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Cesaretti M, Izzo A, Pellegrino RA, Galli A, Mavrothalassitis O. Cold ischemia time in liver transplantation: An overview. World J Hepatol 2024; 16:883-890. [PMID: 38948435 PMCID: PMC11212655 DOI: 10.4254/wjh.v16.i6.883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 04/26/2024] [Accepted: 05/20/2024] [Indexed: 06/20/2024] Open
Abstract
The standard approach to organ preservation in liver transplantation is by static cold storage and the time between the cross-clamping of a graft in a donor and its reperfusion in the recipient is defined as cold ischemia time (CIT). This simple definition reveals a multifactorial time frame that depends on donor hepatectomy time, transit time, and recipient surgery time, and is one of the most important donor-related risk factors which may influence the graft and recipient's survival. Recently, the growing demand for the use of marginal liver grafts has prompted scientific exploration to analyze ischemia time factors and develop different organ preservation strategies. This review details the CIT definition and analyzes its different factors. It also explores the most recent strategies developed to implement each timestamp of CIT and to protect the graft from ischemic injury.
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Affiliation(s)
- Manuela Cesaretti
- Department of HPB and Liver Transplantation, Brotzu Hospital, Cagliari 09122, Italy
- Department of Nanophysic, Istituto Italiano di Tecnologia, Genova 16163, Italy.
| | - Alessandro Izzo
- Department of HPB and Liver Transplantation, Brotzu Hospital, Cagliari 09122, Italy
| | | | - Alessandro Galli
- Department of Critical Care Medicine and Anesthesia, ASST Papa Giovanni XXIII, Bergamo 24100, Italy
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA 94143, United States
| | - Orestes Mavrothalassitis
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA 94143, United States
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Martin JL, Rhodes F, Upponi S, Udeaja Y, Swift L, Fear C, Webster R, Webb GJ, Allison M, Paterson A, Gaurav R, Butler AJ, Watson CJE. Localized Liver Injury During Normothermic Ex Situ Liver Perfusion Has No Impact on Short-term Liver Transplant Outcomes. Transplantation 2024; 108:1403-1409. [PMID: 38419153 PMCID: PMC11115454 DOI: 10.1097/tp.0000000000004970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 11/17/2023] [Accepted: 12/31/2023] [Indexed: 03/02/2024]
Abstract
BACKGROUND Normothermic ex situ liver perfusion (NESLiP) has the potential to increase organ utilization. Radiological evidence of localized liver injury due to compression at the time of NESLiP, termed cradle compression, is a recognized phenomenon but is poorly characterized. METHODS A retrospective analysis of a prospectively collected database was performed of transplanted livers that underwent NESLiP and subsequently had a computed tomography performed within the first 14 d posttransplant. The primary study outcome was 1-y graft survival. RESULTS Seventy livers (63%) were included in the analysis. Radiological evidence of cradle compression was observed in 21 of 70 (30%). There was no difference in rate of cradle compression between donor after circulatory death and donated after brain death donors ( P = 0.37) or with duration of NESLiP. Univariate analysis demonstrated younger (area under the receiver operating characteristic, 0.68; P = 0.008; 95% confidence interval [CI], 0.55-0.82) and heavier (area under the receiver operating characteristic, 0.80; P < 0.001; 95% CI, 0.69-0.91) livers to be at risk of cradle compression. Only liver weight was associated with cradle compression on multivariate analysis (odds ratio, 1.003; P = 0.005; 95% CI, 1.001-1.005). There was no difference in 1-y graft survival (16/17 [94.1%] versus 44/48 [91.6%]; odds ratio, 0.69; P = 0.75; 95% CI, 0.07-6.62). CONCLUSIONS This is the first study assessing the impact of cradle compression on outcome. We have identified increased donor liver weight and younger age as risk factors for the development of this phenomenon. Increasing utilization of NESLiP will result in the increased incidence of cradle compression but the apparent absence of long-term sequelae is reassuring. Routine postoperative axial imaging may be warranted.
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Affiliation(s)
- Jack L. Martin
- Roy Calne Transplant Unit, Cambridge University Hospitals NHS Foundation Trust, and Cambridge NIHR Biomedical Research Centre, Biomedical Campus, Cambridge, United Kingdom
| | | | - Sara Upponi
- Department of Radiology, Biomedical Campus, University of Cambridge, Cambridge, United Kingdom
| | - Yagazie Udeaja
- Department of Radiology, Biomedical Campus, University of Cambridge, Cambridge, United Kingdom
| | - Lisa Swift
- Roy Calne Transplant Unit, Cambridge University Hospitals NHS Foundation Trust, and Cambridge NIHR Biomedical Research Centre, Biomedical Campus, Cambridge, United Kingdom
| | - Corina Fear
- Roy Calne Transplant Unit, Cambridge University Hospitals NHS Foundation Trust, and Cambridge NIHR Biomedical Research Centre, Biomedical Campus, Cambridge, United Kingdom
| | - Rachel Webster
- Roy Calne Transplant Unit, Cambridge University Hospitals NHS Foundation Trust, and Cambridge NIHR Biomedical Research Centre, Biomedical Campus, Cambridge, United Kingdom
| | - Gwilym James Webb
- Department of Hepatology, Cambridge NIHR Biomedical Research Centre, Biomedical Campus, University of Cambridge, Cambridge, United Kingdom
| | - Michael Allison
- Department of Hepatology, Cambridge NIHR Biomedical Research Centre, Biomedical Campus, University of Cambridge, Cambridge, United Kingdom
| | - Anna Paterson
- Histopathology Department, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Rohit Gaurav
- Roy Calne Transplant Unit, Cambridge University Hospitals NHS Foundation Trust, and Cambridge NIHR Biomedical Research Centre, Biomedical Campus, Cambridge, United Kingdom
| | - Andrew J. Butler
- Roy Calne Transplant Unit, Cambridge University Hospitals NHS Foundation Trust, and Cambridge NIHR Biomedical Research Centre, Biomedical Campus, Cambridge, United Kingdom
| | - Christopher J. E. Watson
- Roy Calne Transplant Unit, Cambridge University Hospitals NHS Foundation Trust, and Cambridge NIHR Biomedical Research Centre, Biomedical Campus, Cambridge, United Kingdom
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Watson CJ, Gaurav R, Butler AJ. Current Techniques and Indications for Machine Perfusion and Regional Perfusion in Deceased Donor Liver Transplantation. J Clin Exp Hepatol 2024; 14:101309. [PMID: 38274508 PMCID: PMC10806097 DOI: 10.1016/j.jceh.2023.101309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 11/27/2023] [Indexed: 01/27/2024] Open
Abstract
Since the advent of University of Wisconsin preservation solution in the 1980s, clinicians have learned to work within its confines. While affording improved outcomes, considerable limitations still exist and contribute to the large number of livers that go unused each year, often for fear they may never work. The last 10 years have seen the widespread availability of new perfusion modalities which provide an opportunity for assessing organ viability and prolonged organ storage. This review will discuss the role of in situ normothermic regional perfusion for livers donated after circulatory death. It will also describe the different modalities of ex situ perfusion, both normothermic and hypothermic, and discuss how they are thought to work and the opportunities afforded by them.
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Affiliation(s)
- Christopher J.E. Watson
- University of Cambridge Department of Surgery, Box 210, Addenbrooke's Hospital, Cambridge, CB2 2QQ, UK
- The Roy Calne Transplant Unit, Addenbrooke's Hospital, Cambridge, CB2 2QQ, UK
| | - Rohit Gaurav
- The Roy Calne Transplant Unit, Addenbrooke's Hospital, Cambridge, CB2 2QQ, UK
| | - Andrew J. Butler
- University of Cambridge Department of Surgery, Box 210, Addenbrooke's Hospital, Cambridge, CB2 2QQ, UK
- The Roy Calne Transplant Unit, Addenbrooke's Hospital, Cambridge, CB2 2QQ, UK
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Lascaris B, Hoffmann RF, Nijsten MW, Porte RJ, de Meijer VE. Continuous Renal Replacement Therapy During Long-term Normothermic Machine Perfusion of Human Donor Livers for up to 7 D. Transplant Direct 2024; 10:e1568. [PMID: 38274473 PMCID: PMC10810577 DOI: 10.1097/txd.0000000000001568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 10/28/2023] [Indexed: 01/27/2024] Open
Abstract
Background Normothermic machine perfusion (NMP) is used to preserve and test donor livers before transplantation. During NMP, the liver is metabolically active and produces waste products, which are released into the perfusate. In this study, we describe our simplified and inexpensive setup that integrates continuous renal replacement therapy (CRRT) with NMP for up to 7 d. We also investigated if the ultrafiltrate could be used for monitoring perfusate concentrations of small molecules such as glucose and lactate. Methods Perfusate composition (urea, osmolarity, sodium, potassium, chloride, calcium, magnesium, phosphate, glucose, and lactate) was analyzed from 56 human NMP procedures without CRRT. Next, in 6 discarded human donor livers, CRRT was performed during NMP by integrating a small dialysis filter (0.2 m2) into the circuit to achieve continuous ultrafiltration combined with continuous fluid substitution for up to 7 d. Results Within a few hours of NMP without CRRT, a linear increase in osmolarity and concentrations of urea and phosphate to supraphysiological levels was observed. After integration of CRRT into the NMP circuit, the composition of the perfusate was corrected to physiological values within 12 h, and this homeostasis was maintained during NMP for up to 7 d. Glucose and lactate levels, as measured in the CRRT ultrafiltrate, were strongly correlated with perfusate levels (r = 0.997, P < 0.001 and r = 0.999, P < 0.001, respectively). Conclusions The integration of CRRT into the NMP system corrected the composition of the perfusate to near-physiological values, which could be maintained for up to 7 d. The ultrafiltrate can serve as an alternative to the perfusate to monitor concentrations of small molecules without potentially compromising sterility.
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Affiliation(s)
- Bianca Lascaris
- Department of Surgery, Section of Hepatobiliary Surgery and Liver Transplantation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- UMCG Comprehensive Transplant Center, Groningen, The Netherlands
| | - Roland F. Hoffmann
- Department of Cardiothoracic Surgery, Section Extracorporeal Circulation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Maarten W.N. Nijsten
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Robert J. Porte
- Department of Surgery, Section of Hepatobiliary Surgery and Liver Transplantation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Division of HPB and Transplant Surgery, Department of Surgery, Erasmus MC Transplant Institute, Rotterdam, The Netherlands
| | - Vincent E. de Meijer
- Department of Surgery, Section of Hepatobiliary Surgery and Liver Transplantation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- UMCG Comprehensive Transplant Center, Groningen, The Netherlands
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López-Martínez S, Simón C, Santamaria X. Normothermic Machine Perfusion Systems: Where Do We Go From Here? Transplantation 2024; 108:22-44. [PMID: 37026713 DOI: 10.1097/tp.0000000000004573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023]
Abstract
Normothermic machine perfusion (NMP) aims to preserve organs ex vivo by simulating physiological conditions such as body temperature. Recent advancements in NMP system design have prompted the development of clinically effective devices for liver, heart, lung, and kidney transplantation that preserve organs for several hours/up to 1 d. In preclinical studies, adjustments to circuit structure, perfusate composition, and automatic supervision have extended perfusion times up to 1 wk of preservation. Emerging NMP platforms for ex vivo preservation of the pancreas, intestine, uterus, ovary, and vascularized composite allografts represent exciting prospects. Thus, NMP may become a valuable tool in transplantation and provide significant advantages to biomedical research. This review recaps recent NMP research, including discussions of devices in clinical trials, innovative preclinical systems for extended preservation, and platforms developed for other organs. We will also discuss NMP strategies using a global approach while focusing on technical specifications and preservation times.
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Affiliation(s)
- Sara López-Martínez
- Carlos Simon Foundation, Centro de Investigación Príncipe Felipe, Valencia, Spain
| | - Carlos Simón
- Carlos Simon Foundation, Centro de Investigación Príncipe Felipe, Valencia, Spain
- Department of Obstetrics and Gynecology, Universidad de Valencia, Valencia, Spain
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Harvard University, Boston, MA
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX
| | - Xavier Santamaria
- Carlos Simon Foundation, Centro de Investigación Príncipe Felipe, Valencia, Spain
- INCLIVA Biomedical Research Institute, Valencia, Spain
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Abdominal Organ Preservation Solutions in the Age of Machine Perfusion. Transplantation 2023; 107:326-340. [PMID: 35939388 DOI: 10.1097/tp.0000000000004269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The past decade has been the foreground for a radical revolution in the field of preservation in abdominal organ transplantation. Perfusion has increasingly replaced static cold storage as the preferred and even gold standard preservation method for marginal-quality organs. Perfusion is dynamic and offers several advantages in comparison with static cold storage. These include the ability to provide a continuous supply of new metabolic substrates, clear metabolic waste products, and perform some degree of organ viability assessment before actual transplantation in the recipient. At the same time, the ongoing importance of static cold storage cannot be overlooked, in particular when it comes to logistical and technical convenience and cost, not to mention the fact that it continues to work well for the majority of transplant allografts. The present review article provides an overview of the fundamental concepts of organ preservation, providing a brief history of static cold preservation and description of the principles behind and basic components of cold preservation solutions. An evaluation of current evidence supporting the use of different preservation solutions in abdominal organ transplantation is provided. As well, the range of solutions used for machine perfusion of abdominal organs is described, as are variations in their compositions related to changing metabolic needs paralleling the raising of the temperature of the perfusate from hypothermic to normothermic range. Finally, appraisal of new preservation solutions that are on the horizon is provided.
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Li B, Zhang J, Shen C, Zong T, Zhao C, Zhao Y, Lu Y, Sun S, Zhu H. Application of polymerized porcine hemoglobin in the ex vivo normothermic machine perfusion of rat livers. Front Bioeng Biotechnol 2022; 10:1072950. [PMID: 36686244 PMCID: PMC9854803 DOI: 10.3389/fbioe.2022.1072950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 11/22/2022] [Indexed: 12/04/2022] Open
Abstract
Background: In contrast to traditional static cold preservation of donor livers, normothermic machine perfusion (NMP) may reduce preservation injury, improve graft viability and potentially allows ex vivo assessment of graft viability before transplantation. The polymerized porcine hemoglobin is a kind of hemoglobin oxygen carrier prepared by crosslinking porcine hemoglobin by glutaraldehyde to form a polymer. The pPolyHb has been proved to have the ability of transporting oxygen which could repair the organ ischemia-reperfusion injury in rats. Objective: In order to evaluate the effectiveness of rat liver perfusion in vitro based on pPolyHb, we established the NMP system, optimized the perfusate basic formula and explored the optimal proportion of pPolyHb and basal perfusate. Methods: The liver was removed and perfused for 6 h at 37°C. We compared the efficacy of liver perfusion with different ratios of pPolyHb. Subsequently, compared the perfusion effect using Krebs Henseleit solution and pPolyHb perfusate of the optimal proportion, and compared with the liver preserved with UW solution. At 0 h, 1 h, 3 h and 6 h after perfusion, appropriate samples were collected for blood gas analysis and liver injury indexes detection. Some tissue samples were collected for H&E staining and TUNEL staining to observe the morphology and detect the apoptosis rate of liver cells. And we used Western Blot test to detect the expression of Bcl-2 and Bax in the tissues. Results: According to the final results, the optimal addition ratio of pPolyHb was 24%. By comparing the values of Bcl-2/Bax, the apoptosis rate of pPolyHb group was significantly reduced. Under this ratio, the results of H&E staining and TUNEL staining showed that the liver morphology was well preserved without additional signs of hepatocyte ischemia, biliary tract injury, or hepatic sinusoid injury, and hepatocyte apoptosis was relatively mild. Conclusion: Through the above-mentioned study we show that within 6 h of perfusion based on pPolyHb, liver physiological and biochemical activities may essentially be maintained in vitro. This study demonstrates that a pPolyHb-based perfusate is feasible for NMP of rat livers. This opens up a prospect for further research on NMP.
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Affiliation(s)
- Bin Li
- The College of Life Sciences, Northwest University, Xi’an, Shaanxi, China,National Engineering Research Center for Miniaturized Detection Systems, Northwest University, Xi’an, China,Key Laboratory of Resource Biology and Biotechnology in Western China, Ministry of Education, School of Medicine, Northwest University, Xi’an, China
| | - Jie Zhang
- The College of Life Sciences, Northwest University, Xi’an, Shaanxi, China
| | - Chuanyan Shen
- The College of Life Sciences, Northwest University, Xi’an, Shaanxi, China
| | - Tingting Zong
- The College of Life Sciences, Northwest University, Xi’an, Shaanxi, China
| | - Cong Zhao
- The College of Life Sciences, Northwest University, Xi’an, Shaanxi, China
| | - Yumin Zhao
- The College of Life Sciences, Northwest University, Xi’an, Shaanxi, China
| | - Yunhua Lu
- The College of Life Sciences, Northwest University, Xi’an, Shaanxi, China
| | - Siyue Sun
- The College of Life Sciences, Northwest University, Xi’an, Shaanxi, China
| | - Hongli Zhu
- The College of Life Sciences, Northwest University, Xi’an, Shaanxi, China,National Engineering Research Center for Miniaturized Detection Systems, Northwest University, Xi’an, China,Key Laboratory of Resource Biology and Biotechnology in Western China, Ministry of Education, School of Medicine, Northwest University, Xi’an, China,*Correspondence: Hongli Zhu,
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8
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Sousa Da Silva RX, Weber A, Dutkowski P, Clavien PA. Machine perfusion in liver transplantation. Hepatology 2022; 76:1531-1549. [PMID: 35488496 DOI: 10.1002/hep.32546] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 02/24/2022] [Accepted: 02/24/2022] [Indexed: 12/29/2022]
Abstract
Although liver transplantation is a true success story, many patients still die awaiting an organ. The increasing need for liver grafts therefore remains an unsolved challenge to the transplant community. To address this, transplant donor criteria have been expanded and, for example, more liver grafts with significant steatosis or from donors with circulatory death are being used. These marginal grafts, however, carry an increased risk of graft-associated complications, such as primary nonfunction, delayed graft function, or late biliary injuries. Therefore, reliable assessment of graft viability before use is essential for further success. To achieve this, machine liver perfusion, a procedure developed more than 50 years ago but almost forgotten at the end of the last century, is again of great interest. We describe in this review the clinical most applied machine perfusion techniques, their mechanistic background, and a novel concept of combining immediate organ assessment during hypothermic oxygenated perfusion, followed by an extended phase of normothermic machine perfusion, with simultaneous ex situ treatment of the perfused liver. Such a new approach may allow the pool of usable livers to dramatically increase and improve outcomes for recipients.
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Affiliation(s)
- Richard X Sousa Da Silva
- Department of Surgery and Transplantation, Swiss Hepato-Pancreato-Biliary and Transplant Center, University Hospital Zurich, Zurich, Switzerland.,Wyss Zurich Translational Center, Swiss Federal Institute of Technology ETH Zurich/University of Zurich, Zurich, Switzerland
| | - Achim Weber
- Department of Pathology and Molecular Pathology, Institute of Molecular Cancer Research, University Hospital Zurich and University Zurich, Zurich, Switzerland
| | - Philipp Dutkowski
- Department of Surgery and Transplantation, Swiss Hepato-Pancreato-Biliary and Transplant Center, University Hospital Zurich, Zurich, Switzerland
| | - Pierre-Alain Clavien
- Department of Surgery and Transplantation, Swiss Hepato-Pancreato-Biliary and Transplant Center, University Hospital Zurich, Zurich, Switzerland.,Wyss Zurich Translational Center, Swiss Federal Institute of Technology ETH Zurich/University of Zurich, Zurich, Switzerland
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9
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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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Lascaris B, Thorne AM, Lisman T, Nijsten MWN, Porte RJ, de Meijer VE. Long-term normothermic machine preservation of human livers: what is needed to succeed? Am J Physiol Gastrointest Liver Physiol 2022; 322:G183-G200. [PMID: 34756122 DOI: 10.1152/ajpgi.00257.2021] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Although short-term machine perfusion (≤24 h) allows for resuscitation and viability assessment of high-risk donor livers, the donor organ shortage might be further remedied by long-term perfusion machines. Extended preservation of injured donor livers may allow reconditioning, repairing, and regeneration. This review summarizes the necessary requirements and challenges for long-term liver machine preservation, which requires integrating multiple core physiological functions to mimic the physiological environment inside the body. A pump simulates the heart in the perfusion system, including automatically controlled adjustment of flow and pressure settings. Oxygenation and ventilation are required to account for the absence of the lungs combined with continuous blood gas analysis. To avoid pressure necrosis and achieve heterogenic tissue perfusion during preservation, diaphragm movement should be simulated. An artificial kidney is required to remove waste products and control the perfusion solution's composition. The perfusate requires an oxygen carrier, but will also be challenged by coagulation and activation of the immune system. The role of the pancreas can be mimicked through closed-loop control of glucose concentrations by automatic injection of insulin or glucagon. Nutrients and bile salts, generally transported from the intestine to the liver, have to be supplemented when preserving livers long term. Especially for long-term perfusion, the container should allow maintenance of sterility. In summary, the main challenge to develop a long-term perfusion machine is to maintain the liver's homeostasis in a sterile, carefully controlled environment. Long-term machine preservation of human livers may allow organ regeneration and repair, thereby ultimately solving the shortage of donor livers.
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Affiliation(s)
- Bianca Lascaris
- Section of Hepatopancreatobiliary Surgery & Liver Transplantation, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Adam M Thorne
- Section of Hepatopancreatobiliary Surgery & Liver Transplantation, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Ton Lisman
- Surgical Research Laboratory, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Maarten W N Nijsten
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Robert J Porte
- Section of Hepatopancreatobiliary Surgery & Liver Transplantation, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Vincent E de Meijer
- Section of Hepatopancreatobiliary Surgery & Liver Transplantation, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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11
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Brüggenwirth IMA, Lantinga VA, Rayar M, van den Berg AP, Blokzijl H, Reyntjens KMEM, Porte RJ, de Meijer VE. Prolonged dual hypothermic oxygenated machine preservation (DHOPE-PRO) in liver transplantation: study protocol for a stage 2, prospective, dual-arm, safety and feasibility clinical trial. BMJ Open Gastroenterol 2022; 9:bmjgast-2021-000842. [PMID: 35039326 PMCID: PMC8764996 DOI: 10.1136/bmjgast-2021-000842] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 12/14/2021] [Indexed: 12/20/2022] Open
Abstract
Introduction End-ischaemic preservation of a donor liver by dual hypothermic oxygenated machine perfusion (DHOPE) for 2 hours prior to transplantation is sufficient to mitigate ischaemia-reperfusion damage and fully restore cellular energy levels. Clinical studies have shown beneficial outcomes after transplantation of liver grafts preserved by DHOPE compared with static cold storage. In addition to graft reconditioning, DHOPE may also be used to prolong preservation time, which could facilitate logistics for allocation and transplantation globally. Methods and analysis This is a prospective, pseudo-randomised, dual-arm, IDEAL-D (Idea, Development, Exploration, Assessment, Long term study-Framework for Devices) stage 2 clinical device trial designed to determine safety and feasibility of prolonged DHOPE (DHOPE-PRO). The end-time of the donor hepatectomy will determine whether the graft will be assigned to the intervention (16:00–3:59 hour) or to the control arm (4:00–15:59 hour). In total, 36 livers will be included in the study. Livers in the intervention group (n=18) will undergo DHOPE-PRO (≥4 hours) until implantation the following morning, whereas livers in the control group (n=18) will undergo regular DHOPE (2 hours) prior to implantation. The primary endpoint of this study is a composite of the occurrence of all (serious) adverse events during DHOPE and up to 30 days after liver transplantation. Ethics and dissemination The protocol was approved by the Medical Ethical Committee of Groningen, METc2020.126 in June 2020, and the study was registered in the Netherlands National Trial Registry (https://www.trialregister.nl/) prior to initiation. Trial registration number NL8740.
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Affiliation(s)
- Isabel M A Brüggenwirth
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University of Groningen and University Medical Center Groningen, Groningen, The Netherlands
| | - Veerle A Lantinga
- Organ Preservation and Resuscitation Unit, University of Groningen and University Medical Center Groningen, Groningen, The Netherlands
| | - Michel Rayar
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University of Groningen and University Medical Center Groningen, Groningen, The Netherlands.,Centre Hospitalier Universitaire de Rennes, Rennes, France
| | - Aad P van den Berg
- Hepatology, University of Groningen and University Medical Center Groningen, Groningen, The Netherlands
| | - Hans Blokzijl
- Hepatology, University of Groningen and University Medical Center Groningen, Groningen, The Netherlands
| | - Koen M E M Reyntjens
- Anesthesiology, University of Groningen and University Medical Center Groningen, Groningen, The Netherlands
| | - Robert J Porte
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University of Groningen and University Medical Center Groningen, Groningen, The Netherlands
| | - Vincent E de Meijer
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University of Groningen and University Medical Center Groningen, Groningen, The Netherlands
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Tchouta LN, Alghanem F, Rojas-Pena A, Bartlett RH. Prolonged (≥24 Hours) Normothermic (≥32 °C) Ex Vivo Organ Perfusion: Lessons From the Literature. Transplantation 2021; 105:986-998. [PMID: 33031222 DOI: 10.1097/tp.0000000000003475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
For 2 centuries, researchers have studied ex vivo perfusion intending to preserve the physiologic function of isolated organs. If it were indeed possible to maintain ex vivo organ viability for days, transplantation could become an elective operation with clinicians methodically surveilling and reconditioning allografts before surgery. To this day, experimental reports of successfully prolonged (≥24 hours) organ perfusion are rare and have not translated into clinical practice. To identify the crucial factors necessary for successful perfusion, this review summarizes the history of prolonged normothermic ex vivo organ perfusion. By examining successful techniques and protocols used, this review outlines the essential elements of successful perfusion, limitations of current perfusion systems, and areas where further research in preservation science is required.
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Affiliation(s)
- Lise N Tchouta
- Department of Surgery, Columbia University Medical Center, New York, NY
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Fares Alghanem
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Central Michigan University College of Medicine, Mount Pleasant, MI
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13
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Oldhafer F, Beetz O, Cammann S, Richter N, Klempnauer J, Vondran FWR. [Machine Perfusion for Liver Transplantation - What is Possible and Where Do We Stand in Germany? Review of the Literature and Results of a National Survey]. Zentralbl Chir 2021; 146:382-391. [PMID: 33761573 DOI: 10.1055/a-1363-2520] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Machine perfusion of donor livers is currently regarded as the most important innovation in transplant surgery to address the continuing shortage of organs in liver transplantation. Hypothermic machine perfusion (HMP) is safe to use and appears to reduce the risk of biliary complications and improve the long-term survival of transplanted organs following preservation by cold static storage - even in donors after cardiac death. A potential functional test of donor organs during HMP uses flavin mononucleotide and is still under clinical investigation. Normothermic machine perfusion (NMP) has a greater risk of technical problems, but functional testing using conventional laboratory parameters during NMP allows significant expansion of the donor pool, even though no prospective randomised study has been able to demonstrate a survival advantage for transplanted organs after NMP. In addition, the preservation time of the donor organs can be significantly extended with the help of NMP, which is particularly advantageous for complex recipient operations and/or logistics. Both methods could be applied for various scenarios in transplantation medicine - theoretically also in combination. The majority of German transplant centres regard machine perfusion as an important innovation and already actively perform perfusions or are in preparation for doing so. However, the overall practical experience in Germany is still relatively low, with only 2 centres having performed more than 20 perfusions. In the coming years, multi-centre efforts to conduct clinical trials and to develop national guidelines on machine perfusion will therefore be indispensable in order to define the potential of these technological developments objectively and to exploit it optimally for the field of transplantation medicine.
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Affiliation(s)
- Felix Oldhafer
- Allgemein-, Viszeral- und Transplantationschirurgie, Medizinische Hochschule Hannover, Deutschland
| | - Oliver Beetz
- Allgemein-, Viszeral- und Transplantationschirurgie, Medizinische Hochschule Hannover, Deutschland
| | - Sebastian Cammann
- Allgemein-, Viszeral- und Transplantationschirurgie, Medizinische Hochschule Hannover, Deutschland
| | - Nicolas Richter
- Allgemein-, Viszeral- und Transplantationschirurgie, Medizinische Hochschule Hannover, Deutschland
| | - Juergen Klempnauer
- Allgemein-, Viszeral- und Transplantationschirurgie, Medizinische Hochschule Hannover, Deutschland
| | - Florian W R Vondran
- Allgemein-, Viszeral- und Transplantationschirurgie, Medizinische Hochschule Hannover, Deutschland
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14
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Bile formation in long-term ex situ perfused livers. Surgery 2021; 169:894-902. [PMID: 33422346 DOI: 10.1016/j.surg.2020.11.042] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 11/18/2020] [Accepted: 11/27/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Long-term ex situ liver perfusion may rescue injured grafts. Little is known about bile flow during long-term perfusion. We report the development of a bile stimulation protocol and motivate bile flow as a viability marker during long-term ex situ liver perfusion. METHODS Porcine and human livers were perfused with blood at close to physiologic conditions. Our perfusion protocol was established during phase 1 with porcine livers (n = 23). Taurocholic acid was applied to stimulate bile flow. The addition of piperacillin-tazobactam (tazobac) and methylprednisolone was modified from daily bolus to controlled continuous application. We adapted the protocol to human livers (n = 12) during phase 2. Taurocholic acid was replaced with medical grade ursodeoxycholic acid. RESULTS Phase 2: Despite administering taurocholic acid, bile flow declined from 29.3 ± 6.5 to 9.3 ± 1.4 mL/h (P < .001). Shortly after bolus of tazobac/methylprednisolone, bile flow recovered to 39.0 ± 9.7 mL/h with a decrease of solid bile components. This implied bile salt independent bile flow stimulation by tazobac/methylprednisolone. Phase 2: Ursodeoxycholic acid was shown to stimulate bile flow ex situ in human livers. Eight livers were perfused successfully for 1 week with continuous bile flow. The other 4 livers demonstrated progressive cell death, of which only 1 exhibited bile flow. CONCLUSION A lack of bile flow stimulation leads to a decline in bile flow and is not necessarily a sign of deterioration in liver function. Proper administration of stimulators can induce constant bile flow during ex situ liver perfusion for up to 1 week. Medical grade ursodeoxycholic acid is a suitable replacement for nonmedical grade taurocholic acid. The presence of bile flow alone is not sufficient to assess liver viability.
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15
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Sherman M. The second volume. JHEP Rep 2020; 2:100095. [PMID: 32195458 PMCID: PMC7078376 DOI: 10.1016/j.jhepr.2020.100095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Accepted: 02/28/2020] [Indexed: 11/22/2022] Open
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16
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Brüggenwirth IMA, van Leeuwen OB, de Vries Y, Bodewes SB, Adelmeijer J, Wiersema-Buist J, Lisman T, Martins PN, de Meijer VE, Porte RJ. Extended hypothermic oxygenated machine perfusion enables ex situ preservation of porcine livers for up to 24 hours. JHEP Rep 2020; 2:100092. [PMID: 32195456 PMCID: PMC7078381 DOI: 10.1016/j.jhepr.2020.100092] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 01/16/2020] [Indexed: 12/19/2022] Open
Abstract
Background & Aims End-ischemic hypothermic oxygenated machine perfusion (HOPE) of the donor liver for 1-2 h mitigates ischemia-reperfusion injury during subsequent liver transplantation. Extended preservation time may be preferred to facilitate difficult recipient hepatectomy or to optimize logistics. We therefore investigated whether end-ischemic dual HOPE (DHOPE) could extend preservation time for up to 24 h using a porcine liver reperfusion model. Methods Following 30 min warm ischemia, porcine livers were subjected to 2 h static cold storage (SCS), followed by 2 h, 6 h, or 24 h DHOPE (n = 6 per group). Subsequent normothermic reperfusion was performed for 4 h using autologous blood. Two livers preserved by 24 h SCS served as additional controls. A proof of principle confirmation was carried out in 2 discarded human livers subjected to extended DHOPE. Hepatocellular and cholangiocyte injury and function were assessed. Oxidative stress levels and histology were compared between groups. Results Perfusion flows remained stable during DHOPE, regardless of duration. After normothermic reperfusion, livers perfused for 24 h by DHOPE had similar lactate clearance, blood pH, glucose, and alanine aminotransferase levels, and biliary pH, bicarbonate, and LDH levels, as livers perfused for 2 h and 6 h. Levels of malondialdehyde and high-mobility group box 1 in serum and liver parenchyma were similar for all groups. Histological analysis of bile ducts and liver parenchyma revealed no differences between the groups. Extended DHOPE in discarded human livers preserved hepatocellular and cholangiocyte function and histology after reperfusion. In contrast, livers preserved by 24 h SCS were non-functioning. Conclusion Extended end-ischemic DHOPE enabled successful preservation of porcine and discarded human donor livers for up to 24 h. Extended DHOPE enables safe extension of preservation time, which may facilitate allocation and transplantation from a logistical perspective, and further expand the donor pool. Lay summary It has been suggested that preserving liver grafts with a technique called (dual) hypothermic oxygenated machine perfusion ([D]HOPE) leads to better outcomes after transplantation than if livers are stored on ice, especially if an organ is of lesser quality. In this study, we showed that DHOPE could be used to preserve liver grafts for up to 24 h. This extended procedure could be used globally to facilitate transplantation and expand the donor pool.
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Key Words
- 8-OHdG, 8-hydroxydeoxyguanosine
- ALT, alanine aminotransferase
- DCD, donation after circulatory death
- DHOPE, dual hypothermic oxygenated machine perfusion
- ECD, extended criteria donor
- HMGB-1, high-mobility group box 1
- HMP, hypothermic machine perfusion
- HOPE, hypothermic oxygenated machine perfusion
- HPF, high-powered field
- IL-6, interleukin 6
- LDH, lactate dehydrogenase
- MDA, malondialdehyde
- NMP, normothermic machine perfusion
- SCS, static cold storage
- SEM, standard error of the mean
- TNFα, tumor necrosis factor-alpha
- UW, University of Wisconsin
- VWF, von Willebrand factor
- cfDNA, cell-free DNA
- donation after circulatory death
- extended preservation
- hypothermic machine perfusion
- liver preservation
- sTM, soluble thrombomodulin
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Affiliation(s)
- Isabel M A Brüggenwirth
- Department of Surgery, Section of Hepatobiliary Surgery and Liver Transplantation, University Medical Center Groningen, Groningen, The Netherlands
| | - Otto B van Leeuwen
- Department of Surgery, Section of Hepatobiliary Surgery and Liver Transplantation, University Medical Center Groningen, Groningen, The Netherlands
| | - Yvonne de Vries
- Department of Surgery, Section of Hepatobiliary Surgery and Liver Transplantation, University Medical Center Groningen, Groningen, The Netherlands
| | - Silke B Bodewes
- Department of Surgery, Section of Hepatobiliary Surgery and Liver Transplantation, University Medical Center Groningen, Groningen, The Netherlands
| | - Jelle Adelmeijer
- Surgical Research Laboratory, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Janneke Wiersema-Buist
- Surgical Research Laboratory, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Ton Lisman
- Surgical Research Laboratory, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Paulo N Martins
- Division of Organ Transplantation, Department of Surgery, UMass Memorial Medical Center, University of Massachusetts, Worcester, MA, United States
| | - Vincent E de Meijer
- Department of Surgery, Section of Hepatobiliary Surgery and Liver Transplantation, University Medical Center Groningen, Groningen, The Netherlands
| | - Robert J Porte
- Department of Surgery, Section of Hepatobiliary Surgery and Liver Transplantation, University Medical Center Groningen, Groningen, The Netherlands
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Liu Q, Hassan A, Pezzati D, Soliman B, Lomaglio L, Grady P, Del Angel Diaz L, Simioni A, Maikhor S, Etterling J, D'Amico G, Iuppa G, Diago Uso T, Hashimoto K, Aucejo F, Fujiki M, Eghtesad B, Sasaki K, Kwon CHD, Cywinski J, Irefin S, Bennett A, Baldwin W, Miller C, Quintini C. Ex Situ Liver Machine Perfusion: The Impact of Fresh Frozen Plasma. Liver Transpl 2020; 26:215-226. [PMID: 31642164 DOI: 10.1002/lt.25668] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 10/07/2019] [Indexed: 12/14/2022]
Abstract
The primary aim of this single-center, phase 1 exploratory study was to investigate the safety, feasibility, and impact on intrahepatic hemodynamics of a fresh frozen plasma (FFP)-based perfusate in ex situ liver normothermic machine perfusion (NMP) preservation. Using an institutionally developed perfusion device, 21 livers (13 donations after brain death and 8 donations after circulatory death) were perfused for 3 hours 21 minutes to 7 hours 52 minutes and successfully transplanted. Outcomes were compared in a 1:4 ratio to historical control patients matched according to donor and recipient characteristics and preservation time. Perfused livers presented a very low resistance state with high flow during ex situ perfusion (arterial and portal flows 340 ± 150 and 890 ± 70 mL/minute/kg liver, respectively). This hemodynamic state was maintained even after reperfusion as demonstrated by higher arterial flow observed in the NMP group compared with control patients (220 ± 120 versus 160 ± 80 mL/minute/kg liver, P = 0.03). The early allograft dysfunction (EAD) rate, peak alanine aminotransferase (ALT), and peak aspartate aminotransferase (AST) levels within 7 days after transplantation were lower in the NMP group compared with the control patients (EAD 19% versus 46%, P = 0.02; peak ALT 363 ± 318 versus 1021 ± 999 U/L, P = 0.001; peak AST 1357 ± 1492 versus 2615 ± 2541 U/L, P = 0.001 of the NMP and control groups, respectively). No patient developed ischemic type biliary stricture. One patient died, and all other patients are alive and well at a follow-up of 12-35 months. No device-related adverse events were recorded. In conclusion, with this study, we showed that ex situ NMP of human livers can be performed safely and effectively using a noncommercial device and an FFP-based preservation solution. Future studies should further investigate the impact of an FFP-based perfusion solution on liver hemodynamics during ex situ normothermic machine preservation.
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Affiliation(s)
- Qiang Liu
- Transplantation Center, Department of Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
| | - Ahmed Hassan
- Transplantation Center, Department of Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
| | - Daniele Pezzati
- Transplantation Center, Department of Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
| | - Basem Soliman
- Transplantation Center, Department of Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
| | - Laura Lomaglio
- Transplantation Center, Department of Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
| | - Patrick Grady
- Perfusion Services, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - Laurent Del Angel Diaz
- Transplantation Center, Department of Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
| | - Andrea Simioni
- Transplantation Center, Department of Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
| | - Shana Maikhor
- Transplantation Center, Department of Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
| | - John Etterling
- Transplantation Center, Department of Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
| | - Giuseppe D'Amico
- Transplantation Center, Department of Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
| | - Giuseppe Iuppa
- Transplantation Center, Department of Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
| | - Teresa Diago Uso
- Transplantation Center, Department of Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
| | - Koji Hashimoto
- Transplantation Center, Department of Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
| | - Federico Aucejo
- Transplantation Center, Department of Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
| | - Masato Fujiki
- Transplantation Center, Department of Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
| | - Bijan Eghtesad
- Transplantation Center, Department of Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
| | - Kazunari Sasaki
- Transplantation Center, Department of Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
| | - Choon Hyuck David Kwon
- Transplantation Center, Department of Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
| | - Jacek Cywinski
- Anesthesiology Institute, Cleveland Clinic, Cleveland, OH
| | - Samuel Irefin
- Anesthesiology Institute, Cleveland Clinic, Cleveland, OH
| | - Ana Bennett
- Transplantation Center, Department of Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
| | - William Baldwin
- Inflammation and Immunity Department, Lerner Research Institute, Cleveland Clinic, Cleveland, OH
| | - Charles Miller
- Transplantation Center, Department of Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
| | - Cristiano Quintini
- Transplantation Center, Department of Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
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18
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Eshmuminov D, Becker D, Bautista Borrego L, Hefti M, Schuler MJ, Hagedorn C, Muller X, Mueller M, Onder C, Graf R, Weber A, Dutkowski P, Rudolf von Rohr P, Clavien PA. An integrated perfusion machine preserves injured human livers for 1 week. Nat Biotechnol 2020; 38:189-198. [PMID: 31932726 PMCID: PMC7008032 DOI: 10.1038/s41587-019-0374-x] [Citation(s) in RCA: 219] [Impact Index Per Article: 54.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Accepted: 11/18/2019] [Indexed: 12/26/2022]
Abstract
The ability to preserve metabolically active livers ex vivo for 1 week or more could allow repair of poor-quality livers that would otherwise be declined for transplantation. Current approaches for normothermic perfusion can preserve human livers for only 24 h. Here we report a liver perfusion machine that integrates multiple core physiological functions, including automated management of glucose levels and oxygenation, waste-product removal and hematocrit control. We developed the machine in a stepwise fashion using pig livers. Study of multiple ex vivo parameters and early phase reperfusion in vivo demonstrated the viability of pig livers perfused for 1 week without the need for additional blood products or perfusate exchange. We tested the approach on ten injured human livers that had been declined for transplantation by all European centers. After a 7-d perfusion, six of the human livers showed preserved function as indicated by bile production, synthesis of coagulation factors, maintained cellular energy (ATP) and intact liver structure. Livers are stored long term in a sophisticated perfusion system.
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Affiliation(s)
- Dilmurodjon Eshmuminov
- Department of Surgery and Transplantation, Swiss Hepato-Pancreato-Biliary (HPB) Center, University Hospital Zurich, Zurich, Switzerland.,Wyss Zurich, ETH Zurich and University of Zurich, Zurich, Switzerland
| | - Dustin Becker
- Wyss Zurich, ETH Zurich and University of Zurich, Zurich, Switzerland.,Transport Processes and Reactions Laboratory, Department of Mechanical and Process Engineering, ETH Zurich, Zurich, Switzerland
| | - Lucia Bautista Borrego
- Department of Surgery and Transplantation, Swiss Hepato-Pancreato-Biliary (HPB) Center, University Hospital Zurich, Zurich, Switzerland.,Wyss Zurich, ETH Zurich and University of Zurich, Zurich, Switzerland
| | - Max Hefti
- Wyss Zurich, ETH Zurich and University of Zurich, Zurich, Switzerland.,Transport Processes and Reactions Laboratory, Department of Mechanical and Process Engineering, ETH Zurich, Zurich, Switzerland
| | - Martin J Schuler
- Wyss Zurich, ETH Zurich and University of Zurich, Zurich, Switzerland.,Transport Processes and Reactions Laboratory, Department of Mechanical and Process Engineering, ETH Zurich, Zurich, Switzerland
| | - Catherine Hagedorn
- Department of Surgery and Transplantation, Swiss Hepato-Pancreato-Biliary (HPB) Center, University Hospital Zurich, Zurich, Switzerland.,Wyss Zurich, ETH Zurich and University of Zurich, Zurich, Switzerland
| | - Xavier Muller
- Department of Surgery and Transplantation, Swiss Hepato-Pancreato-Biliary (HPB) Center, University Hospital Zurich, Zurich, Switzerland.,Wyss Zurich, ETH Zurich and University of Zurich, Zurich, Switzerland
| | - Matteo Mueller
- Department of Surgery and Transplantation, Swiss Hepato-Pancreato-Biliary (HPB) Center, University Hospital Zurich, Zurich, Switzerland.,Wyss Zurich, ETH Zurich and University of Zurich, Zurich, Switzerland
| | - Christopher Onder
- Wyss Zurich, ETH Zurich and University of Zurich, Zurich, Switzerland.,Institute for Dynamic Systems and Control, Department of Mechanical and Process Engineering, ETH Zurich, Zurich, Switzerland
| | - Rolf Graf
- Department of Surgery and Transplantation, Swiss Hepato-Pancreato-Biliary (HPB) Center, University Hospital Zurich, Zurich, Switzerland.,Wyss Zurich, ETH Zurich and University of Zurich, Zurich, Switzerland
| | - Achim Weber
- Department of Pathology and Molecular Pathology, and Institute of Molecular Cancer Research (IMCR), University Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Philipp Dutkowski
- Department of Surgery and Transplantation, Swiss Hepato-Pancreato-Biliary (HPB) Center, University Hospital Zurich, Zurich, Switzerland.,Wyss Zurich, ETH Zurich and University of Zurich, Zurich, Switzerland
| | - Philipp Rudolf von Rohr
- Wyss Zurich, ETH Zurich and University of Zurich, Zurich, Switzerland.,Transport Processes and Reactions Laboratory, Department of Mechanical and Process Engineering, ETH Zurich, Zurich, Switzerland
| | - Pierre-Alain Clavien
- Department of Surgery and Transplantation, Swiss Hepato-Pancreato-Biliary (HPB) Center, University Hospital Zurich, Zurich, Switzerland. .,Wyss Zurich, ETH Zurich and University of Zurich, Zurich, Switzerland.
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19
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Affiliation(s)
- Qiang Zhao
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China
| | - Yu Nie
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China
| | - Zhiyong Guo
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China
| | - Xiaoshun He
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China
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20
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Combined Ex Vivo Hypothermic and Normothermic Perfusion for Assessment of High-risk Deceased Donor Human Kidneys for Transplantation. Transplantation 2019; 103:392-400. [PMID: 29952816 PMCID: PMC6365241 DOI: 10.1097/tp.0000000000002299] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background Despite careful clinical examination, procurement biopsy and assessment on hypothermic machine perfusion, a significant number of potentially useable deceased donor kidneys will be discarded because they are deemed unsuitable for transplantation. Ex vivo normothermic perfusion (EVNP) may be useful as a means to further assess high-risk kidneys to determine suitability for transplantation. Methods From June 2014 to October 2015, 7 kidneys (mean donor age, 54.3 years and Kidney Donor Profile Index, 79%) that were initially procured with the intention to transplant were discarded based on a combination of clinical findings, suboptimal biopsies, long cold ischemia time (CIT) and/or poor hypothermic perfusion parameters. They were subsequently placed on EVNP using oxygenated packed red blood cells and supplemental nutrition for a period of 3 hours. Continuous hemodynamic and functional parameters were assessed. Results After a mean CIT of 43.7 hours, all 7 kidneys appeared viable on EVNP with progressively increasing renal blood flow over the 3-hour period of perfusion. Five of the 7 kidneys had excellent macroscopic appearance, rapid increase in blood flow to 200 to 250 mL/min, urine output of 40 to 260 mL/h and increasing creatinine clearance. Conclusions Favorable perfusion characteristics and immediate function after a 3-hour course of EVNP suggests that high-risk kidneys subjected to long CIT may have been considered for transplantation. The combined use of ex vivo hypothermic and normothermic perfusion may be a useful strategy to more adequately assess and preserve high-risk kidneys deemed unsuitable for transplantation. A clinical trial will be necessary to validate the usefulness of this approach. The combined use of ex vivo hypothermic and normothermic perfusion may be a useful strategy to more adequately assess and preserve high-risk kidneys deemed unsuitable for transplantation.
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21
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Hessheimer AJ, Riquelme F, Fundora-Suárez Y, García Pérez R, Fondevila C. Normothermic perfusion and outcomes after liver transplantation. Transplant Rev (Orlando) 2019; 33:200-208. [PMID: 31239189 DOI: 10.1016/j.trre.2019.06.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 06/04/2019] [Accepted: 06/09/2019] [Indexed: 01/04/2023]
Abstract
Ischemia has been a persistent and largely unavoidable element in solid organ transplantation, contributing to graft deterioration and adverse post-transplant outcomes. In liver transplantation, where available organs arise with greater frequency from marginal donors (i.e., ones that are older, obese, and/or declared dead following cardiac arrest through the donation after circulatory death process), there is increasing interest using dynamic perfusion strategies to limit, assess, and even reverse the adverse effects of ischemia in these grafts. Normothermic perfusion, in particular, is used to restore the flow of oxygen and other metabolic substrates at physiological temperatures. It may be used in liver transplantation both in situ following cardiac arrest in donation after circulatory death donors or during part or all of the ex situ preservation phase. This review article addresses issues relevant to use of normothermic perfusion strategies in liver transplantation, including technical and logistical aspects associated with establishing and maintaining normothermic perfusion in its different forms and clinical outcomes that have been reported to date.
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Affiliation(s)
- Amelia J Hessheimer
- Hepatopancreatobiliary Surgery & Transplantation, General & Digestive Surgery Service, Digestive & Metabolic Disease Institute (ICMDM), Hospital Clínic, CIBERehd, IDIBAPS, University of Barcelona, Spain.
| | - Francisco Riquelme
- Hepatopancreatobiliary Surgery & Transplantation, General & Digestive Surgery Service, Digestive & Metabolic Disease Institute (ICMDM), Hospital Clínic, CIBERehd, IDIBAPS, University of Barcelona, Spain
| | - Yiliam Fundora-Suárez
- Hepatopancreatobiliary Surgery & Transplantation, General & Digestive Surgery Service, Digestive & Metabolic Disease Institute (ICMDM), Hospital Clínic, CIBERehd, IDIBAPS, University of Barcelona, Spain
| | - Rocío García Pérez
- Hepatopancreatobiliary Surgery & Transplantation, General & Digestive Surgery Service, Digestive & Metabolic Disease Institute (ICMDM), Hospital Clínic, CIBERehd, IDIBAPS, University of Barcelona, Spain
| | - Constantino Fondevila
- Hepatopancreatobiliary Surgery & Transplantation, General & Digestive Surgery Service, Digestive & Metabolic Disease Institute (ICMDM), Hospital Clínic, CIBERehd, IDIBAPS, University of Barcelona, Spain
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22
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Petrenko A, Carnevale M, Somov A, Osorio J, Rodríguez J, Guibert E, Fuller B, Froghi F. Organ Preservation into the 2020s: The Era of Dynamic Intervention. Transfus Med Hemother 2019; 46:151-172. [PMID: 31244584 PMCID: PMC6558325 DOI: 10.1159/000499610] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 02/04/2019] [Indexed: 12/12/2022] Open
Abstract
Organ preservation has been of major importance ever since transplantation developed into a global clinical activity. The relatively simple procedures were developed on a basic comprehension of low-temperature biology as related to organs outside the body. In the past decade, there has been a significant increase in knowledge of the sequelae of effects in preserved organs, and how dynamic intervention by perfusion can be used to mitigate injury and improve the quality of the donated organs. The present review focuses on (1) new information about the cell and molecular events impacting on ischemia/reperfusion injury during organ preservation, (2) strategies which use varied compositions and additives in organ preservation solutions to deal with these, (3) clear definitions of the developing protocols for dynamic organ perfusion preservation, (4) information on how the choice of perfusion solutions can impact on desired attributes of dynamic organ perfusion, and (5) summary and future horizons.
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Affiliation(s)
- Alexander Petrenko
- Department of Cryobiochemistry, Institute for Problems of Cryobiology and Cryomedicine, Ukraine Academy of Sciences, Kharkov, Ukraine
| | - Matias Carnevale
- Centro Binacional (Argentina-Italia) de Investigaciones en Criobiología Clínica y Aplicada (CAIC), Universidad Nacional de Rosario, Rosario, Argentina
- Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Buenos Aires, Argentina
| | - Alexander Somov
- Department of Cryobiochemistry, Institute for Problems of Cryobiology and Cryomedicine, Ukraine Academy of Sciences, Kharkov, Ukraine
| | - Juliana Osorio
- Centro Binacional (Argentina-Italia) de Investigaciones en Criobiología Clínica y Aplicada (CAIC), Universidad Nacional de Rosario, Rosario, Argentina
| | - Joaquin Rodríguez
- Centro Binacional (Argentina-Italia) de Investigaciones en Criobiología Clínica y Aplicada (CAIC), Universidad Nacional de Rosario, Rosario, Argentina
| | - Edgardo Guibert
- Centro Binacional (Argentina-Italia) de Investigaciones en Criobiología Clínica y Aplicada (CAIC), Universidad Nacional de Rosario, Rosario, Argentina
- Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Buenos Aires, Argentina
| | - Barry Fuller
- UCL Division of Surgery and Interventional Sciences, Royal Free Hospital, London, United Kingdom
| | - Farid Froghi
- UCL Division of Surgery and Interventional Sciences, Royal Free Hospital, London, United Kingdom
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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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Abstract
IMPACT STATEMENT Over the past several decades, ex vivo perfusion has emerged as a promising technology for the assessment, preservation, and recovery of donor organs. Many exciting pre-clinical findings have now been translated to clinical use, and successful transplantation following ex vivo perfusion has been achieved for heart, lung, and liver. While machine perfusion provides distinct advantages over traditional cold preservation, many challenges remain, including that of long-term (multi-day) ex vivo support. Here, we provide an overview of the current status of ex vivo machine perfusion in the pre-clinical and clinical setting and share our perspective on the future direction of the field.
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Affiliation(s)
- Meghan Pinezich
- Department of Biomedical Engineering, Columbia University, New York, NY 10032, USA
| | - Gordana Vunjak-Novakovic
- Department of Biomedical Engineering, Columbia University, New York, NY 10032, USA
- Department of Medicine, Columbia University, New York NY 10032, USA
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25
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Bral M, Aboelnazar N, Hatami S, Thiesen A, Bigam DL, Freed DH, Shapiro AMJ. Clearance of transaminases during normothermic ex situ liver perfusion. PLoS One 2019; 14:e0215619. [PMID: 31017974 PMCID: PMC6481840 DOI: 10.1371/journal.pone.0215619] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 04/04/2019] [Indexed: 01/02/2023] Open
Abstract
Background One of the most promising applications of liver normothermic machine perfusion (NMP) is the potential to directly assess graft viability and injury. In most NMP studies, perfusate transaminases are utilized as markers of graft injury. Our aim was to further elucidate the metabolism of transaminases by healthy porcine livers during NMP, specifically whether such livers could clear circuit perfusate transaminases. Methods A highly concentrated transaminase solution was prepared from homogenized liver, with an aspartate aminotransferase (AST) level of 107,427 U/L. Three livers in the treatment group were compared to three controls, during 48 hours of NMP. In the treatment group, the circuit perfusate was injected with the transaminase solution to artificially raise the AST level to a target of 7,500 U/L. Perfusate samples were taken at two-hour intervals and analyzed for biochemistry until NMP end. Graft oxygen consumption and vascular parameters were monitored. Results Compared to controls, treated perfusions demonstrated abrupt elevations in transaminase levels (p>0.0001) and lactate dehydrogenase (LDH) (p>0.0001), which decreased over time, but never to control baseline. Liver function, as demonstrated by lactate clearance and oxygen consumption was not different between groups. The treatment group demonstrated a higher portal vein resistance (p = 0.0003), however hepatic artery resistance was similar. Treated livers had higher bile production overall (p<0.0001). Conclusions Addition of high levels of transaminases and LDH to a healthy porcine liver during ex situ perfusion results in progressive clearance of these enzymes, suggesting preserved liver metabolism. Such tolerance tests may provide valuable indicators of prospective graft function.
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Affiliation(s)
- Mariusz Bral
- Department of Surgery, University of Alberta, Edmonton, Canada
| | | | - Sanaz Hatami
- Department of Surgery, University of Alberta, Edmonton, Canada
| | - Aducio Thiesen
- Department of Pathology, University of Alberta, Edmonton, Canada
| | - David L. Bigam
- Department of Surgery, University of Alberta, Edmonton, Canada
| | - Darren H. Freed
- Department of Surgery, University of Alberta, Edmonton, Canada
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26
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de Meijer VE, Fujiyoshi M, Porte RJ. Ex situ machine perfusion strategies in liver transplantation. J Hepatol 2019; 70:203-205. [PMID: 30409464 DOI: 10.1016/j.jhep.2018.09.019] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 08/25/2018] [Accepted: 09/18/2018] [Indexed: 01/06/2023]
Affiliation(s)
- Vincent Erwin de Meijer
- Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University Medical Center Groningen, University of Groningen, the Netherlands
| | - Masato Fujiyoshi
- Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University Medical Center Groningen, University of Groningen, the Netherlands
| | - Robert Jack Porte
- Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University Medical Center Groningen, University of Groningen, the Netherlands.
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