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Croome KP, Lee DD, Taner CB. The "Skinny" on Assessment and Utilization of Steatotic Liver Grafts: A Systematic Review. Liver Transpl 2019; 25:488-499. [PMID: 30817859 DOI: 10.1002/lt.25408] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2018] [Accepted: 12/25/2018] [Indexed: 02/07/2023]
Abstract
The frequency at which steatotic deceased donor liver grafts are encountered will likely continue to increase. Utilization of liver grafts with moderate-to-severe steatosis for liver transplantation (LT) has been previously shown to be associated with increased rates of primary nonfunction and decreased recipient survival. In order to better inform clinical decision making and guide future research, critical evaluation of the literature on donor liver steatosis and posttransplantation outcome is needed. This literature review aims to provide the "skinny" on using deceased donor steatotic livers for LT.
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Affiliation(s)
| | - David D Lee
- Department of Transplant, Mayo Clinic Florida, Jacksonville, FL
| | - C Burcin Taner
- Department of Transplant, Mayo Clinic Florida, Jacksonville, FL
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Extracellular Vesicles from Human Liver Stem Cells Reduce Injury in an Ex Vivo Normothermic Hypoxic Rat Liver Perfusion Model. Transplantation 2019; 102:e205-e210. [PMID: 29424767 DOI: 10.1097/tp.0000000000002123] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND The gold standard for organ preservation before transplantation is static cold storage, which is unable to fully protect suboptimal livers from ischemia/reperfusion injury. An emerging alternative is normothermic machine perfusion (NMP), which permits organ reconditioning. Here, we aimed to explore the feasibility of a pharmacological intervention on isolated rat livers by using a combination of NMP and human liver stem cells-derived extracellular vesicles (HLSC-EV). METHODS We established an ex vivo murine model of NMP capable to maintain liver function despite an ongoing hypoxic injury induced by hemodilution. Livers were perfused for 4 hours without (control group, n = 10) or with HLSC-EV (treated group, n = 9). Bile production was quantified; perfusate samples were collected hourly to measure metabolic (pH, pO2, pCO2) and cytolysis parameters (AST, alanine aminotransferase, lactate dehydrogenase). At the end of perfusion, we assessed HLSC-EV engraftment by immunofluorescence, tissue injury by histology, apoptosis by terminal deoxynucleotidyl transferase dUTP nick-end labeling assay, tissue hypoxia-inducible factor 1-α, and transforming growth factor-beta 1 RNA expression by quantitative reverse transcription-polymerase chain reaction. RESULTS During hypoxic NMP, livers were able to maintain homeostasis and produce bile. In the treated group, AST (P = 0.018) and lactate dehydrogenase (P = 0.032) levels were significantly lower than those of the control group at 3 hours of perfusion, and AST levels persisted lower at 4 hours (P = 0.003). By the end of NMP, HLSC-EV had been uptaken by hepatocytes, and EV treatment significantly reduced histological damage (P = 0.030), apoptosis (P = 0.049), and RNA overexpression of hypoxia-inducible factor 1-α (P < 0.0001) and transforming growth factor-beta 1 (P = 0.014). CONCLUSIONS HLSC-EV treatment, even in a short-duration model, was feasible and effectively reduced liver injury during hypoxic NMP.
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Ashammakhi N, Elkhammas E, Hasan A. Translating advances in organ‐on‐a‐chip technology for supporting organs. J Biomed Mater Res B Appl Biomater 2018; 107:2006-2018. [DOI: 10.1002/jbm.b.34292] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Revised: 09/24/2018] [Accepted: 10/07/2018] [Indexed: 12/11/2022]
Affiliation(s)
- Nureddin Ashammakhi
- Division of Plastic Surgery, Department of SurgeryOulu University Hospital Oulu Finland
- Department of BioengineeringUniversity of California Los Angeles Los Angeles California
- School of Technology and InnovationsUniversity of Vaasa Vaasa Finland
- Biotechnology Research CenterAuthority for Natural Sciences Research and Technology Tripoli Libya
| | - Elmahdi Elkhammas
- Division of Transplantation Surgery, Department of SurgeryThe Ohio State University Wexner Medical Center, Comprehensive Transplant Center Columbus Ohio
| | - Anwarul Hasan
- Department of Mechanical and Industrial EngineeringQatar University Doha Qatar
- Biomedical Research CenterQatar University Doha Qatar
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Boteon YL, Boteon APCS, Attard J, Mergental H, Mirza DF, Bhogal RH, Afford SC. Ex situ machine perfusion as a tool to recondition steatotic donor livers: Troublesome features of fatty livers and the role of defatting therapies. A systematic review. Am J Transplant 2018; 18:2384-2399. [PMID: 29947472 DOI: 10.1111/ajt.14992] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 06/13/2018] [Accepted: 06/18/2018] [Indexed: 02/06/2023]
Abstract
Long-standing research has shown that increased lipid content in donor livers is associated with inferior graft outcomes posttransplant. The global epidemic that is obesity has increased the prevalence of steatosis in organ donors, to the extent that it has become one of the main reasons for declining livers for transplantation. Consequently, it is one of the major culprits behind the discrepancy between the number of donor livers offered for transplantation and those that go on to be transplanted. Steatotic livers are characterized by poor microcirculation, depleted energy stores because of an impaired capacity for mitochondrial recovery, and a propensity for an exaggerated inflammatory response following reperfusion injury culminating in poorer graft function postoperatively. Ex situ machine perfusion, currently a novel method in graft preservation, is showing great promise in providing a tool for the recovery and reconditioning of marginal livers. Hence, reconditioning these steatotic livers using machine perfusion has the potential to increase the number of liver transplants performed. In this review, we consider the problematic issues associated with fatty livers in the realm of transplantation and discuss pharmacological and nonpharmacological options that are being developed to enhance recovery of these organs using machine perfusion and defatting strategies.
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Affiliation(s)
- Yuri L Boteon
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, Institute of Immunology and Immunotherapy, College of Medical and Dental Sciences, University of Birmingham, UK
| | - Amanda P C S Boteon
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Joseph Attard
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Hynek Mergental
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Darius F Mirza
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Ricky H Bhogal
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Simon C Afford
- National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, Institute of Immunology and Immunotherapy, College of Medical and Dental Sciences, University of Birmingham, UK
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Jayant K, Reccia I, Shapiro AMJ. Normothermic ex-vivo liver perfusion: where do we stand and where to reach? Expert Rev Gastroenterol Hepatol 2018; 12:1045-1058. [PMID: 30064278 DOI: 10.1080/17474124.2018.1505499] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Nowadays liver transplantation is considered as the treatment of choice, however, the scarcity of suitable donor organs limits the delivery of care to the end-stage liver disease patients leading to the death while on the waiting list. The advent of ex-situ normothermic machine perfusion (NMP) has emerged as an alternative to the standard organ preservation technique, static cold storage (SCS). The newer technique promises to not only restore the normal metabolic activity but also attempt to recondition the marginal livers back to the pristine state, which are otherwise more susceptible to ischemic injury and foster the poor post-transplant outcomes. Areas covered: An extensive search of all the published literature describing the role of NMP based device in liver transplantation as an alternative to SCS was made on MEDLINE, EMBASE, Cochrane, BIOSIS, Crossref, Scopus databases and clinical trial registry on 10 May 2018. Expert commentary: The main tenet of NMP is the establishment of the physiological milieu, which permits aerobic metabolism to continue through out the period of preservation and limits the effects of ischemia-reperfusion (I/R) injury. In addition, by assessing the various metabolic and synthetic parameters the viability and suitability of donor livers for transplantation can be determined. This important technological advancement has scored satisfactorily on the safety and efficacy parameters in preliminary clinical studies. The present review suggests that NMP can offer the opportunity to assess and safely utilize the marginal donor livers if deemed appropriate for the transplantation. However, ongoing trials will determine its full potential and further adoption.
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Affiliation(s)
- Kumar Jayant
- a Department of Surgery and Cancer , Imperial College London , London , UK
| | - Isabella Reccia
- a Department of Surgery and Cancer , Imperial College London , London , UK
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Akateh C, Beal EW, Whitson BA, Black SM. Normothermic Ex-vivo Liver Perfusion and the Clinical Implications for Liver Transplantation. J Clin Transl Hepatol 2018; 6:276-282. [PMID: 30271739 PMCID: PMC6160298 DOI: 10.14218/jcth.2017.00048] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Revised: 02/07/2018] [Accepted: 03/01/2018] [Indexed: 12/13/2022] Open
Abstract
Despite significant improvements in outcomes after liver transplantation, many patients continue to die on the waiting list, while awaiting an available organ for transplantation. Organ shortage is not only due to an inadequate number of available organs, but also the inability to adequately assess and evaluate these organs prior to transplantation. Over the last few decades, ex-vivo perfusion of the liver has emerged as a useful technique for both improved organ preservation and assessment of organs prior to transplantation. Large animal studies have shown the superiority of ex-vivo perfusion over cold static storage. However, these studies have not, necessarily, been translatable to human livers. Small animal studies have been essential in understanding and improving this technology. Similarly, these results have yet to be translated into clinical use. A few Phase 1 clinical trials have shown promise and confirmed the viability of this technology. However, more robust studies are needed before ex-vivo liver perfusion can be widely accepted as the new clinical standard of organ preservation. Here, we aimed to review all relevant large and small animal research, as well as human liver studies on normothermic ex-vivo perfusion, and to identify areas of deficiency and opportunities for future research endeavors.
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Affiliation(s)
- Clifford Akateh
- General and Gastrointestinal Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
- *Correspondence to: Clifford Akateh, General and Gastrointestinal Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, 395 W 12th Ave, Room 654, Columbus, OH-43210-1267, USA. Tel: +1-614-293-8704, Fax: +1-614-293-4063, E-mail:
| | - Eliza W. Beal
- General and Gastrointestinal Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Bryan A. Whitson
- Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Sylvester M. Black
- Division of Transplant Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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Green CJ, Parry SA, Gunn PJ, Ceresa CDL, Rosqvist F, Piché ME, Hodson L. Studying non-alcoholic fatty liver disease: the ins and outs of in vivo, ex vivo and in vitro human models. Horm Mol Biol Clin Investig 2018; 41:/j/hmbci.ahead-of-print/hmbci-2018-0038/hmbci-2018-0038.xml. [PMID: 30098284 DOI: 10.1515/hmbci-2018-0038] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 06/22/2018] [Indexed: 02/07/2023]
Abstract
The prevalence of non-alcoholic fatty liver disease (NAFLD) is increasing. Determining the pathogenesis and pathophysiology of human NAFLD will allow for evidence-based prevention strategies, and more targeted mechanistic investigations. Various in vivo, ex situ and in vitro models may be utilised to study NAFLD; but all come with their own specific caveats. Here, we review the human-based models and discuss their advantages and limitations in regards to studying the development and progression of NAFLD. Overall, in vivo whole-body human studies are advantageous in that they allow for investigation within the physiological setting, however, limited accessibility to the liver makes direct investigations challenging. Non-invasive imaging techniques are able to somewhat overcome this challenge, whilst the use of stable-isotope tracers enables mechanistic insight to be obtained. Recent technological advances (i.e. normothermic machine perfusion) have opened new opportunities to investigate whole-organ metabolism, thus ex situ livers can be investigated directly. Therefore, investigations that cannot be performed in vivo in humans have the potential to be undertaken. In vitro models offer the ability to perform investigations at a cellular level, aiding in elucidating the molecular mechanisms of NAFLD. However, a number of current models do not closely resemble the human condition and work is ongoing to optimise culturing parameters in order to recapitulate this. In summary, no single model currently provides insight into the development, pathophysiology and progression across the NAFLD spectrum, each experimental model has limitations, which need to be taken into consideration to ensure appropriate conclusions and extrapolation of findings are made.
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Affiliation(s)
- Charlotte J Green
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Churchill Hospital, Oxford, UK
| | - Siôn A Parry
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Churchill Hospital, Oxford, UK
| | - Pippa J Gunn
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Churchill Hospital, Oxford, UK
| | - Carlo D L Ceresa
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Churchill Hospital, Oxford, UK
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Fredrik Rosqvist
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Churchill Hospital, Oxford, UK
- Department of Public Health and Caring Sciences, Clinical Nutrition and Metabolism, Uppsala University, Uppsala, Sweden
| | - Marie-Eve Piché
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Churchill Hospital, Oxford, UK
- Quebec Heart and Lung Institute, Laval University, Quebec, Canada
| | - Leanne Hodson
- University of Oxford, Oxford Centre for Diabetes, Endocrinology and Metabolism, Radcliffe Department of Medicine, Churchill Hospital,Old Road Headington, Oxford OX3 7LE, United Kingdom of Great Britain and Northern Ireland
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Vinaixa C, Selzner N, Berenguer M. Fat and liver transplantation: clinical implications. Transpl Int 2018; 31:828-837. [DOI: 10.1111/tri.13288] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 03/14/2018] [Accepted: 06/01/2018] [Indexed: 02/06/2023]
Affiliation(s)
- Carmen Vinaixa
- Hepatology and Liver Transplantation Unit; Hospital Universitario y Politécnico La Fe; Valencia Spain
| | - Nazia Selzner
- Multi Organ Transplant Program; Liver Transplant Unit; University Health Network; University of Toronto; Toronto ON Canada
| | - Marina Berenguer
- Hepatology and Liver Transplantation Unit; Hospital Universitario y Politécnico La Fe; Valencia Spain
- CIBERehd; Instituto Carlos III; Madrid Spain
- Faculty of Medicine; University of Valencia; Valencia Spain
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Eshmuminov D, Leoni F, Schneider MA, Becker D, Muller X, Onder C, Hefti M, Schuler MJ, Dutkowski P, Graf R, Rudolf von Rohr P, Clavien PA, Bautista Borrego L. Perfusion settings and additives in liver normothermic machine perfusion with red blood cells as oxygen carrier. A systematic review of human and porcine perfusion protocols. Transpl Int 2018; 31:956-969. [PMID: 29928775 DOI: 10.1111/tri.13306] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 06/10/2018] [Accepted: 06/18/2018] [Indexed: 12/30/2022]
Abstract
Liver machine perfusion (MP) at normothermic temperature (NMP) is a promising way to preserve and evaluate extended criteria donor livers. Currently, no consensus exists in methodology and perfusion protocols. Here, the authors performed a systematic literature search to identify human and porcine studies reporting on liver NMP with red blood cells. A qualitative synthesis was performed concerning technical aspects of MP, fluid composition, gas supply, and liver positioning. Thirty-seven publications including 11 human and 26 porcine studies were considered for qualitative synthesis. Control mode, pressure, flow, perfusate additives, and targeted blood gas parameters varied across human as well as porcine studies. For future analyses, it is advisable to report flow adjusted to liver weight and exact pressure parameters including mean, systolic, and diastolic pressure. Parenteral nutrition and insulin addition was common. Parenteral nutrition included amino acids and/or glucose without lipids. Taurocholic acid derivatives were used as bile flow promoters. However, short-term human NMP without taurocholic acid derivatives seems to be possible. This finding is relevant due to the lack of clinical grade bile salts. Near physiological oxygen tension in the perfusate is doable by adjusting gas flows, while blood gas parameters regulation needs more detailed description.
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Affiliation(s)
- Dilmurodjon Eshmuminov
- Department of Surgery, Swiss HPB and Transplantation Center, University Hospital Zurich, Zurich, Switzerland
| | - Filippo Leoni
- Department of Surgery, Swiss HPB and Transplantation Center, University Hospital Zurich, Zurich, Switzerland
| | - Marcel André Schneider
- Department of Surgery, Swiss HPB and Transplantation Center, University Hospital Zurich, Zurich, Switzerland
| | - Dustin Becker
- Wyss Zurich - ETH Zurich/University of Zurich, Zurich, Switzerland
| | - Xavier Muller
- Department of Surgery, Swiss HPB and Transplantation Center, University Hospital Zurich, Zurich, Switzerland
| | - Christopher Onder
- Institute for Dynamic Systems and Control, ETH Zurich, Zurich, Switzerland
| | - Max Hefti
- Wyss Zurich - ETH Zurich/University of Zurich, Zurich, Switzerland
| | - Martin J Schuler
- Wyss Zurich - ETH Zurich/University of Zurich, Zurich, Switzerland
| | - Philipp Dutkowski
- Department of Surgery, Swiss HPB and Transplantation Center, University Hospital Zurich, Zurich, Switzerland
| | - Rolf Graf
- Department of Surgery, Swiss HPB and Transplantation Center, University Hospital Zurich, Zurich, Switzerland
| | | | - Pierre-Alain Clavien
- Department of Surgery, Swiss HPB and Transplantation Center, University Hospital Zurich, Zurich, Switzerland
| | - Lucia Bautista Borrego
- Department of Surgery, Swiss HPB and Transplantation Center, University Hospital Zurich, Zurich, Switzerland
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Jayant K, Reccia I, Virdis F, Shapiro AMJ. The Role of Normothermic Perfusion in Liver Transplantation (TRaNsIT Study): A Systematic Review of Preliminary Studies. HPB SURGERY : A WORLD JOURNAL OF HEPATIC, PANCREATIC AND BILIARY SURGERY 2018; 2018:6360423. [PMID: 29887782 PMCID: PMC5985064 DOI: 10.1155/2018/6360423] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 04/18/2018] [Indexed: 12/17/2022]
Abstract
INTRODUCTION The success of liver transplantation has been limited by the unavailability of suitable donor livers. The current organ preservation technique, i.e., static cold storage (SCS), is not suitable for marginal organs. Alternatively, normothermic machine perfusion (NMP) promises to recreate the physiological environment and hence holds promise for the better organ preservation. The objective of this systematic review is to provide an overview of the safety, benefits, and insight into the other potential useful parameters of NMP in the liver preservation. MATERIAL AND METHODS We searched the current literature following registration in the International Prospective Register of Systematic Reviews (PROSPERO) with registration number CRD42018086034 for prospective trials comparing the role of NMP device to SCS in liver transplant by searching the PubMed, EMBASE, Cochrane, BIOSIS, Crossref, and Scopus databases and clinical trial registry. RESULTS The literature search identified five prospective clinical trials (four being early phase single institutional and single randomized multi-institutional) comparing 187 donor livers on NMP device to 273 donor livers on SCS. The primary outcome of interest was to assess the safety and graft survival at day 30 after transplant following NMP of the donor liver. Secondary outcomes included were early allograft dysfunction (EAD) in the first seven days; serum measures of liver functions as bilirubin, aspartate aminotransferase (AST), alanine amino transferase (ALT), alkaline phosphatase (ALP), and international normalized ratio (INR) on days 1-7; major complications as defined by a Clavien-Dindo score ≥ 3; and patient and graft survival and biliary complications at six months. The peaked median AST level between days 1 and 7 in the five trials was 417-1252 U/L (range 84-15009 U/L) while on NMP and 839-1474 U/L (range 153-8786 U/L) in SCS group. The median bilirubin level on day 7 ranged within 25-79 µmol/L (range 8-344 µmol/l) and 30-47.53 µmol/l (range 9-340 µmol/l) in NMP and SCS groups, respectively. A single case of PNF was reported in NMP group in the randomized trial while none of the other preliminary studies reported any in either group. There was intertrial variability in EAD which ranged within 15-56% in NMP group while being within 23-37% in SCS group. Biliary complications observed in NMP group ranged from 0 to 20%. Single device malfunction was reported in randomized controlled trial leading to renouncement of transplant while none of the other trials reported any machine failure, although two user related device errors inadvertent were reported. CONCLUSION This review outlines that NMP not only demonstrated safety and efficacy but also provided the favourable environment of organ preservation, repair, and viability assessment to donor liver prior to the transplantation with low rate of posttransplantation complication as PNF, EAD, and biliary complication; however further studies are needed to broaden our horizon.
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Affiliation(s)
- Kumar Jayant
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Isabella Reccia
- Department of Surgery and Cancer, Imperial College London, London, UK
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Kumar R, Chung WY, Runau F, Isherwood JD, Kuan KG, West K, Garcea G, Dennison AR. Ex vivo normothermic porcine pancreas: A physiological model for preservation and transplant study. Int J Surg 2018; 54:206-215. [PMID: 29730077 DOI: 10.1016/j.ijsu.2018.04.057] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2017] [Revised: 04/04/2018] [Accepted: 04/29/2018] [Indexed: 10/17/2022]
Abstract
INTRODUCTION An ex vivo normothermic porcine pancreas perfusion (ENPPP) model was established to investigate effects of machine perfusion pressures on graft preservation. METHODOLOGY Nine porcine pancreata were perfused with autologous blood at 50 mmHg (control) pressure. Graft viability was compared against four ex-vivo porcine pancreata perfused at 20 mmHg ('low') pressure. Arterio-venous oxygen gas differentials, biochemistry, and graft insulin responses to glucose stimulation were compared. Immunohistochemistry stains compared the cellular viability. RESULTS Control pancreata were perfused for a median of 3 h (range 2-4 h) with a mean pressure 50 mmHg and graft flow 141 mL min-1. In comparison, all of the 'low' pressure models were perfused for 4 h, with mean perfusion pressure 20 mmHg and graft flow 40 mL.min-1. All pancreata demonstrated cellular viability with evidence of oxygen consumption with preserved endocrine and exocrine function. However, following statistical analysis, the 'low' pressure perfusion of porcine pancreata compared favourably in important biochemical and immunohistochemistry cellular profiles; potentially arguing for an improved method for graft preservation. CONCLUSION ENPPP will facilitate whole organ preservation to be studied in further detail and avoids use of expensive live animals. ENPPP is reproducible and mimics a "donation after circulatory death" scenario.
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Affiliation(s)
- Rohan Kumar
- Department of Hepato-Pancreato-Biliary Surgery, University Hospitals of Leicester, Leicester, LE5 4PW, United Kingdom.
| | - Wen Yuan Chung
- Department of Hepato-Pancreato-Biliary Surgery, University Hospitals of Leicester, Leicester, LE5 4PW, United Kingdom
| | - Franscois Runau
- Department of Hepato-Pancreato-Biliary Surgery, University Hospitals of Leicester, Leicester, LE5 4PW, United Kingdom
| | - John David Isherwood
- Department of Hepato-Pancreato-Biliary Surgery, University Hospitals of Leicester, Leicester, LE5 4PW, United Kingdom
| | - Kean Guan Kuan
- Department of Hepato-Pancreato-Biliary Surgery, University Hospitals of Leicester, Leicester, LE5 4PW, United Kingdom
| | - Kevin West
- Department of Hepato-Pancreato-Biliary Surgery, University Hospitals of Leicester, Leicester, LE5 4PW, United Kingdom
| | - Giuseppe Garcea
- Department of Hepato-Pancreato-Biliary Surgery, University Hospitals of Leicester, Leicester, LE5 4PW, United Kingdom
| | - Ashley Robert Dennison
- Department of Hepato-Pancreato-Biliary Surgery, University Hospitals of Leicester, Leicester, LE5 4PW, United Kingdom
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Bral M, Gala-Lopez B, Bigam DL, Freed DH, Shapiro AMJ. Ex situ liver perfusion: Organ preservation into the future. Transplant Rev (Orlando) 2018; 32:132-141. [PMID: 29691119 DOI: 10.1016/j.trre.2018.03.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Revised: 03/27/2018] [Accepted: 03/27/2018] [Indexed: 12/15/2022]
Abstract
In recent years, remarkable progress has occurred in the development of technologies to support ex situ liver perfusion. Building upon extensive preclinical studies in large animal models, pilot and randomized clinical trials have been initiated, and preliminary outcomes suggest more optimal protection of both standard and extended criteria liver grafts. There currently exists an incredible opportunity and need to further refine this technology, determine appropriate viability measures to predict usable liver grafts, and to explore potent protective additive strategies to further optimize the quality of extended criteria organs. These findings will have major bearing in expanding the limited liver donor pool, and may save lives where up to a quarter of listed patients die on wait-lists. Herein we offer a brief overview of the history and current status of ex situ liver perfusion, and discuss future directions that will likely have major impact on the practice of clinical liver transplantation.
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Affiliation(s)
- Mariusz Bral
- Department of Surgery, University of Alberta, 2D4.43 Walter D MacKenzie Health Sciences Centre, 8440 112 St, Edmonton, Alberta T6G2B7, Canada; Members of the Canadian National Transplant Research Program (CNTRP), 2D4.43 Walter D MacKenzie Health Sciences Centre, 8440 112 St, Edmonton, Alberta T6G2B7, Canada.
| | - Boris Gala-Lopez
- Department of Surgery, University of Alberta, 2D4.43 Walter D MacKenzie Health Sciences Centre, 8440 112 St, Edmonton, Alberta T6G2B7, Canada; Members of the Canadian National Transplant Research Program (CNTRP), 2D4.43 Walter D MacKenzie Health Sciences Centre, 8440 112 St, Edmonton, Alberta T6G2B7, Canada.
| | - David L Bigam
- Department of Surgery, University of Alberta, 2D4.43 Walter D MacKenzie Health Sciences Centre, 8440 112 St, Edmonton, Alberta T6G2B7, Canada; Members of the Canadian National Transplant Research Program (CNTRP), 2D4.43 Walter D MacKenzie Health Sciences Centre, 8440 112 St, Edmonton, Alberta T6G2B7, Canada.
| | - Darren H Freed
- Department of Surgery, University of Alberta, 2D4.43 Walter D MacKenzie Health Sciences Centre, 8440 112 St, Edmonton, Alberta T6G2B7, Canada; Members of the Canadian National Transplant Research Program (CNTRP), 2D4.43 Walter D MacKenzie Health Sciences Centre, 8440 112 St, Edmonton, Alberta T6G2B7, Canada.
| | - A M James Shapiro
- Department of Surgery, University of Alberta, 2D4.43 Walter D MacKenzie Health Sciences Centre, 8440 112 St, Edmonton, Alberta T6G2B7, Canada; Members of the Canadian National Transplant Research Program (CNTRP), 2D4.43 Walter D MacKenzie Health Sciences Centre, 8440 112 St, Edmonton, Alberta T6G2B7, Canada.
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Pushing the Limits: Machine Preservation of the Liver as a Tool to Recondition High-Risk Grafts. CURRENT TRANSPLANTATION REPORTS 2018; 5:113-120. [PMID: 29774176 PMCID: PMC5945712 DOI: 10.1007/s40472-018-0188-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Purpose of the Review Machine perfusion (MP) is a novel technology recently introduced in liver transplantation, redefining the current practice of organ preservation and pushing the limits of high-risk liver utilisation. This review highlights the key benefits of machine perfusion over conventional static cold storage (SCS), demonstrated in human liver research and clinical transplants. Recent Findings The first clinical trials have demonstrated both safety and feasibility of MP. The most recent transplant series and result from a randomised trial suggest the technology is superior to SCS. The key benefits include extended period of organ preservation, decreased incidence of early allograft dysfunction and reduction of biliary complications. Normothermic liver perfusion allows viability testing to guide transplantability of the highest-risk organs. This technology also provides opportunities for therapeutic interventions to improve liver function and quality in organs that are currently declined for clinical use. Summary Machine perfusion is likely to transform the liver preservation pathway and to improve utilisation of high-risk grafts.
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Ceresa CDL, Nasralla D, Jassem W. Normothermic Machine Preservation of the Liver: State of the Art. CURRENT TRANSPLANTATION REPORTS 2018; 5:104-110. [PMID: 29564207 PMCID: PMC5843699 DOI: 10.1007/s40472-018-0186-9] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Purpose of Review This review aims to introduce the concept of normothermic machine perfusion (NMP) and its role in liver transplantation. By discussing results from recent clinical studies and highlighting the potential opportunities provided by this technology, we aim to provide a greater insight into NMP and the role it can play to enhance liver transplantation. Recent Findings NMP has recently been shown to be both safe and feasible in liver transplantation and has also demonstrated its superiority to traditional cold storage in terms of early biochemical liver function. Through the ability to perform a viability assessment during preservation and extend preservation times, it is likely that an increase in organ utilisation will follow. NMP may facilitate the enhanced preservation with improved outcomes from donors after cardiac death and steatotic livers. Furthermore, it provides the exciting potential for liver-directed therapeutic interventions. Summary Evidence to date suggests that NMP facilitates the enhanced preservation of liver grafts with improved early post-transplant outcomes. The key role for this technology is to increase the number and quality of liver grafts available for transplantation and to reduce waiting list deaths.
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Affiliation(s)
- Carlo D L Ceresa
- 1Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - David Nasralla
- 1Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Wayel Jassem
- 2Institute of Liver Studies, King's College Hospital, London, UK
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Ceresa CDL, Nasralla D, Coussios CC, Friend PJ. The case for normothermic machine perfusion in liver transplantation. Liver Transpl 2018; 24:269-275. [PMID: 29272051 DOI: 10.1002/lt.25000] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 12/19/2017] [Indexed: 12/22/2022]
Abstract
In recent years, there has been growing interest in normothermic machine perfusion (NMP) as a preservation method in liver transplantation. In most countries, because of a donor organ shortage, an unacceptable number of patients die while awaiting transplantation. In an attempt to increase the number of donor organs available, transplant teams are implanting a greater number of high-risk livers, including those from donation after circulatory death, older donors, and donors with steatosis. NMP maintains the liver ex vivo on a circuit by providing oxygen and nutrition at 37°C. This permits extended preservation times, the ability to perform liver viability assessment, and the potential for liver-directed therapeutic interventions during preservation. It is hoped that this technology may facilitate the enhanced preservation of marginal livers with improved posttransplant outcomes by reducing ischemia/reperfusion injury. Clinical trials have demonstrated its short-term superiority over cold storage in terms of early biochemical liver function, and it is anticipated that it may result in increased organ utilization, helping to reduce the number of wait-list deaths. However, further studies are required to demonstrate longer-term efficacy and the impact on biliary complications as well as further knowledge to exploit and maximize the potential of this exciting new technology. Liver Transplantation 24 269-275 2018 AASLD.
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Affiliation(s)
- Carlo D L Ceresa
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - David Nasralla
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | | | - Peter J Friend
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
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Liu Q, Nassar A, Buccini L, Iuppa G, Soliman B, Pezzati D, Hassan A, Blum M, Baldwin W, Bennett A, Chavin K, Okamoto T, Uso TD, Fung J, Abu-Elmagd K, Miller C, Quintini C. Lipid metabolism and functional assessment of discarded human livers with steatosis undergoing 24 hours of normothermic machine perfusion. Liver Transpl 2018; 24:233-245. [PMID: 29125712 DOI: 10.1002/lt.24972] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 09/18/2017] [Accepted: 11/05/2017] [Indexed: 02/07/2023]
Abstract
Normothermic machine perfusion (NMP) is an emerging technology to preserve liver allografts more effectively than cold storage (CS). However, little is known about the effect of NMP on steatosis and the markers indicative of hepatic quality during NMP. To address these points, we perfused 10 discarded human livers with oxygenated NMP for 24 hours after 4-6 hours of CS. All livers had a variable degree of steatosis at baseline. The perfusate consisted of packed red blood cells and fresh frozen plasma. Perfusate analysis showed an increase in triglyceride levels from the 1st hour (median, 127 mg/dL; interquartile range [IQR], 95-149 mg/dL) to 24th hour of perfusion (median, 203 mg/dL; IQR, 171-304 mg/dL; P = 0.004), but tissue steatosis did not decrease. Five livers produced a significant amount of bile (≥5 mL/hour) consistently throughout 24 hours of NMP. Lactate in the perfusate cleared to <3 mmol/L in most livers within 4-8 hours of NMP, which was independent of bile production rate. This is the first study to characterize the lipid profile and functional assessment of discarded human livers at 24 hours of NMP. Liver Transplantation 24 233-245 2018 AASLD.
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Affiliation(s)
- Qiang Liu
- Transplantation Center, Cleveland Clinic, Cleveland, OH
| | - Ahmed Nassar
- Transplantation Center, Cleveland Clinic, Cleveland, OH
| | - Laura Buccini
- Transplantation Center, Cleveland Clinic, Cleveland, OH
| | | | - Basem Soliman
- Transplantation Center, Cleveland Clinic, Cleveland, OH
| | | | - Ahmed Hassan
- Transplantation Center, Cleveland Clinic, Cleveland, OH
| | - Matthew Blum
- Transplantation Center, Cleveland Clinic, Cleveland, OH
| | | | - Ana Bennett
- Transplantation Center, Cleveland Clinic, Cleveland, OH
| | - Kenneth Chavin
- University Hospital, Case Western Reserve University, Cleveland, OH
| | | | | | - John Fung
- Transplantation Center, Cleveland Clinic, Cleveland, OH
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Reiling J, Forrest E, Bridle KR, Britton LJ, Santrampurwala N, Crawford DH, Dejong CH, Fawcett J. The Implications of the Shift Toward Donation After Circulatory Death in Australia. Transplant Direct 2017; 3:e226. [PMID: 29536027 PMCID: PMC5828691 DOI: 10.1097/txd.0000000000000743] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 09/08/2017] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND In recent years, an increasing number of donor livers are being declined for transplantation in Australia. The aim of this study was to evaluate the impact of donation after cardiac death and other factors associated with organ quality on liver utilization rates in Australia. METHODS Data on organ donors who donated at least 1 organ between 2005 and 2014 were obtained from the Australia and New Zealand organ donation registry. Temporal changes in donor characteristics were assessed and a logistical regression analysis was performed to evaluate their association with liver nonuse. RESULTS The number of organ donors increased from 175 in 2005 to 344 in 2014, with overall 19% being donation after cardiac death donors (P < 0.001). The percentage of livers deemed unsuitable for transplantation increased from 24% in 2005 to 41% in 2014 (P < 0.001). Donation after cardiac death was identified as the most important risk factor for nonuse with an odds ratio of 25.88 (95% confidence interval, 18.84-35.56), P < 0.001) followed by donor age, obesity, and diabetes. DISCUSSION This study shows that livers donated after circulatory death are an underused resource in Australia. Better use of these currently available organs would be a highly cost-effective way of reducing waiting list mortality in liver transplantation.
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Affiliation(s)
- Janske Reiling
- Faculty of Medicine, the University of Queensland, Brisbane, Australia
- Australian and New Zealand Organ Donation, Adelaide, Australia
- Gallipoli Medical Research Institute, Greenslopes Private Hospital, Brisbane, Australia
- Department of Surgery, NUTRIM - School for Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands
| | - Elizabeth Forrest
- Queensland Liver Transplant Service, Princess Alexandra Hospital, Brisbane, Australia
| | | | - Laurence J. Britton
- Faculty of Medicine, the University of Queensland, Brisbane, Australia
- Gallipoli Medical Research Institute, Greenslopes Private Hospital, Brisbane, Australia
| | - Nishreen Santrampurwala
- Faculty of Medicine, the University of Queensland, Brisbane, Australia
- Gallipoli Medical Research Institute, Greenslopes Private Hospital, Brisbane, Australia
| | - Darrell H.G. Crawford
- Faculty of Medicine, the University of Queensland, Brisbane, Australia
- Gallipoli Medical Research Institute, Greenslopes Private Hospital, Brisbane, Australia
| | - Cornelis H.C. Dejong
- Department of Surgery, NUTRIM - School for Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands
- Department of Surgery, RWTH Universitätsklinikum Aachen, Aachen, Germany
| | - Jonathan Fawcett
- Faculty of Medicine, the University of Queensland, Brisbane, Australia
- Department of Surgery, RWTH Universitätsklinikum Aachen, Aachen, Germany
- PA Research Foundation, Princess Alexandra Hospital, Brisbane, Australia
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Abstract
PURPOSE OF REVIEW The liberalization of donor selection criteria in organ transplantation, with the increased use of suboptimal grafts, has stimulated interest in ischemia-reperfusion injury prevention and graft reconditioning. Organ preservation technologies are changing considerably, mostly through the reintroduction of dynamic machine preservation. Here, we review the current evidence on the role of temperature and oxygenation during dynamic machine preservation. RECENT FINDINGS A large but complex body of evidence exists and comparative studies are few. Oxygenation seems to support an advantageous effect in hypothermic machine preservation and is mandatory in normothermic machine preservation, although in the latter, supraphysiological oxygen tensions should be avoided. High-risk grafts, such as suboptimal organs, may optimally benefit from oxygenated perfusion conditions that support metabolism and activate mechanisms of repair such as subnormothermic machine preservation, controlled oxygenated rewarming, and normothermic machine preservation. For lower risk grafts, oxygenation during hypothermic machine preservation may sufficiently reduce injuries and recharge the cellular energy to secure functional recovery after transplantation. SUMMARY The relationship between temperature and oxygenation in organ preservation is more complex than physiological laws would suggest. Rather than one default perfusion temperature/oxygenation standard, perfusion protocols should be tailored for specific needs of grafts of different quality.
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Cold storage or normothermic perfusion for liver transplantation: probable application and indications. Curr Opin Organ Transplant 2017; 22:300-305. [PMID: 28301388 DOI: 10.1097/mot.0000000000000410] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
PURPOSE OF REVIEW Preservation of the liver via normothermic machine perfusion (NMP) is rapidly becoming an area of great academic and clinical interest. This review focuses on the benefits and limitations of NMP and where the role for static cold storage may lie. RECENT FINDINGS Clinical studies have recently been published reporting the use of NMP in liver preservation for transplantation. They have described the technology to be well tolerated and feasible with potentially improved posttransplant outcomes. NMP facilitates extended preservation times as well as the potential to increase organ utilization through viability assessment and regeneration. However, this technology is considerably more costly than cold storage and carries significant logistical challenges. Cold storage remains the gold standard preservation for standard criteria livers with good long-term patient and graft survival. SUMMARY NMP is an exciting new technological advancement in liver preservation, which is likely to have a positive impact in liver transplantation. However, randomized controlled trials are required to justify its inclusion into standard practice and provide evidence to support its efficacy.
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Ghinolfi D, Rreka E, Pezzati D, Filipponi F, De Simone P. Perfusion machines and hepatocellular carcinoma: a good match between a marginal organ and an advanced disease? Transl Gastroenterol Hepatol 2017; 2:87. [PMID: 29264425 DOI: 10.21037/tgh.2017.10.01] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Accepted: 09/27/2017] [Indexed: 12/12/2022] Open
Abstract
Hepatocellular carcinoma (HCC) accounts for 90% of primary liver cancers, is the second leading cause of cancer-related deaths and the leading cause of death in patients with cirrhosis. Liver transplantation (LT) represents the ideal treatment for selected patients as it removes both the tumor and the underlying cirrhotic liver with 5-year survival rates higher than 70%. Unfortunately, due to tumor characteristics, patient co-morbidities or shortage of organs available for transplant, only 20% of patients can undergo curative treatment. Ex situ machine perfusion (MP) is a technology recently introduced that might potentially improve organ preservation, allow graft assessment and increase the pool of available organs. The purpose of this review is to provide an update on the current role of ex situ liver MP in liver transplantation for HCC patients.
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Affiliation(s)
- Davide Ghinolfi
- Division of Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Tuscany, Italy
| | - Erion Rreka
- Division of Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Tuscany, Italy
| | - Daniele Pezzati
- Division of Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Tuscany, Italy
| | - Franco Filipponi
- Division of Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Tuscany, Italy
| | - Paolo De Simone
- Division of Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Tuscany, Italy
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Hamar M, Selzner M. Steatotic donor livers: Where is the risk-benefit maximized? Liver Transpl 2017; 23:S34-S39. [PMID: 28734124 DOI: 10.1002/lt.24826] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Revised: 07/19/2017] [Accepted: 07/20/2017] [Indexed: 02/07/2023]
Affiliation(s)
- Matyas Hamar
- Multi Organ Transplant Program, Department of Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Markus Selzner
- Multi Organ Transplant Program, Department of Surgery, Toronto General Hospital, Toronto, Ontario, Canada
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Abstract
The demand of donor livers for transplantation exceeds the supply. In an attempt to maximize the number of potentially usable donor livers, several centers are exploring the role of machine perfusion. This review provides an update on machine perfusion strategies and basic concepts, based on current clinical issues, and discuss challenges, including currently used biomarkers for assessing the quality and viability of perfused organs. The potential benefits of machine perfusion on immunogenicity and the consequences on post-operative immunosuppression management are discussed.
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Kumar R, Chung WY, Dennison AR, Garcea G. Ex Vivo Porcine Organ Perfusion Models as a Suitable Platform for Translational Transplant Research. Artif Organs 2017; 41:E69-E79. [PMID: 28266040 DOI: 10.1111/aor.12865] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Revised: 08/03/2016] [Accepted: 08/24/2016] [Indexed: 12/24/2022]
Abstract
In transplantation surgery, extending the criteria for organ donation to include organs that may have otherwise been previously discarded has provided the impetus to improve organ preservation. The traditional method of cold static storage (CS) has been tried and tested and is suitable for organs meeting standard criteria donation. Ex vivo machine perfusion is, however, associated with evidence suggesting that it may be better than CS alone and may allow for organ donation criteria to be extended. Much of our knowledge of organ preservation is derived from animal studies. We review ex vivo porcine organ perfusion models and discuss the relevance to the field of transplantation surgery. Following a systematic literature search, only articles that reported on experimental studies with focus on any aspect(s) of ex vivo and porcine perfusion of organs yet limited to the context of organ transplantation surgery were included. The database search and inclusion/exclusion criteria identified 22 journal articles. All 22 articles discussed ex vivo porcine organ perfusion within the context of transplant preservation surgery: 8 liver, 3 kidney, 3 lung, 2 pancreas/islet, 4 discussed a combined liver-kidney multiorgan model, 1 small bowel, and 1 cardiac perfusion model systems. The ex vivo porcine perfusion model is a suitable, reliable, and safe translational research model. It has advantages to investigate organ preservation techniques in a reproducible fashion in order to improve our understanding and has implications to extend the criteria for organ donation.
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Affiliation(s)
- Rohan Kumar
- Department of Hepato-Pancreato-Biliary Surgery, University Hospitals of Leicester, Leicester, UK
| | - Wen Yuan Chung
- Department of Hepato-Pancreato-Biliary Surgery, University Hospitals of Leicester, Leicester, UK
| | | | - Giuseppe Garcea
- Department of Hepato-Pancreato-Biliary Surgery, University Hospitals of Leicester, Leicester, UK
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Echeverri J, Selzner M. "In 10 years" debate: Con-machine perfusion will be limited to specific situations (Steatotic, donation after circulatory death). Liver Transpl 2016; 22:29-32. [PMID: 27588758 DOI: 10.1002/lt.24622] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Accepted: 08/30/2016] [Indexed: 12/31/2022]
Affiliation(s)
- Juan Echeverri
- Department of Surgery, Multi Organ Transplant Program, Toronto General Hospital, Toronto, ON, Canada
| | - Markus Selzner
- Department of Surgery, Multi Organ Transplant Program, Toronto General Hospital, Toronto, ON, Canada.
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Gilbo N, Catalano G, Salizzoni M, Romagnoli R. Liver graft preconditioning, preservation and reconditioning. Dig Liver Dis 2016; 48:1265-1274. [PMID: 27448845 DOI: 10.1016/j.dld.2016.06.031] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Revised: 05/02/2016] [Accepted: 06/27/2016] [Indexed: 12/11/2022]
Abstract
Liver transplantation is the successful treatment of end-stage liver disease; however, the ischaemia-reperfusion injury still jeopardizes early and long-term post-transplant outcomes. In fact, ischaemia-reperfusion is associated with increased morbidity and graft dysfunction, especially when suboptimal donors are utilized. Strategies to reduce the severity of ischaemia-reperfusion can be applied at different steps of the transplantation process: organ procurement, preservation phase or before revascularization. During the donor procedure, preconditioning consists of pre-treating the graft prior to a sustained ischaemia either by a transient period of ischaemia-reperfusion or administration of anti-ischaemic medication, although a multi-pharmacological approach seems more promising. Different preservation solutions were developed to maintain graft viability during static cold storage, achieving substantial results in terms of liver function and survival in good quality organs but not in suboptimal ones. Indeed, preservation solutions do not prevent dysfunction of poor quality organs and are burdened with inadequate preservation of the biliary epithelium. Advantages derived from either hypo- or normothermic machine perfusion are currently investigated in experimental and clinical settings, suggesting a reconditioning effect possibly improving hepatocyte and biliary preservation and resuscitating graft function prior to transplantation. In this review, we highlight acquired knowledge and recent advances in liver graft preconditioning, preservation and reconditioning.
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Affiliation(s)
- Nicholas Gilbo
- Liver Transplantation Center, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Giorgia Catalano
- Liver Transplantation Center, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Mauro Salizzoni
- Liver Transplantation Center, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Renato Romagnoli
- Liver Transplantation Center, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy.
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Quillin RC, Guarrera JV. "In 10 years" of debate: Pro-machine perfusion for liver preservation will be universal. Liver Transpl 2016; 22:25-28. [PMID: 27597547 DOI: 10.1002/lt.24630] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Accepted: 08/29/2016] [Indexed: 12/31/2022]
Affiliation(s)
- R Cutler Quillin
- Center for Liver Disease and Transplantation, Department of Surgery, Columbia University Medical Center, New York, NY
| | - James V Guarrera
- Center for Liver Disease and Transplantation, Department of Surgery, Columbia University Medical Center, New York, NY.
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Affiliation(s)
- Babak Banan
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Yiing Lin
- Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - William Chapman
- Department of Surgery, Washington University School of Medicine, St. Louis, MO.
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Quillin RC, Guarrera JV. Machine Perfusion for the Assessment and Resuscitation of Marginal Donors in Liver Transplantation. CURRENT TRANSPLANTATION REPORTS 2016. [DOI: 10.1007/s40472-016-0131-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Abstract
BACKGROUND The high demand for livers for transplantation has led to organs of limited quality being accepted to expand the donor pool. This is associated with inferior outcomes due to more pronounced preservation injury. Accordingly, recent research has aimed to develop preservation modalities for improved preservation as well as strategies for liver viability assessment and liver reconditioning. METHODS The PubMed database was searched using the terms 'perfusion', 'liver', 'preservation', and 'reconditioning' in various combinations, and the according literature was reviewed. RESULTS Several perfusion techniques have been developed in recent years with the potential for liver reconditioning. Preclinical and first emerging clinical data suggest feasibility, safety, and superiority over the current gold standard of cold storage. CONCLUSION This review outlines current advances in the field of liver preservation with an emphasis on liver reconditioning methods.
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Affiliation(s)
- Dieter P Hoyer
- General, Visceral and Transplantation Surgery, University Hospital Essen, Essen, Germany
| | - Thomas Minor
- General, Visceral and Transplantation Surgery, University Hospital Essen, Essen, Germany
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Karangwa SA, Dutkowski P, Fontes P, Friend PJ, Guarrera JV, Markmann JF, Mergental H, Minor T, Quintini C, Selzner M, Uygun K, Watson CJ, Porte RJ. Machine Perfusion of Donor Livers for Transplantation: A Proposal for Standardized Nomenclature and Reporting Guidelines. Am J Transplant 2016; 16:2932-2942. [PMID: 27129409 PMCID: PMC5132023 DOI: 10.1111/ajt.13843] [Citation(s) in RCA: 97] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Revised: 03/28/2016] [Accepted: 04/19/2016] [Indexed: 02/06/2023]
Abstract
With increasing demand for donor organs for transplantation, machine perfusion (MP) promises to be a beneficial alternative preservation method for donor livers, particularly those considered to be of suboptimal quality, also known as extended criteria donor livers. Over the last decade, numerous studies researching MP of donor livers have been published and incredible advances have been made in both experimental and clinical research in this area. With numerous research groups working on MP, various techniques are being explored, often applying different nomenclature. The objective of this review is to catalog the differences observed in the nomenclature used in the current literature to denote various MP techniques and the manner in which methodology is reported. From this analysis, we propose a standardization of nomenclature on liver MP to maximize consistency and to enable reliable comparison and meta-analyses of studies. In addition, we propose a standardized set of guidelines for reporting the methodology of future studies on liver MP that will facilitate comparison as well as clinical implementation of liver MP procedures.
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Affiliation(s)
- S. A. Karangwa
- Section of Hepatobiliary Surgery and Liver TransplantationDepartment of SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
- Surgical Research LaboratoryUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
| | - P. Dutkowski
- Department of Surgery & TransplantationUniversity Hospital ZurichZurichSwitzerland
| | - P. Fontes
- Thomas E. Starzl Transplantation Institute Department of SurgeryUniversity of Pittsburgh Medical CenterPittsburghPA
- McGowan Institute of Regenerative MedicineUniversity of PittsburghPittsburghPA
| | - P. J. Friend
- Nuffield Department of SurgeryOxford Transplant CentreUniversity of OxfordChurchill HospitalOxfordUK
| | - J. V. Guarrera
- Department of SurgeryCenter for Liver Disease and TransplantationColumbia University Medical CenterNew YorkNY
| | | | - H. Mergental
- Liver UnitUniversity Hospital BirminghamBirminghamUK
| | - T. Minor
- Department of Surgical ResearchClinic for General Visceral and Transplantation SurgeryUniversity Hospital EssenEssenGermany
| | - C. Quintini
- Department of SurgeryTransplant CenterDigestive Disease InstituteCleveland Clinic FoundationClevelandOH
| | - M. Selzner
- Department of SurgeryMulti Organ Transplant ProgramToronto General HospitalTorontoONCanada
| | - K. Uygun
- Department of SurgeryCenter for Engineering in MedicineMassachusetts General HospitalHarvard Medical SchoolBostonMA
| | - C. J. Watson
- University of Cambridge Department of Surgery and the NIHR Blood and Transplant Research Unit in Organ Donation and Transplantation University of CambridgeAddenbrooke's HospitalCambridgeUK
| | - R. J. Porte
- Section of Hepatobiliary Surgery and Liver TransplantationDepartment of SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
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Lee DD, Croome KP, Shalev JA, Musto KR, Sharma M, Keaveny AP, Taner CB. Early allograft dysfunction after liver transplantation: an intermediate outcome measure for targeted improvements. Ann Hepatol 2016; 15:53-60. [PMID: 26626641 DOI: 10.5604/16652681.1184212] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The term early allograft dysfunction (EAD) identifies liver transplant (LT) allografts with initial poor function and portends poor allograft and patient survival. Aims of this study are to use EAD as an intermediate outcome measure in a large single center cohort and identify donor, recipient and peri-operative risk factors. MATERIAL AND METHODS In 1950 consecutive primary LT, donor, recipient and peri-operative data were collected. EAD was defined by the presence of one or more of the following: total bilirubin ≥ 10 mg/dL (171 μmol/L) or, INR ≥ 1.6 on day 7, and ALT/AST > 2,000 IU/L within the first 7 days. RESULTS The incidence of EAD was 26.5%. 1-, 3-, and 5-year allograft and patient survival for patients who developed EAD were significantly inferior to those who did not (P < 0.01 at all time points). Multivariate analysis demonstrated associations in the development of EAD with recipient pre-operative ventilator status, donation after cardiac death allografts, donor age, allograft size, degree of steatosis, operative time and intra-operative transfusion requirements (all P < 0.01). Patients with EAD had a significantly longer hospitalization at 20.9 ± 38.9 days (median: 9; range: 4-446) compared with 10.7 ± 13.5 days (median: 7; range: 3-231) in patients with no EAD (P < 0.01). CONCLUSIONS This is the largest single center experience demonstrating incidence of EAD and identifying factors associated with development of EAD. EAD is a useful intermediate outcome measure for allograft and patient survival. Balancing recipient pretransplant conditions, donor risk factors and intra-operative conditions are necessary for avoiding EAD.
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Affiliation(s)
- David D Lee
- Mayo Clinic Collaborative in Transplant Research and Outcomes, Department of Transplant. Mayo Clinic Florida. USA
| | - Kristopher P Croome
- Mayo Clinic Collaborative in Transplant Research and Outcomes, Department of Transplant. Mayo Clinic Florida. USA
| | - Jefree A Shalev
- Mayo Clinic Collaborative in Transplant Research and Outcomes, Department of Transplant. Mayo Clinic Florida. USA
| | - Kaitlyn R Musto
- Mayo Clinic Collaborative in Transplant Research and Outcomes, Department of Transplant. Mayo Clinic Florida. USA
| | - Meenu Sharma
- Mayo Clinic Collaborative in Transplant Research and Outcomes, Department of Transplant. Mayo Clinic Florida. USA
| | - Andrew P Keaveny
- Mayo Clinic Collaborative in Transplant Research and Outcomes, Department of Transplant. Mayo Clinic Florida. USA
| | - C Burcin Taner
- Mayo Clinic Collaborative in Transplant Research and Outcomes, Department of Transplant. Mayo Clinic Florida. USA
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87
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Hoyer DP, Paul A, Luer S, Reis H, Efferz P, Minor T. End-ischemic reconditioning of liver allografts: Controlling the rewarming. Liver Transpl 2016; 22:1223-30. [PMID: 27398813 DOI: 10.1002/lt.24515] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Accepted: 06/28/2016] [Indexed: 12/13/2022]
Abstract
Different nonhypothermic preservation modalities have shown beneficial effects in liver transplantation models. This study compares controlled oxygenated rewarming (COR) to normothermic machine perfusion (NMP) to resuscitate liver grafts following cold storage (CS). Porcine livers were preserved for 18 hours by CS. Before reperfusion, the grafts were put on a machine perfusion device (Liver Assist) for 3 hours and were randomly assigned to COR (n = 6) or NMP (n = 5) and compared to standard CS. COR was carried out with the new Custodiol-N solution, slowly increasing temperature from 8 °C to 20 °C during the first 90 minutes. NMP was carried out with diluted autologous blood at 37 °C for 3 hours. In both cases, the perfusate was oxygenated to partial pressure of oxygen > 500 mm Hg. Then liver viability was tested for 180 minutes during in vitro isolated sanguineous reperfusion. Activity of the mitochondrial caspase 9 was lower after COR. Measurement of tissue adenosine triphosphate and total adenine nucleotides at the end of the reconditioning period showed better energetic recovery after COR. COR also resulted in significantly lower enzyme leakage and higher bile production (P < 0.05) during reperfusion. This first comparison of COR and NMP as end-ischemic reconditioning modalities demonstrates superior results in terms of mitochondrial integrity resulting in better energetic recovery, less hepatocellular injury, and ultimately superior function in favor of COR. Liver Transplantation 22 1223-1230 2016 AASLD.
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Affiliation(s)
- Dieter Paul Hoyer
- General, Visceral and Transplantation Surgery, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Andreas Paul
- General, Visceral and Transplantation Surgery, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Sebastian Luer
- General, Visceral and Transplantation Surgery, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Henning Reis
- Institute of Pathology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Patrik Efferz
- General, Visceral and Transplantation Surgery, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Thomas Minor
- General, Visceral and Transplantation Surgery, University Hospital Essen, University Duisburg-Essen, Essen, Germany
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88
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Banan B, Watson R, Xu M, Lin Y, Chapman W. Development of a normothermic extracorporeal liver perfusion system toward improving viability and function of human extended criteria donor livers. Liver Transpl 2016; 22:979-93. [PMID: 27027254 DOI: 10.1002/lt.24451] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Revised: 03/08/2016] [Accepted: 03/21/2016] [Indexed: 12/23/2022]
Abstract
Donor organ shortages have led to an increased interest in finding new approaches to recover organs from extended criteria donors (ECD). Normothermic extracorporeal liver perfusion (NELP) has been proposed as a superior preservation method to reduce ischemia/reperfusion injury (IRI), precondition suboptimal grafts, and treat ECD livers so that they can be successfully used for transplantation. The aim of this study was to investigate the beneficial effects of a modified NELP circuit on discarded human livers. Seven human livers that were rejected for transplantation were placed on a modified NELP circuit for 8 hours. Perfusate samples and needle core biopsies were obtained at hourly intervals. A defatting solution that contained exendin-4 (50 nM) and L-carnitine (10 mM) was added to the perfusate for 2 steatotic livers. NELP provided normal temperature, electrolytes, and pH and glucose levels in the perfusate along with physiological vascular flows and pressures. Functional, biochemical, and microscopic evaluation revealed no additional injuries to the grafts during NELP with an improved oxygen extraction ratio (>0.5) and stabilized markers of hepatic injury. All livers synthesized adequate amounts of bile and coagulation factors. We also demonstrated a mild reduction (10%) of macroglobular steatosis with the use of the defatting solution. Histology demonstrated normal parenchymal architecture and a minimal to complete lack of IRI at the end of NELP. In conclusion, a modified NELP circuit preserved hepatocyte architecture, recovered synthetic functions, and hepatobiliary parameters of ECD livers without additional injuries to the grafts. This approach has the potential to increase the donor pool for clinical transplantation. Liver Transplantation 22 979-993 2016 AASLD.
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Affiliation(s)
- Babak Banan
- Departments of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Rao Watson
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO.,Department of Pathology and Laboratory Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Min Xu
- Departments of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Yiing Lin
- Departments of Surgery, Washington University School of Medicine, St. Louis, MO
| | - William Chapman
- Departments of Surgery, Washington University School of Medicine, St. Louis, MO
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89
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Ravikumar R, Jassem W, Mergental H, Heaton N, Mirza D, Perera MTPR, Quaglia A, Holroyd D, Vogel T, Coussios CC, Friend PJ. Liver Transplantation After Ex Vivo Normothermic Machine Preservation: A Phase 1 (First-in-Man) Clinical Trial. Am J Transplant 2016; 16:1779-87. [PMID: 26752191 DOI: 10.1111/ajt.13708] [Citation(s) in RCA: 336] [Impact Index Per Article: 42.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2015] [Accepted: 12/08/2015] [Indexed: 01/25/2023]
Abstract
The number of donor organs suitable for liver transplantation is restricted by cold preservation and ischemia-reperfusion injury. We present the first patients transplanted using a normothermic machine perfusion (NMP) device that transports and stores an organ in a fully functioning state at 37°C. In this Phase 1 trial, organs were retrieved using standard techniques, attached to the perfusion device at the donor hospital, and transported to the implanting center in a functioning state. NMP livers were matched 1:2 to cold-stored livers. Twenty patients underwent liver transplantation after NMP. Median NMP time was 9.3 (3.5-18.5) h versus median cold ischaemia time of 8.9 (4.2-11.4) h. Thirty-day graft survival was similar (100% NMP vs. 97.5% control, p = 1.00). Median peak aspartate aminotransferase in the first 7 days was significantly lower in the NMP group (417 IU [84-4681]) versus (902 IU [218-8786], p = 0.03). This first report of liver transplantation using NMP-preserved livers demonstrates the safety and feasibility of using this technology from retrieval to transplantation, including transportation. NMP may be valuable in increasing the number of donor livers and improving the function of transplantable organs.
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Affiliation(s)
- R Ravikumar
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK.,Institute of Biomedical Engineering, University of Oxford, Oxford, UK
| | - W Jassem
- Liver Unit, Kings College Hospital, London, UK
| | - H Mergental
- Liver Unit, University Hospital Birmingham, Birmingham, UK
| | - N Heaton
- Liver Unit, Kings College Hospital, London, UK
| | - D Mirza
- Liver Unit, University Hospital Birmingham, Birmingham, UK
| | - M T P R Perera
- Liver Unit, University Hospital Birmingham, Birmingham, UK
| | - A Quaglia
- Liver Unit, Kings College Hospital, London, UK
| | - D Holroyd
- Institute of Biomedical Engineering, University of Oxford, Oxford, UK
| | - T Vogel
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - C C Coussios
- Institute of Biomedical Engineering, University of Oxford, Oxford, UK
| | - P J Friend
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
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90
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Nassar A, Liu Q, Farias K, Buccini L, Baldwin W, Bennett A, Mangino M, Irefin S, Cywinski J, Okamoto T, Diago Uso T, Iuppa G, Soliman B, Miller C, Quintini C. Impact of Temperature on Porcine Liver Machine Perfusion From Donors After Cardiac Death. Artif Organs 2016; 40:999-1008. [PMID: 27086771 DOI: 10.1111/aor.12699] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2015] [Revised: 12/22/2015] [Accepted: 12/28/2015] [Indexed: 12/11/2022]
Abstract
Normothermic machine perfusion (NMP) has been introduced as a promising technology to preserve and possibly repair marginal liver grafts. The aim of this study was to compare the effect of temperature on the preservation of donation after cardiac death (DCD) liver grafts in an ex vivo perfusion model after NMP (38.5°C) and subnormothermic machine perfusion (SNMP, 21°C) with a control group preserved by cold storage (CS, 4°C). Fifteen porcine livers with 60 min of warm ischemia were preserved for 10 h by NMP, SNMP or CS (n = 5/group). After the preservation phase all livers were reperfused for 24 h in an isolated perfusion system with whole blood at 38.5°C to simulate transplantation. At the end of transplant simulation, the NMP group showed significantly lower hepatocellular enzyme level (AST: 277 ± 69 U/L; ALT: 22 ± 2 U/L; P < 0.03) compared to both SNMP (AST: 3243 ± 1048 U/L; ALT: 127 ± 70 U/L) and CS (AST: 3150 ± 1546 U/L; ALT: 185 ± 97 U/L). There was no significant difference between SNMP and CS. Bile production was significantly higher in the NMP group (219 ± 43 mL; P < 0.01) compared to both SNMP (49 ± 84 mL) and CS (12 ± 16 mL) with no significant difference between the latter two groups. Histologically, the NMP livers showed preserved cellular architecture compared to the SNMP and CS groups. NMP was able to recover DCD livers showing superior hepatocellular integrity, biliary function, and microcirculation compared to SNMP and CS. SNMP showed some significant benefit over CS, yet has not shown any advantage over NMP.
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Affiliation(s)
- Ahmed Nassar
- Transplantation Center, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Qiang Liu
- Transplantation Center, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Kevin Farias
- Transplantation Center, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Laura Buccini
- Transplantation Center, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - William Baldwin
- Transplantation Center, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Ana Bennett
- Transplantation Center, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Martin Mangino
- Department of Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Samuel Irefin
- Transplantation Center, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Jacek Cywinski
- Transplantation Center, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Toshihiro Okamoto
- Transplantation Center, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Teresa Diago Uso
- Transplantation Center, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Giuseppe Iuppa
- Transplantation Center, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Basem Soliman
- Transplantation Center, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Charles Miller
- Transplantation Center, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Cristiano Quintini
- Transplantation Center, Cleveland Clinic Foundation, Cleveland, OH, USA.
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91
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Vakili STT, Kailar R, Rahman K, Nezami BG, Mwangi SM, Anania FA, Srinivasan S. Glial cell line-derived neurotrophic factor-induced mice liver defatting: A novel strategy to enable transplantation of steatotic livers. Liver Transpl 2016; 22:459-67. [PMID: 26714616 PMCID: PMC4809758 DOI: 10.1002/lt.24385] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Revised: 10/28/2015] [Accepted: 11/28/2015] [Indexed: 12/12/2022]
Abstract
Moderate macrovesicular steatosis (>30%), which is present in almost 50% of livers considered for transplantation, increases the risk of primary graft dysfunction. Our previously published data showed that glial cell line-derived neurotrophic factor (GDNF) is protective against high-fat diet (HFD)-induced hepatic steatosis in mice. Hence, we hypothesized that perfusion of steatotic livers with GDNF may reduce liver fat content before transplantation. Livers from 8 weeks of regular diet (RD) and of HFD-fed mice were perfused ex vivo for 4 hours with either vehicle, GDNF, or a previously described defatting cocktail. The liver's residual fat was quantified colorimetrically using a triglyceride (TG) assay kit and by Oil Red O (ORO) and Nile red/Hoechst staining. Liver tissue injury was assessed by using a lactate dehydrogenase (LDH) activity assay. In vitro induction of lipolysis in HepG2 cells was assessed by measuring glycerol and free fatty acid release. ORO staining showed significantly more steatosis in livers from HFD-fed mice compared with RD-fed mice (P < 0.001). HFD livers perfused with GDNF had significantly less steatosis than those not perfused (P = 0.001) or perfused with vehicle (P < 0.05). GDNF is equally effective in steatotic liver defatting compared to the defatting cocktail; however, GDNF induces less liver damage than the defatting cocktail. These observations were consistent with data obtained from assessment of liver TG content. Assessment of liver injury revealed significant hepatocyte injury in livers perfused with the control defatting cocktail but no evidence of injury in livers perfused with either GDNF or vehicle. In vitro, GDNF reduced TG accumulation in HepG2 cells and stimulated increased TG lipolysis. In conclusion, GDNF can decrease mice liver fat content to an acceptable range and could be a potential defatting agent before liver transplantation.
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Affiliation(s)
- Sahar Taba Taba Vakili
- Division of Digestive Diseases, Emory University School of Medicine, 615 Michael Street, Atlanta, GA 30322,Atlanta VA Medical Center, Decatur, GA, USA
| | - Roshni Kailar
- Division of Digestive Diseases, Emory University School of Medicine, 615 Michael Street, Atlanta, GA 30322
| | - Khalidur Rahman
- Division of Digestive Diseases, Emory University School of Medicine, 615 Michael Street, Atlanta, GA 30322
| | - Behtash Ghazi Nezami
- Division of Digestive Diseases, Emory University School of Medicine, 615 Michael Street, Atlanta, GA 30322,Atlanta VA Medical Center, Decatur, GA, USA
| | - Simon Musyoka Mwangi
- Division of Digestive Diseases, Emory University School of Medicine, 615 Michael Street, Atlanta, GA 30322,Atlanta VA Medical Center, Decatur, GA, USA
| | - Frank A. Anania
- Division of Digestive Diseases, Emory University School of Medicine, 615 Michael Street, Atlanta, GA 30322,Atlanta VA Medical Center, Decatur, GA, USA
| | - Shanthi Srinivasan
- Division of Digestive Diseases, Emory University School of Medicine, 615 Michael Street, Atlanta, GA 30322,Atlanta VA Medical Center, Decatur, GA, USA
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92
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Donor Hepatic Steatosis Induce Exacerbated Ischemia-Reperfusion Injury Through Activation of Innate Immune Response Molecular Pathways. Transplantation 2016; 99:2523-33. [PMID: 26285018 DOI: 10.1097/tp.0000000000000857] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Severe liver steatosis is a known risk factor for increased ischemia-reperfusion injury (IRI) and poor outcomes after liver transplantation (LT). This study aimed to identify steatosis-related molecular mechanisms associated with IRI exacerbation after LT. METHODS Paired graft biopsies (n = 60) were collected before implantation (L1) and 90 minutes after reperfusion (L2). The LT recipients (n = 30) were classified by graft macrosteatosis: without steatosis (WS) of 5% or less (n = 13) and with steatosis (S) of 25% or greater (n = 17). Plasma samples were collected at L1, L2, and 1 day after LT (postoperative [POD]1) for cytokines evaluation. Tissue RNA was isolated for gene expression microarrays. Probeset summaries were obtained using robust multiarray average algorithm. Pairwise comparisons were fit using 2-sample t test. P values 0.01 or less were significant (false discovery rate <5%). Molecular pathway analyses were conducted using Ingenuity Pathway Analysis tool. RESULTS Significantly differentially expressed genes were identified for WS and S grafts after reperfusion. Comprehensive comparison analysis of molecular profiles revealed significant association of S grafts molecular profile with innate immune response activation, macrophage production of nitric oxide and reactive oxygen species, IL-6, IL-8, IL-10 signaling activation, recruitment of granulocytes, and accumulation of myeloid cells. Postreperfusion histological patterns of S grafts revealed neutrophilic infiltration surrounding fat accumulation. Circulating proinflammatory cytokines after reperfusion and 24 hours after LT concurred with intragraft-deregulated molecular pathways. All tested cytokines were significantly increased in plasma of S grafts recipients after reperfusion when compared with WS group at same time. CONCLUSIONS Increases of graft steatosis exacerbate IRI by exacerbation of innate immune response after LT. Preemptive strategies should consider it for safety usage of steatotic livers.
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93
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Spetzler VN, Goldaracena N, Echiverri J, Kaths JM, Louis KS, Adeyi OA, Yip PM, Grant DR, Selzner N, Selzner M. Subnormothermic ex vivo liver perfusion is a safe alternative to cold static storage for preserving standard criteria grafts. Liver Transpl 2016; 22:111-9. [PMID: 26390093 DOI: 10.1002/lt.24340] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2015] [Revised: 08/01/2015] [Accepted: 09/01/2015] [Indexed: 02/07/2023]
Abstract
We developed a novel technique of subnormothermic ex vivo liver perfusion (SNEVLP) for the storage of liver grafts before transplantation. To test the safety of SNEVLP for the nonextended criteria grafts (standard grafts), we compared it to a control group with minimal cold static storage (CS) time. Heart-beating pig liver retrieval was performed. Grafts were either stored in cold unmodified University of Wisconsin solution (CS-1), in cold University of Wisconsin solution with ex vivo perfusion additives (CS-2), or preserved with a sequence of 3 hours CS and 3 hours SNEVLP (33°C), followed by orthotopic liver transplantation. Liver function tests and histology were investigated. Aspartate aminotransferase (AST) levels during SNEVLP remained stable (54.3 ± 12.6 U/L at 1 hour to 47.0 ± 31.9 U/L at 3 hours). Posttransplantation, SNEVLP versus CS-1 livers had decreased AST levels (peak at day 1, 1081.9 ± 788.5 versus 1546.7 ± 509.3 U/L; P = 0.14; at day 2, 316.7 ± 188.1 versus 948.2 ± 740.9 U/L; P = 0.04) and alkaline phosphatase levels (peak at day 1, 150.4 ± 19.3 versus 203.7 ± 33.6 U/L; P = 0.003). Bilirubin levels were constantly within the physiological range in the SNEVLP group, whereas the CS-1 group presented a large standard deviation, including pathologically increased values. Hyaluronic acid as a marker of endothelial cell (EC) function was markedly improved by SNEVLP during the early posttransplant phase (5 hours posttransplant, 1172.75 ± 598.5 versus 5540.5 ± 2755.4 ng/mL). Peak international normalized ratio was similar between SNEVLP and CS-1 groups after transplantation. Immunohistochemistry for cleaved caspase 3 demonstrated more apoptotic sinusoidal cells in the CS-1 group when compared to SNEVLP grafts 2 hours after reperfusion (19.4 ± 19.5 versus 133.2 ± 48.8 cells/high-power field; P = 0.002). Adding normothermic CS-2 had no impact on liver injury or function after transplantation when compared to CS-1. In conclusion, SNEVLP is safe to use for standard donor grafts and is associated with improved EC and bile duct injury even in grafts with minimal CS time.
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Affiliation(s)
- Vinzent N Spetzler
- Multi-Organ Transplant Program, Department of Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Nicolas Goldaracena
- Multi-Organ Transplant Program, Department of Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Juan Echiverri
- Multi-Organ Transplant Program, Department of Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - J Moritz Kaths
- Multi-Organ Transplant Program, Department of Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Kristine S Louis
- Multi-Organ Transplant Program, Department of Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Oyedele A Adeyi
- Departments of Pathology, University of Toronto, Toronto, Ontario, Canada
| | - Paul M Yip
- Departments of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - David R Grant
- Multi-Organ Transplant Program, Department of Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Nazia Selzner
- Departments of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Markus Selzner
- Multi-Organ Transplant Program, Department of Surgery, Toronto General Hospital, Toronto, Ontario, Canada
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94
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Utilization of Machine Perfusion and Nanotechnology for Liver Transplantation. CURRENT TRANSPLANTATION REPORTS 2015. [DOI: 10.1007/s40472-015-0076-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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95
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Tashiro H, Kuroda S, Mikuriya Y, Ohdan H. Ischemia–reperfusion injury in patients with fatty liver and the clinical impact of steatotic liver on hepatic surgery. Surg Today 2015; 44:1611-25. [PMID: 24078000 DOI: 10.1007/s00595-013-0736-9] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2013] [Accepted: 08/22/2013] [Indexed: 12/15/2022]
Abstract
Hepatic steatosis is one of the most common hepatic disorders in developed countries. The epidemic of obesity in developed countries has increased with its attendant complications, including metabolic syndrome and non-alcoholic fatty liver disease. Steatotic livers are particularly vulnerable to ischemia/reperfusion injury, resulting in an increased risk of postoperative morbidity and mortality after liver surgery, including liver transplantation. There is growing understanding of the molecular and cellular mechanisms and therapeutic approaches for treating ischemia/reperfusion injury in patients with steatotic livers. This review discusses the mechanisms underlying the susceptibility of steatotic livers to ischemia/reperfusion injuries, such as mitochondrial dysfunction and signal transduction alterations, and summarizes the clinical impact of steatotic livers in the setting of hepatic resection and liver transplantation. This review also describes potential therapeutic approaches, such as ischemic and pharmacological preconditioning, to prevent ischemia/reperfusion injury in patients with steatotic livers. Other approaches, including machine perfusion, are also under clinical investigation; however, many pharmacological approaches developed through basic research are not yet suitable for clinical application.
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96
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Ravikumar R, Leuvenink H, Friend PJ. Normothermic liver preservation: a new paradigm? Transpl Int 2015; 28:690-9. [PMID: 25847684 DOI: 10.1111/tri.12576] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2014] [Revised: 09/29/2014] [Accepted: 03/27/2015] [Indexed: 12/14/2022]
Abstract
Despite increasing donor numbers, waiting lists and pre-transplant mortality continue to grow in many countries. The number of donor organs suitable for liver transplantation is restricted by cold preservation and ischemia-reperfusion injury (IRI). Transplantation of marginal donor organs has led to renewed interest in new techniques which have the potential to improve the quality of preservation, assess the quality of the organ and allow repair of the donor organ prior to transplantation. If successful, such techniques would not only improve the outcome of currently transplanted marginal livers, but also increase the donor pool. Experimental evidence suggests that preservation under near physiological conditions of temperature and oxygenation abrogates IRI. Normothermic perfusion maintains the organ in a physiological state, avoiding the depletion of cellular energy and the accumulation of waste products, which occurs with static cold storage. It enables viability assessment prior to transplantation thereby reducing the risk of transplanting inherently marginal organs. Here we review the use of normothermic machine perfusion as a means of organ preservation.
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Affiliation(s)
- Reena Ravikumar
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Henri Leuvenink
- Groningen Transplant Center, University Medical Center, Groningen, The Netherlands
| | - Peter J Friend
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
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97
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Adam R, Delvart V, Karam V, Ducerf C, Navarro F, Letoublon C, Belghiti J, Pezet D, Castaing D, Le Treut YP, Gugenheim J, Bachellier P, Pirenne J, Muiesan P. Compared efficacy of preservation solutions in liver transplantation: a long-term graft outcome study from the European Liver Transplant Registry. Am J Transplant 2015; 15:395-406. [PMID: 25612492 DOI: 10.1111/ajt.13060] [Citation(s) in RCA: 101] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Revised: 08/08/2014] [Accepted: 08/09/2014] [Indexed: 01/25/2023]
Abstract
Between 2003 and 2012, 42 869 first liver transplantations performed in Europe with the use of either University of Wisconsin solution (UW; N = 24 562), histidine-tryptophan-ketoglutarate(HTK; N = 8696), Celsior solution (CE; N = 7756) or Institute Georges Lopez preservation solution (IGL-1; N = 1855) preserved grafts. Alternative solutions to the UW were increasingly used during the last decade. Overall, 3-year graft survival was higher with UW, IGL-1 and CE (75%, 75% and 73%, respectively), compared to the HTK (69%) (p < 0.0001). The same trend was observed with a total ischemia time (TIT) >12 h or grafts used for patients with cancer (p < 0.0001). For partial grafts, 3-year graft survival was 89% for IGL-1, 67% for UW, 68% for CE and 64% for HTK (p = 0.009). Multivariate analysis identified HTK as an independent factor of graft loss, with recipient HIV (+), donor age ≥65 years, recipient HCV (+), main disease acute hepatic failure, use of a partial liver graft, recipient age ≥60 years, no identical ABO compatibility, recipient hepatitis B surface antigen (-), TIT ≥ 12 h, male recipient and main disease other than cirrhosis. HTK appears to be an independent risk factor of graft loss. Both UW and IGL-1, and CE to a lesser extent, provides similar results for full size grafts. For partial deceased donor liver grafts, IGL-1 tends to offer the best graft outcome.
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Affiliation(s)
- R Adam
- Centre Hépatobiliaire, AP-HP Hôpital Paul Brousse, Inserm U 776, Univ Paris Sud, Villejuif, France
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Abstract
PURPOSE OF REVIEW This review considers the biliary complications associated with liver transplantation using donation after cardiac death (DCD) donor grafts. RECENT FINDINGS The increasing use of DCD liver grafts with their increased incidence of biliary complications is discussed. The ethics of this greater use is briefly analysed. Recent animal and human study evidence to support the peribiliary vascular plexus' role in ischaemic cholangiopathy is reviewed. Recent advances in in-vivo and ex-vivo perfusion are explored. In particular, the latest theories regarding perfusion's peribiliary plexus preserving effects and the mechanism by which biliary regeneration may be promoted as a consequence are discussed. SUMMARY This article explores the need for DCD liver graft use and the associated biliary complications. The current theories regarding the cause of DCD biliary complications are reviewed, as are the current strategies to reduce them.
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Bejaoui M, Pantazi E, Folch-Puy E, Baptista PM, García-Gil A, Adam R, Roselló-Catafau J. Emerging concepts in liver graft preservation. World J Gastroenterol 2015; 21:396-407. [PMID: 25593455 PMCID: PMC4292271 DOI: 10.3748/wjg.v21.i2.396] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Revised: 10/24/2014] [Accepted: 12/08/2014] [Indexed: 02/06/2023] Open
Abstract
The urgent need to expand the donor pool in order to attend to the growing demand for liver transplantation has obliged physicians to consider the use of suboptimal liver grafts and also to redefine the preservation strategies. This review examines the different methods of liver graft preservation, focusing on the latest advances in both static cold storage and machine perfusion (MP). The new strategies for static cold storage are mainly designed to increase the fatty liver graft preservation via the supplementation of commercial organ preservation solutions with additives. In this paper we stress the importance of carrying out effective graft washout after static cold preservation, and present a detailed discussion of the future perspectives for dynamic graft preservation using MP at different temperatures (hypothermia at 4 °C, normothermia at 37 °C and subnormothermia at 20 °C-25 °C). Finally, we highlight some emerging applications of regenerative medicine in liver graft preservation. In conclusion, this review discusses the "state of the art" and future perspectives in static and dynamic liver graft preservation in order to improve graft viability.
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