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Broere R, Luijmes SH, de Jonge J, Porte RJ. Graft repair during machine perfusion: a current overview of strategies. Curr Opin Organ Transplant 2024; 29:248-254. [PMID: 38726753 PMCID: PMC11224572 DOI: 10.1097/mot.0000000000001151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/03/2024]
Abstract
PURPOSE OF REVIEW With changing donor characteristics (advanced age, obesity), an increase in the use of extended criteria donor (ECD) livers in liver transplantation is seen. Machine perfusion allows graft viability assessment, but still many donor livers are considered nontransplantable. Besides being used as graft viability assessment tool, ex situ machine perfusion offers a platform for therapeutic strategies to ameliorate grafts prior to transplantation. This review describes the current landscape of graft repair during machine perfusion. RECENT FINDINGS Explored anti-inflammatory therapies, including inflammasome inhibitors, hemoabsorption, and cellular therapies mitigate the inflammatory response and improve hepatic function. Cholangiocyte organoids show promise in repairing the damaged biliary tree. Defatting during normothermic machine perfusion shows a reduction of steatosis and improved hepatobiliary function compared to nontreated livers. Uptake of RNA interference therapies during machine perfusion paves the way for an additional treatment modality. SUMMARY The possibility to repair injured donor livers during ex situ machine perfusion might increase the utilization of ECD-livers. Application of defatting agents is currently explored in clinical trials, whereas other therapeutics require further research or optimization before entering clinical research.
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Affiliation(s)
- Roberto Broere
- Department of Surgery, Division of Hepato-Pancreato- Biliary and Transplant Surgery, Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
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2
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Schlegel A, Mergental H, Fondevila C, Porte RJ, Friend PJ, Dutkowski P. Machine perfusion of the liver and bioengineering. J Hepatol 2023; 78:1181-1198. [PMID: 37208105 DOI: 10.1016/j.jhep.2023.02.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 02/03/2023] [Accepted: 02/09/2023] [Indexed: 05/21/2023]
Abstract
With the increasing number of accepted candidates on waiting lists worldwide, there is an urgent need to expand the number and the quality of donor livers. Dynamic preservation approaches have demonstrated various benefits, including improving liver function and graft survival, and reducing liver injury and post-transplant complications. Consequently, organ perfusion techniques are being used in clinical practice in many countries. Despite this success, a proportion of livers do not meet current viability tests required for transplantation, even with the use of modern perfusion techniques. Therefore, devices are needed to further optimise machine liver perfusion - one promising option is to prolong machine liver perfusion for several days, with ex situ treatment of perfused livers. For example, stem cells, senolytics, or molecules targeting mitochondria or downstream signalling can be administered during long-term liver perfusion to modulate repair mechanisms and regeneration. Besides, today's perfusion equipment is also designed to enable the use of various liver bioengineering techniques, to develop scaffolds or for their re-cellularisation. Cells or entire livers can also undergo gene modulation to modify animal livers for xenotransplantation, to directly treat injured organs or to repopulate such scaffolds with "repaired" autologous cells. This review first discusses current strategies to improve the quality of donor livers, and secondly reports on bioengineering techniques to design optimised organs during machine perfusion. Current practice, as well as the benefits and challenges associated with these different perfusion strategies are discussed.
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Affiliation(s)
- Andrea Schlegel
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Centre of Preclinical Research, Milan, 20122, Italy; Department of Surgery and Transplantation, Swiss HPB Center, University Hospital Zurich, Switzerland
| | - Hynek Mergental
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, United Kingdom
| | - Constantino Fondevila
- Hepatopancreatobiliary Surgery & Transplantation, General & Digestive Surgery Service, Hospital Universitario La Paz, IdiPAZ, CIBERehd, Madrid, Spain
| | - Robert J Porte
- Erasmus MC Transplant Institute, Department of Surgery, Division of HPB & Transplant Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Peter J Friend
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Philipp Dutkowski
- Department of Surgery and Transplantation, Swiss HPB Center, University Hospital Zurich, Switzerland.
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3
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Vargas PA, Yu C, Goldaracena N. Comprehensive review of the application of MP and the potential for graft modification. FRONTIERS IN TRANSPLANTATION 2023; 2:1163539. [PMID: 38993846 PMCID: PMC11235300 DOI: 10.3389/frtra.2023.1163539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 04/20/2023] [Indexed: 07/13/2024]
Abstract
Introduction Following procurement, the liver graft is exposed to an ischemic period that triggers several pathophysiologic changes in response to oxygen deprivation. Therefore, the goal during organ preservation is to attenuate such response and provide an adequate environment that prepares the graft for its metabolic reactivation following implantation. This has been widely achieved via static cold storage preservation, where the maintenance of the graft using cold preservation solutions reduce its metabolic activity and confer cytoprotection until transplantation. However, despite being the gold standard for organ preservation, static cold storage holds several disadvantages. In addition, the ongoing organ shortage has led to the use of unconventional grafts that could benefit from therapies pre-transplant. Organ preservation via machine perfusion systems appears as a promising solution to address both. Methods Here, we aim to present a state-of-the-art narrative review regarding liver graft modification options using machine perfusion systems in combination with adjuvant strategies including immunomodulation, gene therapy and pharmacotherapy. Results Available reports are scarce and mostly on experimental animal models. Most of the literature reflects the use of normothermic or subnormothermic machine perfusion devices given that these particular type of machine allows for a metabolically active organ, and therefore facilitates its modification. Although limited, promising findings in available reports suggest that organ preservation using machine perfusion system when combined with alternative therapies can be feasible and safe strategies for graft modification. Discussion Further research on clinical settings are needed to better elucidate the true effect of graft modification pre-transplant on short- and long-term graft and patient survival. There is a long way ahead to develop guidelines and approve these novel therapies for clinical practice. However, the path looks promising.
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Affiliation(s)
- Paola A. Vargas
- Division of Transplant Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, VA, United States
| | - Christine Yu
- Department of Public Health Sciences, University of Virginia, Charlottesville, VA, United States
| | - Nicolas Goldaracena
- Division of Transplant Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, VA, United States
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4
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Li SX, Chen L, Li MQ, Lv GY. Pharmacological agents for defatting livers by normothermic machine perfusion. Artif Organs 2022. [PMID: 36514256 DOI: 10.1111/aor.14478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 11/28/2022] [Accepted: 12/04/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Ex-vivo normothermic machine perfusion (NMP) preserves the liver metabolism at 37°C and has rapidly developed as a promising approach for assessing the viability and improving the performance of organs from expanded criteria donors, including fatty liver grafts. NMP is an effective method for defatting fatty livers when combined with pharmaceutical therapies. Pharmacological agents have been shown to facilitate liver defatting by NMP. OBSERVATIONS This systematic review summarizes available pharmacological therapies for liver defatting, with a particular emphasis on defatting agents that can be employed clinically as defatting components during liver NMP as an ex vivo translational paradigm. CONCLUSION NMP provides an opportunity for organ treatment and can be used as a defatting platform in the future with defatting agents. Nagrath's cocktail is the most commonly used defatting cocktail in NMP; however, its carcinogenic components may limit its clinical application. Thus, the combination of a defatting cocktail with a new clinically applicable component, for example, a polyphenolic natural compound, may be a novel pharmacological option.
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Affiliation(s)
- Shu-Xuan Li
- Department of Hepatobiliary and Pancreatic Surgery, First Hospital of Jilin University, Jilin, China
| | - Lanlan Chen
- Department of Hepatobiliary and Pancreatic Surgery, First Hospital of Jilin University, Jilin, China
| | - Ming-Qian Li
- Department of Hepatobiliary and Pancreatic Surgery, First Hospital of Jilin University, Jilin, China
| | - Guo-Yue Lv
- Department of Hepatobiliary and Pancreatic Surgery, First Hospital of Jilin University, Jilin, China
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5
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Young EN, Dogan M, Watkins C, Bajwa A, Eason JD, Kuscu C, Kuscu C. A Review of Defatting Strategies for Non-Alcoholic Fatty Liver Disease. Int J Mol Sci 2022; 23:ijms231911805. [PMID: 36233107 PMCID: PMC9569609 DOI: 10.3390/ijms231911805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Revised: 09/26/2022] [Accepted: 09/28/2022] [Indexed: 11/30/2022] Open
Abstract
Non-alcoholic fatty liver disease is a huge cause of chronic liver failure around the world. This condition has become more prevalent as rates of metabolic syndrome, type 2 diabetes, and obesity have also escalated. The unfortunate outcome for many people is liver cirrhosis that warrants transplantation or being unable to receive a transplant since many livers are discarded due to high levels of steatosis. Over the past several years, however, a great deal of work has gone into understanding the pathophysiology of this disease as well as possible treatment options. This review summarizes various defatting strategies including in vitro use of pharmacologic agents, machine perfusion of extracted livers, and genomic approaches targeting specific proteins. The goal of the field is to reduce the number of necessary transplants and expand the pool of organs available for use.
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Lascaris B, de Meijer VE, Porte RJ. Normothermic liver machine perfusion as a dynamic platform for regenerative purposes: What does the future have in store for us? J Hepatol 2022; 77:825-836. [PMID: 35533801 DOI: 10.1016/j.jhep.2022.04.033] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 04/19/2022] [Accepted: 04/27/2022] [Indexed: 01/06/2023]
Abstract
Liver transplantation has become an immense success; nevertheless, far more recipients are registered on waiting lists than there are available donor livers for transplantation. High-risk, extended criteria donor livers are increasingly used to reduce the discrepancy between organ demand and supply. Especially for high-risk livers, dynamic preservation using machine perfusion can decrease post-transplantation complications and may increase donor liver utilisation by improving graft quality and enabling viability testing before transplantation. To further increase the availability of donor livers suitable for transplantation, new strategies are required that make it possible to use organs that are initially too damaged to be transplanted. With the current progress in experimental liver transplantation research, (long-term) normothermic machine perfusion may be used in the future as a dynamic platform for regenerative medicine approaches, enabling repair and regeneration of injured donor livers. Currently explored therapeutics such as defatting cocktails, RNA interference, senolytics, and stem cell therapy may assist in the repair and/or regeneration of injured livers before transplantation. This review will provide a forecast of the future utility of normothermic machine perfusion in decreasing the imbalance between donor liver demand and supply by enabling the repair and regeneration of damaged donor livers.
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Affiliation(s)
- Bianca Lascaris
- Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Vincent E de Meijer
- Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Robert J Porte
- Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
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7
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Lin F, Zhen F, Yan X, Shaojun Y, Guizhu P, Yanfeng W, Qifa Y. Hypothermic oxygenated perfusion with defatting cocktail further improves steatotic liver grafts in a transplantation rat model. Artif Organs 2021; 45:E304-E316. [PMID: 33908066 DOI: 10.1111/aor.13976] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 03/06/2021] [Accepted: 03/19/2021] [Indexed: 12/18/2022]
Abstract
In this study, we evaluated the restoring and defatting effect of hypothermic oxygenated perfusion (HOPE) on severe steatotic liver grafts with a defatting cocktail (DF) in a rat model. Severe (≥60%) hepatic macrosteatosis was induced by a high-fat diet (HFD) for 6 weeks, after which the rats were randomly divided into four following groups: Control group, with lean livers being preserved in static cold storage (SCS) at 0°C-4°C for 45 minutes; SCS group, with a steatotic liver graft (SLG) being preserved in SCS at 0°C-4°C for 4 hours; HOPE group, where SLG was perfused with 3-hours HOPE followed by 1-hours SCS; and HOPE + DF group, HOPE with the addition of DF. Graft function after orthotopic liver transplantation was assessed in terms of mitochondrial function (adenosine triphosphate [ATP], Glycogen), endoplasmic reticulum stress (PPY, GRP78, CHOP, and ATF-6), cell apoptosis (Tunel assay, Caspase-3), inflammatory level (HMGB1, TLR4, IL-1β, IL-6. TNF-α, Factor V), and posttransplantation survival. HOPE protected steatotic liver grafts from microcirculation disturbance and endoplasmic reticulum stress and then promoted ATP and glycogen synthesis that improved mitochondrial function. Meanwhile, under conditions of ischemia-reperfusion injury, it prevented nuclear injury and endothelial damage by suppressing the release of an inflammatory mediator. The high efficacy of HOPE was enhanced after the addition of the DF. DF agents cannot promote the lipid decomposition of the steatotic liver graft at 0°C-4°C, but they can further improve steatotic liver and postoperative survival compared to the HOPE. The defatted steatotic liver grafts can be safely used in rat orthotopic liver transplantation.
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Affiliation(s)
- Fan Lin
- Hubei Key Laboratory of Medical Technology on Transplantation, Transplant Center of Wuhan University, Institute of Hepatobiliary Diseases of Wuhan University, Zhongnan Hospital of Wuhan University, Wuhan, PR China
| | - Fu Zhen
- Hubei Key Laboratory of Medical Technology on Transplantation, Transplant Center of Wuhan University, Institute of Hepatobiliary Diseases of Wuhan University, Zhongnan Hospital of Wuhan University, Wuhan, PR China
| | - Xiong Yan
- Hubei Key Laboratory of Medical Technology on Transplantation, Transplant Center of Wuhan University, Institute of Hepatobiliary Diseases of Wuhan University, Zhongnan Hospital of Wuhan University, Wuhan, PR China
| | - Ye Shaojun
- Hubei Key Laboratory of Medical Technology on Transplantation, Transplant Center of Wuhan University, Institute of Hepatobiliary Diseases of Wuhan University, Zhongnan Hospital of Wuhan University, Wuhan, PR China
| | - Peng Guizhu
- Hubei Key Laboratory of Medical Technology on Transplantation, Transplant Center of Wuhan University, Institute of Hepatobiliary Diseases of Wuhan University, Zhongnan Hospital of Wuhan University, Wuhan, PR China
| | - Wang Yanfeng
- Hubei Key Laboratory of Medical Technology on Transplantation, Transplant Center of Wuhan University, Institute of Hepatobiliary Diseases of Wuhan University, Zhongnan Hospital of Wuhan University, Wuhan, PR China
| | - Ye Qifa
- Hubei Key Laboratory of Medical Technology on Transplantation, Transplant Center of Wuhan University, Institute of Hepatobiliary Diseases of Wuhan University, Zhongnan Hospital of Wuhan University, Wuhan, PR China
- Research Center of National Health Ministry on Transplantation Medicine Engineering and Technology, The 3rd Xiangya Hospital of Central South University, Changsha, PR China
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8
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Goumard C, Turco C, Sakka M, Aoudjehane L, Lesnik P, Savier E, Conti F, Scatton O. Ex-Vivo Pharmacological Defatting of the Liver: A Review. J Clin Med 2021; 10:jcm10061253. [PMID: 33803539 PMCID: PMC8002874 DOI: 10.3390/jcm10061253] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 03/12/2021] [Accepted: 03/15/2021] [Indexed: 12/16/2022] Open
Abstract
The ongoing organ shortage has forced transplant teams to develop alternate sources of liver grafts. In this setting, ex-situ machine perfusion has rapidly developed as a promising tool to assess viability and improve the function of organs from extended criteria donors, including fatty liver grafts. In particular, normothermic machine perfusion represents a powerful tool to test a liver in full 37 °C metabolism and add pharmacological corrections whenever needed. In this context, many pharmacological agents and therapeutics have been tested to induce liver defatting on normothermic machine perfusion with promising results even on human organs. This systematic review makes a comprehensive synthesis on existing pharmacological therapies for liver defatting, with special focus on normothermic liver machine perfusion as an experimental ex-vivo translational model.
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Affiliation(s)
- Claire Goumard
- Department of Hepatobiliary Surgery and Liver Transplantation, Sorbonne Université, Hôpital Pitié-Salpêtrière, Assistance Publique-Hopitaux de Paris, 75013 Paris, France; (C.T.); (E.S.); (O.S.)
- Sorbonne Université, Centre de Recherche Saint Antoine, INSERM UMRS-938, Institute of Cardiometabolism and Nutrition (ICAN), 75013 Paris, France; (L.A.); (F.C.)
- Correspondence:
| | - Célia Turco
- Department of Hepatobiliary Surgery and Liver Transplantation, Sorbonne Université, Hôpital Pitié-Salpêtrière, Assistance Publique-Hopitaux de Paris, 75013 Paris, France; (C.T.); (E.S.); (O.S.)
- Sorbonne Université, Centre de Recherche Saint Antoine, INSERM UMRS-938, Institute of Cardiometabolism and Nutrition (ICAN), 75013 Paris, France; (L.A.); (F.C.)
| | - Mehdi Sakka
- Department of Metabolic Biochemistry, Sorbonne Université, Hôpital Pitié-Salpêtrière, Assistance Publique- Hopitaux de Paris, 75013 Paris, France;
| | - Lynda Aoudjehane
- Sorbonne Université, Centre de Recherche Saint Antoine, INSERM UMRS-938, Institute of Cardiometabolism and Nutrition (ICAN), 75013 Paris, France; (L.A.); (F.C.)
| | - Philippe Lesnik
- Sorbonne Université, INSERM UMRS-1166, Institute of Cardiometabolism and Nutrition (ICAN), 75013 Paris, France;
| | - Eric Savier
- Department of Hepatobiliary Surgery and Liver Transplantation, Sorbonne Université, Hôpital Pitié-Salpêtrière, Assistance Publique-Hopitaux de Paris, 75013 Paris, France; (C.T.); (E.S.); (O.S.)
- Sorbonne Université, Centre de Recherche Saint Antoine, INSERM UMRS-938, Institute of Cardiometabolism and Nutrition (ICAN), 75013 Paris, France; (L.A.); (F.C.)
| | - Filomena Conti
- Sorbonne Université, Centre de Recherche Saint Antoine, INSERM UMRS-938, Institute of Cardiometabolism and Nutrition (ICAN), 75013 Paris, France; (L.A.); (F.C.)
| | - Olivier Scatton
- Department of Hepatobiliary Surgery and Liver Transplantation, Sorbonne Université, Hôpital Pitié-Salpêtrière, Assistance Publique-Hopitaux de Paris, 75013 Paris, France; (C.T.); (E.S.); (O.S.)
- Sorbonne Université, Centre de Recherche Saint Antoine, INSERM UMRS-938, Institute of Cardiometabolism and Nutrition (ICAN), 75013 Paris, France; (L.A.); (F.C.)
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9
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Mazilescu LI, Selzner M, Selzner N. Defatting strategies in the current era of liver steatosis. JHEP Rep 2021; 3:100265. [PMID: 34027337 PMCID: PMC8121960 DOI: 10.1016/j.jhepr.2021.100265] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 02/14/2021] [Accepted: 02/19/2021] [Indexed: 12/25/2022] Open
Abstract
Liver steatosis is emerging as a major cause of chronic liver disease worldwide, mainly due to the increasing rate of obesity, type 2 diabetes, and metabolic syndrome. Because of the increased incidence of liver steatosis, many organs are currently declined for transplantation despite high demand and waiting list mortality. Defatting strategies have recently emerged as a means of rapidly reducing liver steatosis to expand the pool of available organs. This review summarises advances in defatting strategies in experimental and human models of liver steatosis over the last 20 years.
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Key Words
- GDNF, glial cell-line derived neurotrophic factor
- HFD, high-fat diet
- HIEC, hepatic endothelial cells
- HOPE, hypothermic machine perfusion
- LDs, lipid droplets
- Macrosteatosis
- NAFL, non-alcoholic fatty liver
- NAFLD, non-alcoholic fatty liver disease
- NASH, non-alcoholic steatohepatitis
- NEsLP, normothermic ex situ machine perfusion
- PHHs, primary human hepatocytes
- PPAR, peroxisome proliferator-activated receptor
- PXR, pregnane X receptor
- SCS, static cold storage
- SRS, steatosis reduction supplements
- TG, triglyceride
- ischemia-reperfusion injury
- liver transplantation
- machine perfusion
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Affiliation(s)
- Laura Ioana Mazilescu
- Ajmera Transplant Program, Toronto General Hospital, Ontario, Canada
- Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of General, Visceral, and Transplantation Surgery, University Hospital Essen, Essen, Germany
| | - Markus Selzner
- Ajmera Transplant Program, Toronto General Hospital, Ontario, Canada
| | - Nazia Selzner
- Ajmera Transplant Program, Toronto General Hospital, Ontario, Canada
- Corresponding author. Address: Multi-Organ Transplant Program, Toronto General Hospital, 585 University Avenue, 11 PMB-178 Toronto, ON, Canada M5G 2N2.
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10
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Amir M, Yu M, He P, Srinivasan S. Hepatic Autonomic Nervous System and Neurotrophic Factors Regulate the Pathogenesis and Progression of Non-alcoholic Fatty Liver Disease. Front Med (Lausanne) 2020; 7:62. [PMID: 32175323 PMCID: PMC7056867 DOI: 10.3389/fmed.2020.00062] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 02/11/2020] [Indexed: 12/21/2022] Open
Abstract
Non-alcoholic fatty liver disease represents a continuum of excessive hepatic steatosis, inflammation and fibrosis. It is a growing epidemic in the United States of America and worldwide. Progression of non-alcoholic fatty liver disease can lead to morbidity and mortality due to complications such as cirrhosis or hepatocellular carcinoma. Pathogenesis of non-alcoholic fatty liver disease is centered on increased hepatic lipogenesis and decreased hepatic lipolysis in the setting of hepatic and systemic insulin resistance. Adipose tissue and hepatic inflammation can further perpetuate the severity of illness. Currently there are no approved therapies for non-alcoholic fatty liver disease. Most of the drugs being explored for non-alcoholic fatty liver disease focus on classical pathogenic pathways surrounding hepatic lipid accumulation, inflammation or fibrosis. Studies have demonstrated that the autonomic nervous system innervating the liver plays a crucial role in regulation of hepatic lipid homeostasis, inflammation and fibrosis. Additionally, there is growing evidence that neurotrophic factors can modulate all stages of non-alcoholic fatty liver disease. Both the autonomic nervous system and neurotrophic factors are altered in patients and murine models of non-alcoholic fatty liver disease. In this review we focus on the pathophysiological role of the autonomic nervous system and neurotrophic factors that could be potential targets for novel therapeutic approaches to treat non-alcoholic fatty liver disease.
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Affiliation(s)
- Muhammad Amir
- Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, United States
| | - Michael Yu
- Department of Medicine, Emory University School of Medicine, Atlanta, GA, United States
| | - Peijian He
- Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, United States
| | - Shanthi Srinivasan
- Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, United States.,Research-Gastroenterology, Atlanta VA Health Care System, Decatur, GA, United States
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11
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Desai CS, Gerber DA. Concise review of machine perfusion in liver transplantation. World J Hepatol 2020; 12:6-9. [PMID: 31984116 PMCID: PMC6946625 DOI: 10.4254/wjh.v12.i1.6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Revised: 11/21/2019] [Accepted: 12/01/2019] [Indexed: 02/06/2023] Open
Abstract
With the advances and clinical growth in liver transplantation over the last four decades the focus on expanding deceased donor organs has been in need of scientific research. In the past ten years several researchers have looked at the domain of machine perfusion as it applies to deceased donor livers. The following review focuses on the clinical trials and recent advances that will likely have the earliest entrance into the clinical arena.
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Affiliation(s)
- Chirag S Desai
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, United States
| | - David A Gerber
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, United States
- Lineberger Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, United States
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12
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Boteon YL, Attard J, Boteon APCS, Wallace L, Reynolds G, Hubscher S, Mirza DF, Mergental H, Bhogal RH, Afford SC. Manipulation of Lipid Metabolism During Normothermic Machine Perfusion: Effect of Defatting Therapies on Donor Liver Functional Recovery. Liver Transpl 2019; 25:1007-1022. [PMID: 30821045 PMCID: PMC6618030 DOI: 10.1002/lt.25439] [Citation(s) in RCA: 83] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 02/12/2019] [Indexed: 12/20/2022]
Abstract
Strategies to increase the use of steatotic donor livers are required to tackle the mortality on the transplant waiting list. We aimed to test the efficacy of pharmacological enhancement of the lipid metabolism of human livers during ex situ normothermic machine perfusion to promote defatting and improve the functional recovery of the organs. Because of steatosis, 10 livers were discarded and were allocated either to a defatting group that had the perfusate supplemented with a combination of drugs to enhance lipid metabolism or to a control group that received perfusion fluid with vehicle only. Steatosis was assessed using tissue homogenate and histological analyses. Markers for lipid oxidation and solubilization, oxidative injury, inflammation, and biliary function were evaluated by enzyme-linked immunosorbent assay, immunohistochemistry, and in-gel protein detection. Treatment reduced tissue triglycerides by 38% and macrovesicular steatosis by 40% over 6 hours. This effect was driven by increased solubility of the triglycerides (P = 0.04), and mitochondrial oxidation as assessed by increased ketogenesis (P = 0.008) and adenosine triphosphate synthesis (P = 0.01) were associated with increased levels of the enzymes acyl-coenzyme A oxidase 1, carnitine palmitoyltransferase 1A, and acetyl-coenzyme A synthetase. Concomitantly, defatted livers exhibited enhanced metabolic functional parameters such as urea production (P = 0.03), lower vascular resistance, lower release of alanine aminotransferase (P = 0.049), and higher bile production (P = 0.008) with a higher bile pH (P = 0.03). The treatment down-regulated the expression of markers for oxidative injury as well as activation of immune cells (CD14; CD11b) and reduced the release of inflammatory cytokines in the perfusate (tumor necrosis factor α; interleukin 1β). In conclusion, pharmacological enhancement of intracellular lipid metabolism during normothermic machine perfusion decreased the lipid content of human livers within 6 hours. It also improved the intracellular metabolic support to the organs, leading to successful functional recovery and decreased expression of markers of reperfusion injury.
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Affiliation(s)
- Yuri L. Boteon
- Liver UnitQueen Elizabeth Hospital, University Hospitals Birmingham National Health Service Foundation TrustBirminghamUnited Kingdom,National Institute for Health Research Birmingham Biomedical Research CentreUniversity Hospitals Birmingham National Health Service Foundation TrustBirminghamUnited Kingdom,Centre for Liver and Gastrointestinal ResearchInstitute of Immunology and Immunotherapy, College of Medical and Dental Sciences, University of BirminghamBirminghamUnited Kingdom
| | - Joseph Attard
- Liver UnitQueen Elizabeth Hospital, University Hospitals Birmingham National Health Service Foundation TrustBirminghamUnited Kingdom,National Institute for Health Research Birmingham Biomedical Research CentreUniversity Hospitals Birmingham National Health Service Foundation TrustBirminghamUnited Kingdom,Centre for Liver and Gastrointestinal ResearchInstitute of Immunology and Immunotherapy, College of Medical and Dental Sciences, University of BirminghamBirminghamUnited Kingdom
| | - Amanda P. C. S. Boteon
- Liver UnitQueen Elizabeth Hospital, University Hospitals Birmingham National Health Service Foundation TrustBirminghamUnited Kingdom
| | - Lorraine Wallace
- National Institute for Health Research Birmingham Biomedical Research CentreUniversity Hospitals Birmingham National Health Service Foundation TrustBirminghamUnited Kingdom,Centre for Liver and Gastrointestinal ResearchInstitute of Immunology and Immunotherapy, College of Medical and Dental Sciences, University of BirminghamBirminghamUnited Kingdom
| | - Gary Reynolds
- National Institute for Health Research Birmingham Biomedical Research CentreUniversity Hospitals Birmingham National Health Service Foundation TrustBirminghamUnited Kingdom,Centre for Liver and Gastrointestinal ResearchInstitute of Immunology and Immunotherapy, College of Medical and Dental Sciences, University of BirminghamBirminghamUnited Kingdom
| | - Stefan Hubscher
- Liver UnitQueen Elizabeth Hospital, University Hospitals Birmingham National Health Service Foundation TrustBirminghamUnited Kingdom,Department of Cellular PathologyQueen Elizabeth Hospital, University Hospitals Birmingham National Health Service Foundation TrustBirminghamUnited Kingdom
| | - Darius F. Mirza
- Liver UnitQueen Elizabeth Hospital, University Hospitals Birmingham National Health Service Foundation TrustBirminghamUnited Kingdom,National Institute for Health Research Birmingham Biomedical Research CentreUniversity Hospitals Birmingham National Health Service Foundation TrustBirminghamUnited Kingdom,Centre for Liver and Gastrointestinal ResearchInstitute of Immunology and Immunotherapy, College of Medical and Dental Sciences, University of BirminghamBirminghamUnited Kingdom
| | - Hynek Mergental
- Liver UnitQueen Elizabeth Hospital, University Hospitals Birmingham National Health Service Foundation TrustBirminghamUnited Kingdom,National Institute for Health Research Birmingham Biomedical Research CentreUniversity Hospitals Birmingham National Health Service Foundation TrustBirminghamUnited Kingdom,Centre for Liver and Gastrointestinal ResearchInstitute of Immunology and Immunotherapy, College of Medical and Dental Sciences, University of BirminghamBirminghamUnited Kingdom
| | - Ricky H. Bhogal
- The Royal Marsden, Department of Academic SurgeryFulham RoadChelseaLondon
| | - Simon C. Afford
- National Institute for Health Research Birmingham Biomedical Research CentreUniversity Hospitals Birmingham National Health Service Foundation TrustBirminghamUnited Kingdom,Centre for Liver and Gastrointestinal ResearchInstitute of Immunology and Immunotherapy, College of Medical and Dental Sciences, University of BirminghamBirminghamUnited Kingdom
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13
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Abstract
PURPOSE OF REVIEW Normothermic machine perfusion (NMP) is an emerging technology for liver preservation. Early clinical results demonstrate beneficial effects in reconditioning high-risk grafts. This review discusses the role of normothermic perfusion as a tool to assess graft viability and as a platform for graft intervention and modification. RECENT FINDINGS The potential benefits of NMP extend far beyond organ reconditioning. Recent pilot studies have identified clinically relevant viability criteria, which now require validation in large randomized control trials prior to implementation. Furthermore, preclinical studies demonstrate tremendous potential for NMP as a method to extend the preservation period, thus improving transplant logistics as well as serve as a platform for graft-targeted interventions to optimize the preservation period. SUMMARY NMP is a multifunctional tool with potential to transform liver preservation and the field of transplantation. Large clinical trials are necessary to optimize perfusion protocols, clarify indications for NMP therapy and justify use as the standard preservation modality.
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14
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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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15
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Ritschl PV, Günther J, Hofhansel L, Kühl AA, Sattler A, Ernst S, Friedersdorff F, Ebner S, Weiss S, Bösmüller C, Weissenbacher A, Oberhuber R, Cardini B, Öllinger R, Schneeberger S, Biebl M, Denecke C, Margreiter C, Resch T, Aigner F, Maglione M, Pratschke J, Kotsch K. Graft Pre-conditioning by Peri-Operative Perfusion of Kidney Allografts With Rabbit Anti-human T-lymphocyte Globulin Results in Improved Kidney Graft Function in the Early Post-transplantation Period-a Prospective, Randomized Placebo-Controlled Trial. Front Immunol 2018; 9:1911. [PMID: 30197644 PMCID: PMC6117415 DOI: 10.3389/fimmu.2018.01911] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 08/02/2018] [Indexed: 12/21/2022] Open
Abstract
Introduction: Although prone to a higher degree of ischemia reperfusion injury (IRI), the use of extended criteria donor (ECD) organs has become reality in transplantation. We therefore postulated that peri-operative perfusion of renal transplants with anti-human T-lymphocyte globulin (ATLG) ameliorates IRI and results in improved graft function. Methods: We performed a randomized, single-blinded, placebo-controlled trial involving 50 kidneys (KTx). Prior to implantation organs were perfused and incubated with ATLG (AP) (n = 24 kidney). Control organs (CP) were perfused with saline only (n = 26 kidney). Primary endpoint was defined as graft function reflected by serum creatinine at day 7 post transplantation (post-tx). Results: AP-KTx recipients illustrated significantly better graft function at day 7 post-tx as reflected by lower creatinine levels, whereas no treatment effect was observed after 12 months surveillance. During the early hospitalization phase, 16 of the 26 CP-KTx patients required dialysis during the first 7 days post-tx, whereas only 10 of the 24 AP-KTx patients underwent dialysis. No treatment-specific differences were detected for various lymphocytes subsets in the peripheral blood of patients. Additionally, mRNA analysis of 0-h biopsies post incubation with ATLG revealed no changes of intragraft inflammatory expression patterns between AP and CP organs. Conclusion: We here present the first clinical study on peri-operative organ perfusion with ATLG illustrating improved graft function in the early period post kidney transplantation. Clinical Trial Registration:www.ClinicalTrials.gov, NCT03377283
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Affiliation(s)
- Paul V Ritschl
- Department of Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany.,BIH Charité Clinical Scientist Program, Berlin Institute of Health, Berlin, Germany
| | - Julia Günther
- Department of Visceral, Center for Operative Medicine, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Lena Hofhansel
- Department of Visceral, Center for Operative Medicine, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Anja A Kühl
- iPATH.Berlin-Immunopathology for Experimental Models, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Arne Sattler
- Department of Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Stefanie Ernst
- Biostatistics Unit, Clinical Research Unit, Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | | | - Susanne Ebner
- Department of Visceral, Center for Operative Medicine, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Sascha Weiss
- Department of Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Claudia Bösmüller
- Department of Visceral, Center for Operative Medicine, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Annemarie Weissenbacher
- Department of Visceral, Center for Operative Medicine, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Rupert Oberhuber
- Department of Visceral, Center for Operative Medicine, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Benno Cardini
- Department of Visceral, Center for Operative Medicine, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Robert Öllinger
- Department of Visceral, Center for Operative Medicine, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Stefan Schneeberger
- Department of Visceral, Center for Operative Medicine, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Matthias Biebl
- Department of Visceral, Center for Operative Medicine, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Christian Denecke
- Department of Visceral, Center for Operative Medicine, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Christian Margreiter
- Department of Visceral, Center for Operative Medicine, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Thomas Resch
- Department of Visceral, Center for Operative Medicine, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Felix Aigner
- Department of Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Manuel Maglione
- Department of Visceral, Center for Operative Medicine, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Johann Pratschke
- Department of Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Katja Kotsch
- Department of Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
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16
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Rajkumar R, Bhaya B, Mamilla D, Czech T, Kisseih E, Saini A, Chouthai N. A preliminary evaluation of glial cell line-derived neurotrophic factor (GDNF) levels in cerebrospinal fluid across various gestational ages and clinical conditions of the neonate. Int J Dev Neurosci 2017; 65:61-65. [PMID: 29031644 DOI: 10.1016/j.ijdevneu.2017.10.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Revised: 08/23/2017] [Accepted: 10/04/2017] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND This study aims to investigate glial cell derived neurotrophic factor (GDNF) levels in newborns' umbilical cord blood and cerebrospinal fluid across various perinatal growth parameters and clinical conditions. METHODS Cord blood from 20 newborns and 58 residual CSF samples (stored after completion of clinical testing) were collected. GDNF levels were determined using GDNF ELISA kits from R&D Systems in triplicates with appropriate controls to eliminate background. RESULTS Cord blood GDNF levels were significantly higher (p=0.004) in preterm newborns (n=6) (115.05±57.17,pg/ml) when compared to term newborns (n=14) (19.67±10.67,pg/ml). GDNF levels in CSF trended (p=0.07) higher in term newborns (n=10) (19.56±9.11,pg/ml) when compared to preterm newborns at term or post term corrected gestational ages (n=5) (14.49±3.53,pg/ml). CONCLUSIONS GDNF levels in preterm newborns were higher in cord blood and lower in CSF as compared to term newborns. It is important to further study circulating and CSF-GDNF levels in newborns at different gestational ages and clinical conditions.
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Affiliation(s)
- Rahul Rajkumar
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Wayne State University, Detroit, MI, United States; Bloomberg School of Public Health, Department of International Health, Johns Hopkins University, Baltimore, MD, United States
| | - Bhavana Bhaya
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Wayne State University, Detroit, MI, United States; University Medical Center, Department of Internal Medicine, University of Nevada-Las Vegas, Las Vegas, NV, United States
| | - Divya Mamilla
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Wayne State University, Detroit, MI, United States
| | - Theresa Czech
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Wayne State University, Detroit, MI, United States; Ann and Robert H. Lurie Children's Hospital, Department of Pediatrics, Division of Pediatric Neurology, Northwestern University, Chicago, IL, United States
| | - Esther Kisseih
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Wayne State University, Detroit, MI, United States
| | - Arun Saini
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Wayne State University, Detroit, MI, United States; Le Bonheur Children's Hospital, Department of Pediatrics, Division of Critical Care, University of Tennessee, Memphis, TN, United States
| | - Nitin Chouthai
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Wayne State University, Detroit, MI, United States.
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17
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Abstract
Research and clinical experience with vagotomy have confirmed that damage to the central nervous system severely affects physiological movement in the gastrointestinal system. The aim of this study was to investigate the effects of synchronized dual-pulse gastric electrical stimulation (SGES) on the apoptosis of enteric neurons and the possible pathways involved in these effects in vagotomized rats. For this purpose, Male Sprague-Dawley (SD) rats were randomized into a control group, an early subdiaphragmatic vagotomized group (ESDV group), an early subdiaphragmatic vagotomized group with short-term SGES (ESDV + SSGES group), a terminal subdiaphragmatic vagotomized group (TSDV group) and a terminal subdiaphragmatic vagotomized group with long-term SGES (TSDV + LSGES group). The expression levels of connexin 43 (Cx43), glial cell line-derived neurotrophic factor (GDNF), p-Akt, pan-Akt and PGP9.5 were assessed by RT-qPCR, western blot analysis and immunofluorescence staining. Apoptosis was determined by terminal-deoxynucleoitidyl transferase-mediated nick-end labeling (TUNEL) assay. We found that Cx43 expression was decreased in the ESDV and TSDV groups, but was significantly upregulated in the SSGES and LSGES groups. In addition, the GDNF and PGP9.5 expression levels were significantly decreased in the ESDV group compared with the control and TSDV groups and were upregulated in both the SSGES and LSGES groups. The LSGES group exhibited a clear increase in p-Akt expression compared with the TSDV group. Fewer TUNEL-positive cells were observed in the SSGES and LSGES groups than in the ESDV and TSDV groups. More TUNEL-positive cells were found in the stomach of rats subjected to subdiaphragmatic vagotomy. On the whole, our data indicate that SGES improved enteric neuronal survival, possibly through GDNF and the phosphatidylinositol 3-kinase (PI3K)/Akt pathways.
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Affiliation(s)
- Nian Wang
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430022, P.R. China
| | - Kun Li
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430022, P.R. China
| | - Shuangning Song
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430022, P.R. China
| | - Jie Chen
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430022, P.R. China
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