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Treska V, Kuntscher V, Molácek J, Kobr J, Racek J, Trefil L. Can ischemia-reperfusion syndrome in transplanted kidneys procured from non–heart-beating donors be influenced by adding selenium into the reperfusion solution? an experimental study. Transplant Proc 2003; 35:3125-7. [PMID: 14697994 DOI: 10.1016/j.transproceed.2003.10.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Ischemia-reperfusion syndrome significantly influences the function of a kidney transplanted from a non-heart-beating donor (NHBD). An animal model of NHBD was used to monitor the influence of the exogenous addition of selenium in the perfusion solution (HTK, Custodiol) on the generation of free oxygen radicals between 0 and 120 minutes after transplantation of the NHBD organ. During this interval, the malondialdehyde concentration, an indicator of free oxygen radicals in the venous blood of the transplanted kidney, significantly decreased. The augmentation of the anti-oxidant capacity of the preservation solution might represent a possible improvement in the function of kidneys transplanted from NHBDs.
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Affiliation(s)
- V Treska
- Department of Surgery, University Hospital, Alej Svobody 80, 304 60 Plzen, Czech Republic.
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52
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Gok MA, Pelzers M, Glatz JFC, Shenton BK, Buckley PE, Peaston R, Cornell C, Mantle D, Soomro N, Jaques BC, Manas DM, Talbot D. Do tissue damage biomarkers used to assess machine-perfused NHBD kidneys predict long-term renal function post-transplant? Clin Chim Acta 2003; 338:33-43. [PMID: 14637263 DOI: 10.1016/j.cccn.2003.07.023] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Renal transplantation in many units is limited by the availability of donor organs. Kidneys obtained from non-heart-beating donors (NHBD) represent an important resource, with the potential to substantially increase the available donor organ pool. Such kidneys are associated with increased warm ischaemic tissue injury which may be assessed by hypothermic machine perfusion. Within our transplant centre, a key component of such damage assessment and viability screening involves the quantification of the tissue damage biomarkers glutathione S-transferase in kidney perfusates. METHODS Since 1998, 126 NHBD kidneys were machine-perfused prior to implantation, resulting in 74 transplants. Kidney perfusate samples were assayed for glutathione S-transferase in "real time", and alanine aminopeptidase and fatty acid binding protein in "retrospect". RESULTS The pre-transplant concentration of these tissue injury biomarkers determined pre-transplant did not correlate with subsequent longer-term renal function, as assessed by measurement of serum creatinine (tGST: Spearman correlation r=-0.02; Ala-AP: r=0.02; H-FABP: r=-0.05) and creatinine clearance (tGST: r=0.08; Ala-AP: r=-0.02; H-FABP: r=0.14) for those kidneys that had passed their viability tests. CONCLUSIONS Thus whilst these biomarkers may represent reliable pre-transplant indicators of immediate kidney viability and short-term kidney function, they do not predict the efficacy of renal function in the longer term.
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Affiliation(s)
- Muhammed A Gok
- Renal/Liver Transplant Unit, The Freeman Hospital, University of Newcastle Upon Tyne, Level 5, NE7 7DN, Newcastle Upon Tyne, England, UK.
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53
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Aitchison JD, Orr HE, Flecknell PA, Kirby JA, Dark JH. Nitric oxide during perfusion improves posttransplantation function of non- heart-beating donor lungs. Transplantation 2003; 75:1960-4. [PMID: 12829894 DOI: 10.1097/01.tp.0000067528.58552.34] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND We attempted to determine in a pig model whether 20 ppm of nitric oxide (NO) during perfusion ameliorates warm ischemic lung injury in the non-heart-beating donor (NHBD), thereby improving function with longer warm ischemia. METHODS Lungs were retrieved from three groups (n=6): 1 hr (NHBD(1)) and 2 hr with and without NO (NHBD(2)NO, NHBD(2)) after hypoxic death. For assessment and preservation, left lungs were ventilated with 100% oxygen (NHBD(2)NO with added NO) and perfused for 20 min with neutrophil-depleted, deoxygenated blood in Perfadex solution. Pulmonary vascular and airway pressures and blood flow were measured with pulmonary venous blood gases. Perfusion temperature was reduced to 18 degrees C prior to storage at 4 degrees C before transplantation. RESULTS NO during perfusion significantly improved posttransplantation pulmonary venous oxygenation (NHBD(1) [mean +/- SD] 51+/-14 kPa, NHBD(2) 54+/-16 kPa, and NHBD(2)NO 61+/-6 kPa; P=0.01) and airway pressures (NHBD(1) 30.8+/-3.5, NHBD(2) 32.5+/-5.6, NHDB(2)NO 29.4+/-5.3; P=0.0001). NO significantly improved pulmonary vascular resistance (excluding the initial cold-induced vasoconstricted reperfusion period): NHBD(1) 19+/-9 Wood units, NHBD(2) 28+/-25 Wood units, NHDB(2)NO 16+/-10 Wood units, P=0.029. Neutrophil uptake was significantly lowered by NO: NHBD(1) 0.6+/-1.4*10(9) minute-1, NHBD(2) 1.2+/-1.0*10(9) minute-1, NHBD(2)NO 0.4+/-0.9*10(9) minute-1 (P=0.029). CONCLUSIONS This technique satisfactorily assesses and preserves the non-heart-beating lung. NO during preservation reverses the slight deterioration seen when increasing warm ischemia from 1 to 2 hr, significantly improving transplant oxygenation, vascular resistance, and airway pressures. This may be a result of the observed significant reduction in neutrophil sequestration.
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Affiliation(s)
- J Douglas Aitchison
- Department of Surgery, University of Newcastle upon Tyne, Newcastle upon Tyne, England, UK.
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54
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Treska V, Kuntscher V, Molácek J, Kobr J, Racek J, Trefil L. Can the ischemia-reperfusion syndrome in transplanted kidneys procured from non-heart-beating donors be influenced by adding selenium into the reperfusion solution? An experimental study. Transplant Proc 2003; 35:1584-6. [PMID: 12826226 DOI: 10.1016/s0041-1345(03)00466-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The ischemic-reperfusion syndrome significantly influences the function of a kidney transplanted from a non-heart-beating donor (NHBD). The animal model of a NHBD was used to monitor the influence of exogenous addition of selenium into the reperfusion solution (HTK, Custodiol) with respect to the formation of free oxygen radicals at 0 to 120 minutes after the NHBD transplantation. This maneuvers produced a statistically significant decrease in malondialdehyde concentration, an indicator of free oxygen radicals in the venous blood of the transplanted kidney. The augmentation of the antioxidative capacity of the preservation solution might be a possible route to improve the function of kidneys transplanted from NHBDs.
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Affiliation(s)
- V Treska
- Department of Surgery, University Hospital, Plzen, Czech Republic.
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55
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Markmann JF, Deng S, Desai NM, Huang X, Velidedeoglu E, Frank A, Liu C, Brayman KL, Lian MM, Wolf B, Bell E, Vitamaniuk M, Doliba N, Matschinsky F, Markmann E, Barker CF, Naji A. The use of non-heart-beating donors for isolated pancreatic islet transplantation. Transplantation 2003; 75:1423-9. [PMID: 12792491 DOI: 10.1097/01.tp.0000061119.32575.f4] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Recent improvements in isolated islet transplantation indicate that this therapy may ultimately prove applicable to patients with type I diabetes. An obstacle preventing widespread application of islet transplantation is an insufficient supply of cadaveric pancreata. Non-heart-beating donors (NHBDs) are generally not deemed suitable for whole-organ pancreas donation and could provide a significant source of pancreata for islet transplantation. Isolated pancreatic islets prepared from 10 NHBDs were compared with those procured from 10 brain-dead donors (BDDs). The success of the isolation for the two groups was analyzed for preparation purity, quality, and recovered islet mass. The function of NHBD and BDD islets was evaluated using in vitro and in vivo assays. On the basis of the results of this analysis, an NHBD isolated islet allograft was performed in a type I diabetic. The recovery of islets from NHBDs was comparable to that of control BDDs. In vitro assessment of NHBD islet function revealed function-equivalent BDD islets, and NHBD islets transplanted to non-obese diabetic-severe combined immunodeficient (NOD-SCID) mice efficiently reversed diabetes. Transplantation of 446,320 islet equivalents (IEq) (8,500 IEq/kg of recipient body weight) from a single NHBD successfully reversed the diabetes of a type I diabetic recipient. Normally functioning pancreatic islets can be isolated successfully from NHBDs. A single donor transplant from an NHBD resulted in a state of stable insulin independence in a type I diabetic recipient. These results indicate that NHBDs may provide an as yet untapped source of pancreatic tissue for preparation of isolated islets for clinical transplantation.
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Affiliation(s)
- James F Markmann
- Department of Surgery, University of Pennsylvania Health System, Philadelphia 19104, USA.
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56
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Sudhindran S, Pettigrew GJ, Drain A, Shrotri M, Watson CJE, Jamieson NV, Bradley JA. Outcome of transplantation using kidneys from controlled (Maastricht category 3) non-heart-beating donors. Clin Transplant 2003; 17:93-100. [PMID: 12709073 DOI: 10.1034/j.1399-0012.2003.00014.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Many renal transplant centres are reluctant to use kidneys from non-heart-beating (NHB) donors because of the high incidence of primary non-function and delayed graft function reported in the literature. Here, we report our favourable experience of using kidneys from Maastricht category 3 donors (controlled NHB donors). MATERIALS AND METHODS From January 1996 to June 2002, 42 renal transplants using kidneys from 25 controlled NHB donors were undertaken at our centre. The rates of primary non-function, delayed graft function (DGF), rejection and long-term graft and patient survival were compared with those of 84 recipients of grafts from heart-beating (HB donors) transplanted contemporaneously. RESULTS Primary non-function did not occur in recipients of grafts from NHB donors but was seen in two grafts from HB donors. DGF occurred in 21 of 42 (50%) kidneys from NHB donors and 14 of 84 (17%) kidneys from HBD donars (p < 0.001). The acute rejection rates in the two groups were similar (33% for grafts from NHB donors vs. 40% from HB donors). By 1 month after transplantation, there was no significant difference in serum creatinine concentration between the two groups. Over a median follow-up period of 32 months (range 2-75 months), the actuarial graft survival rates at 1, 3 and 5 yr after transplantation were 84, 80 and 74% for recipients of kidneys from NHB donors, compared with 89, 85 and 80% for kidneys from HB donors. CONCLUSION Controlled NHB donors are a valuable and under-used source of kidneys for renal transplantation. The outcome for recipients of kidney allografts from category 3 NHB donors is similar to that seen in recipients of grafts from conventional HB cadaveric donors.
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Affiliation(s)
- S Sudhindran
- University Department of Surgery, Addenbrooke's Hospital, Cambridge, UK
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57
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Yamauchi JI, Schramm R, Richter S, Vollmar B, Menger MD, Minor T. Improvement of microvascular graft equilibration and preservation in non-heart-beating donors by warm preflush with streptokinase. Transplantation 2003; 75:449-53. [PMID: 12605108 DOI: 10.1097/01.tp.0000053404.67581.f4] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Using in situ fluorescence microscopy with Sprague Dawley rats, we studied the hypothesis of compromised microvascular kidney perfusion on organ harvest in non-heart-beating donors (NHBDs), and we evaluated the potential benefit of an additional preflush with saline solution containing streptokinase. Aortal flush of NHBD kidneys solely with University of Wisconsin solution resulted in a significantly (P <0.05) reduced functional capillary density (FCD) with increased perfusion heterogeneity compared with kidneys of heart-beating controls. This was associated with an increased lactate dehydrogenase (LDH) release on 24 hr postpreservation rinse of the grafts (76.7+/-18.9 U/L). Warm preflush with low-viscosity Ringer's lactate (RL) solution alone did not influence the decreased renal FCD and the postpreservation LDH release (76.2+/-29.1 U/L). In contrast, the addition of streptokinase to the RL preflush solution resulted in a significant (P <0.05) improvement of FCD with values not statistically different from those of heart-beating controls. This was associated with an attenuation of perfusion heterogeneity and a significantly lowered postpreservation LDH release (17.0+/-2.5 U/L). Furthermore, in transplanted and reperfused NHBD kidney grafts, the use of streptokinase-supplemented RL for preflush during organ harvest significantly (P <0.05) reduced early manifestation of tubular necrosis (29%+/-8%) when compared with kidneys preflushed exclusively with University of Wisconsin solution (56%+/-4%). Thus, we conclude that kidney harvest from NHBDs is prone to severe microvascular perfusion deficits, which are likely to preclude successful preservation of organ integrity during cold storage. Temporary fibrinolytic preflush with streptokinase may represent a feasible tool to improve microvascular graft equilibration, which effectively protects the renal integrity during both cold storage and posttransplant reperfusion.
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Affiliation(s)
- Jun-Ichiro Yamauchi
- Institute for Clinical & Experimental Surgery, University of Saarland, D-66421 Homburg/Saar, Germany
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58
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Treska V, Kuntscher V, Hasman D, Neprasová P, Kobr J, Racek J, Trefil L, Hes O. Importance of selenium for the influence of ischemia-reperfusion syndrome after kidney transplantation from a non-heart beating donor in a pig model. Transplant Proc 2002; 34:3057-9. [PMID: 12493374 DOI: 10.1016/s0041-1345(02)03694-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- V Treska
- Department of Surgery, University Hospital Plzen, Plzen, Czech Republic.
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59
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Burgos FJ, Alcaraz A, Castillón I, González Martín M, Lledó E, Matesanz R, Marcén R, Montañés P, Pascual J. [Present and future of kidney transplantation]. Actas Urol Esp 2002; 26:731-58. [PMID: 12645371 DOI: 10.1016/s0210-4806(02)72853-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Renal transplant is the treatment of choice for the patient with end stage renal disease. Spain is the country with the highest donation rate (33 ppm). However, at present this figure is stabilized. The development of non-beating heart programmes, living-donor nephrectomy (specially laparoscopic nephrectomy) programmes, and may be xenotransplantation in a non-immediate future could increase the transplantation activity. The knowledge of preservation mechanisms, specially with the use of perfusion machines allows to rescue for transplantation kidneys with a long warm-ischemia time. Furthermore, these machines are useful for analyzing viability markers. The new immunosuppressive drugs: Tacrolimus, Mycophenolate-Mophetil, Rapamycin and monoclonal antibodies against alpha chain of the interleukine-2 receptor (Basoliximab and Dazcizumab) have reduced the incidence of acute rejection in the immediate renal transplant period. However, its effect in the long-term follow-up period is still a matter of controversy. The incidence of tumour in the renal transplant recipient is increased, specially those of lymphoma, skin cancer and Kaposi sarcoma. Periodical exams for detecting the development of tumours are mandatory in this population. Finally, xenotransplantation is an attractive alternative, although immunological, infective and ethical barriers should previously be resolved.
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Affiliation(s)
- F J Burgos
- Servicio de Urología, Hospital Ramón y Cajal, Universidad Alcalá, Madrid
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60
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Affiliation(s)
- Emilio Ramos
- Nephrology Division, University of Maryland Medical System, Baltimore, Maryland 21201, USA.
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61
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62
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Kalmár Nagy K. Liver and pancreas transplantation in Europe--and in Hungary. ACTA PHYSIOLOGICA HUNGARICA 2002; 88:15-24. [PMID: 11811843 DOI: 10.1556/aphysiol.88.2001.1.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Liver transplantation (LT) is the sole treatment modality of most of diffuse liver diseases. Simultaneous-pancreas-kidney (SPK) transplantation is also a life saving operation for IDDM patients. Both procedures are established treatment options in the European Community (EC) and in the US. These procedures are performed in a significantly smaller number in Hungary. Having a larger demand for LT than the supply of cadaver donors alternative solutions are sought to increase the number of transplantable livers. In Hungary partly the shortage of donors and the shortage of recipients are the factors rendering the number of LTs and SPKs low. These factors can be changed by better organisation and good survival data that make the two procedures accepted by the community of physicians.
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Affiliation(s)
- K Kalmár Nagy
- Department of Surgery, Faculty of Medicine, Pécs University, Hungary
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63
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Minor T, Olschewski P, Tolba RH, Akbar S, Kocálková M, Dombrowski F. Liver preservation with HTK: salutary effect of hypothermic aerobiosis by either gaseous oxygen or machine perfusion. Clin Transplant 2002; 16:206-11. [PMID: 12010145 DOI: 10.1034/j.1399-0012.2002.01128.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The aim of the present study was to improve the viability of marginal livers from non-heart beating donors upon cold preservation using two different techniques for the provision of tissue aerobiosis. Livers from male Wistar rats (250-300 g bw) were harvested after 60 min of cardiac arrest, flushed via the portal vein with 20 mL of heparinized Ringer's solution and 60 mL of histidine-tryptophan-ketoglutarate (HTK) preservation solution. Control livers were then stored submerged in HTK for 24 h at 4 degrees C while other organs were subjected to aerobic conditions by either insufflation of gaseous oxygen via the venous vascular system of the cold stored organ (VSOP) or pulsatile machine perfusion (MP) with oxygenated HTK at 5 mL/min at 4 degrees C. Superoxide dismutase (SOD) (7500 IU) was added to the last 10 mL of HTK in order to prevent adverse effects of high oxygen tensions at hypothermia. Viability of the livers was assessed upon isolated perfusion in vitro with oxygenated Krebs-Henseleit buffer at constant flow. VSOP or MP, both significantly improved vascular conductivity upon reperfusion as evaluated by portal venous pressure, reduced hepatic enzyme release and led to a rise in hepatic bile production upon reperfusion. Induction of apoptosis was also looked for in tissue homogenates by Western analysis for cleavage of poly(ADP-ribose)polymerase (PARP). Expression of cleaved PARP fragment could be found in reperfused control livers but also, though to a lesser extend, after VSOP or MP. In conclusion, provision of oxygen during cold preservation significantly contributes to improve organ viability upon reperfusion and must be regarded as a useful adjunct for marginal or pre-damaged livers. HTK has been shown for the first time to be also suitable for long-term MP preservation of the liver, but, as inferred from these data, simple insufflation of gaseous O2 may be considered a feasible alternative.
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Affiliation(s)
- Thomas Minor
- Surgical Research Division, University Clinic of Surgery, Bonn, Germany.
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64
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Brasile L, Stubenitsky BM, Kootstra G. Solving the organ shortage: potential strategies and the likelihood of success. ASAIO J 2002; 48:211-5. [PMID: 12058991 DOI: 10.1097/00002480-200205000-00002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The discrepancy between the demand and supply of organs for clinical transplantation remains a major problem. The current incidence of end-stage renal disease results in a patient population that doubles every decade. However, there have been no advancements in developing a comparable increase in the number of available allografts. There are three potential approaches to solving the shortage. In the near-term, the development of technology to access the pool of warm ischemically damaged organs may represent a solution. To achieve this goal, it will be necessary to develop technology that mimics the physiologic processes of wound repair. Alternatively, it has been proposed that an increased supply of organs can be developed with xenografts. To make xenotransplantation a clinical reality, it will be necessary to overcome the barriers that exist in nature between the species. Recent work in the area of stem cell research has provided evidence supporting the potential of generating biohybrid organs. A major undertaking of this emerging field will be to develop the ability to define and control the differentiation processes involved in organ specificity. The following is a review of the current status and relative issues involved with these three potential approaches to solving the organ shortage.
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Affiliation(s)
- Lauren Brasile
- Department of Surgery, University Hospital Maastricht, The Netherlands
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65
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Minor T, Hachenberg A, Tolba R, Pauleit D, Akbar S. Fibrinolytic preflush upon liver retrieval from non-heart beating donors to enhance postpreservation viability and energetic recovery upon reperfusion. Transplantation 2001; 71:1792-6. [PMID: 11455260 DOI: 10.1097/00007890-200106270-00015] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Our objective was to evaluate graft equilibration with high viscosity (University of Wisconsin solution [UW]) or low viscosity (Bretschneider's histidine-tryptophan-ketoglutarate [HTK]) during liver procurement from non-heart beating donors (NHBD) and the potential impact of a preceding fibrinolysis with streptokinase on postpreservation viability. METHODS After 60 min of cardiac arrest, rat livers were perfused by gravity (60 cm H2O) via the portal vein with either 60 ml of HTK, 20 ml of UW, or 20 ml of Ringer's solution (22 degrees C including 7500U of streptokinase) and, subsequently, 20 ml of UW. After 24 h of storage at 4 degrees C, viability of the livers was assessed upon isolated reperfusion in vitro. RESULTS Magnetic resonance imaging revealed severe perfusion deficits, which were mildly attenuated with HTK, upon flush-out with UW. After preflush with streptokinase, a mostly homogenous distribution of the preservation solution was observed throughout the liver tissue. The choice of the flush-out solution (UW or HTK) had no influence on parenchymal enzyme leakage, hepatic bile production, or tissue levels of ATP after reperfusion of the livers. Fibrinolytic preflush, however, resulted in a relevant and significant improvement of structural integrity as well as functional and metabolic recovery. CONCLUSIONS Compromised vascular tissue perfusion upon organ harvest in NHBD triggers graft dysfunction after cold storage and can easily be circumvented by temporary fibrinolysis before graft retrieval.
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Affiliation(s)
- T Minor
- Surgical Research Division, University Clinic of Surgery, University of Bonn, 53127 Bonn, Germany.
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66
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Saad S, Minor T, Kötting M, Fu ZX, Hagn U, Paul A, Nagelschmidt M. Extension of ischemic tolerance of porcine livers by cold preservation including postconditioning with gaseous oxygen. Transplantation 2001; 71:498-502. [PMID: 11258427 DOI: 10.1097/00007890-200102270-00003] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Transplantation of organs from nonheartbeating donors was recommended to reduce organ shortage. In vitro experiments with rat livers have shown that the warm ischemic tolerance of the liver may be extended by persufflation with gaseous oxygen during cold storage. The qualification of this method for procurement of livers harvested after cardiac arrest was tested in an in vivo approach with pigs. METHODS Livers from 15 donor pigs were explanted, heparinized, flushed with and stored in University of Wisconsin solution for 4 hr at 4 degrees C, and then implanted into 15 recipients. The organs were dissected immediately after cardiac arrest (group 1) or after 60 min of warm ischemia (groups 2 and 3). Group 2 livers received 75,000 IU of superoxide dismutase together with the flush solution and were persufflated with gaseous oxygen via the venous vascular system during cold storage. Main end point was survival after 5 days. Additionally, metabolic, functional and inflammatory criteria were measured in the blood. RESULTS All animals of the groups 1 and 2 survived, all animals of group 3 died within 3 hr after reperfusion. In all groups the blood parameters reflected significant damage of the livers. However, the ischemic damage was comparable in the groups 1 and 2 whereas the livers of group 3 exhibited significantly higher levels of aspartate alanine aminotransferase and lactate dehydrogenase, and a significantly elongated partial thromboplastin time 1 hr after reperfusion (P=0.016). CONCLUSIONS Venous systemic oxygen persufflation in combination with antioxidative medication is a promising new method of resuscitating ischemically altered livers from nonheartbeating donors for successful transplantation.
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Affiliation(s)
- S Saad
- Second Department of Surgery, University of Cologne, Germany
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67
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Laskowski IA, Hancock WW, Pratchke J, Wilhelm MJ, Tilney NL. Accelerated graft dysfunction in renal isografts from non-heart-beating donors. Transplant Proc 2001; 33:909-10. [PMID: 11267125 DOI: 10.1016/s0041-1345(00)02372-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- I A Laskowski
- Surgical Research Laboratory, Harvard Medical School, Brigham and Womens' Hospital, Boston, MA 02115, USA
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68
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Degawa H, Matsuno N, Iwamoto H, Hama K, Nakamura Y, Narumi Y, Kikuchi K, Uchiyama M, Kozaki K, Nagao T. Primary nonfunctioning grafts in cadaveric kidney transplantation. Transplant Proc 2000; 32:1903-4. [PMID: 11119993 DOI: 10.1016/s0041-1345(00)01485-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- H Degawa
- 5th Surgical Department, Hachioji Medical Center, Tokyo Medical University, Tokyo, Japan
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69
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Yamauchi JI, Richter S, Vollmar B, Menger MD, Minor T. Warm preflush with streptokinase improves microvascular procurement and tissue integrity in liver graft retrieval from non-heart-beating donors. Transplantation 2000; 69:1780-4. [PMID: 10830211 DOI: 10.1097/00007890-200005150-00009] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Apart from the warm ischemic insult, integrity of liver grafts from non-heart-beating donors (NHBD) is additionally affected by microvascular alterations including erythrocyte aggregation and thrombus formation, which might hamper appropriate equilibration of the preservation solution to the grafts' microvasculature precluding cold preservation. Thus, the objective of our study was to characterize microvascular perfusion quality of University of Wisconsin (UW) solution during initial flushout of livers from NHBD rats, and to analyze the effects of an additional warm preflush with Ringer's lactated solution (RL) and with RL containing streptokinase (SK). METHODS Cardiocirculatory arrest was induced by phrenotomy. Subsequent to 30 min of warm ischemia, livers were perfused via an aortic catheter by gravity of 100 cm H2O either with 4 degrees C 100 ml UW solution (UW, n=7), or with 25 degrees C 30 ml RL preflush followed by 4 degrees C 100 ml UW solution (RL+UW, n=7), or with 25 degrees C 30 ml SK- (7500 IU) containing RL preflush and 4 degrees C 100 ml UW solution (SK/RL+UW, n=6). Liver microperfusion was quantified using in situ fluorescence epi-illumination microscopy. Liver microcirculation of sham-operated living animals (n=4) served as controls. Enzyme release after a 24-hr cold preservation period was used as an indicator of graft integrity. RESULTS After 30 min of warm ischemia, microvascular perfusion of UW solution was found markedly altered when compared with that of sham-operated living controls, as indicated by a significant reduction (P<0.05) of acinar and sinusoidal perfusion. Preflush with RL (RL+UW) only slightly attenuated the acinar and sinusoidal perfusion deficits, whereas the addition of SK to RL (SK/RL+UW) resulted in a significant improvement of microvascular graft perfusion (P<0.05). Accordingly, the increased enzyme release observed in solely UW-flushed livers after 24 hr cold preseravtion was only slightly influenced by preflush with RL, but markedly attenuated (P<0.05) by pre-flush with RL containing SK. CONCLUSION The additive fibrinolytic therapy using SK is effective to improve microvascular procurement of livers after warm ischemia and may thus represent a promising approach to attenuate parenchymal cell injury in liver graft retrieval from NHBD.
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Affiliation(s)
- J I Yamauchi
- Institute for Clinical and Experimental Surgery, University of Saarland, 66421 Homburg/Saar and Division of Surgical Research, Surgical Clinic, University of Bonn, Germany
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Affiliation(s)
- D Z Levine
- Ottawa Hospital, University of Ottawa, Ontario, Canada.
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Balupuri S, Buckley P, Snowden C, Mustafa M, Sen B, Griffiths P, Hannon M, Manas D, Kirby J, Talbot D. The trouble with kidneys derived from the non heart-beating donor: a single center 10-year experience. Transplantation 2000; 69:842-6. [PMID: 10755537 DOI: 10.1097/00007890-200003150-00029] [Citation(s) in RCA: 90] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND The demand for renal transplantation has increasingly outstripped the supply of donor organs especially over the past 10 years. Although related and unrelated live donation is being promoted as one option for increasing the donor pool, it is unlikely that this will in itself be able to bridge the gap. Non-heart beating donors (NHBD) can provide an alternative supply of organs, which should substantially increase the donor pool. METHODS In Newcastle, NHBD kidneys have been used for transplantation for a period of 10 years. In the early period (1988-1993) excellent results were obtained (90.5% success); however, these donors were controlled NHBD, Maastricht category III. In the second phase (1994-1998) increasing numbers of donors were obtained from the Accident and Emergency Department unit. These were failed resuscitation for cardiac arrest (category II). The rates of success in this period were poor (45.5% success) and the program was halted. The third phase of the program used machine perfusion of the kidneys and glutathione S transferase enzyme analysis to assess viability. RESULTS Using such approaches renal transplants from largely category II donors produced a success rate of 92.3% which was significantly better than the phase II period of the program (P=0.023, Fisher two-tail test). CONCLUSION Machine perfusion and viability assessment of NHB kidneys in phase III of the program has increased our donor pool as well as improved the graft survival. This is particularly relevant for the use of the category II NHB donor where the incidence of primary nonfunction was high, illustrated by phase II where machine perfusion/viability assessment was not used.
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Affiliation(s)
- S Balupuri
- Department of Surgery, University of Newcastle upon Tyne, UK
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Minor T, Kötting M. Gaseous oxygen for hypothermic preservation of predamaged liver grafts: fuel to cellular homeostasis or radical tissue alteration? Cryobiology 2000; 40:182-6. [PMID: 10788318 DOI: 10.1006/cryo.2000.2231] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Gaseous persufflation with molecular oxygen during cold storage has recently been discussed as an adjunct in the preservation of predamaged livers from non-heart-beating donors. In this study, the actual importance of an antioxidant medication prior to oxygen persufflation was investigated for the first time. Rat livers were excised 60 min after cardiac arrest of the donor, flushed with UW, and stored at 4 degrees C for 24 h. Gaseous oxygen, applied to the livers during the storage period via the caval vein at a pressure limited to 18 mm Hg, was only effective in improving hepatic viability upon reperfusion when antioxidants (superoxide dismutase (SOD) or n-acetylcysteine) were added to the UW rinse solution. Either drug prevented an increase in free radical mediated lipid peroxidation. Acetylcysteine but not SOD also counteracted the phosphorylation of Ikappab and thus the transcriptional activation of NFkappab. Poor results after oxygen persufflation without antioxidants may hence be explained by concomitant free radical induced tissue alterations upon introduction of molecular oxygen into ischemically predamaged organs.
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Affiliation(s)
- T Minor
- Surgical Research Division, University of Bonn, Bonn, 53127, Germany
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Minor T, Akbar S, Yamamoto Y. Adenosine A2 receptor stimulation protects the predamaged liver from cold preservation through activation of cyclic adenosine monophosphate-protein kinase A pathway. Liver Transpl 2000; 6:196-200. [PMID: 10719020 DOI: 10.1002/lt.500060217] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
The shortage of organ donors has led to reconsideration for the use of non-heart-beating donors (NHBDs). However, graft injury caused by warm ischemia in livers from NHBDs strongly affects posttransplantation outcome. The aim of the present study is to investigate the role of adenosine A2 receptor with regard to hepatic viability after cold preservation of NHBD livers. Cardiac arrest was induced in Wistar rats by phrenotomy of the anesthetized nonheparinized animal. After 60 minutes, the livers were excised and flushed with 60 mL of histidine-tryptophan-ketoglutarate (HTK) and stored submerged in HTK at 4 degrees C for 24 hours. Reperfusion was performed in vitro after all livers were incubated at 22 degrees C in saline solution to account for the period of slow rewarming during surgical implantation in vivo. Addition of the selective A2-receptor agonist (CGS 21680; 30microg/100 mL) to the preservation solution resulted in a significant reduction to one quarter of the parenchymal enzyme release of alanine aminotransferase or lactate dehydrogenase on reperfusion and promoted a 2-fold increase in hepatic bile production. This salutory effect was accompanied by a significant increase (40%) in the activity ratio of protein kinase A (PKA) in the liver tissue and could be abrogated in large part by the PKA inhibitor, Rp-cAMPs. Stimulation of the adenosine A2 receptor during harvest and storage of the graft improves maintenance of tissue integrity in liver grafts. A major part of this effect, which may represent a promising approach for the use of NHBD grafts, seems to be mediated through activation of PKA.
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Affiliation(s)
- T Minor
- Division of Surgical Research, Clinic of Surgery, University of Bonn, Germany
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Rizvi SA. Non-heart-beating donor transplantation: machine perfusion preservation is the answer to prolonged cold ischemia time. Transplant Proc 2000; 32:143. [PMID: 10701000 DOI: 10.1016/s0041-1345(99)00913-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- S A Rizvi
- Sindh Institute of Urology and Transplantation (SIUT), Dow Medical College, Karachi, Pakistan.
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Affiliation(s)
- S Aoun
- University of Maryland Medical System, Nephrology Division, Baltimore 21201-1595, USA
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Affiliation(s)
- I A Laskowski
- Harvard Medical School and Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
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Jacobs RW, Kievit JK, Nederstigt AP, Stubenitsky BM, Kootstra G. Non-heartbeating donors: are they worth the effort? Curr Opin Nephrol Hypertens 1998; 7:655-8. [PMID: 9864661 DOI: 10.1097/00041552-199811000-00005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This review on non-heartbeating donation focusses on three issues: the number of kidneys procured from a non-heartbeating donor programme, the transplant results and the influence of a non-heartbeating programme on public opinion regarding transplantation.
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Affiliation(s)
- R W Jacobs
- Department of Surgery, University Hospital Maastricht, The Netherlands.
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