawi
- Department of Research, Shriners Hospitals for Children, Boston, MA, United States
- Transplant Center, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - O Sila Ozgur
- Center for Engineering in Medicine and Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
- Department of Research, Shriners Hospitals for Children, Boston, MA, United States
| | - Casie Pendexter
- Center for Engineering in Medicine and Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
- Department of Research, Shriners Hospitals for Children, Boston, MA, United States
| | - Stephanie Cronin
- Center for Engineering in Medicine and Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
- Department of Research, Shriners Hospitals for Children, Boston, MA, United States
| | - Florence Min Lin
- Department of Research, Shriners Hospitals for Children, Boston, MA, United States
| | - Rohil Jain
- Center for Engineering in Medicine and Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
- Department of Research, Shriners Hospitals for Children, Boston, MA, United States
| | - Murat N Karabacak
- Center for Engineering in Medicine and Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
- Department of Research, Shriners Hospitals for Children, Boston, MA, United States
| | - Negin Karimian
- Center for Engineering in Medicine and Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
- Department of Research, Shriners Hospitals for Children, Boston, MA, United States
| | - Shannon N Tessier
- Center for Engineering in Medicine and Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
- Department of Research, Shriners Hospitals for Children, Boston, MA, United States
| | - James F Markmann
- Transplant Center, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Heidi Yeh
- Transplant Center, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Korkut Uygun
- Center for Engineering in Medicine and Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
- Department of Research, Shriners Hospitals for Children, Boston, MA, United States
| |
Collapse
|
26
|
Arykbaeva AS, Lerink LJS, Vos J, Engelse MA, van Kooten C, de Korte D, Lagerberg JWM, Klei TRL, Mulder AA, Minnee RC, Ploeg RJ, Kers J, Moers C, Pol RA, Alwayn IPJ, de Vries DK, Lindeman JHN. Red blood cells as oxygen carrier during normothermic machine perfusion of kidney grafts: Friend or foe? Am J Transplant 2024; 24:1172-1179. [PMID: 38215981 DOI: 10.1016/j.ajt.2024.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 12/16/2023] [Accepted: 01/01/2024] [Indexed: 01/14/2024]
Abstract
Renal ex vivo normothermic machine perfusion (NMP) is under development as an assessment tool for high-risk kidney grafts and as a means of achieving more physiologically accurate organ preservation. On-going hemolysis has been reported during NMP, as this technique relies on red blood cells for oxygen delivery. In this study, we confirm the occurrence of progressive hemolysis during 6-hour kidney NMP. NMP-associated erythrostasis in the glomeruli and in peri-glomerular vascular networks points to an interaction between the red blood cells and the graft. Continuous hemolysis resulted in prooxidative changes in the perfusate, which could be quenched by addition of fresh frozen plasma. In a cell-based system, this hemolysis induced redox stress and exhibited toxic effects at high concentrations. These findings highlight the need for a more refined oxygen carrier in the context of renal NMP.
Collapse
Affiliation(s)
- Asel S Arykbaeva
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands; Transplant Center, Leiden University Medical Center, Leiden, The Netherlands
| | - Lente J S Lerink
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands; Transplant Center, Leiden University Medical Center, Leiden, The Netherlands
| | - Jaël Vos
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands; Transplant Center, Leiden University Medical Center, Leiden, The Netherlands
| | - Marten A Engelse
- Transplant Center, Leiden University Medical Center, Leiden, The Netherlands; Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Cees van Kooten
- Transplant Center, Leiden University Medical Center, Leiden, The Netherlands; Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Dirk de Korte
- Division of Nephrology and Transplant Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Johan W M Lagerberg
- Division of Nephrology and Transplant Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Thomas R L Klei
- Division of Nephrology and Transplant Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Aat A Mulder
- Department of Product and Process Development, Sanquin Blood Bank, Amsterdam, The Netherlands
| | - Robert C Minnee
- Department of Cell and Chemical Biology, Leiden University Medical Center, Leiden, The Netherlands
| | - Rutger J Ploeg
- Transplant Center, Leiden University Medical Center, Leiden, The Netherlands; Department of Surgery, Division of Hepatopancreatobiliary and Transplant Surgery, Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Jesper Kers
- Transplant Center, Leiden University Medical Center, Leiden, The Netherlands; Department of Pathology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands; Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands; Van 't Hoff Institute for Molecular Sciences, University of Amsterdam, Amsterdam, The Netherlands
| | - Cyril Moers
- Department of Surgery - Organ Donation and Transplantation, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Robert A Pol
- Department of Surgery - Organ Donation and Transplantation, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Ian P J Alwayn
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands; Transplant Center, Leiden University Medical Center, Leiden, The Netherlands
| | - Dorottya K de Vries
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands; Transplant Center, Leiden University Medical Center, Leiden, The Netherlands
| | - Jan H N Lindeman
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands; Transplant Center, Leiden University Medical Center, Leiden, The Netherlands.
| |
Collapse
|
27
|
Mesnard B, Ogbemudia E, Bruneau S, Le Bas-Bernardet S, Minault D, Hervouet J, Kervella D, Masset C, Cantarovich D, Rigaud J, Badet L, Friend P, Ploeg R, Blancho G, Hunter J, Prudhomme T, Branchereau J. Pancreas Preservation: Hypothermic Oxygenated Perfusion to Improve Graft Reperfusion. Transplantation 2024:00007890-990000000-00799. [PMID: 38995954 DOI: 10.1097/tp.0000000000005111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/14/2024]
Abstract
BACKGROUND The clinical standard for pancreas preservation for transplantation is static cold storage (SCS). Oxygenation during preservation has been shown to be advantageous in clinical studies. This study evaluates the efficiency of different oxygenation modalities during hypothermic pancreas preservation. METHODS Thirty-two porcine pancreases were procured in a controlled donation after circulatory death model and were divided to be preserved in 8 groups: (1) SCS, (2) hypothermic machine perfusion (HMP), (3) hypothermic oxygenated machine perfusion (HOPE) with 21% oxygen, (4) HOPE and 100%, (5) SCS and oxygen carrier, M101, (6) HMP and M101, (7) HOPE 21% and M101, and (8) HOPE 100% and M101. All the groups underwent 24 h of hypothermic preservation, followed by 2 h of normothermic reperfusion. Oxygen partial pressures were assessed using parenchymal probes. Perfusion parameters, perfusate samples, and tissue biopsies were analyzed. RESULTS This study showed that HMP was linked to higher tissue oxygen partial pressures, lower succinate levels, and better reperfusion parameters. Furthermore, the addition of M101 to either SCS or HMP was associated with lower succinate and creatinine phosphokinase accumulation, suggesting a protective effect against ischemia. CONCLUSIONS Our research has demonstrated the efficacy of machine perfusion in hypothermic conditions in providing oxygen to the pancreas during preservation and conditioning the pancreatic microvasculature for reperfusion during transplantation. Furthermore, the addition of M101 suggests a protective effect on the graft from ischemia.
Collapse
Affiliation(s)
- Benoit Mesnard
- Department of Urology and Transplantation Surgery, Nantes University Hospital, Nantes, France
- Nantes Université, CHU Nantes1, INSERM, Centre for Research in Transplantation and Translational Immunology, Nantes, France
| | | | - Sarah Bruneau
- Nantes Université, CHU Nantes1, INSERM, Centre for Research in Transplantation and Translational Immunology, Nantes, France
| | - Stéphanie Le Bas-Bernardet
- Nantes Université, CHU Nantes1, INSERM, Centre for Research in Transplantation and Translational Immunology, Nantes, France
| | - David Minault
- Nantes Université, CHU Nantes1, INSERM, Centre for Research in Transplantation and Translational Immunology, Nantes, France
| | - Jeremy Hervouet
- Nantes Université, CHU Nantes1, INSERM, Centre for Research in Transplantation and Translational Immunology, Nantes, France
| | - Delphine Kervella
- Nantes Université, CHU Nantes1, INSERM, Centre for Research in Transplantation and Translational Immunology, Nantes, France
| | - Christophe Masset
- Nantes Université, CHU Nantes1, INSERM, Centre for Research in Transplantation and Translational Immunology, Nantes, France
| | - Diego Cantarovich
- Nantes Université, CHU Nantes1, INSERM, Centre for Research in Transplantation and Translational Immunology, Nantes, France
| | - Jérôme Rigaud
- Department of Urology and Transplantation Surgery, Nantes University Hospital, Nantes, France
| | - Lionel Badet
- Department of Urology Surgery and Transplantation, Edouard Herriot Hospital, Lyon, France
| | - Peter Friend
- Nuffield Department of Surgical Science, Oxford, United Kingdom
| | - Rutger Ploeg
- Nuffield Department of Surgical Science, Oxford, United Kingdom
| | - Gilles Blancho
- Nantes Université, CHU Nantes1, INSERM, Centre for Research in Transplantation and Translational Immunology, Nantes, France
| | - James Hunter
- Nuffield Department of Surgical Science, Oxford, United Kingdom
| | - Thomas Prudhomme
- Nantes Université, CHU Nantes1, INSERM, Centre for Research in Transplantation and Translational Immunology, Nantes, France
| | - Julien Branchereau
- Department of Urology and Transplantation Surgery, Nantes University Hospital, Nantes, France
- Nantes Université, CHU Nantes1, INSERM, Centre for Research in Transplantation and Translational Immunology, Nantes, France
- Nuffield Department of Surgical Science, Oxford, United Kingdom
| |
Collapse
|
28
|
Vogel T, Szardenings C, Becker F, Jordan S, Katou S, Morgul H, Flammang I, Houben P, Kneifel F, Pascher A. Viability assessment and transplantation of extended criteria donor liver grafts using normothermic machine perfusion. Surgery 2024:S0039-6060(24)00325-8. [PMID: 38902125 DOI: 10.1016/j.surg.2024.05.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2024] [Revised: 04/26/2024] [Accepted: 05/15/2024] [Indexed: 06/22/2024]
Abstract
BACKGROUND The scarcity of available liver grafts necessitates the use of organs from extended criteria donors, a practice associated with an increased risk of graft failure. A notable percentage of deceased donor liver allografts are rejected due to subjective criteria. Normothermic machine perfusion holds promise for introducing objective parameters into this decision-making process. The aim of this study was to compare the outcomes of standard criteria and extended criteria donor allografts after liver transplantation, following viability assessment, using normothermic machine perfusion. METHODS Liver allografts preserved by normothermic machine perfusion before liver transplantation at the University Hospital of Münster were retrospectively analyzed. Organs were stratified according to the Eurotransplant Donor Risk Index. In total, 101 liver grafts were included in this study and divided into 2 groups: (1) standard criteria donors with a Donor Risk Index <1.8 (DRI-low) and (2) extended criteria donors with a Donor Risk Index ≥1.8 (DRI-high). RESULTS An increased risk profile of donor livers, as assessed by the Eurotransplant Donor Risk Index, did not correlate with patient or graft survival. High-risk liver grafts were effectively transplanted into recipients with different risk levels after viability assessment by normothermic machine perfusion. However, the recipients' model for end-stage liver disease scores showed a significant association with both overall patient and graft survival. CONCLUSION The use of normothermic machine perfusion for viability assessment allows safe transplantation of high-risk donor livers and effectively addresses the disparity between donor liver availability and transplantation demand.
Collapse
Affiliation(s)
- Thomas Vogel
- Department of General, Visceral, and Transplant Surgery, University Hospital Münster, Germany
| | - Carsten Szardenings
- Institute of Biostatistics and Clinical Research, University Münster, Germany
| | - Felix Becker
- Department of General, Visceral, and Transplant Surgery, University Hospital Münster, Germany
| | - Stephanie Jordan
- Department of General, Visceral, and Transplant Surgery, University Hospital Münster, Germany
| | - Shadi Katou
- Department of General, Visceral, and Transplant Surgery, University Hospital Münster, Germany
| | - Haluk Morgul
- Department of General, Visceral, and Transplant Surgery, University Hospital Münster, Germany
| | - Isabelle Flammang
- Department of General, Visceral, and Transplant Surgery, University Hospital Münster, Germany
| | - Philipp Houben
- Department of General, Visceral, and Transplant Surgery, University Hospital Münster, Germany
| | - Felicia Kneifel
- Department of General, Visceral, and Transplant Surgery, University Hospital Münster, Germany.
| | - Andreas Pascher
- Department of General, Visceral, and Transplant Surgery, University Hospital Münster, Germany
| |
Collapse
|
29
|
Yang C, Shannon CP, Zhao H, Tebbutt SJ. Donor-specific graft injury in solid organ transplantation: potential mechanisms and therapeutic strategies. FRONTIERS IN TRANSPLANTATION 2024; 3:1427106. [PMID: 38993776 PMCID: PMC11235368 DOI: 10.3389/frtra.2024.1427106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/02/2024] [Accepted: 06/06/2024] [Indexed: 07/13/2024]
Affiliation(s)
- Chengliang Yang
- Prevention of Organ Failure (PROOF) Centre of Excellence, St Paul’s Hospital, Vancouver, BC, Canada
- Centre for Heart Lung Innovation, Providence Research, St Paul’s Hospital, Vancouver, BC, Canada
- Division of Respiratory Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Casey P. Shannon
- Prevention of Organ Failure (PROOF) Centre of Excellence, St Paul’s Hospital, Vancouver, BC, Canada
- Centre for Heart Lung Innovation, Providence Research, St Paul’s Hospital, Vancouver, BC, Canada
| | - Hedi Zhao
- Department of Surgery, University of British Columbia, Vancouver, BC, Canada
| | - Scott J. Tebbutt
- Prevention of Organ Failure (PROOF) Centre of Excellence, St Paul’s Hospital, Vancouver, BC, Canada
- Centre for Heart Lung Innovation, Providence Research, St Paul’s Hospital, Vancouver, BC, Canada
- Division of Respiratory Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| |
Collapse
|
30
|
Abbas SH, Ceresa CDL, Hodson L, Nasralla D, Watson CJE, Mergental H, Coussios C, Kaloyirou F, Brusby K, Mora A, Thomas H, Kounali D, Keen K, Pollok JM, Gaurav R, Iype S, Jassem W, Perera MTP, Hakeem AR, Knight S, Friend PJ. Defatting of donor transplant livers during normothermic perfusion-a randomised clinical trial: study protocol for the DeFat study. Trials 2024; 25:386. [PMID: 38886851 PMCID: PMC11181618 DOI: 10.1186/s13063-024-08189-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 05/22/2024] [Indexed: 06/20/2024] Open
Abstract
BACKGROUND Liver disease is the third leading cause of premature death in the UK. Transplantation is the only successful treatment for end-stage liver disease but is limited by a shortage of suitable donor organs. As a result, up to 20% of patients on liver transplant waiting lists die before receiving a transplant. A third of donated livers are not suitable for transplant, often due to steatosis. Hepatic steatosis, which affects 33% of the UK population, is strongly associated with obesity, an increasing problem in the potential donor pool. We have recently tested defatting interventions during normothermic machine perfusion (NMP) in discarded steatotic human livers that were not transplanted. A combination of therapies including forskolin (NKH477) and L-carnitine to defat liver cells and lipoprotein apheresis filtration were investigated. These interventions resulted in functional improvement during perfusion and reduced the intrahepatocellular triglyceride (IHTG) content. We hypothesise that defatting during NMP will allow more steatotic livers to be transplanted with improved outcomes. METHODS In the proposed multi-centre clinical trial, we will randomly assign 60 livers from donors with a high-risk of hepatic steatosis to either NMP alone or NMP with defatting interventions. We aim to test the safety and feasibility of the defatting intervention and will explore efficacy by comparing ex-situ and post-reperfusion liver function between the groups. The primary endpoint will be the proportion of livers that achieve predefined functional criteria during perfusion which indicate potential suitability for transplantation. These criteria reflect hepatic metabolism and injury and include lactate clearance, perfusate pH, glucose metabolism, bile composition, vascular flows and transaminase levels. Clinical secondary endpoints will include proportion of livers transplanted in the two arms, graft function; cell-free DNA (cfDNA) at follow-up visits; patient and graft survival; hospital and ITU stay; evidence of ischemia-reperfusion injury (IRI); non-anastomotic biliary strictures and recurrence of steatosis (determined on MRI at 6 months). DISCUSSION This study explores ex-situ pharmacological optimisation of steatotic donor livers during NMP. If the intervention proves effective, it will allow the safe transplantation of livers that are currently very likely to be discarded, thereby reducing waiting list deaths. TRIAL REGISTRATION ISRCTN ISRCTN14957538. Registered in October 2022.
Collapse
Affiliation(s)
- Syed Hussain Abbas
- Nuffield Department of Surgical Sciences, University of Oxford, The Churchill Hospital, Oxford, OX3 7LJ, UK.
| | - Carlo D L Ceresa
- Royal Free London NHS Foundation Trust, The Royal Free Hospital, Pond St, Hampstead, London, NW3 2QG, UK
| | - Leanne Hodson
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, The Churchill Hospital, Oxford, OX3 7LJ, UK
| | - David Nasralla
- Royal Free London NHS Foundation Trust, The Royal Free Hospital, Pond St, Hampstead, London, NW3 2QG, UK
| | - Christopher J E Watson
- Department of Surgery, Addenbrooke's Hospital, Hills Road, University of Cambridge, Box 202, Cambridge, CB2 2QQ, UK
| | - Hynek Mergental
- Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Mindelsohn Way, Birmingham, B15 2TH, UK
- TransMedics Inc, 200 Minuteman Road, Andover, MA, 01810, USA
| | - Constantin Coussios
- Institute of Biomedical Engineering, Old Road Campus Research Building, University of Oxford, Oxford, OX3 7DQ, UK
| | | | | | - Ana Mora
- Victor Phillip Dahdaleh Heart and Lung Research Institute, University of Cambridge, Cambridge Biomedical Campus, Hills Road, Cambridge, CB2 0BB, UK
| | - Helen Thomas
- NHS Blood and Transplant Clinical Trials Unit, Fox Den Road, Stoke Gifford, Bristol, BS34 8RR, UK
| | - Daphne Kounali
- Oxford Clinical Trials Research Unit (OCTRU), Centre for Statistics in Medicine (CSM), Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), Medical Sciences Division, The Botnar Research Centre, University of Oxford, Windmill Road, Oxford, OX3 7LD, UK
| | - Katie Keen
- NHSBT CTU, Long Road, Cambridge, CB2 0PT, UK
| | - Joerg-Matthias Pollok
- Royal Free London NHS Foundation Trust, The Royal Free Hospital, Pond St, Hampstead, London, NW3 2QG, UK
| | - Rohit Gaurav
- Department of Surgery, Addenbrooke's Hospital, Hills Road, University of Cambridge, Box 202, Cambridge, CB2 2QQ, UK
| | - Satheesh Iype
- Royal Free London NHS Foundation Trust, The Royal Free Hospital, Pond St, Hampstead, London, NW3 2QG, UK
| | - Wayel Jassem
- Kings College Hospital, King's College Hospital NHS Foundation Trust, Denmark Hill, London, SE5 9RS, UK
| | - M Thamara Pr Perera
- Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Mindelsohn Way, Birmingham, B15 2TH, UK
| | - Abdul Rahman Hakeem
- Kings College Hospital, King's College Hospital NHS Foundation Trust, Denmark Hill, London, SE5 9RS, UK
- St James's University Hospital, Leeds Teaching Hospitals NHS Trust, Beckett Street, Leeds, LS9 7TF, UK
| | - Simon Knight
- Nuffield Department of Surgical Sciences, University of Oxford, The Churchill Hospital, Oxford, OX3 7LJ, UK
| | - Peter J Friend
- Nuffield Department of Surgical Sciences, University of Oxford, The Churchill Hospital, Oxford, OX3 7LJ, UK
| |
Collapse
|
31
|
Rössler F, Kalliola F, de Rougemont O, Hübel K, Hügli S, Viggiani d’Avalos L, Schachtner T, Oberholzer J. Simultaneous Pancreas and Kidney Transplantation from Donors after Circulatory Death in Switzerland. J Clin Med 2024; 13:3525. [PMID: 38930054 PMCID: PMC11204996 DOI: 10.3390/jcm13123525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2024] [Revised: 06/08/2024] [Accepted: 06/13/2024] [Indexed: 06/28/2024] Open
Abstract
Background: Simultaneous pancreas and kidney transplantation (SPK) remains the only curative treatment for type I diabetics with end-stage kidney disease. SPK using donors after circulatory death (DCD) is one important measure to expand the organ pool for pancreas transplantation (PT). After initial doubts due to higher complications, DCD SPK is now considered safe and equivalent to donation after brain death in terms of survival and graft function. Materials and Methods: We assessed pancreas and kidney graft function, as well as complications of the first three patients who underwent a DCD SPK in Switzerland. Two transplantations were after rapid procurement, one following normothermic regional perfusion (NRP). Results: Intra- and postoperative courses were uneventful and without major complications in all patients. In the two SPK after rapid procurement, pancreas graft function was excellent, with 100% insulin-free survival, and hemoglobin A1C dropped from 7.9 and 7.5 before SPK and to 5.1 and 4.3 after three years, respectively. Kidney graft function was excellent in the first year, followed by a gradual decline due to recurrent infections. The patient, after NRP SPK, experienced short-term delayed pancreatic graft function requiring low-dose insulin treatment for 5 days post-transplant, most likely due to increased peripheral insulin resistance in obesity. During follow-up, there was persistent euglycemia and excellent kidney function. Conclusions: We report on the first series of DCD SPK ever performed in Switzerland. Results were promising, with low complication rates and sustained graft survival. With almost half of all donors in Switzerland currently being DCD, we see great potential for the expansion of DCD PT.
Collapse
Affiliation(s)
- Fabian Rössler
- Department of Surgery and Transplantation, University Hospital Zurich, 8091 Zurich, Switzerland; (F.K.); (O.d.R.); (S.H.); (L.V.d.); (J.O.)
| | - Fiona Kalliola
- Department of Surgery and Transplantation, University Hospital Zurich, 8091 Zurich, Switzerland; (F.K.); (O.d.R.); (S.H.); (L.V.d.); (J.O.)
| | - Olivier de Rougemont
- Department of Surgery and Transplantation, University Hospital Zurich, 8091 Zurich, Switzerland; (F.K.); (O.d.R.); (S.H.); (L.V.d.); (J.O.)
| | - Kerstin Hübel
- Department of Nephrology, University Hospital Zurich, 8091 Zurich, Switzerland; (K.H.); (T.S.)
| | - Sandro Hügli
- Department of Surgery and Transplantation, University Hospital Zurich, 8091 Zurich, Switzerland; (F.K.); (O.d.R.); (S.H.); (L.V.d.); (J.O.)
| | - Lorenzo Viggiani d’Avalos
- Department of Surgery and Transplantation, University Hospital Zurich, 8091 Zurich, Switzerland; (F.K.); (O.d.R.); (S.H.); (L.V.d.); (J.O.)
| | - Thomas Schachtner
- Department of Nephrology, University Hospital Zurich, 8091 Zurich, Switzerland; (K.H.); (T.S.)
| | - Jose Oberholzer
- Department of Surgery and Transplantation, University Hospital Zurich, 8091 Zurich, Switzerland; (F.K.); (O.d.R.); (S.H.); (L.V.d.); (J.O.)
| |
Collapse
|
32
|
Goto T, Noguchi Y, Linares I, Mazilescu L, Nogueira E, Hobeika C, Ray S, Parmentier C, Ganesh S, Peranantharuban J, Chan HHL, Reichman T, Selzner N, Selzner M. Indocyanine green fluorescence quantification during normothermic ex situ perfusion for the assessment of porcine liver grafts after circulatory death. Liver Transpl 2024:01445473-990000000-00402. [PMID: 38869990 DOI: 10.1097/lvt.0000000000000416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Accepted: 04/25/2024] [Indexed: 06/15/2024]
Abstract
Current graft evaluation during normothermic ex situ liver perfusion lacks real-time parameters for predicting posttransplant hepatocyte and biliary function. Indocyanine green (ICG) imaging has been widely used in liver surgery, enabling the visualization of hepatic uptake and excretion through bile using near-infrared light. In this research, porcine livers under various ischemic conditions were examined during a 5-hour normothermic ex situ liver perfusion procedure, introducing ICG at 1 hour through the hepatic artery. These conditions included livers from heart-beating donors, donation after circulatory death (DCD) with warm ischemic durations of 60 minutes (DCD60) and 120 minutes (DCD120), as well as interventions utilizing tissue plasminogen activator in DCD120 cases (each n = 5). Distinct hepatic fluorescence patterns correlated with different degrees of ischemic injury ( p = 0.01). Low ICG uptake in the parenchyma (less than 40% of maximum intensity) was more prevalent in DCD120 (21.4%) compared to heart-beating donors (6.2%, p = 0.06) and DCD60 (3.0%, p = 0.02). Moreover, ICG clearance from 60 minutes to 240 minutes was significantly higher in heart-beating donors (69.3%) than in DCD60 (17.5%, p < 0.001) and DCD120 (32.1%, p = 0.01). Furthermore, thrombolytic intervention using tissue plasminogen activator in DCD120 resulted in noteworthy outcomes, including significantly reduced ALP levels ( p = 0.04) and improved ICG clearance ( p = 0.02) with a trend toward mitigating fibrin deposition similar to DCD60, as well as enhancements in bile production ( p = 0.09). In conclusion, ICG fluorescence imaging during normothermic ex situ liver perfusion provides real-time classification of hepatic vascular and biliary injuries, offering valuable insights for the more accurate selection and postintervention evaluation of marginal livers in transplantation.
Collapse
Affiliation(s)
- Toru Goto
- Department of Surgery, Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
- Department of Surgery, Divisions of Hepato-biliary-Pancreatic Surgery and Transplantation, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yuki Noguchi
- Department of Surgery, Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Ivan Linares
- Department of Surgery, Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Laura Mazilescu
- Department of Surgery, Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Emmanuel Nogueira
- Department of Surgery, Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Christian Hobeika
- Department of Surgery, Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Samrat Ray
- Department of Surgery, Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Catherine Parmentier
- Department of Surgery, Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Sujani Ganesh
- Department of Surgery, Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Jathuya Peranantharuban
- Department of Surgery, Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Harley H L Chan
- TECHNA Institute, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Trevor Reichman
- Department of Surgery, Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Nazia Selzner
- Department of Surgery, Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Markus Selzner
- Department of Surgery, Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| |
Collapse
|
33
|
Krendl FJ, Cardini B, Laimer G, Singh J, Resch T, Oberhuber R, Schneeberger S. Normothermic Liver Machine Perfusion and Successful Transplantation of Split Liver Grafts: From Proof of Concept to Clinical Implementation. Transplantation 2024; 108:1410-1416. [PMID: 38548703 DOI: 10.1097/tp.0000000000004997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2024]
Abstract
BACKGROUND Normothermic liver machine perfusion (NLMP) is advancing the field of liver transplantation (LT). Beyond improved preservation and organ assessment, NLMP helps to increase organ utilization. We herein address the feasibility and merit of NLMP in split liver transplantation (SLT) to postpone the transplantation of the second split graft to the following day. METHODS We analyzed the perfusion characteristics and outcomes of all consecutive adult recipients who underwent SLT following NLMP from February 1, 2018, to June 30, 2023. The primary endpoint was 90-d graft and patient survival. Secondary endpoints were posttransplant complications and 90-d morbidity. RESULTS Three right and 3 extended right SLT following NLMP have been performed. NLMP was uneventful in all cases. Perfusion characteristics differed according to graft volume. Mean perfusion time was 17:00 h (±05:13) and bile production ranged between 8 and 21 mL/h. All split grafts fulfilled predefined center viability criteria during NLMP and were transplanted on the following day. The 90-d graft and patient survival rate was 100%. Three patients (50%) required an early relaparotomy, and 2 patients (33.3%) developed biliary complications. The 90-d morbidity as recorded by the comprehensive complication index was 62.7 (±24.7). CONCLUSIONS NLMP of split liver grafts is technically feasible and safe. Through prolongation of preservation time, NLMP allows to safely postpone transplantation of the second split liver graft to the next day.
Collapse
Affiliation(s)
- Felix J Krendl
- Department of Visceral, Transplant and Thoracic Surgery, Center for Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Benno Cardini
- Department of Visceral, Transplant and Thoracic Surgery, Center for Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Gregor Laimer
- Interventional Oncology/Stereotaxy and Robotics, Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Jessica Singh
- Department of Visceral, Transplant and Thoracic Surgery, Center for Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Thomas Resch
- Department of Visceral, Transplant and Thoracic Surgery, Center for Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Rupert Oberhuber
- Department of Visceral, Transplant and Thoracic Surgery, Center for Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Stefan Schneeberger
- Department of Visceral, Transplant and Thoracic Surgery, Center for Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| |
Collapse
|
34
|
Lindemann J, Yu J, Doyle MM. Normothermic machine perfusion for liver transplantation: current state and future directions. Curr Opin Organ Transplant 2024; 29:186-194. [PMID: 38483109 DOI: 10.1097/mot.0000000000001141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/30/2024]
Abstract
PURPOSE OF REVIEW The number of patients on the liver transplant waitlist continues to grow and far exceeds the number of livers available for transplantation. Normothermic machine perfusion (NMP) allows for ex-vivo perfusion under physiologic conditions with the potential to significantly increase organ yield and expand the donor pool. RECENT FINDINGS Several studies have found increased utilization of donation after cardiac death and extended criteria brain-dead donor livers with implementation of NMP, largely due to the ability to perform viability testing during machine perfusion. Recently, proposed viability criteria include lactate clearance, maintenance of perfusate pH more than 7.2, ALT less than 6000 u/l, evidence of glucose metabolism and bile production. Optimization of liver grafts during NMP is an active area of research and includes interventions for defatting steatotic livers, preventing ischemic cholangiopathy and rejection, and minimizing ischemia reperfusion injury. SUMMARY NMP has resulted in increased organ utilization from marginal donors with acceptable outcomes. The added flexibility of prolonged organ storage times has the potential to improve time constraints and transplant logistics. Further research to determine ideal viability criteria and investigate ways to optimize marginal and otherwise nontransplantable liver grafts during NMP is warranted.
Collapse
Affiliation(s)
- Jessica Lindemann
- Department of Surgery, Section of Abdominal Organ Transplantation, Washington University School of Medicine, Saint Louis, Missouri, USA
| | | | | |
Collapse
|
35
|
Sonnenberg EM, Abu-Gazala S, Bittermann T, Abt PL. Following the Flow: Changes in Organ Preservation Methods Require Changes in Our Data Collection. Transplantation 2024; 108:1265-1268. [PMID: 38291568 DOI: 10.1097/tp.0000000000004920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
Affiliation(s)
| | - Samir Abu-Gazala
- Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Therese Bittermann
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, PA
| | - Peter L Abt
- Department of Surgery, University of Pennsylvania, Philadelphia, PA
| |
Collapse
|
36
|
Martin JL, Rhodes F, Upponi S, Udeaja Y, Swift L, Fear C, Webster R, Webb GJ, Allison M, Paterson A, Gaurav R, Butler AJ, Watson CJE. Localized Liver Injury During Normothermic Ex Situ Liver Perfusion Has No Impact on Short-term Liver Transplant Outcomes. Transplantation 2024; 108:1403-1409. [PMID: 38419153 PMCID: PMC11115454 DOI: 10.1097/tp.0000000000004970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 11/17/2023] [Accepted: 12/31/2023] [Indexed: 03/02/2024]
Abstract
BACKGROUND Normothermic ex situ liver perfusion (NESLiP) has the potential to increase organ utilization. Radiological evidence of localized liver injury due to compression at the time of NESLiP, termed cradle compression, is a recognized phenomenon but is poorly characterized. METHODS A retrospective analysis of a prospectively collected database was performed of transplanted livers that underwent NESLiP and subsequently had a computed tomography performed within the first 14 d posttransplant. The primary study outcome was 1-y graft survival. RESULTS Seventy livers (63%) were included in the analysis. Radiological evidence of cradle compression was observed in 21 of 70 (30%). There was no difference in rate of cradle compression between donor after circulatory death and donated after brain death donors ( P = 0.37) or with duration of NESLiP. Univariate analysis demonstrated younger (area under the receiver operating characteristic, 0.68; P = 0.008; 95% confidence interval [CI], 0.55-0.82) and heavier (area under the receiver operating characteristic, 0.80; P < 0.001; 95% CI, 0.69-0.91) livers to be at risk of cradle compression. Only liver weight was associated with cradle compression on multivariate analysis (odds ratio, 1.003; P = 0.005; 95% CI, 1.001-1.005). There was no difference in 1-y graft survival (16/17 [94.1%] versus 44/48 [91.6%]; odds ratio, 0.69; P = 0.75; 95% CI, 0.07-6.62). CONCLUSIONS This is the first study assessing the impact of cradle compression on outcome. We have identified increased donor liver weight and younger age as risk factors for the development of this phenomenon. Increasing utilization of NESLiP will result in the increased incidence of cradle compression but the apparent absence of long-term sequelae is reassuring. Routine postoperative axial imaging may be warranted.
Collapse
Affiliation(s)
- Jack L. Martin
- Roy Calne Transplant Unit, Cambridge University Hospitals NHS Foundation Trust, and Cambridge NIHR Biomedical Research Centre, Biomedical Campus, Cambridge, United Kingdom
| | | | - Sara Upponi
- Department of Radiology, Biomedical Campus, University of Cambridge, Cambridge, United Kingdom
| | - Yagazie Udeaja
- Department of Radiology, Biomedical Campus, University of Cambridge, Cambridge, United Kingdom
| | - Lisa Swift
- Roy Calne Transplant Unit, Cambridge University Hospitals NHS Foundation Trust, and Cambridge NIHR Biomedical Research Centre, Biomedical Campus, Cambridge, United Kingdom
| | - Corina Fear
- Roy Calne Transplant Unit, Cambridge University Hospitals NHS Foundation Trust, and Cambridge NIHR Biomedical Research Centre, Biomedical Campus, Cambridge, United Kingdom
| | - Rachel Webster
- Roy Calne Transplant Unit, Cambridge University Hospitals NHS Foundation Trust, and Cambridge NIHR Biomedical Research Centre, Biomedical Campus, Cambridge, United Kingdom
| | - Gwilym James Webb
- Department of Hepatology, Cambridge NIHR Biomedical Research Centre, Biomedical Campus, University of Cambridge, Cambridge, United Kingdom
| | - Michael Allison
- Department of Hepatology, Cambridge NIHR Biomedical Research Centre, Biomedical Campus, University of Cambridge, Cambridge, United Kingdom
| | - Anna Paterson
- Histopathology Department, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Rohit Gaurav
- Roy Calne Transplant Unit, Cambridge University Hospitals NHS Foundation Trust, and Cambridge NIHR Biomedical Research Centre, Biomedical Campus, Cambridge, United Kingdom
| | - Andrew J. Butler
- Roy Calne Transplant Unit, Cambridge University Hospitals NHS Foundation Trust, and Cambridge NIHR Biomedical Research Centre, Biomedical Campus, Cambridge, United Kingdom
| | - Christopher J. E. Watson
- Roy Calne Transplant Unit, Cambridge University Hospitals NHS Foundation Trust, and Cambridge NIHR Biomedical Research Centre, Biomedical Campus, Cambridge, United Kingdom
| |
Collapse
|
37
|
Liou PH, Emond JC. Machine Preservation and the Full Potential of Split Liver Transplantation. Transplantation 2024; 108:1275-1276. [PMID: 38755747 DOI: 10.1097/tp.0000000000005067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2024]
|
38
|
De Goeij FHC, De Meijer V, Mergental H, Guarrera JV, Asthana S, Ghinolfi D, Boteon YL, Selzner N, Kalisvaart M, Pulitano C, Sonnenday C, Martins PN, Berlakovich G, Schlegel A. Challenges With the Implementation of Machine Perfusion in Clinical Liver Transplantation. Transplantation 2024; 108:1296-1307. [PMID: 38057969 DOI: 10.1097/tp.0000000000004872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/08/2023]
Abstract
Dynamic organ preservation is a relatively old technique which has regained significant interest in the last decade. Machine perfusion (MP) techniques are applied in various fields of solid organ transplantation today. The first clinical series of ex situ MP in liver transplantation was presented in 2010. Since then, the number of research and clinical applications has substantially increased. Despite the notable beneficial effect on organ quality and recipient outcome, MP is still not routinely used in liver transplantation. Based on the enormous need to better preserve organs and the subsequent demand to continuously innovate and develop perfusion equipment further, this technology is also beneficial to test and deliver future therapeutic strategies to livers before implantation. This article summarizes the various challenges observed during the current shift from static to dynamic liver preservation in the clinical setting. The different organ perfusion strategies are discussed first, together with ongoing clinical trials and future study design. The current status of research and the impact of costs and regulations is highlighted next. Factors contributing to costs and other required resources for a worldwide successful implementation and reimbursement are presented third. The impact of research on cost-utility and effectivity to guide the tailored decision-making regarding the optimal perfusion strategy is discussed next. Finally, this article provides potential solutions to the challenging field of innovation in healthcare considering the various social and economic factors and the role of clinical, regulatory, and financial stakeholders worldwide.
Collapse
Affiliation(s)
- Femke H C De Goeij
- Department of Surgery, Division of Hepatopancreatobiliary and Transplant Surgery, Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Vincent De Meijer
- Department of Surgery, Section of Hepatobiliary Surgery and Liver Transplantation, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
- Department of Surgery, Surgical Research Laboratory, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Hynek Mergental
- The Liver Unit, Queen Elizabeth University Hospital, Birmingham, United Kingdom
- The Liver Unit, Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - James V Guarrera
- Division of Abdominal Transplant Surgery, Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ
| | | | - Davide Ghinolfi
- Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
| | - Yuri L Boteon
- Instituto Israelita de Ensino e Pesquisa Albert Einstein, Faculdade Israelita de Ciências da Saúde Albert Einstein, São Paulo, Brazil
| | - Nazia Selzner
- Ajmera Transplant Center, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Marit Kalisvaart
- Department of Surgery and Transplantation, Swiss HPB Centre, University Hospital Zurich, Zurich, Switzerland
| | - Carlo Pulitano
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital and Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | | | - Paulo N Martins
- Division of Organ Transplantation, Department of Surgery, University of Massachusetts Memorial Hospital, University of Massachusetts, Worcester, MA
| | - Gabriela Berlakovich
- Division of Transplantation, Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - Andrea Schlegel
- Transplantation Center, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
- Department of Immunology, Lerner Research Institute, Cleveland Clinic, Cleveland, OH
| |
Collapse
|
39
|
Gilbo N, Blondeel J, Wylin T, Heedfeld V, Jochmans I, Pirenne J, Korf H, Monbaliu D. The dynamics of cytokine release during 24 hours continuous normothermic machine perfusion liver preservation: An explorative porcine study. Artif Organs 2024; 48:606-618. [PMID: 38270437 DOI: 10.1111/aor.14717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 12/22/2023] [Accepted: 01/12/2024] [Indexed: 01/26/2024]
Abstract
BACKGROUND Normothermic machine perfusion (NMP) has been proposed to preserve liver grafts in a less pro-inflammatory environment. However, the effect of NMP on liver inflammation remains unclear. Therefore, we aimed at characterizing the inflammatory response during continuous NMP with a comprehensive investigation of cytokine release during perfusion. METHODS Ten porcine livers underwent either 24 h NMP or whole blood-based NMP (WB-NMP) immediately after procurement. WB-NMP was used as a positive control to mimic early post-reperfusion inflammation. High mobility group box-1 (HMGB1), interleukin 1-beta (IL-1beta), tumor necrosis factor-alpha (TNFalpha), interleukin 6 (IL-6), 8 (IL-8), and 10 (IL-10), transforming growth factor-beta (TGFbeta), aspartate transferase (AST), and hyaluronic acid were measured in the perfusate. The area under the curve (AUC) of their perfusate concentration was compared between groups. Median (IQR) is given. RESULTS The AUC of HMGB1 and IL-1beta was similar between groups. Compared to WB-NMP, NMP inhibited the release of TNFalpha [NMP: 20275 (18402-32 152), WB-NMP: 242100 (203511-244 238); p = 0.01], IL-6 [NMP: 1206 (338.9-1686), WB-NMP: 8444 (7359-10 087); p = 0.03], and IL-8 [NMP: 1635 (106.90-2130), WB-NMP: 3951 (3090-4116); p = 0.008]. The release of TGFbeta remained unchanged but IL-10 release was lower in NMP [1612 (1313-1916), WB-NMP: 5591 (4312-6421); p = 0.01]. The ratios TGFbeta:TNFalpha and IL-10:TNFalpha were significantly higher in the NMP than in the WB-NMP group. Importantly, the AUC of AST was significantly lower during NMP [1960 (1950-2893)] than WB-NMP [6812 (6370-7916); p = 0.02]. CONCLUSIONS Continuous NMP leads to the release of detectable levels of cytokines with a slow, linear increase over time and a shift toward anti-inflammatory signaling.
Collapse
Affiliation(s)
- Nicholas Gilbo
- Transplantation Research Group, Department of Microbiology Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Joris Blondeel
- Transplantation Research Group, Department of Microbiology Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Abdominal Transplantation Surgery and Coordination, University Hospitals Leuven, Leuven, Belgium
| | - Tine Wylin
- Transplantation Research Group, Department of Microbiology Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Veerle Heedfeld
- Transplantation Research Group, Department of Microbiology Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Ina Jochmans
- Transplantation Research Group, Department of Microbiology Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Abdominal Transplantation Surgery and Coordination, University Hospitals Leuven, Leuven, Belgium
| | - Jacques Pirenne
- Transplantation Research Group, Department of Microbiology Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Abdominal Transplantation Surgery and Coordination, University Hospitals Leuven, Leuven, Belgium
| | - Hannelie Korf
- Laboratory of Hepatology, CHROMETA Department, KU Leuven, Leuven, Belgium
| | - Diethard Monbaliu
- Transplantation Research Group, Department of Microbiology Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Abdominal Transplantation Surgery and Coordination, University Hospitals Leuven, Leuven, Belgium
| |
Collapse
|
40
|
Muller X, Rossignol G, Mohkam K, Mabrut JY. Back to Basics: Liver Graft Ischemia in the Era of Machine Perfusion. Transplantation 2024; 108:1269-1272. [PMID: 38277262 DOI: 10.1097/tp.0000000000004912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2024]
Affiliation(s)
- Xavier Muller
- Department of General Surgery and Liver Transplantation, Croix Rousse University Hospital, Lyon, France
- Institute of Hepatology Lyon (IHL), INSERM U1052, Lyon, France
- ED 340 BMIC, Claude Bernard Lyon 1 University, Villeurbanne, France
| | - Guillaume Rossignol
- Department of General Surgery and Liver Transplantation, Croix Rousse University Hospital, Lyon, France
- Institute of Hepatology Lyon (IHL), INSERM U1052, Lyon, France
- ED 340 BMIC, Claude Bernard Lyon 1 University, Villeurbanne, France
- Department of Pediatric Surgery and Liver Transplantation, Femme Mere Enfant University Hospital, Lyon, France
| | - Kayvan Mohkam
- Department of General Surgery and Liver Transplantation, Croix Rousse University Hospital, Lyon, France
- Institute of Hepatology Lyon (IHL), INSERM U1052, Lyon, France
- Department of Pediatric Surgery and Liver Transplantation, Femme Mere Enfant University Hospital, Lyon, France
| | - Jean-Yves Mabrut
- Department of General Surgery and Liver Transplantation, Croix Rousse University Hospital, Lyon, France
- Institute of Hepatology Lyon (IHL), INSERM U1052, Lyon, France
| |
Collapse
|
41
|
Li T, Li S, Ma K, Kong J. Application potential of senolytics in clinical treatment. Biogerontology 2024; 25:379-398. [PMID: 38109001 DOI: 10.1007/s10522-023-10084-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 11/13/2023] [Indexed: 12/19/2023]
Abstract
Of the factors studied in individual ageing, the accumulation of senescent cells has been considered as an essential cause of organ degeneration to eventually initiate age-related diseases. Cellular senescence is attributed to the accumulation of damage for an inducement in the activation of cell cycle inhibitory pathways, resulting the cell permanently withdraw from the cell proliferation cycle. Further, senescent cells will activate the inflammatory factor secretion pathway to promote the development of various age-related diseases. Senolytics, a small molecule compound, can delay disease development and extend mammalian lifespan. The evidence from multiple trials shows that the targeted killing of senescent cells has a significant clinical application for the treatment of age-related diseases. In addition, senolytics are also significant for the development of ageing research in solid organ transplantation, which can fully develop the potential of elderly organs and reduce the age gap between demand and supply. We conclude that the main characteristics of cellular senescence, the anti-ageing drug senolytics in the treatment of chronic diseases and organ transplantation, and the latest clinical progress of related researches in order to provide a theoretical basis for the prevention and treatment of ageing and related diseases.
Collapse
Affiliation(s)
- Tiantian Li
- School of Environmental and Biological Engineering, Nanjing University of Science and Technology, Nanjing, 210094, Jiangsu, People's Republic of China
| | - Shiyuan Li
- West China School of Pharmacy, Sichuan University, Chengdu, 610207, Sichuan, People's Republic of China
| | - Kefeng Ma
- School of Environmental and Biological Engineering, Nanjing University of Science and Technology, Nanjing, 210094, Jiangsu, People's Republic of China.
| | - Jinming Kong
- School of Environmental and Biological Engineering, Nanjing University of Science and Technology, Nanjing, 210094, Jiangsu, People's Republic of China.
| |
Collapse
|
42
|
Mathis S, Putzer G, Gasteiger L, Eschertzhuber S, Schneeberger S, Cardini B, Hell T, Martini J. Normothermic Machine Perfusion Reduces Transfusion Requirements Even After Static Cold Storage: A 1 y Retrospective Single-center Analysis. Transplant Direct 2024; 10:e1628. [PMID: 38757047 PMCID: PMC11098234 DOI: 10.1097/txd.0000000000001628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 01/26/2024] [Accepted: 02/15/2024] [Indexed: 05/18/2024] Open
Abstract
Background Normothermic machine perfusion (NMP) of liver grafts has been shown to reduce intraoperative catecholamine consumption and the need for allogenic blood products after reperfusion compared with organs undergoing classical static cold storage (SCS). This study aimed to investigate the effects of an NMP phase after SCS (NMP after SCS) of liver grafts in terms of postreperfusion hemodynamics and transfusion requirements. Methods Eighteen recipients of NMP after SCS grafts were matched according to recipient age, donor age, and model for end-stage liver disease score in a 1:2 ratio with recipients of an SCS graft. Postreperfusion hemodynamics and the need for catecholamines, blood products, and clotting factors were compared. Results After reperfusion of the organ, patients in the NMP after SCS group showed significantly reduced transfusion requirements for packed red blood cells and platelet concentrates compared with patients of the SCS group (P < 0.001 and P = 0.018, respectively). In addition, patients in the NMP after SCS group received less fibrinogen concentrate (NMP after SCS group 0 [0-1.5] g versus SCS group 2 [0-4] g; P = 0.0163). No differences in postreperfusion hemodynamics could be detected between groups. Conclusions This retrospective analysis shows that NMP reduces postreperfusion requirements of red blood cells, platelet concentrates, and fibrinogen concentrate even if installed after a phase of organ SCS, because it may be practiced on most centers where NMP is available.
Collapse
Affiliation(s)
- Simon Mathis
- Department of Anaesthesiology and Critical Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Gabriel Putzer
- Department of Anaesthesiology and Critical Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Lukas Gasteiger
- Department of Anaesthesiology and Critical Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Stephan Eschertzhuber
- Department of Anaesthesiology and Intensive Care Medicine, Hospital Hall in Tirol, Austria
| | - Stefan Schneeberger
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Benno Cardini
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | | | - Judith Martini
- Department of Anaesthesiology and Critical Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| |
Collapse
|
43
|
Dixon W, Feng S, Roll GR, Tavakol M, Fenton C, Cullaro G. The type, duration, and severity of pretransplant kidney injury predict prolonged kidney dysfunction after liver transplantation. Liver Transpl 2024:01445473-990000000-00388. [PMID: 38982612 DOI: 10.1097/lvt.0000000000000386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 04/04/2024] [Indexed: 07/11/2024]
Abstract
Chronic kidney disease (CKD) is a major complication of liver transplantation (LT) associated with substantial morbidity and mortality. Knowing the drivers of post-LT kidney dysfunction-with a granular focus on the type, duration, and severity of pre-LT kidney disease-can highlight intervention opportunities and inform dual-organ allocation policies. We retrospectively analyzed predictors of safety net kidney after liver transplant (KALT) eligibility and kidney replacement therapy (KRT) for > 14 days after LT. Among 557 recipients of adult deceased-donor LT, 49% had normal kidney function, 25% had acute kidney injury (AKI), and 25% had CKD±AKI at the time of LT. A total of 36 (6.5%) qualified for KALT and 63 (11%) required KRT > 14 days. In univariable analysis, factors associated with KALT eligibility and KRT > 14 days, respectively, included stage 3 AKI (OR 7.87; OR 7.06), CKD±AKI (OR 4.58; OR 4.22), CKD III-V duration (OR 1.10 per week; OR 1.06 per week), and increasing CKD stage (stage III: OR 3.90, IV: OR 5.24, V: OR 16.8; stage III: OR 2.23, IV: OR 3.62, V: OR 19.4). AKI stage I-II and AKI duration in the absence of CKD were not associated with the outcomes. Pre-LT KRT had a robust impact on KALT eligibility (OR 4.00 per week) and prolonged post-LT KRT (OR 5.22 per week), with 19.8% of patients who received any pre-LT KRT ultimately qualifying for KALT. Eligibility for KALT was similar between those who received 0 days and ≤ 14 days of KRT after LT (2.1% vs. 2.9%, p = 0.53). In conclusion, the type, duration, and severity of pre-LT kidney dysfunction have unique impacts on post-LT kidney-related morbidity, and future research must use these novel classifications to study mitigation strategies.
Collapse
Affiliation(s)
- Wesley Dixon
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Medicine, University of California, San Francisco, California, USA
| | - Sandy Feng
- Department of Surgery, University of California, San Francisco, California, USA
| | - Garrett R Roll
- Department of Surgery, University of California, San Francisco, California, USA
| | - Mehdi Tavakol
- Department of Surgery, University of California, San Francisco, California, USA
| | - Cynthia Fenton
- Department of Medicine, University of California, San Francisco, California, USA
| | - Giuseppe Cullaro
- Department of Medicine, University of California, San Francisco, California, USA
| |
Collapse
|
44
|
Tan Q, Xiao J, Chen J, Wang Y, Zhang Z, Zhao T, Li Y. ifDEEPre: large protein language-based deep learning enables interpretable and fast predictions of enzyme commission numbers. Brief Bioinform 2024; 25:bbae225. [PMID: 38942594 PMCID: PMC11213619 DOI: 10.1093/bib/bbae225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 03/26/2024] [Accepted: 04/22/2024] [Indexed: 06/30/2024] Open
Abstract
Accurate understanding of the biological functions of enzymes is vital for various tasks in both pathologies and industrial biotechnology. However, the existing methods are usually not fast enough and lack explanations on the prediction results, which severely limits their real-world applications. Following our previous work, DEEPre, we propose a new interpretable and fast version (ifDEEPre) by designing novel self-guided attention and incorporating biological knowledge learned via large protein language models to accurately predict the commission numbers of enzymes and confirm their functions. Novel self-guided attention is designed to optimize the unique contributions of representations, automatically detecting key protein motifs to provide meaningful interpretations. Representations learned from raw protein sequences are strictly screened to improve the running speed of the framework, 50 times faster than DEEPre while requiring 12.89 times smaller storage space. Large language modules are incorporated to learn physical properties from hundreds of millions of proteins, extending biological knowledge of the whole network. Extensive experiments indicate that ifDEEPre outperforms all the current methods, achieving more than 14.22% larger F1-score on the NEW dataset. Furthermore, the trained ifDEEPre models accurately capture multi-level protein biological patterns and infer evolutionary trends of enzymes by taking only raw sequences without label information. Meanwhile, ifDEEPre predicts the evolutionary relationships between different yeast sub-species, which are highly consistent with the ground truth. Case studies indicate that ifDEEPre can detect key amino acid motifs, which have important implications for designing novel enzymes. A web server running ifDEEPre is available at https://proj.cse.cuhk.edu.hk/aihlab/ifdeepre/ to provide convenient services to the public. Meanwhile, ifDEEPre is freely available on GitHub at https://github.com/ml4bio/ifDEEPre/.
Collapse
Affiliation(s)
- Qingxiong Tan
- Department of Computer Science and Engineering, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Jin Xiao
- Department of Computer Science, Hong Kong Baptist University, Hong Kong SAR, China
| | - Jiayang Chen
- Department of Computer Science and Engineering, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Yixuan Wang
- Department of Computer Science and Engineering, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Zeliang Zhang
- Department of Computer Science, University of Rochester, Rochester, New York State, USA
- School of Computer Science and Technology, Huazhong University of Science and Technology, Wuhan, China
| | | | - Yu Li
- Department of Computer Science and Engineering, The Chinese University of Hong Kong, Hong Kong SAR, China
- The CUHK Shenzhen Research Institute, Nanshan, Shenzhen, China
| |
Collapse
|
45
|
Hofmann J, Kofler A, Schartner M, Buch ML, Hermann M, Zelger B, Öfner D, Oberhuber R, Hautz T, Schneeberger S, Meszaros AT. Assessment of Mitochondrial Respiration During Hypothermic Storage of Liver Biopsies Following Normothermic Machine Perfusion. Transpl Int 2024; 37:12787. [PMID: 38845758 PMCID: PMC11153658 DOI: 10.3389/ti.2024.12787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 05/07/2024] [Indexed: 06/09/2024]
Abstract
Organ quality can be assessed prior to transplantation, during normothermic machine perfusion (NMP) of the liver. Evaluation of mitochondrial function by high-resolution respirometry (HRR) may serve as a viability assessment concept in this setting. Freshly collected tissue is considered as optimal sample for HRR, but due to technical and personnel requirements, more flexible and schedulable measurements are needed. However, the impact of cold storage following NMP before processing biopsy samples for mitochondrial analysis remains unknown. We aimed at establishing an appropriate storage protocol of liver biopsies for HRR. Wedge biopsies of 5 human livers during NMP were obtained and assessed by HRR. Analysis was performed after 0, 4, 8, and 12 h of hypothermic storage (HTS) in HTK organ preservation solution at 4°C. With HTS up to 4 h, mitochondrial performance did not decrease in HTS samples compared with 0 h (OXPHOS, 44.62 [34.75-60.15] pmol·s-1·mg wet mass-1 vs. 43.73 [40.69-57.71], median [IQR], p > 0.999). However, at HTS beyond 4 h, mitochondrial respiration decreased. We conclude that HTS can be safely applied for extending the biopsy measurement window for up to 4 h to determine organ quality, but also that human liver respiration degrades beyond 4 h HTS following NMP.
Collapse
Affiliation(s)
- Julia Hofmann
- OrganLife Laboratory, Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Alexander Kofler
- OrganLife Laboratory, Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Melanie Schartner
- OrganLife Laboratory, Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Madita L. Buch
- OrganLife Laboratory, Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Martin Hermann
- OrganLife Laboratory, Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Bettina Zelger
- Institute of Pathology, Neuropathology and Molecular Pathology, Medical University of Innsbruck, Innsbruck, Austria
| | - Dietmar Öfner
- OrganLife Laboratory, Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Rupert Oberhuber
- OrganLife Laboratory, Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Theresa Hautz
- OrganLife Laboratory, Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Stefan Schneeberger
- OrganLife Laboratory, Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Andras T. Meszaros
- OrganLife Laboratory, Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| |
Collapse
|
46
|
Cywes C, Banker A, Muñoz N, Levine M, Abu-Gazala S, Bittermann T, Abt P. The Potential Utilization of Machine Perfusion to Increase Transplantation of Macrosteatotic Livers. Transplantation 2024:00007890-990000000-00774. [PMID: 38773856 DOI: 10.1097/tp.0000000000005057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/24/2024]
Abstract
BACKGROUND The demand for liver transplantation has led to the utilization of marginal grafts including moderately macrosteatotic livers (macrosteatosis ≥30% [Mas30]), which are associated with an elevated risk of graft failure. Machine perfusion (MP) has emerged as a technique for organ preservation and viability testing; however, little is known about MP in Mas30 livers. This study evaluates the utilization and outcomes of Mas30 livers in the era of MP. METHODS The Organ Procurement and Transplantation Network database was queried to identify biopsy-proven Mas30 deceased donor liver grafts between June 1, 2016, and June 23, 2023. Univariable and multivariable models were constructed to study the association between MP and graft utilization and survival. RESULTS The final cohort with 3317 Mas30 livers was identified, of which 72 underwent MP and were compared with 3245 non-MP livers. Among Mas30 livers, 62 (MP) and 1832 (non-MP) were transplanted (utilization of 86.1% versus 56.4%, P < 0.001). Donor and recipient characteristics were comparable between MP and non-MP groups. In adjusted analyses, MP was associated with significantly increased Mas30 graft utilization (odds ratio, 7.89; 95% confidence interval [CI], 3.76-16.58; P < 0.001). In log-rank tests, MP was not associated with 1- and 3-y graft failure (hazard ratio, 0.49; 95% CI, 0.12-1.99; P = 0.319 and hazard ratio 0.43; 95% CI, 0.11-1.73; P = 0.235, respectively). CONCLUSIONS The utilization rate of Mas30 grafts increases with MP without detriment to graft survival. This early experience may have implications for increasing the available donor pool of Mas30 livers.
Collapse
Affiliation(s)
- Claire Cywes
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Amay Banker
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Nicolas Muñoz
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Matthew Levine
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Samir Abu-Gazala
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Therese Bittermann
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Peter Abt
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| |
Collapse
|
47
|
Malik AK, Tingle SJ, Varghese C, Owen R, Mahendran B, Figueiredo R, Amer AO, Currie IS, White SA, Manas DM, Wilson CH. Does Time to Asystole in Donors After Circulatory Death Impact Recipient Outcome in Liver Transplantation? Transplantation 2024:00007890-990000000-00767. [PMID: 38780399 DOI: 10.1097/tp.0000000000005074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
BACKGROUND The agonal phase can vary following treatment withdrawal in donor after circulatory death (DCD). There is little evidence to support when procurement teams should stand down in relation to donor time to death (TTD). We assessed what impact TTD had on outcomes following DCD liver transplantation. METHODS Data were extracted from the UK Transplant Registry on DCD liver transplant recipients from 2006 to 2021. TTD was the time from withdrawal of life-sustaining treatment to asystole, and functional warm ischemia time was the time from donor systolic blood pressure and/or oxygen saturation falling below 50 mm Hg and 70%, respectively, to aortic perfusion. The primary endpoint was 1-y graft survival. Potential predictors were fitted into Cox proportional hazards models. Adjusted restricted cubic spline models were generated to further delineate the relationship between TTD and outcome. RESULTS One thousand five hundred fifty-eight recipients of a DCD liver graft were included. Median TTD in the entire cohort was 13 min (interquartile range, 9-17 min). Restricted cubic splines revealed that the risk of graft loss was significantly greater when TTD ≤14 min. After 14 min, there was no impact on graft loss. Prolonged hepatectomy time was significantly associated with graft loss (hazard ratio, 1.87; 95% confidence interval, 1.23-2.83; P = 0.003); however, functional warm ischemia time had no impact (hazard ratio, 1.00; 95% confidence interval, 0.44-2.27; P > 0.9). CONCLUSIONS A very short TTD was associated with increased risk of graft loss, possibly because of such donors being more unstable and/or experiencing brain stem death as well as circulatory death. Expanding the stand down times may increase the utilization of donor livers without significantly impairing graft outcome.
Collapse
Affiliation(s)
- Abdullah K Malik
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, United Kingdom
- NIHR Blood and Transplant Research Unit in Organ Donation and Transplantation, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Samuel J Tingle
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, United Kingdom
- NIHR Blood and Transplant Research Unit in Organ Donation and Transplantation, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Chris Varghese
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Ruth Owen
- Department of Surgery, The Royal Oldham Hospital, Greater Manchester, United Kingdom
| | - Balaji Mahendran
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, United Kingdom
- NIHR Blood and Transplant Research Unit in Organ Donation and Transplantation, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Rodrigo Figueiredo
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Aimen O Amer
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Ian S Currie
- National Health Service Blood and Transplant, Bristol, United Kingdom
- Edinburgh Transplant Centre, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Steven A White
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Derek M Manas
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, United Kingdom
- NIHR Blood and Transplant Research Unit in Organ Donation and Transplantation, Newcastle University, Newcastle upon Tyne, United Kingdom
- National Health Service Blood and Transplant, Bristol, United Kingdom
| | - Colin H Wilson
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, United Kingdom
- NIHR Blood and Transplant Research Unit in Organ Donation and Transplantation, Newcastle University, Newcastle upon Tyne, United Kingdom
| |
Collapse
|
48
|
Wang BK, Shubin AD, Harvey JA, MacConmara MM, Hwang CS, Patel MS, Vagefi PA. From Patients to Providers: Assessing Impact of Normothermic Machine Perfusion on Liver Transplant Practices in the US. J Am Coll Surg 2024; 238:844-852. [PMID: 38078619 DOI: 10.1097/xcs.0000000000000924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/18/2024]
Abstract
BACKGROUND Normothermic machine perfusion (NMP) of livers allows for the expansion of the donor pool and minimization of posttransplant complications. Results to date have focused on both donor and recipient outcomes, but there remains potential for NMP to also impact transplant providers. STUDY DESIGN Using United Network for Organ Sharing Standard Transplant Analysis file data, adult deceased donors who underwent transplantation between January 1, 2016, and December 31, 2022, were identified. Transplanted livers were divided by preservation methods (static cold storage [SCS] and NMP) and case time (day-reperfusion 8 am to 6 pm ). Patient factors, transplant characteristics, and short-term outcomes were analyzed between Mahalanobis-metric-matched groups. RESULTS NMP livers represented 742 (1.4%) of 52,132 transplants. NMP donors were more marginal with higher Donor Risk Index scores (1.78 ± 0.50 NMP vs 1.49 ± 0.38 SCS, p < 0.001) and donation after cardiac death frequency (36.9% vs 8.4%, p < 0.001). NMP recipients more often had model for end-stage liver disease (MELD) exception status (29.9% vs 23.4%, p < 0.001), lower laboratory MELD scores (20.7 ± 9.7 vs 24.3 ± 10.9, p < 0.001), and had been waitlisted longer (111.5 [21.0 to 307.0] vs 60.0 [9.0 to 245.0] days, p < 0.001). One-year graft survival (90.2% vs 91.6%, p = 0.505) was similar between groups, whereas length of stay was lower for NMP recipients (8.0 [6.0 to 14.0] vs 10.0 [6.0 to 16.0], p = 0.017) after adjusting for confounders. Notably, peak case volume occurred at 11 am with NMP livers (vs 9 pm with SCS). Overall, a higher proportion of transplants was performed during daytime hours with NMP (51.5% vs 43.0%, p < 0.001). CONCLUSIONS NMP results in increased use of marginal allografts, which facilitated transplantation in lower laboratory MELD recipients who have been waitlisted longer and often have exception points. Importantly, NMP also appeared to shift peak caseloads from nighttime to daytime, which may have significant effects on the quality of life for the entire liver transplant team.
Collapse
Affiliation(s)
- Benjamin K Wang
- From the Division of Surgical Transplantation, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX (Wang, Shubin, Harvey, Hwang, Patel, Vagefi)
| | - Andrew D Shubin
- From the Division of Surgical Transplantation, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX (Wang, Shubin, Harvey, Hwang, Patel, Vagefi)
| | - Jalen A Harvey
- From the Division of Surgical Transplantation, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX (Wang, Shubin, Harvey, Hwang, Patel, Vagefi)
| | | | - Christine S Hwang
- From the Division of Surgical Transplantation, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX (Wang, Shubin, Harvey, Hwang, Patel, Vagefi)
| | - Madhukar S Patel
- From the Division of Surgical Transplantation, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX (Wang, Shubin, Harvey, Hwang, Patel, Vagefi)
| | - Parsia A Vagefi
- From the Division of Surgical Transplantation, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX (Wang, Shubin, Harvey, Hwang, Patel, Vagefi)
| |
Collapse
|
49
|
Concors SJ, Hernandez PT, O'Brien C, DePaolo J, Murken DR, Aufhauser DD, Wang Z, Xiong Y, Krumeich L, Ge G, Beier UH, Bhatti TR, Kozikowski AP, Avelar LAA, Kurz T, Hancock WW, Levine MH. Differential Effects of HDAC6 Inhibition Versus Knockout During Hepatic Ischemia-reperfusion Injury Highlight Importance of HDAC6 C-terminal Zinc-finger Ubiquitin-binding Domain. Transplantation 2024:00007890-990000000-00744. [PMID: 38685198 DOI: 10.1097/tp.0000000000005042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Abstract
BACKGROUND Ischemia-reperfusion injury (IRI) causes significant morbidity in liver transplantation among other medical conditions. IRI following liver transplantation contributes to poor outcomes and early graft loss. Histone/protein deacetylases (HDACs) regulate diverse cellular processes, play a role in mediating tissue responses to IRI, and may represent a novel therapeutic target in preventing IRI in liver transplantation. METHODS Using a previously described standardized model of murine liver warm IRI, aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels were assessed at 24 and 48 h after reperfusion to determine the effect of different HDAC inhibitors. RESULTS Broad HDAC inhibition with trichostatin-A (TSA) was protective against hepatocellular damage (P < 0.01 for AST and P < 0.05 for ALT). Although HDAC class I inhibition with MS-275 provided statistically insignificant benefit, tubastatin-A (TubA), an HDAC6 inhibitor with additional activity against HDAC10, provided significant protection against liver IRI (P < 0.01 for AST and P < 0.001 for ALT). Surprisingly genetic deletion of HDAC6 or -10 did not replicate the protective effects of HDAC6 inhibition with TubA, whereas treatment with an HDAC6 BUZ-domain inhibitor, LakZnFD, eliminated the protective effect of TubA treatment in liver ischemia (P < 0.01 for AST and P < 0.01 for ALT). CONCLUSIONS Our findings suggest TubA, a class IIb HDAC inhibitor, can mitigate hepatic IRI in a manner distinct from previously described class I HDAC inhibition and requires the HDAC6 BUZ-domain activity. Our data corroborate previous findings that HDAC targets for therapeutic intervention of IRI may be tissue-specific, and identify HDAC6 inhibition as a possible target in the treatment of liver IRI.
Collapse
Affiliation(s)
- Seth J Concors
- Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Paul T Hernandez
- Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Ciaran O'Brien
- Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - John DePaolo
- Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Douglas R Murken
- Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | | | - Zhonglin Wang
- Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Yan Xiong
- Division of Transplant Immunology, Department of Pathology and Laboratory Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Lauren Krumeich
- Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Guanghui Ge
- Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Ulf H Beier
- Division of Nephrology and Department of Pediatrics, Children's Hospital of Pennsylvania and University of Pennsylvania, Philadelphia, PA
| | - Tricia R Bhatti
- Division of Transplant Immunology, Department of Pathology and Laboratory Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | | | - Leandro A Alves Avelar
- Institute of Pharmaceutical and Medicinal Chemistry, Heinrich-Heine-University, Düsseldorf, Germany
| | - Thomas Kurz
- Institute of Pharmaceutical and Medicinal Chemistry, Heinrich-Heine-University, Düsseldorf, Germany
| | - Wayne W Hancock
- Division of Transplant Immunology, Department of Pathology and Laboratory Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
- Department of Pathology and Laboratory Medicine, University of Pennsylvania, Philadelphia, PA
| | - Matthew H Levine
- Department of Surgery, University of Pennsylvania, Philadelphia, PA
- Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA
| |
Collapse
|
50
|
Abbas SH, Ceresa CDL, Pollok JM. Steatotic Donor Transplant Livers: Preservation Strategies to Mitigate against Ischaemia-Reperfusion Injury. Int J Mol Sci 2024; 25:4648. [PMID: 38731866 PMCID: PMC11083584 DOI: 10.3390/ijms25094648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 04/21/2024] [Accepted: 04/22/2024] [Indexed: 05/13/2024] Open
Abstract
Liver transplantation (LT) is the only definitive treatment for end-stage liver disease, yet the UK has seen a 400% increase in liver disease-related deaths since 1970, constrained further by a critical shortage of donor organs. This shortfall has necessitated the use of extended criteria donor organs, including those with evidence of steatosis. The impact of hepatic steatosis (HS) on graft viability remains a concern, particularly for donor livers with moderate to severe steatosis which are highly sensitive to the process of ischaemia-reperfusion injury (IRI) and static cold storage (SCS) leading to poor post-transplantation outcomes. This review explores the pathophysiological predisposition of steatotic livers to IRI, the limitations of SCS, and alternative preservation strategies, including novel organ preservation solutions (OPS) and normothermic machine perfusion (NMP), to mitigate IRI and improve outcomes for steatotic donor livers. By addressing these challenges, the liver transplant community can enhance the utilisation of steatotic donor livers which is crucial in the context of the global obesity crisis and the growing need to expand the donor pool.
Collapse
Affiliation(s)
- Syed Hussain Abbas
- Oxford Transplant Centre, Nuffield Department of Surgical Sciences, University of Oxford, Oxford OX1 2JD, UK;
| | - Carlo Domenico Lorenzo Ceresa
- Department of Hepatopancreatobiliary and Liver Transplant Surgery, Royal Free Hospital, Pond Street, Hampstead, London NW3 2QG, UK;
| | - Joerg-Matthias Pollok
- Department of Hepatopancreatobiliary and Liver Transplant Surgery, Royal Free Hospital, Pond Street, Hampstead, London NW3 2QG, UK;
- Division of Surgery & Interventional Science, University College London, Gower Street, London WC1E 6BT, UK
| |
Collapse
|