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Flores Carvalho M, Boteon YL, Guarrera JV, Modi PR, Lladó L, Lurje G, Kasahara M, Dutkowski P, Schlegel A. Obstacles to implement machine perfusion technology in routine clinical practice of transplantation: Why are we not there yet? Hepatology 2024; 79:713-730. [PMID: 37013926 DOI: 10.1097/hep.0000000000000394] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Accepted: 03/05/2023] [Indexed: 04/05/2023]
Abstract
Machine perfusion of solid human organs is an old technique, and the basic principles were presented as early as 1855 by Claude Barnard. More than 50 years ago, the first perfusion system was used in clinical kidney transplantation. Despite the well-known benefits of dynamic organ preservation and significant medical and technical development in the last decades, perfusion devices are still not in routine use. This article describes the various challenges to implement this technology in practice, critically analyzing the role of all involved stakeholders, including clinicians, hospitals, regulatory, and industry, on the background of regional differences worldwide. The clinical need for this technology is discussed first, followed by the current status of research and the impact of costs and regulations. Considering the need for strong collaborations between clinical users, regulatory bodies, and industry, integrated road maps and pathways required to achieve a wider implementation are presented. The role of research development, clear regulatory pathways, and the need for more flexible reimbursement schemes is discussed together with potential solutions to address the most relevant hurdles. This article paints an overall picture of the current liver perfusion landscape and highlights the role of clinical, regulatory, and financial stakeholders worldwide.
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Affiliation(s)
- Mauricio Flores Carvalho
- Department of Clinical and Experimental Medicine, Hepatobiliary Unit, University of Florence, AOU Careggi, Florence, Italy
| | - Yuri L Boteon
- Liver Unit, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - James V Guarrera
- Division of Abdominal Transplant Surgery, Rutgers New Jersey Medical School, Department of Surgery, Newark, New Jersey, USA
| | - Pranjal R Modi
- Department of Transplantation Surgery, Institute of Kidney Diseases and Research Center and Dr. H L Trivedi Institute of Transplantation Sciences (IKDRC-ITS), Ahmedabad, India
| | - Laura Lladó
- Liver Transplant Unit, Hospital Universitario de Bellvitge, Barcelona, Spain
| | - Georg Lurje
- Department of Surgery, Campus Charité Mitte, Campus Virchow-Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Mureo Kasahara
- Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Philipp Dutkowski
- Department of Surgery and Transplantation, Swiss HPB Centre, University Hospital Zurich, Switzerland
| | - Andrea Schlegel
- Department of Clinical and Experimental Medicine, Hepatobiliary Unit, University of Florence, AOU Careggi, Florence, Italy
- Department of Surgery and Transplantation, Swiss HPB Centre, University Hospital Zurich, Switzerland
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Center for Preclinical Research, 20100 Milan, Italy
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Quintini C, Martins PN, Shah S, Killackey M, Reed A, Guarrera J, Axelrod DA. Implementing an innovated preservation technology: The American Society of Transplant Surgeons' (ASTS) Standards Committee White Paper on Ex Situ Liver Machine Perfusion. Am J Transplant 2018; 18:1865-1874. [PMID: 29791060 DOI: 10.1111/ajt.14945] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 04/15/2018] [Accepted: 05/15/2018] [Indexed: 01/25/2023]
Abstract
The pervasive shortage of deceased donor liver allografts contributes to significant waitlist mortality despite efforts to increase organ donation. Ex vivo liver perfusion appears to enhance preservation of donor organs, extending viability and potentially evaluating function in organs previously considered too high risk for transplant. These devices pose novel challenges for organ allocation, safety, training, and finances. This white paper describes the American Society of Transplant Surgeons' belief that organ preservation technology is a vital advance, but its use should not change fundamental aspects of organ allocation. Additional data elements need to be collected, made available for organ assessment by transplant professionals to allow determination of organ suitability in the case of reallocation and incorporated into risk adjustment methodology. Finally, further work is needed to determine the optimal strategy for management and oversight of perfused organs prior to transplantation.
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Affiliation(s)
| | | | - Shimul Shah
- University of Cincinnati, Cincinnati, OH, USA
| | - Mary Killackey
- Tulane University School of Medicine, New Orleans, LA, USA
| | - Alan Reed
- University of Iowa, Iowa City, IA, USA
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Bochimoto H, Matsuno N, Ishihara Y, Shonaka T, Koga D, Hira Y, Nishikawa Y, Furukawa H, Watanabe T. The ultrastructural characteristics of porcine hepatocytes donated after cardiac death and preserved with warm machine perfusion preservation. PLoS One 2017; 12:e0186352. [PMID: 29023512 PMCID: PMC5638504 DOI: 10.1371/journal.pone.0186352] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Accepted: 10/01/2017] [Indexed: 12/15/2022] Open
Abstract
The effects of warm machine perfusion preservation of liver grafts donated after cardiac death on the intracellular three-dimensional ultrastructure of the organelles in hepatocytes remain unclear. Here we analyzed comparatively the ultrastructure of the endomembrane systems in porcine hepatocytes under warm ischemia and successive hypothermic and midthermic machine perfusion preservation, a type of the warm machine perfusion. Porcine liver grafts which had a warm ischemia time of 60 minutes were perfused for 4 hours with modified University of Wisconsin gluconate solution. Group A grafts were preserved with hypothermic machine perfusion preservation at 8°C constantly for 4 hours. Group B grafts were preserved with rewarming up to 22°C by warm machine perfusion preservation for 4 hours. An analysis of hepatocytes after 60 minutes of warm ischemia by scanning electron microscope revealed the appearance of abnormal vacuoles and invagination of mitochondria. In the hepatocytes preserved by subsequent hypothermic machine perfusion preservation, strongly swollen mitochondria were observed. In contrast, the warm machine perfusion preservation could preserve the functional appearance of mitochondria in hepatocytes. Furthermore, abundant vacuoles and membranous structures sequestrating cellular organelles like autophagic vacuoles were frequently observed in hepatocytes after warm machine perfusion preservation. In conclusion, the ultrastructure of the endomembrane systems in the hepatocytes of liver grafts changed in accordance with the temperature conditions of machine perfusion preservation. In addition, temperature condition of the machine perfusion preservation may also affect the condition of the hepatic graft attributed to autophagy systems, and consequently alleviate the damage of the hepatocytes.
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Affiliation(s)
- Hiroki Bochimoto
- Health Care Administration Center, Obihiro University of Agriculture and Veterinary Medicine, Obihiro, Hokkaido, Japan
| | - Naoto Matsuno
- Department of Surgery, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
- * E-mail:
| | - Yo Ishihara
- Department of Microscopic Anatomy and Cell Biology, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Tatsuya Shonaka
- Department of Surgery, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Daisuke Koga
- Department of Microscopic Anatomy and Cell Biology, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Yoshiki Hira
- Area of Functional Anatomy, Department of Nursing, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Yuji Nishikawa
- Department of Pathology, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Hiroyuki Furukawa
- Department of Surgery, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Tsuyoshi Watanabe
- Department of Microscopic Anatomy and Cell Biology, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
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