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Clatworthy MR, Watson CJE. Understanding the Immunology of Normothermic Machine Perfusion. Transpl Int 2023; 36:11670. [PMID: 37538137 PMCID: PMC10395750 DOI: 10.3389/ti.2023.11670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Accepted: 07/07/2023] [Indexed: 08/05/2023]
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Brüggenwirth IMA, van Leeuwen OB, Porte RJ, Martins PN. The Emerging Role of Viability Testing During Liver Machine Perfusion. Liver Transpl 2022; 28:876-886. [PMID: 33963657 DOI: 10.1002/lt.26092] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 04/30/2021] [Indexed: 12/23/2022]
Abstract
The transplant community continues to be challenged by the disparity between the need for liver transplantation and the shortage of suitable donor organs. At the same time, the number of unused donor livers continues to increase, most likely attributed to the worsening quality of these organs. To date, there is no reliable marker of liver graft viability that can predict good posttransplant outcomes. Ex situ machine perfusion offers additional data to assess the viability of donor livers before transplantation. Hence, livers initially considered unsuitable for transplantation can be assessed during machine perfusion in terms of appearance and consistency, hemodynamics, and metabolic and excretory function. In addition, postoperative complications such as primary nonfunction or posttransplant cholangiopathy may be predicted and avoided. A variety of viability criteria have been used in machine perfusion, and to date there is no widely accepted composition of criteria for clinical use. This review discusses potential viability markers for hepatobiliary function during machine perfusion, describes current limitations, and provides future recommendations for the use of viability criteria in clinical liver transplantation.
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Affiliation(s)
- Isabel M A Brüggenwirth
- Department of Surgery, Section of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.,Division of Organ Transplantation, Department of Surgery, UMass Memorial Medical Center, University of Massachusetts, Worcester, MA
| | - Otto B van Leeuwen
- Department of Surgery, Section of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Robert J Porte
- Department of Surgery, Section of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, 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
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3
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OuYang Q, Liang G, Tan X, He X, Zhang L, Kuang W, Chen J, Wang S, Liang M, Huo F. Evaluation of the ex vivo liver viability using a nuclear magnetic resonance relaxation time-based assay in a porcine machine perfusion model. Sci Rep 2021; 11:4117. [PMID: 33603011 PMCID: PMC7892848 DOI: 10.1038/s41598-021-83202-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 01/27/2021] [Indexed: 01/07/2023] Open
Abstract
There is a dearth of effective parameters for selecting potentially transplantable liver grafts from expanded-criteria donors. In this study, we used a nuclear magnetic resonance (NMR) relaxation analyzer-based assay to assess the viability of ex vivo livers obtained via porcine donation after circulatory death (DCD). Ex situ normothermic machine perfusion (NMP) was utilized as a platform for viability test of porcine DCD donor livers. A liver-targeted contrast agent, gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid (Gd-EOB-DTPA), was injected into the perfusate during NMP, and the dynamic biliary excretion of the Gd-EOB-DTPA was monitored by measuring the longitudinal relaxation time (T1). The longitudinal relaxation rate (R1) of the bile was served as a parameter. The delay of increase in biliary R1 during early stage of NMP indicated the impaired function of liver grafts in both warm and cold ischemia injury, which was correlated with the change of alanine aminotransferase. The preservative superiority in cold ischemia of dual hypothermic oxygenated machine perfusion could also be verified by assessing biliary R1 and other biochemical parameters. This study allows for the dynamic assessment of the viability of porcine DCD donor livers by combined usage of ex situ NMP and NMR relaxation time based assay, which lays a foundation for further clinical application.
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Affiliation(s)
- Qing OuYang
- Department of Hepatobiliary Surgery and Liver Transplant Center, The General Hospital of Southern Theater, Guangzhou, China
| | - Guohai Liang
- The MOE Key Laboratory of Laser Life Science, South China Normal University, Guangzhou, China
| | - Xiaoyu Tan
- Department of Hepatobiliary Surgery and Liver Transplant Center, The General Hospital of Southern Theater, Guangzhou, China
| | - Xiran He
- Guangdong Shunde Industry Design Institute (Guangdong Shunde Innovative Design Institute), Shunde, Guangdong, China
| | - Lin Zhang
- Guangdong Devocean Medical Instrument Co., Ltd., Shunde, Guangdong, China
| | - Weijian Kuang
- Guangdong Shunde Industry Design Institute (Guangdong Shunde Innovative Design Institute), Shunde, Guangdong, China
| | - Jianxiong Chen
- Department of Hepatobiliary Surgery and Liver Transplant Center, The General Hospital of Southern Theater, Guangzhou, China
| | - Shaoping Wang
- Department of Hepatobiliary Surgery and Liver Transplant Center, The General Hospital of Southern Theater, Guangzhou, China
| | - Mingju Liang
- Guangdong Shunde Industry Design Institute (Guangdong Shunde Innovative Design Institute), Shunde, Guangdong, China.
| | - Feng Huo
- Department of Hepatobiliary Surgery and Liver Transplant Center, The General Hospital of Southern Theater, Guangzhou, China.
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van Leeuwen OB, de Vries Y, de Meijer VE, Porte RJ. Hypothermic machine perfusion before viability testing of previously discarded human livers. Nat Commun 2021; 12:1008. [PMID: 33579908 PMCID: PMC7881206 DOI: 10.1038/s41467-021-21182-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 01/18/2021] [Indexed: 12/31/2022] Open
Affiliation(s)
- Otto B van Leeuwen
- Department of Surgery, Section of Hepatobiliary Surgery & Liver Transplantation, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Yvonne de Vries
- Department of Surgery, Section of Hepatobiliary Surgery & Liver Transplantation, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Vincent E de Meijer
- Department of Surgery, Section of Hepatobiliary Surgery & Liver Transplantation, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Robert J Porte
- Department of Surgery, Section of Hepatobiliary Surgery & Liver Transplantation, University Medical Center Groningen, University of Groningen, Groningen, Netherlands.
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Brüggenwirth IMA, Porte RJ, Martins PN. Bile Composition as a Diagnostic and Prognostic Tool in Liver Transplantation. Liver Transpl 2020; 26:1177-1187. [PMID: 32246581 DOI: 10.1002/lt.25771] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 03/06/2020] [Accepted: 03/22/2020] [Indexed: 02/07/2023]
Abstract
Bile secretion and composition reflects the functional status of hepatocytes and cholangiocytes. Bile composition can have a role in the assessment of donor grafts before implantation in the recipient. In addition, changes in bile composition after liver transplantation can serve as a diagnostic and prognostic tool to predict posttransplant complications, such as primary nonfunction, acute cellular rejection, or nonanastomotic biliary strictures. With the popularization of liver machine perfusion preservation in the clinical setting, there is a revisited interest in biliary biomarkers to assess graft viability before implantation. This review discusses current literature on biliary biomarkers that could predict or assess liver graft and bile duct viability. Bile composition offers an exciting and novel perspective in the search for reliable hepatocyte and cholangiocyte viability biomarkers.
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Affiliation(s)
- Isabel M A Brüggenwirth
- Division of Organ Transplantation, Department of Surgery, UMass Memorial Medical Center, University of Massachusetts, Worcester, MA
- 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
| | - Paulo N Martins
- Division of Organ Transplantation, Department of Surgery, UMass Memorial Medical Center, University of Massachusetts, Worcester, MA
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Bonaccorsi-Riani E, Brüggenwirth IMA, Buchwald JE, Iesari S, Martins PN. Machine Perfusion: Cold versus Warm, versus Neither. Update on Clinical Trials. Semin Liver Dis 2020; 40:264-281. [PMID: 32557478 DOI: 10.1055/s-0040-1713118] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Machine perfusion (MP) preservation is potentially one of the most significant improvements in the field of liver transplantation in the last 20 years, and it has been considered a promising strategy for improved preservation and ex situ evaluation of extended criteria donor (ECD) organs. However, MP preservation adds significant cost and logistical considerations to liver transplantation. MP protocols are mainly classified according to the perfusion temperature with hypothermic machine perfusion (HMP) and normothermic machine perfusion (NMP) being the two categories most studied so far. After extensive preclinical work, MP entered the clinical setting, and there are now several studies that demonstrated feasibility and safety. However, because of the limited quality of clinical trials, there is no compelling evidence of superiority in preservation quality, and liver MP is still considered experimental in most countries. MP preservation is moving to a more mature phase, where ongoing and future studies will bring new evidence in order to confirm their superiority in terms of clinical outcomes, organ utilization, and cost-effectiveness. Here, we present an overview of all preclinical MP studies using discarded human livers and liver MP clinical trials, and discuss their results. We describe the different perfusion protocols, pitfalls in MP study design, and provide future perspectives. Recent trials in liver MP have revealed unique challenges beyond those seen in most clinical studies. Randomized trials, correct trial design, and interpretation of data are essential to generate the data necessary to prove if MP will be the new gold standard method of liver preservation.
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Affiliation(s)
- E Bonaccorsi-Riani
- Abdominal Transplant Unit, Cliniques Universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium.,Pôle de Chirurgie Expérimentale et Transplantation, Université Catholique de Louvain, Brussels, Belgium
| | - I M A Brüggenwirth
- Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - J E Buchwald
- Division of Transplant, Department of Surgery, UMass Memorial Medical Center, University of Massachusetts, Worcester, Massachusetts
| | - S Iesari
- Pôle de Chirurgie Expérimentale et Transplantation, Université Catholique de Louvain, Brussels, Belgium.,Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - P N Martins
- Division of Transplant, Department of Surgery, UMass Memorial Medical Center, University of Massachusetts, Worcester, Massachusetts
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van Leeuwen OB, de Vries Y, Fujiyoshi M, Nijsten MWN, Ubbink R, Pelgrim GJ, Werner MJM, Reyntjens KMEM, van den Berg AP, de Boer MT, de Kleine RHJ, Lisman T, de Meijer VE, Porte RJ. Transplantation of High-risk Donor Livers After Ex Situ Resuscitation and Assessment Using Combined Hypo- and Normothermic Machine Perfusion: A Prospective Clinical Trial. Ann Surg 2019; 270:906-914. [PMID: 31633615 DOI: 10.1097/sla.0000000000003540] [Citation(s) in RCA: 143] [Impact Index Per Article: 28.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The aim of this study was to evaluate sequential hypothermic and normothermic machine perfusion (NMP) as a tool to resuscitate and assess viability of initially declined donor livers to enable safe transplantation. SUMMARY BACKGROUND DATA Machine perfusion is increasingly used to resuscitate and test the function of donor livers. Although (dual) hypothermic oxygenated machine perfusion ([D]HOPE) resuscitates livers after cold storage, NMP enables assessment of hepatobiliary function. METHODS In a prospective clinical trial, nationwide declined livers were subjected to ex situ NMP (viability assessment phase), preceded by 1-hour DHOPE (resuscitation phase) and 1 hour of controlled oxygenated rewarming (COR), using a perfusion fluid containing an hemoglobin-based oxygen carrier. During the first 2.5 hours of NMP, hepatobiliary viability was assessed, using predefined criteria: perfusate lactate <1.7 mmol/L, pH 7.35 to 7.45, bile production >10 mL, and bile pH >7.45. Livers meeting all criteria were accepted for transplantation. Primary endpoint was 3-month graft survival. RESULTS Sixteen livers underwent DHOPE-COR-NMP. All livers were from donors after circulatory death, with median age of 63 (range 42-82) years and median Eurotransplant donor risk index of 2.82. During NMP, all livers cleared lactate and produced sufficient bile volume, but in 5 livers bile pH remained <7.45. The 11 (69%) livers that met all viability criteria were successfully transplanted, with 100% patient and graft survival at 3 and 6 months. Introduction of DHOPE-COR-NMP increased the number of deceased donor liver transplants by 20%. CONCLUSIONS Sequential DHOPE-COR-NMP enabled resuscitation and safe selection of initially declined high-risk donor livers, thereby increasing the number of transplantable livers by 20%. TRIAL REGISTRATION www.trialregister.nl; NTR5972.
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Affiliation(s)
- Otto B van Leeuwen
- Department of Surgery, Section of HPB Surgery & Liver Transplantation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Yvonne de Vries
- Department of Surgery, Section of HPB Surgery & Liver Transplantation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Masato Fujiyoshi
- Department of Surgery, Section of HPB Surgery & Liver Transplantation, 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
| | - Rinse Ubbink
- Organ Preservation and Resuscitation Unit, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Gert Jan Pelgrim
- Organ Preservation and Resuscitation Unit, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Maureen J M Werner
- Department of Surgery, Section of HPB Surgery & Liver Transplantation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Koen M E M Reyntjens
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Aad P van den Berg
- Department of Gastroenterology and Hepatology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Marieke T de Boer
- Department of Surgery, Section of HPB Surgery & Liver Transplantation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Ruben H J de Kleine
- Department of Surgery, Section of HPB Surgery & Liver Transplantation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Ton Lisman
- Surgical Research Laboratory, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Vincent E de Meijer
- Department of Surgery, Section of HPB Surgery & Liver Transplantation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Robert J Porte
- Department of Surgery, Section of HPB Surgery & Liver Transplantation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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