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Ton C, Salehi S, Abasi S, Aggas JR, Liu R, Brandacher G, Guiseppi-Elie A, Grayson WL. Methods of ex vivo analysis of tissue status in vascularized composite allografts. J Transl Med 2023; 21:609. [PMID: 37684651 PMCID: PMC10492401 DOI: 10.1186/s12967-023-04379-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 07/21/2023] [Indexed: 09/10/2023] Open
Abstract
Vascularized composite allotransplantation can improve quality of life and restore functionality. However, the complex tissue composition of vascularized composite allografts (VCAs) presents unique clinical challenges that increase the likelihood of transplant rejection. Under prolonged static cold storage, highly damage-susceptible tissues such as muscle and nerve undergo irreversible degradation that may render allografts non-functional. Skin-containing VCA elicits an immunogenic response that increases the risk of recipient allograft rejection. The development of quantitative metrics to evaluate VCAs prior to and following transplantation are key to mitigating allograft rejection. Correspondingly, a broad range of bioanalytical methods have emerged to assess the progression of VCA rejection and characterize transplantation outcomes. To consolidate the current range of relevant technologies and expand on potential for development, methods to evaluate ex vivo VCA status are herein reviewed and comparatively assessed. The use of implantable physiological status monitoring biochips, non-invasive bioimpedance monitoring to assess edema, and deep learning algorithms to fuse disparate inputs to stratify VCAs are identified.
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Affiliation(s)
- Carolyn Ton
- Department of Biomedical Engineering, Johns Hopkins University, 400 North Broadway, Smith Building 5023, Baltimore, MD, 21231, USA
- Translational Tissue Engineering Center, Johns Hopkins University, 400 North Broadway, Smith Building 5023, Baltimore, MD, 21231, USA
| | - Sara Salehi
- Department of Biomedical Engineering, Johns Hopkins University, 400 North Broadway, Smith Building 5023, Baltimore, MD, 21231, USA
- Translational Tissue Engineering Center, Johns Hopkins University, 400 North Broadway, Smith Building 5023, Baltimore, MD, 21231, USA
| | - Sara Abasi
- Department of Biomedical Engineering, Center for Bioelectronics, Biosensors and Biochips (C3B®), Texas A&M University, Emerging Technologies Building 3120, 101 Bizzell St, College Station, TX, 77843, USA
- Department of Electrical and Computer Engineering, Center for Bioelectronics, Biosensors and Biochips (C3B®), Texas A&M University, Emerging Technologies Building 3120, 101 Bizzell St, College Station, TX, 77843, USA
- Media and Metabolism, Wildtype, Inc., 2325 3rd St., San Francisco, CA, 94107, USA
| | - John R Aggas
- Department of Biomedical Engineering, Center for Bioelectronics, Biosensors and Biochips (C3B®), Texas A&M University, Emerging Technologies Building 3120, 101 Bizzell St, College Station, TX, 77843, USA
- Department of Electrical and Computer Engineering, Center for Bioelectronics, Biosensors and Biochips (C3B®), Texas A&M University, Emerging Technologies Building 3120, 101 Bizzell St, College Station, TX, 77843, USA
- Test Development, Roche Diagnostics, 9115 Hague Road, Indianapolis, IN, 46256, USA
| | - Renee Liu
- Department of Biomedical Engineering, Johns Hopkins University, 400 North Broadway, Smith Building 5023, Baltimore, MD, 21231, USA
- Translational Tissue Engineering Center, Johns Hopkins University, 400 North Broadway, Smith Building 5023, Baltimore, MD, 21231, USA
| | - Gerald Brandacher
- Department of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation (VCA) Laboratory, Reconstructive Transplantation Program, Center for Advanced Physiologic Modeling (CAPM), Johns Hopkins University, Ross Research Building/Suite 749D, 720 Rutland Avenue, Baltimore, MD, 21205, USA.
| | - Anthony Guiseppi-Elie
- Department of Biomedical Engineering, Center for Bioelectronics, Biosensors and Biochips (C3B®), Texas A&M University, Emerging Technologies Building 3120, 101 Bizzell St, College Station, TX, 77843, USA.
- Department of Electrical and Computer Engineering, Center for Bioelectronics, Biosensors and Biochips (C3B®), Texas A&M University, Emerging Technologies Building 3120, 101 Bizzell St, College Station, TX, 77843, USA.
- Department of Cardiovascular Sciences, Houston Methodist Institute for Academic Medicine and Houston Methodist Research Institute, 6670 Bertner Ave., Houston, TX, USA.
- ABTECH Scientific, Inc., Biotechnology Research Park, 800 East Leigh Street, Richmond, VA, USA.
| | - Warren L Grayson
- Department of Biomedical Engineering, Johns Hopkins University, 400 North Broadway, Smith Building 5023, Baltimore, MD, 21231, USA.
- Translational Tissue Engineering Center, Johns Hopkins University, 400 North Broadway, Smith Building 5023, Baltimore, MD, 21231, USA.
- Department of Chemical and Biomolecular Engineering, Johns Hopkins University, Baltimore, MD, USA.
- Department of Materials Science and Engineering, Johns Hopkins University, Baltimore, MD, USA.
- Institute for Nanobiotechnology, Johns Hopkins University, Baltimore, MD, USA.
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Sommerfeld SD, Zhou X, Mejías JC, Oh BC, Maestas DR, Furtmüller GJ, Laffont PA, Elisseeff JH, Brandacher G. Biomaterials-based immunomodulation enhances survival of murine vascularized composite allografts. Biomater Sci 2023; 11:4022-4031. [PMID: 37129566 DOI: 10.1039/d2bm01845d] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
Vascularized composite allotransplantation (VCA) is a restorative option for patients suffering from severe tissue defects not amenable to conventional reconstruction. However, the toxicities associated with life-long multidrug immunosuppression to enable allograft survival and induce immune tolerance largely limit the broader application of VCA. Here, we investigate the potential of targeted immunomodulation using CTLA4-Ig combined with a biological porcine-derived extracellular matrix (ECM) scaffold that elicits a pro-regenerative Th2 response to promote allograft survival and regulate the inflammatory microenvironment in a stringent mouse orthotopic hind limb transplantation model (BALB/c to C57BL/6). The median allograft survival time (MST) increased significantly from 15.0 to 24.5 days (P = 0.0037; Mantel-Cox test) after adding ECM to the CTLA4-Ig regimen. Characterization of the immune infiltration shows a pro-regenerative phenotype prevails over those associated with inflammation and rejection including macrophages (F4/80hi+CD206hi+MHCIIlow), eosinophils (F4/80lowSiglec-F+), and T helper 2 (Th2) T cells (CD4+IL-4+). This was accompanied by an increased expression of genes associated with a Type 2 polarized immune state such as Il4, Ccl24, Arg1 and Ym1 within the graft. Furthermore, when ECM was applied along with a clinically relevant combination of CTLA4-Ig and Rapamycin, allograft survival was prolonged from 33.0 to 72.5 days (P = 0.0067; Mantel-Cox test). These studies implicate the clinical exploration of combined regimens involving local application of pro-regenerative, immunomodulatory biomaterials in surgical wound sites with targeted co-stimulatory blockade to reduce adverse effects of immunosuppression and enhance graft survival in VCA.
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Affiliation(s)
- Sven D Sommerfeld
- Translational Tissue Engineering Center, Department of Ophthalmology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Xianyu Zhou
- Department of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation (VCA) Laboratory, Johns Hopkins School of Medicine, Baltimore, MD, USA.
- Department of Plastic and Reconstructive Surgery, the Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Joscelyn C Mejías
- Translational Tissue Engineering Center, Department of Ophthalmology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Byoung Chol Oh
- Department of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation (VCA) Laboratory, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - David R Maestas
- Translational Tissue Engineering Center, Department of Ophthalmology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
- Department of Biomedical Engineering and the Bloomberg-Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Georg J Furtmüller
- Department of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation (VCA) Laboratory, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Philippe A Laffont
- Translational Tissue Engineering Center, Department of Ophthalmology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Jennifer H Elisseeff
- Translational Tissue Engineering Center, Department of Ophthalmology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
- Department of Biomedical Engineering and the Bloomberg-Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Gerald Brandacher
- Department of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation (VCA) Laboratory, Johns Hopkins School of Medicine, Baltimore, MD, USA.
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Kruit AS, Hummelink S, Eshuis L, Kusters B, Ulrich D. Superior preservation of capillaries, myofibrils and mitochondria after long-term extracorporeal perfusion of free muscle flaps - A descriptive electron microscopy study. Clin Hemorheol Microcirc 2023; 83:11-18. [PMID: 36189585 PMCID: PMC9986692 DOI: 10.3233/ch-211262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Extracorporeal perfusion (ECP) is a promising technique for prolonged tissue preservation, but might have side effects. For instance, increased radical oxygen species or capillary endothelial damage. OBJECTIVE To assess ultra-morphological muscle damage during 36-hour ECP of porcine musculocutaneous flaps, hypothesizing that it would delay the onset of damage compared to static cold storage (SCS). METHODS Bilateral flaps were retrieved from three Dutch Landrace pigs. Three flaps were preserved for 36 hours by hypothermic storage 4-6°C (control group) and three flaps by ECP with cooled University of Wisconsin solution. Muscle biopsies were taken at 0 h, 12 h and 36 h and assessed with transmission electron microscopy. RESULTS Muscle architecture was best preserved by ECP, with a delayed onset and decreased severity of muscle damage. After 36 hours, damage was two-fold lower in ECP-flaps compared to SCS-flaps. Myofibril architecture was best preserved. Mitochondria were greatly preserved with swelling being the most prominent feature. Capillaries were moderately but differently damaged during ECP, with focal endothelial thinning as opposed to luminal obstruction in SCS-preserved flaps. CONCLUSIONS This experiment described favourable cellular preservation of skeletal muscle flaps during ECP compared to SCS. Results showed less severe ultra-morphological damage and a later onset of damage.
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Affiliation(s)
- Anne Sophie Kruit
- Department of Plastic and Reconstructive Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Stefan Hummelink
- Department of Plastic and Reconstructive Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Lilian Eshuis
- Department of Pathology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Benno Kusters
- Department of Pathology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Dietmar Ulrich
- Department of Plastic and Reconstructive Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
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He J, Khan UZ, Qing L, Wu P, Tang J. Improving the ischemia-reperfusion injury in vascularized composite allotransplantation: Clinical experience and experimental implications. Front Immunol 2022; 13:998952. [PMID: 36189311 PMCID: PMC9523406 DOI: 10.3389/fimmu.2022.998952] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 08/29/2022] [Indexed: 11/21/2022] Open
Abstract
Long-time ischemia worsening transplant outcomes in vascularized composite allotransplantation (VCA) is often neglected. Ischemia-reperfusion injury (IRI) is an inevitable event that follows reperfusion after a period of cold static storage. The pathophysiological mechanism activates local inflammation, which is a barrier to allograft long-term immune tolerance. The previous publications have not clearly described the relationship between the tissue damage and ischemia time, nor the rejection grade. In this review, we found that the rejection episodes and rejection grade are usually related to the ischemia time, both in clinical and experimental aspects. Moreover, we summarized the potential therapeutic measures to mitigate the ischemia-reperfusion injury. Compare to static preservation, machine perfusion is a promising method that can keep VCA tissue viability and extend preservation time, which is especially beneficial for the expansion of the donor pool and better MHC-matching.
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Affiliation(s)
- Jiqiang He
- Department of Hand and Microsurgery, Xiangya Hospital of Central South University, Changsha, China
| | - Umar Zeb Khan
- Department of Hand and Microsurgery, Xiangya Hospital of Central South University, Changsha, China
| | - Liming Qing
- Department of Hand and Microsurgery, Xiangya Hospital of Central South University, Changsha, China
| | - Panfeng Wu
- Department of Hand and Microsurgery, Xiangya Hospital of Central South University, Changsha, China
| | - Juyu Tang
- Department of Hand and Microsurgery, Xiangya Hospital of Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital of Central South University, Changsha, China
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Evaluation of Early Markers of Ischemia-reperfusion Injury and Preservation Solutions in a Modified Hindlimb Model of Vascularized Composite Allotransplantation. Transplant Direct 2021; 8:e1251. [PMID: 34912943 PMCID: PMC8670593 DOI: 10.1097/txd.0000000000001251] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 09/02/2021] [Accepted: 09/03/2021] [Indexed: 01/09/2023] Open
Abstract
Background. Ischemia-reperfusion injury plays an important role in vascularized composite allotransplantation (VCA). Currently, there is no ideal preservation solution for VCA. In this study, we investigated the effects of 4 different preservation solutions on different tissues within an allogeneic hindlimb rat model. Methods. Sprague Dawley rat hindlimbs were flushed and placed at 4°C for 6 h in heparinized saline, histidine-tryptophan-ketoglutarate, University of Wisconsin (UW), and Perfadex and heterotopically transplanted for ease of ambulation. Apoptosis, necrosis, and the extracellular matrix of the tissues within the allograft were analyzed 2 h posttransplantation using immunohistochemistry, terminal deoxynucleotidyl transferase 2'-deoxyuridine 5'-triphosphate nick-end labeling (TUNEL) assay, and enzyme-linked immunoassay. Results. Higher expression of cleaved caspase 3, a significant increase of high-mobility group box 1 and TUNEL-positive apoptotic cells were observed in the muscle and vessels preserved with heparinized saline compared with UW and Perfadex following reperfusion. Higher expression of TUNEL-positive apoptotic cells was observed in the skin at 12 h of ischemia and in the nerve following reperfusion with histidine-tryptophan-ketoglutarate as a preservation solution. Conclusions. Our data suggest that UW and Perfadex are preferred solutions in VCA. The vessels within the allografts appear to be very susceptible, with laminins and CD31 playing a role in ischemia-reperfusion injury.
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Kruit AS, Brouwers K, van Midden D, Zegers H, Koers E, van Alfen N, Hummelink S, Ulrich DJO. Successful 18-h acellular extracorporeal perfusion and replantation of porcine limbs - Histology versus nerve stimulation. Transpl Int 2021; 34:365-375. [PMID: 33316847 PMCID: PMC7898521 DOI: 10.1111/tri.13802] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 10/21/2020] [Accepted: 12/10/2020] [Indexed: 11/30/2022]
Abstract
The current standard for composite tissue preservation is static cold storage (SCS) and is limited to 6 h until irreversible muscle damage occurs. Extracorporeal perfusion (ECP) is a promising technique for prolonged preservation, however, functional results have been scarcely researched. This article assessed neuromuscular function and compared results to histological alterations to predict muscle damage after ECP. Forelimbs of twelve Dutch landrace pigs were amputated and preserved by 4 h SCS at 4–6 °C (n = 6) or 18 h mid‐thermic ECP with University of Wisconsin solution (n = 6). Limbs were replanted and observed for 12 h. Sham surgery was performed on contralateral forelimbs (n = 12). Histology analysis scored four subgroups representing different alterations (higher score equals more damage). Muscle contraction after median nerve stimulation was comparable between ECP, SCS, and sham limbs (P = 0.193). Histology scores were higher in ECP limbs compared to SCS limbs (4.8 vs. 1.5, P = 0.013). This was mainly based on more oedema in these limbs. In‐vivo muscle contraction was well preserved after 18 h ECP compared to short SCS, although histology seemed inferior in this group. Histology, therefore, did not correlate to muscle function at 12 h after replantation. This leads to the question whether histology or neuromuscular function is the best predictor for transplant success.
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Affiliation(s)
- Anne Sophie Kruit
- Department of Plastic and Reconstructive Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Kaj Brouwers
- Department of Plastic and Reconstructive Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Dominique van Midden
- Department of Pathology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Her Zegers
- Department of Cardiothoracic Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Erik Koers
- Department of Cardiothoracic Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Nens van Alfen
- Department of Neurology and Clinical Neurophysiolog, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Stefan Hummelink
- Department of Plastic and Reconstructive Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Dietmar J O Ulrich
- Department of Plastic and Reconstructive Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
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Mitsuzawa S, Ikeguchi R, Aoyama T, Ando M, Takeuchi H, Yurie H, Oda H, Noguchi T, Ohta S, Zhao C, Ikeya M, Matsuda S. Induced pluripotent stem cell-derived mesenchymal stem cells prolong hind limb survival in a rat vascularized composite allotransplantation model. Microsurgery 2019; 39:737-747. [PMID: 31471984 DOI: 10.1002/micr.30507] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 08/13/2019] [Accepted: 08/16/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND The reduction of systemic immunosuppressive agents is essential for the expansion of vascularized composite allotransplantation (VCA) in a clinical setting. The purpose of this study is to compare human-induced pluripotent stem cell-derived mesenchymal stem cells (iMSCs) with four other types of mesenchymal stem cells (human bone marrow-derived MSCs [BMMSCs], human adipose-derived MSCs [ADMSCs], rat BMMSCs, and rat ADMSCs) in vitro, and to investigate the in vivo immunomodulatory effect of iMSCs in a rat VCA model. MATERIALS AND METHODS One Brown Norway (BN) rat, 2 Lewis (LEW) rats, and 1 Wistar rat were used in the mixed lymphocyte reaction (MLR), and 9 BN rats and 3 LEW rats (for donors), and 24 LEW rats (for recipients) were used in the VCA model. The abovementioned five types of MSCs were imaged to examine their morphology and were also tested for suppressor function using a MLR. The 24 recipient LEW rats were divided randomly into four groups, and subjected to orthotopic hind limb transplantation. The three control groups were the Iso group, in which transplantation was performed on from three to six LEW rats without immunosuppressive treatment (n = 6); the FK group, in which transplantation was performed from BN rats to LEW rats and recipient rats were treated with tacrolimus alone (FK 506, 0.2 mg/kg, days 0-6 postoperatively, intraperitoneally) (n = 6); and the UT group, in which transplantation was performed from BN rats to LEW rats without any immunosuppressive treatment (n = 6). The experimental group was the iMSC group, in which transplantation was performed from BN rats to LEW rats and recipient rats were treated with tacrolimus (FK 506, 0.2 mg/kg, days 0-6 postoperatively, intraperitoneally) and injected with iMSCs (2 × 106 cells, day 7, intravenously) (n = 6). Hind limb survival was assessed by daily inspection of gross appearance until 50 days postoperatively. Histology of the skin and muscle biopsy were investigated on day 14 postoperatively. A time series of the plasma cytokine level (before transplantation, and at 10, 14, and 17 days after transplantation) was also analyzed. RESULTS The size of adherent and trypsinized iMSCs was 67.5 ± 8.7 and 9.5 ± 1.1 μm, respectively, which was the smallest among the five types of MSCs (p < .01). The absorbance in MLR was significantly smaller with rat ADMSCs (p = .0001), human iMSCs (p = .0006), rat BMMSCs (p = .0014), human ADMSCs (p = .0039), and human BMMSCs (p = .1191) compared to without MSCs. In vivo, iMSC treatment prolonged hind limb survival up to 12.7 days in macroscopic appearance, which is significantly longer than that of the FK group (p < .01). Histology of the skin and muscle biopsy revealed that mononuclear cell infiltration was significantly reduced by iMSC injection (p < .01). iMSC treatment also affected proinflammatory cytokines (interferon-gamma (IFNγ) and tumor necrosis factor α (TNFα)) and the anti-inflammatory cytokine (interleukin-10 (IL-10)) of the recipient plasma. The IFNγ levels at Δ14 and the TNFα levels at Δ14 and Δ17 of the iMSC group were significantly lower than those of the FK group (p = .0226, .0004, and .004, respectively). The IL-10 levels at Δ10 and Δ14 of the iMSC group were significantly higher than those of the FK group (p = .0013 and .0374, respectively). CONCLUSIONS iMSCs induce T cell hyporesponsiveness to prolong hind limb survival in a rat VCA model. This immunomodulatory property against acute rejection could provide one of the promising strategies capable of enabling the toxicities of immunosuppressants to be avoided in clinical settings.
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Affiliation(s)
- Sadaki Mitsuzawa
- Department of Orthopaedic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Ryosuke Ikeguchi
- Department of Orthopaedic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Tomoki Aoyama
- Department of Physical Therapy, Human Health Sciences, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Maki Ando
- Department of Orthopaedic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Hisataka Takeuchi
- Department of Orthopaedic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Hirofumi Yurie
- Department of Orthopaedic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Hiroki Oda
- Department of Orthopaedic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Takashi Noguchi
- Department of Orthopaedic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Souichi Ohta
- Department of Orthopaedic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Chengzhu Zhao
- Department of Clinical Application, Center for iPS Cell Research and Application, Kyoto University, Kyoto, Japan
| | - Makoto Ikeya
- Department of Clinical Application, Center for iPS Cell Research and Application, Kyoto University, Kyoto, Japan
| | - Shuichi Matsuda
- Department of Orthopaedic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
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Kollar B, Kamat P, Klein H, Waldner M, Schweizer R, Plock J. The Significance of Vascular Alterations in Acute and Chronic Rejection for Vascularized Composite Allotransplantation. J Vasc Res 2019; 56:163-180. [DOI: 10.1159/000500958] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 05/14/2019] [Indexed: 11/19/2022] Open
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Successful Long-term Extracorporeal Perfusion of Free Musculocutaneous Flaps in a Porcine Model. J Surg Res 2018; 235:113-123. [PMID: 30691784 DOI: 10.1016/j.jss.2018.09.076] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 07/26/2018] [Accepted: 09/25/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND Extracorporeal perfusion is a technique that aims to safely prolong tissue preservation by reducing ischemia-reperfusion injury. Free muscle flaps provide a sensitive research model due to their low ischemic tolerance. However, long-term perfusion of free muscle flaps is scarcely researched. The aim of this study was to compare tissue damage in musculocutaneous flaps during 36 h of extracorporeal perfusion versus static cold storage. MATERIALS AND METHODS Bilateral free rectus abdominis flaps were harvested from five Dutch Landrace pigs (weight: 53-59 kg). Flaps were treated for 36 h according to the following study groups: (1) cold storage at 4°C-6°C (n = 4), (2) perfusion with histidine-tryptophan-ketoglutarate (HTK) at 8°C-10°C (n = 3), (3) perfusion with University of Wisconsin solution (UW) at 8°C-10°C (n = 3). Perfusion fluid samples (creatinine kinase, blood gas) and biopsies for quantitative polymerase chain reaction were collected at multiple time points. Microcirculation was assessed at 24 h of preservation using indocyanine-green fluorescence angiography. Flap weight was measured at the start and end of the preservation period. RESULTS Successful and stable perfusion for 36 h was achieved in all perfused flaps. The mean creatinine kinase increase in the perfusion fluid was comparable in both the groups (UW: +43,144 U/L, HTK: +44,404 U/L). Mean lactate was higher in the UW group than in the HTK group (6.57 versus 1.07 mmol/L). There were homogenous and complete perfusion patterns on indocyanine-green angiography in both the perfusion groups, in contrast to incomplete and inhomogeneous patterns during cold storage. Expression of genes related to apoptosis and inflammation was lower in perfused flaps than in the cold storage group. Weight increase was highest in the HTK group (78%; standard deviation [SD], 29%) compared with UW (22%; SD, 22%) and cold storage (0.7%; SD, 4%). CONCLUSIONS Long-term extracorporeal perfusion of free rectus abdominis flaps is feasible. Outcomes in the perfusion groups seemed superior compared to cold storage. Hypotheses gained from this research need to be further explored in a replantation setting.
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Ischemia/reperfusion injury in vascularized tissue allotransplantation: tissue damage and clinical relevance. Curr Opin Organ Transplant 2017; 21:503-9. [PMID: 27495915 DOI: 10.1097/mot.0000000000000343] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
PURPOSE OF REVIEW Ischemia and reperfusion injury (IRI) in vascularized tissue allotransplantation (VCA) remain largely undefined. Because VCA is comprised of different tissues, the sensitivity towards IRI may not be uniform. We, herein, attempt to address mechanistic aspects of IRI in VCA and provide a summary on potential technologies and targets for amelioration or treatment of IRI in this novel field. RECENT FINDINGS IRI results in a loosened architecture of musculature, hypertrophic, centrally located cell nuclei as well as a high degree of neovascularization. Mitochondria in muscle tissue show a high degree of degeneration after prolonged ischemia whereas the ultrastructure remains normal after short cold ischemia time (CIT). Muscle cell necrosis accompanied by a diffuse inflammatory infiltrate and vasculopathy of small vessels is observed after 30 h of CIT. Nerves revealed a high degree of separation and vacuolization of myelin lamellae because of Wallerian degeneration. Approaches to minimize IRI include use of novel preservation solutions, administration of antioxidative and anti-inflammatory molecules/drugs as well as the implementation of machine perfusion in the setting of VCA. SUMMARY Hand and face transplantations are logistically challenging procedures. Optimal planning and a highly congruent and motivated team are key to keep ischemia times to a minimum. In addition to pharmacological approaches, machine perfusion seems promising to help circumvent logistic problems and expand the donor pool in VCA.
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Datta N, Devaney SG, Busuttil RW, Azari K, Kupiec-Weglinski JW. Prolonged Cold Ischemia Time Results in Local and Remote Organ Dysfunction in a Murine Model of Vascularized Composite Transplantation. Am J Transplant 2017; 17:2572-2579. [PMID: 28371289 DOI: 10.1111/ajt.14290] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Revised: 03/01/2017] [Accepted: 03/19/2017] [Indexed: 01/25/2023]
Abstract
Vascularized composite allotransplantation (VCA) is a viable reconstructive option for complex tissue defects. Although grafts with a large muscular component may be uniquely susceptible to ischemia-reperfusion (I/R) syndrome, the safe cold ischemia time in VCA has not been established. We investigated the effects of cold ischemia on innate immune response and recipient survival in a murine orthotopic hindlimb transplantation model. Surprisingly, mice receiving grafts exposed to 6 h or longer of cold storage demonstrated reduced survival and massive elevations in serum creatinine, blood urea nitrogen, and creatine kinase, compared with 1 h of cold storage recipients. This was accompanied by progressive increase in macrophage and neutrophil cell infiltration in muscle biopsy specimens, altered platelet endothelial cell adhesion molecule-1 expression, and ultimate renal injury. Multiplex immunoassay analysis identified 21 cytokines in serum and 18 cytokines in muscle biopsy specimens that are likely essential in the complex response to I/R-triggered injury in VCA. In conclusion, this study, in a mouse model of orthotopic hindlimb transplantation, is the first to document that prolonged cold ischemia triggers progressive I/R injury with vascular endothelial damage and may lead to irrecoverable local and remote organ damage. These experimental findings are important in guiding future therapies for human VCA recipients.
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Affiliation(s)
- Neha Datta
- The Dumont-UCLA Transplantation Center, Department of Surgery, Division of Liver and Pancreas Transplantation, David Geffen School of Medicine at University of California, Los Angeles, CA
| | - S G Devaney
- The Dumont-UCLA Transplantation Center, Department of Surgery, Division of Liver and Pancreas Transplantation, David Geffen School of Medicine at University of California, Los Angeles, CA
| | - R W Busuttil
- The Dumont-UCLA Transplantation Center, Department of Surgery, Division of Liver and Pancreas Transplantation, David Geffen School of Medicine at University of California, Los Angeles, CA
| | - K Azari
- The Dumont-UCLA Transplantation Center, Department of Surgery, Division of Liver and Pancreas Transplantation, David Geffen School of Medicine at University of California, Los Angeles, CA
| | - J W Kupiec-Weglinski
- The Dumont-UCLA Transplantation Center, Department of Surgery, Division of Liver and Pancreas Transplantation, David Geffen School of Medicine at University of California, Los Angeles, CA
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Targeted Complement Inhibition Protects Vascularized Composite Allografts From Acute Graft Injury and Prolongs Graft Survival When Combined With Subtherapeutic Cyclosporine A Therapy. Transplantation 2017; 101:e75-e85. [PMID: 28045880 DOI: 10.1097/tp.0000000000001625] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Recipients of vascularized composite allografts require aggressive and lifelong immunosuppression, and because the surgery is usually performed in nonlife-threatening situations, the development of strategies to minimize immunosuppression is especially pertinent for this procedure. We investigated how complement affects acute graft injury, alloimmunity, and immunosuppressive therapy. METHODS Vascularized composite allografts were transplanted from Balb/C to C57BL/6 mice that were complement deficient (C3 or double C3a Receptor (R)/C5aR), or treated with a targeted complement inhibitor (CR2-Crry). Allografts were analyzed for acute inflammation and injury, subacute T cell response, and survival in the absence and presence of cyclosporine A (CsA) therapy. RESULTS Allografts in C3-deficient or CR2-Crry-treated recipients were protected from skin and muscle ischemia-reperfusion injury (IRI). C3aR/C5aR-deficient recipients were more modestly protected. IgM and C3d colocalized within allografts from wild type and C3aR/C5aR-deficient recipients indicating IgM-mediated complement activation, and C3d deposition was almost absent in allografts from C3-deficient and CR2-Crry-treated recipients. Inflammatory cell infiltration and P-selectin expression was also significantly reduced in C3-deficient and CR2-Crry-treated recipients. Acute treatment with CR2-Crry or with 3 mg/kg per day CsA modestly, but significantly increased median allograft survival from 5.8 to 7.4 and 7.2 days, respectively. However, combined acute CR2-Crry treatment and CsA therapy increased mean graft survival to 17.2 days. Protection was associated with significantly reduced T cell infiltration of allografts and Tc1 cells in recipient spleens. CONCLUSIONS Complement-mediated IRI augments graft allogenicity, and appropriate complement inhibition ameliorates IRI, decreases alloimmune priming and allows more immune-sparing CsA dosing.
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Prolonged ischemia elicits acute allograft rejection involved in CXCR3 activation in rat kidney transplants. Transpl Immunol 2015; 33:103-9. [DOI: 10.1016/j.trim.2015.08.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 07/29/2015] [Accepted: 08/17/2015] [Indexed: 01/20/2023]
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Xiao B, Xia W, Zhang J, Liu B, Guo S. Prolonged cold ischemic time results in increased acute rejection in a rat allotransplantation model. J Surg Res 2010; 164:e299-304. [PMID: 20934711 DOI: 10.1016/j.jss.2010.08.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2010] [Revised: 07/22/2010] [Accepted: 08/09/2010] [Indexed: 11/16/2022]
Abstract
BACKGROUND The cold ischemic time may be more prolonged for facial tissue allografts than for organ allografts. Previous researches have shown that prolonged ischemia resulted in increased signs of rejection in a rat groin allotransplantation model; however, the relationship between cold ischemia and alloantigen-induced rejection was unclear. MATERIALS AND METHODS Vascularized groin flaps were transplanted from BN to Lewis rats after 0, 6, 12, 18, or 24 h of storage at 4 °C, and the allografts in each group were evaluated daily. Biopsy samples taken from the allo-0 h and allo-24 h groups on postoperative d 2-8 were graded for signs of acute rejection. Biopsy samples taken from the allo-0 h and allo-24 h groups on postoperative d 5 were stained for chemokine receptor CXCR3. RESULTS When the cold ischemia time was greater than 18 h, the survival time of the grafts was significantly shorter (6.2 ± 1.3 d) than that of the grafts that did not undergo cold ischemia (9.0 ± 1.2 d). Histological valuation showed acceleration of activated lymphocyte infiltration in the allo-24 h group (2.2 ± 0.4 d) compared with the allo-0 h group (4.8 ± 0.4 d). Furthermore, the proportion of CXCR3-positive cells in the allo-24 h group (49.7% ± 6.0%) was significantly higher than that in the allo-0 h group (22.9% ± 3.4%) on d 5 after transplantation. CONCLUSIONS Prolonged ischemia has a deleterious effect on allograft survival, and the chemokine receptor CXCR3 may play a role in this process.
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Affiliation(s)
- Bo Xiao
- Department of Plastic Surgery, Xijing Hospital, The Fourth Military Medical University, Xi'an, PR China
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