1
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Muller X, Rossignol G, Mohkam K, Mabrut JY. Back to Basics: Liver Graft Ischemia in the Era of Machine Perfusion. Transplantation 2024; 108:1269-1272. [PMID: 38277262 DOI: 10.1097/tp.0000000000004912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2024]
Affiliation(s)
- Xavier Muller
- Department of General Surgery and Liver Transplantation, Croix Rousse University Hospital, Lyon, France
- Institute of Hepatology Lyon (IHL), INSERM U1052, Lyon, France
- ED 340 BMIC, Claude Bernard Lyon 1 University, Villeurbanne, France
| | - Guillaume Rossignol
- Department of General Surgery and Liver Transplantation, Croix Rousse University Hospital, Lyon, France
- Institute of Hepatology Lyon (IHL), INSERM U1052, Lyon, France
- ED 340 BMIC, Claude Bernard Lyon 1 University, Villeurbanne, France
- Department of Pediatric Surgery and Liver Transplantation, Femme Mere Enfant University Hospital, Lyon, France
| | - Kayvan Mohkam
- Department of General Surgery and Liver Transplantation, Croix Rousse University Hospital, Lyon, France
- Institute of Hepatology Lyon (IHL), INSERM U1052, Lyon, France
- Department of Pediatric Surgery and Liver Transplantation, Femme Mere Enfant University Hospital, Lyon, France
| | - Jean-Yves Mabrut
- Department of General Surgery and Liver Transplantation, Croix Rousse University Hospital, Lyon, France
- Institute of Hepatology Lyon (IHL), INSERM U1052, Lyon, France
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2
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Parente A, Flores Carvalho M, Schlegel A. Endothelial Cells and Mitochondria: Two Key Players in Liver Transplantation. Int J Mol Sci 2023; 24:10091. [PMID: 37373238 DOI: 10.3390/ijms241210091] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 05/30/2023] [Accepted: 06/02/2023] [Indexed: 06/29/2023] Open
Abstract
Building the inner layer of our blood vessels, the endothelium forms an important line communicating with deeper parenchymal cells in our organs. Previously considered passive, endothelial cells are increasingly recognized as key players in intercellular crosstalk, vascular homeostasis, and blood fluidity. Comparable to other cells, their metabolic function strongly depends on mitochondrial health, and the response to flow changes observed in endothelial cells is linked to their mitochondrial metabolism. Despite the direct impact of new dynamic preservation concepts in organ transplantation, the impact of different perfusion conditions on sinusoidal endothelial cells is not yet explored well enough. This article therefore describes the key role of liver sinusoidal endothelial cells (LSECs) together with their mitochondrial function in the context of liver transplantation. The currently available ex situ machine perfusion strategies are described with their effect on LSEC health. Specific perfusion conditions, including perfusion pressure, duration, and perfusate oxygenation are critically discussed considering the metabolic function and integrity of liver endothelial cells and their mitochondria.
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Affiliation(s)
- Alessandro Parente
- HPB and Transplant Unit, Department of Surgical Science, University of Rome Tor Vergata, 00133 Rome, Italy
- Division of Hepatobiliary and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Republic of Korea
| | | | - Andrea Schlegel
- Department of Experimental and Clinical Medicine, University of Florence, 50121 Florence, Italy
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Centre of Preclinical Research, 20122 Milan, Italy
- Transplantation Center, Digestive Disease and Surgery Institute, Department of Immunity and Inflammation, Lerner Research Institute, Cleveland Clinic, Cleveland, OH 44106, USA
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Schlegel A, Mergental H, Fondevila C, Porte RJ, Friend PJ, Dutkowski P. Machine perfusion of the liver and bioengineering. J Hepatol 2023; 78:1181-1198. [PMID: 37208105 DOI: 10.1016/j.jhep.2023.02.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 02/03/2023] [Accepted: 02/09/2023] [Indexed: 05/21/2023]
Abstract
With the increasing number of accepted candidates on waiting lists worldwide, there is an urgent need to expand the number and the quality of donor livers. Dynamic preservation approaches have demonstrated various benefits, including improving liver function and graft survival, and reducing liver injury and post-transplant complications. Consequently, organ perfusion techniques are being used in clinical practice in many countries. Despite this success, a proportion of livers do not meet current viability tests required for transplantation, even with the use of modern perfusion techniques. Therefore, devices are needed to further optimise machine liver perfusion - one promising option is to prolong machine liver perfusion for several days, with ex situ treatment of perfused livers. For example, stem cells, senolytics, or molecules targeting mitochondria or downstream signalling can be administered during long-term liver perfusion to modulate repair mechanisms and regeneration. Besides, today's perfusion equipment is also designed to enable the use of various liver bioengineering techniques, to develop scaffolds or for their re-cellularisation. Cells or entire livers can also undergo gene modulation to modify animal livers for xenotransplantation, to directly treat injured organs or to repopulate such scaffolds with "repaired" autologous cells. This review first discusses current strategies to improve the quality of donor livers, and secondly reports on bioengineering techniques to design optimised organs during machine perfusion. Current practice, as well as the benefits and challenges associated with these different perfusion strategies are discussed.
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Affiliation(s)
- Andrea Schlegel
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Centre of Preclinical Research, Milan, 20122, Italy; Department of Surgery and Transplantation, Swiss HPB Center, University Hospital Zurich, Switzerland
| | - Hynek Mergental
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, United Kingdom
| | - Constantino Fondevila
- Hepatopancreatobiliary Surgery & Transplantation, General & Digestive Surgery Service, Hospital Universitario La Paz, IdiPAZ, CIBERehd, Madrid, Spain
| | - Robert J Porte
- Erasmus MC Transplant Institute, Department of Surgery, Division of HPB & Transplant Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Peter J Friend
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Philipp Dutkowski
- Department of Surgery and Transplantation, Swiss HPB Center, University Hospital Zurich, Switzerland.
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4
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Darius T, Vergauwen M, Maistriaux L, Evrard R, Schlegel A, Mueller M, O'Neil D, Southam A, Aydin S, Devresse A, De Meyer M, Gianello P, Ludwig C, Dutkowski P, Mourad M. Intermittent Surface Oxygenation Results in Similar Mitochondrial Protection and Maintenance of Aerobic Metabolism as Compared to Continuous Oxygenation during Hypothermic Machine Kidney Machine Perfusion. J Clin Med 2023; 12:jcm12113731. [PMID: 37297930 DOI: 10.3390/jcm12113731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 05/15/2023] [Accepted: 05/24/2023] [Indexed: 06/12/2023] Open
Abstract
Short bubble and subsequent surface oxygenation is an innovative oxygenation technique and alternative for membrane oxygenation during hypothermic machine perfusion (HMP). The metabolic effect of the interruption of surface oxygenation for 4 h (mimicking organ transport) during HMP was compared to continuous surface and membrane oxygenation in a pig kidney ex situ preservation model. After 30 min of warm ischemia by vascular clamping, a kidney of a ±40 kg pig was procured and subsequently preserved according to one of the following groups: (1) 22-h HMP + intermittent surface oxygenation (n = 12); (2) 22-h HMP + continuous membrane oxygenation (n = 6); and (3) 22-h HMP + continuous surface oxygenation (n = 7). Brief perfusate O2 uploading before kidney perfusion was either obtained by direct bubble (groups 1, 3) or by membrane (group 2) oxygenation. Bubble oxygenation during minimum 15 min was as efficient as membrane oxygenation in achieving supraphysiological perfusate pO2 levels before kidney perfusion. Metabolic tissue analysis (i.e., lactate, succinate, ATP, NADH, and FMN) during and at the end of the preservation period demonstrated similar mitochondrial protection between all study groups. Short bubble and subsequent intermittent surface oxygenation of the perfusate of an HMP-kidney might be an effective and cheap preservation strategy to protect mitochondria, eliminating the need/costs of a membrane oxygenator and oxygen source during transport.
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Affiliation(s)
- Tom Darius
- Surgery and Abdominal Transplant Unit, University Clinics Saint Luc, Université Catholique de Louvain, 1200 Brussels, Belgium
| | - Martial Vergauwen
- Institut de Recherche Expérimentale et Clinique (IREC), Pôle de Chirurgie Expérimentale et Transplantation, Université Catholique de Louvain, 1200 Brussels, Belgium
| | - Louis Maistriaux
- Institut de Recherche Expérimentale et Clinique (IREC), Pôle de Chirurgie Expérimentale et Transplantation, Université Catholique de Louvain, 1200 Brussels, Belgium
- Institut de Recherche Expérimentale et Clinique (IREC), Pôle de Morphologie, Université Catholique de Louvain, 1200 Brussels, Belgium
| | - Robin Evrard
- Institut de Recherche Expérimentale et Clinique (IREC), Pôle de Chirurgie Expérimentale et Transplantation, Université Catholique de Louvain, 1200 Brussels, Belgium
- Institut de Recherche Expérimentale et Clinique (IREC), Neuro Musculo-Skeletal Laboratory (NMSK), Université Catholique de Louvain, 1200 Brussels, Belgium
| | - Andrea Schlegel
- Department of Surgery and Transplantation, Swiss HPB Center, University Hospital Zurich, 8091 Zürich, Switzerland
| | - Matteo Mueller
- Department of Surgery and Transplantation, Swiss HPB Center, University Hospital Zurich, 8091 Zürich, Switzerland
| | - Donna O'Neil
- Phenome Centre Birmingham, College of Life and Environmental Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - Andrew Southam
- Phenome Centre Birmingham, College of Life and Environmental Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - Selda Aydin
- Department of Pathology, University Clinics Saint-Luc, Université Catholique de Louvain, 1200 Brussels, Belgium
| | - Arnaud Devresse
- Surgery and Abdominal Transplant Unit, University Clinics Saint Luc, Université Catholique de Louvain, 1200 Brussels, Belgium
- Department of Nephrology, University Clinics Saint-Luc, Université Catholique de Louvain, 1200 Brussels, Belgium
| | - Martine De Meyer
- Surgery and Abdominal Transplant Unit, University Clinics Saint Luc, Université Catholique de Louvain, 1200 Brussels, Belgium
| | - Pierre Gianello
- Institut de Recherche Expérimentale et Clinique (IREC), Pôle de Chirurgie Expérimentale et Transplantation, Université Catholique de Louvain, 1200 Brussels, Belgium
| | - Christian Ludwig
- Institute of Metabolism and Systems Research (IMSR), College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - Philipp Dutkowski
- Department of Surgery and Transplantation, Swiss HPB Center, University Hospital Zurich, 8091 Zürich, Switzerland
| | - Michel Mourad
- Surgery and Abdominal Transplant Unit, University Clinics Saint Luc, Université Catholique de Louvain, 1200 Brussels, Belgium
- Institut de Recherche Expérimentale et Clinique (IREC), Pôle de Chirurgie Expérimentale et Transplantation, Université Catholique de Louvain, 1200 Brussels, Belgium
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Verstraeten L, Den Abt R, Ghesquière B, Jochmans I. Current Insights into the Metabolome during Hypothermic Kidney Perfusion-A Scoping Review. J Clin Med 2023; 12:jcm12113613. [PMID: 37297808 DOI: 10.3390/jcm12113613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 05/16/2023] [Accepted: 05/20/2023] [Indexed: 06/12/2023] Open
Abstract
This scoping review summarizes what is known about kidney metabolism during hypothermic perfusion preservation. Papers studying kidney metabolism during hypothermic (<12 °C) perfusion were identified (PubMed, Embase, Web of Science, Cochrane). Out of 14,335 initially identified records, 52 were included [dog (26/52), rabbit (2/52), pig (20/52), human (7/52)]. These were published between 1970-2023, partially explaining study heterogeneity. There is a considerable risk of bias in the reported studies. Studies used different perfusates, oxygenation levels, kidney injury levels, and devices and reported on perfusate and tissue metabolites. In 11 papers, (non)radioactively labeled metabolites (tracers) were used to study metabolic pathways. Together these studies show that kidneys are metabolically active during hypothermic perfusion, regardless of the perfusion setting. Although tracers give us more insight into active metabolic pathways, kidney metabolism during hypothermic perfusion is incompletely understood. Metabolism is influenced by perfusate composition, oxygenation levels, and likely also by pre-existing ischemic injury. In the modern era, with increasing donations after circulatory death and the emergence of hypothermic oxygenated perfusion, the focus should be on understanding metabolic perturbations caused by pre-existing injury levels and the effect of perfusate oxygen levels. The use of tracers is indispensable to understanding the kidney's metabolism during perfusion, given the complexity of interactions between different metabolites.
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Affiliation(s)
- Laurence Verstraeten
- Laboratory of Abdominal Transplantation KU Leuven, Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, 3000 Leuven, Belgium
| | - Rutger Den Abt
- Laboratory of Abdominal Transplantation KU Leuven, Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, 3000 Leuven, Belgium
| | - Bart Ghesquière
- Metabolomics Expertise Center, Center for Cancer Biology, VIB, 3000 Leuven, Belgium
- Laboratory of Applied Mass Spectrometry, Department of Cellular and Molecular Medicine, KU Leuven, 3000 Leuven, Belgium
| | - Ina Jochmans
- Laboratory of Abdominal Transplantation KU Leuven, Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, 3000 Leuven, Belgium
- Department of Abdominal Transplant Surgery, University Hospitals Leuven, 3000 Leuven, Belgium
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Schutter R, van Varsseveld OC, Lantinga VA, Pool MBF, Hamelink TH, Potze JH, Leuvenink HGD, Laustsen C, Borra RJH, Moers C. Magnetic resonance imaging during warm ex vivo kidney perfusion. Artif Organs 2023; 47:105-116. [PMID: 35996889 PMCID: PMC10086841 DOI: 10.1111/aor.14391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 06/30/2022] [Accepted: 08/02/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND The shortage of donor organs for transplantation remains a worldwide problem. The utilization of suboptimal deceased donors enlarges the pool of potential organs, yet consequently, clinicians face the difficult decision of whether these sub-optimal organs are of sufficient quality for transplantation. Novel technologies could play a pivotal role in making pre-transplant organ assessment more objective and reliable. METHODS Ex vivo normothermic machine perfusion (NMP) at temperatures around 35-37°C allows organ quality assessment in a near-physiological environment. Advanced magnetic resonance imaging (MRI) techniques convey unique information about an organ's structural and functional integrity. The concept of applying magnetic resonance imaging during renal normothermic machine perfusion is novel in both renal and radiological research and we have developed the first MRI-compatible NMP setup for human-sized kidneys. RESULTS We were able to obtain a detailed and real-time view of ongoing processes inside renal grafts during ex vivo perfusion. This new technique can visualize structural abnormalities, quantify regional flow distribution, renal metabolism, and local oxygen availability, and track the distribution of ex vivo administered cellular therapy. CONCLUSION This platform allows for advanced pre-transplant organ assessment, provides a new realistic tool for studies into renal physiology and metabolism, and may facilitate therapeutic tracing of pharmacological and cellular interventions to an isolated kidney.
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Affiliation(s)
- Rianne Schutter
- Department of Surgery - Organ Donation and Transplantation, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Otis C van Varsseveld
- Department of Surgery - Organ Donation and Transplantation, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Veerle A Lantinga
- Department of Surgery - Organ Donation and Transplantation, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Merel B F Pool
- Department of Surgery - Organ Donation and Transplantation, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Tim H Hamelink
- Department of Surgery - Organ Donation and Transplantation, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Jan Hendrik Potze
- Department of Radiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Henri G D Leuvenink
- Department of Surgery - Organ Donation and Transplantation, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Christoffer Laustsen
- Department of Clinical Medicine, The MR Research Center, Aarhus University, Aarhus, Denmark
| | - Ronald J H Borra
- Department of Radiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Cyril Moers
- Department of Surgery - Organ Donation and Transplantation, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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7
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Subnormothermic Ex Vivo Porcine Kidney Perfusion Improves Energy Metabolism: Analysis Using 31P Magnetic Resonance Spectroscopic Imaging. Transplant Direct 2022; 8:e1354. [PMID: 36176724 PMCID: PMC9514833 DOI: 10.1097/txd.0000000000001354] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 05/24/2022] [Indexed: 11/26/2022] Open
Abstract
The ideal preservation temperature for donation after circulatory death kidney grafts is unknown. We investigated whether subnormothermic (22 °C) ex vivo kidney machine perfusion could improve kidney metabolism and reduce ischemia-reperfusion injury.
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Gonzalez-Viedma A, Van Dyck R, De Beule J, Ghesquière B, Jochmans I. Unraveling metabolism during kidney perfusion using tracer studies, a systematic review. Artif Organs 2022; 46:2118-2134. [PMID: 35848397 DOI: 10.1111/aor.14355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 06/02/2022] [Accepted: 07/03/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND Understanding kidney metabolism during perfusion is vital to further develop the technology as a preservation, viability assessment, and resuscitation platform. We reviewed the evidence on the use of labeled metabolites (tracers) to understand "on-pump" kidney behavior. METHODS PubMed, Embase, Web of Science, and Cochrane databases were systematically searched for studies evaluating metabolism of (non)radioactively labeled endogenous compounds during kidney perfusion. RESULTS Of 5899 articles, 30 were included. All were animal studies [rat (70%), dog (13%), pig (10%), rabbit (7%)] perfusing but not transplanting kidneys. Perfusion took place at hypothermic (4-12°C) (20%), normothermic (35-40°C) (77%), or undefined temperatures (3%). Hypothermic perfusion used albumin or a clinical kidney preservation solution, mostly in the presence of oxygen. Normothermic perfusion was mostly performed with oxygenated crystalloids often containing glucose and amino acids with unclear partial oxygen tensions. Active metabolism of carbohydrate, amino acid, lipids, and large molecules was shown in hypothermic and normothermic perfusion. Production of macromolecules, such as prostaglandin, thromboxane, and vitamin D, takes place during normothermic perfusion. No experiments compared differences in metabolic activity between hypothermic and normothermic perfusion. One conference abstract showed increased anaerobic metabolism in kidneys donated after circulatory death by adding labeled glucose to hypothermically perfused human kidneys. CONCLUSIONS Tracer studies during kidney perfusion contribute to unraveling kidney metabolic behavior in pre-clinical models. Whether findings are truly translational needs further investigation in large animal models of human kidneys. Furthermore, it is essential to better understand how ischemia changes this metabolic behavior.
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Affiliation(s)
- Arantxa Gonzalez-Viedma
- Department of Microbiology, Immunology, and Transplantation, Transplantation Research Group, Lab of Abdominal Transplantation, KU Leuven, Leuven, Belgium
| | - Robbe Van Dyck
- Department of Microbiology, Immunology, and Transplantation, Transplantation Research Group, Lab of Abdominal Transplantation, KU Leuven, Leuven, Belgium
| | - Julie De Beule
- Department of Microbiology, Immunology, and Transplantation, Transplantation Research Group, Lab of Abdominal Transplantation, KU Leuven, Leuven, Belgium
| | - Bart Ghesquière
- Metabolomics Expertise Center, Center for Cancer Biology, VIB Center for Cancer Biology, Leuven, Belgium.,Metabolomics Expertise Center, Department of Oncology, KU Leuven, Leuven, Belgium
| | - Ina Jochmans
- Department of Microbiology, Immunology, and Transplantation, Transplantation Research Group, Lab of Abdominal Transplantation, KU Leuven, Leuven, Belgium.,Department of Abdominal Transplant Surgery, University Hospitals Leuven, Leuven, Belgium
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9
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Schlegel A, Porte R, Dutkowski P. Protective mechanisms and current clinical evidence of hypothermic oxygenated machine perfusion (HOPE) in preventing post-transplant cholangiopathy. J Hepatol 2022; 76:1330-1347. [PMID: 35589254 DOI: 10.1016/j.jhep.2022.01.024] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 01/10/2022] [Accepted: 01/31/2022] [Indexed: 12/12/2022]
Abstract
The development of cholangiopathies after liver transplantation impacts on the quality and duration of graft and patient survival, contributing to higher costs as numerous interventions are required to treat strictures and infections at the biliary tree. Prolonged donor warm ischaemia time in combination with additional cold storage are key risk factors for the development of biliary strictures. Based on this, the clinical implementation of dynamic preservation strategies is a current hot topic in the field of donation after circulatory death (DCD) liver transplantation. Despite various retrospective studies reporting promising results, also regarding biliary complications, there are only a few randomised-controlled trials on machine perfusion. Recently, the group from Groningen has published the first randomised-controlled trial on hypothermic oxygenated perfusion (HOPE), demonstrating a significant reduction of symptomatic ischaemic cholangiopathies with the use of a short period of HOPE before DCD liver implantation. The most likely mechanism for this important effect, also shown in several experimental studies, is based on mitochondrial reprogramming under hypothermic aerobic conditions, e.g. exposure to oxygen in the cold, with a controlled and slow metabolism of ischaemically accumulated succinate and simultaneous ATP replenishment. This unique feature prevents mitochondrial oxidative injury and further downstream tissue inflammation. HOPE treatment therefore supports livers by protecting them from ischaemia-reperfusion injury (IRI), and thereby also prevents the development of post-transplant biliary injury. With reduced IRI-associated inflammation, recipients are also protected from activation of the innate immune system, with less acute rejections seen after HOPE.
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Affiliation(s)
- Andrea Schlegel
- Department of Visceral Surgery and Transplantation, University Hospital Zurich, Swiss HPB and Transplant Center, Zurich, Switzerland; General and Liver Transplant Surgery Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20100 Milan, Italy
| | - Robert Porte
- Department of Surgery, Surgical Research Laboratory, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Philipp Dutkowski
- Department of Visceral Surgery and Transplantation, University Hospital Zurich, Swiss HPB and Transplant Center, Zurich, Switzerland.
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Darius T, Nath J, Mourad M. Simply Adding Oxygen during Hypothermic Machine Perfusion to Combat the Negative Effects of Ischemia-Reperfusion Injury: Fundamentals and Current Evidence for Kidneys. Biomedicines 2021; 9:993. [PMID: 34440197 PMCID: PMC8394874 DOI: 10.3390/biomedicines9080993] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 08/04/2021] [Accepted: 08/06/2021] [Indexed: 12/11/2022] Open
Abstract
The use of high-risk renal grafts for transplantation requires optimization of pretransplant preservation and assessment strategies to improve clinical outcomes as well as to decrease organ discard rate. With oxygenation proposed as a resuscitative measure during hypothermic machine preservation, this review provides a critical overview of the fundamentals of active oxygenation during hypothermic machine perfusion, as well as the current preclinical and clinical evidence and suggests different strategies for clinical implementation.
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Affiliation(s)
- Tom Darius
- Surgery and Abdominal Transplant Unit, University Clinics Saint Luc, Université Catholique de Louvain, 1200 Brussels, Belgium;
- Pole de Chirurgie Expérimentale et Transplantation, Université Catholique de Louvain, 1200 Brussels, Belgium
| | - Jay Nath
- Department of Renal Transplantation, Southmead Hospital Bristol, Bristol BS10 5NB, UK;
| | - Michel Mourad
- Surgery and Abdominal Transplant Unit, University Clinics Saint Luc, Université Catholique de Louvain, 1200 Brussels, Belgium;
- Pole de Chirurgie Expérimentale et Transplantation, Université Catholique de Louvain, 1200 Brussels, Belgium
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11
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12
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How Machine Perfusion Ameliorates Hepatic Ischaemia Reperfusion Injury. Int J Mol Sci 2021; 22:ijms22147523. [PMID: 34299142 PMCID: PMC8307386 DOI: 10.3390/ijms22147523] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Revised: 07/07/2021] [Accepted: 07/11/2021] [Indexed: 02/07/2023] Open
Abstract
The increasing disparity between the number of patients listed for transplantation and the number of suitable organs has led to the increasing use of extended criteria donors (ECDs). ECDs are at increased risk of developing ischaemia reperfusion injury and greater risk of post-transplant complications. Ischaemia reperfusion injury is a major complication of organ transplantation defined as the inflammatory changes seen following the disruption and restoration of blood flow to an organ—it is a multifactorial process with the potential to cause both local and systemic organ failure. The utilisation of machine perfusion under normothermic (37 degrees Celsius) and hypothermic (4–10 degrees Celsius) has proven to be a significant advancement in organ preservation and restoration. One of the key benefits is its ability to optimise suboptimal organs for successful transplantation. This review is focused on examining ischaemia reperfusion injury and how machine perfusion ameliorates the graft’s response to this.
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13
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Ischemia-Reperfusion Injuries Assessment during Pancreas Preservation. Int J Mol Sci 2021; 22:ijms22105172. [PMID: 34068301 PMCID: PMC8153272 DOI: 10.3390/ijms22105172] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 04/25/2021] [Accepted: 05/10/2021] [Indexed: 12/20/2022] Open
Abstract
Maintaining organ viability between donation and transplantation is of critical importance for optimal graft function and survival. To date in pancreas transplantation, static cold storage (SCS) is the most widely practiced method of organ preservation. The first experiments in ex vivo perfusion of the pancreas were performed at the beginning of the 20th century. These perfusions led to organ oedema, hemorrhage, and venous congestion after revascularization. Despite these early hurdles, a number of factors now favor the use of perfusion during preservation: the encouraging results of HMP in kidney transplantation, the development of new perfusion solutions, and the development of organ perfusion machines for the lung, heart, kidneys and liver. This has led to a resurgence of research in machine perfusion for whole organ pancreas preservation. This review highlights the ischemia-reperfusion injuries assessment during ex vivo pancreas perfusion, both for assessment in pre-clinical experimental models as well for future use in the clinic. We evaluated perfusion dynamics, oedema assessment, especially by impedance analysis and MRI, whole organ oxygen consumption, tissue oxygen tension, metabolite concentrations in tissue and perfusate, mitochondrial respiration, cell death, especially by histology, total cell free DNA, caspase activation, and exocrine and endocrine assessment.
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14
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Ex Vivo Analysis of Kidney Graft Viability Using 31P Magnetic Resonance Imaging Spectroscopy. Transplantation 2020; 104:1825-1831. [PMID: 32675744 DOI: 10.1097/tp.0000000000003323] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND The lack of organs for kidney transplantation is a growing concern. Expansion in organ supply has been proposed through the use of organs after circulatory death (donation after circulatory death [DCD]). However, many DCD grafts are discarded because of long warm ischemia times, and the absence of reliable measure of kidney viability. P magnetic resonance imaging (pMRI) spectroscopy is a noninvasive method to detect high-energy phosphate metabolites, such as ATP. Thus, pMRI could predict kidney energy state, and its viability before transplantation. METHODS To mimic DCD, pig kidneys underwent 0, 30, or 60 min of warm ischemia, before hypothermic machine perfusion. During the ex vivo perfusion, we assessed energy metabolites using pMRI. In addition, we performed Gadolinium perfusion sequences. Each sample underwent histopathological analyzing and scoring. Energy status and kidney perfusion were correlated with kidney injury. RESULTS Using pMRI, we found that in pig kidney, ATP was rapidly generated in presence of oxygen (100 kPa), which remained stable up to 22 h. Warm ischemia (30 and 60 min) induced significant histological damages, delayed cortical and medullary Gadolinium elimination (perfusion), and reduced ATP levels, but not its precursors (AMP). Finally, ATP levels and kidney perfusion both inversely correlated with the severity of kidney histological injury. CONCLUSIONS ATP levels, and kidney perfusion measurements using pMRI, are biomarkers of kidney injury after warm ischemia. Future work will define the role of pMRI in predicting kidney graft and patient's survival.
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Mariager CØ, Hansen ESS, Bech SK, Munk A, Kjaergaard U, Lyhne MD, Søberg K, Nielsen PF, Ringgaard S, Laustsen C. Graft assessment of the ex vivo perfused porcine kidney using hyperpolarized [1- 13 C]pyruvate. Magn Reson Med 2020; 84:2645-2655. [PMID: 32557782 DOI: 10.1002/mrm.28363] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Revised: 05/07/2020] [Accepted: 05/21/2020] [Indexed: 01/06/2023]
Abstract
PURPOSE Normothermic perfusion is an emerging strategy for donor organ preservation and therapy, incited by the high worldwide demand for organs for transplantation. Hyperpolarized MRI and MRS using [1-13 C]pyruvate and other 13 C-labeled molecules pose a novel way to acquire highly detailed information about metabolism and function in a noninvasive manner. This study investigates the use of this methodology as a means to study and monitor the state of ex vivo perfused porcine kidneys, in the context of kidney graft preservation research. METHODS Kidneys from four 40-kg Danish domestic pigs were perfused ex vivo with whole blood under normothermic conditions, using an MR-compatible perfusion system. Kidneys were investigated using 1 H MRI as well as hyperpolarized [1-13 C]pyruvate MRI and MRS. Using the acquired anatomical, functional and metabolic data, the state of the ex vivo perfused porcine kidney could be quantified. RESULTS Four kidneys were successfully perfused for 120 minutes and verified using a DCE perfusion experiment. Renal metabolism was examined using hyperpolarized [1-13 C]pyruvate MRI and MRS, and displayed an apparent reduction in pyruvate turnover compared with the usual case in vivo. Perfusion and blood gas parameters were in the normal ex vivo range. CONCLUSION This study demonstrates the ability to monitor ex vivo graft metabolism and function in a large animal model, resembling human renal physiology. The ability of hyperpolarized MRI and MRS to directly compare the metabolic state of an organ in vivo and ex vivo, in combination with the simple MR implementation of normothermic perfusion, renders this methodology a powerful future tool for graft preservation research.
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Affiliation(s)
| | | | - Sabrina Kahina Bech
- Department of Clinical Medicine, The MR Research Centre, Aarhus University, Aarhus, Denmark
| | - Anders Munk
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Uffe Kjaergaard
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Mads Dam Lyhne
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Karsten Søberg
- Department of Anesthesia and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Peter Fast Nielsen
- Department of Anesthesia and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Steffen Ringgaard
- Department of Clinical Medicine, The MR Research Centre, Aarhus University, Aarhus, Denmark
| | - Christoffer Laustsen
- Department of Clinical Medicine, The MR Research Centre, Aarhus University, Aarhus, Denmark
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Brief Bubble and Intermittent Surface Oxygenation Is a Simple and Effective Alternative for Membrane Oxygenation During Hypothermic Machine Perfusion in Kidneys. Transplant Direct 2020; 6:e571. [PMID: 32766426 PMCID: PMC7339262 DOI: 10.1097/txd.0000000000001016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 04/27/2020] [Accepted: 04/28/2020] [Indexed: 02/03/2023] Open
Abstract
Background. The aim of this feasibility study was to determine an alternative oxygenation technique (easy, cheap, and compatible with air transport) for membrane oxygenation during hypothermic machine perfusion (HMP) to improve early graft function in a porcine ischemia-reperfusion autotransplant model. Methods. The left kidney of a ±40- kg pig was exposed to 30 minutes of warm ischemia before 22 hours of preservation and autotransplantation. In the experimental group, oxygenation of the perfusate during HMP was obtained by direct bubble and 30-minute surface oxygenation at start and 1-hour end ischemic (n = 4) and outcome measures compared with historical HMP without active oxygenation (n = 6), 22-hour continuous oxygenated HMP (HMPO2) (n = 8), and 2-hour HMPO2 + 20-hour HMP (n = 6) using membrane oxygenation in both historical oxygenated control groups. Results. Brief bubble and 30-minute surface oxygenation of the perfusate effectively maintained supraphysiological Po2 levels during the first 2 hours of HMP with improved flow dynamics. Although the metabolic profile of the perfusate (ie, flavin mononucleotide) and tissue (ie, glutamate, ATP) after brief O2 uploading at the start of HMP seemed to be slightly better with the use of a membrane oxygenator compared with bubble and interrupted surface oxygenation, both techniques yielded similar, superior early graft function when compared with HMP without active oxygenation. Conclusions. The data presented in this feasibility study support the conclusion that brief bubble and intermittent surface oxygenation could be an alternative oxygenation technique during HMP to achieve an improved kidney graft function compared with HMP without active oxygenation and similar functional outcome when compared with membrane HMPO2.
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Czigany Z, Lurje I, Schmelzle M, Schöning W, Öllinger R, Raschzok N, Sauer IM, Tacke F, Strnad P, Trautwein C, Neumann UP, Fronek J, Mehrabi A, Pratschke J, Schlegel A, Lurje G. Ischemia-Reperfusion Injury in Marginal Liver Grafts and the Role of Hypothermic Machine Perfusion: Molecular Mechanisms and Clinical Implications. J Clin Med 2020; 9:E846. [PMID: 32244972 PMCID: PMC7141496 DOI: 10.3390/jcm9030846] [Citation(s) in RCA: 67] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 03/09/2020] [Accepted: 03/11/2020] [Indexed: 12/19/2022] Open
Abstract
Ischemia-reperfusion injury (IRI) constitutes a significant source of morbidity and mortality after orthotopic liver transplantation (OLT). The allograft is metabolically impaired during warm and cold ischemia and is further damaged by a paradox reperfusion injury after revascularization and reoxygenation. Short-term and long-term complications including post-reperfusion syndrome, delayed graft function, and immune activation have been associated with IRI. Due to the current critical organ shortage, extended criteria grafts are increasingly considered for transplantation, however, with an elevated risk to develop significant features of IRI. In recent years, ex vivo machine perfusion (MP) of the donor liver has witnessed significant advancements. Here, we describe the concept of hypothermic (oxygenated) machine perfusion (HMP/HOPE) approaches and highlight which allografts may benefit from this technology. This review also summarizes clinical applications and the main aspects of ongoing randomized controlled trials on hypothermic perfusion. The mechanistic aspects of IRI and hypothermic MP-which include tissue energy replenishment, optimization of mitochondrial function, and the reduction of oxidative and inflammatory damage following reperfusion-will be comprehensively discussed within the context of current preclinical and clinical evidence. Finally, we highlight novel trends and future perspectives in the field of hypothermic MP in the context of recent findings of basic and translational research.
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Affiliation(s)
- Zoltan Czigany
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, 52074 Aachen, Germany; (Z.C.); (U.P.N.)
| | - Isabella Lurje
- Department of Surgery, Campus Charité Mitte | Campus Virchow-Klinikum—Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany; (I.L.); (M.S.); (W.S.); (R.Ö.); (N.R.); (I.M.S.); (J.P.)
| | - Moritz Schmelzle
- Department of Surgery, Campus Charité Mitte | Campus Virchow-Klinikum—Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany; (I.L.); (M.S.); (W.S.); (R.Ö.); (N.R.); (I.M.S.); (J.P.)
| | - Wenzel Schöning
- Department of Surgery, Campus Charité Mitte | Campus Virchow-Klinikum—Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany; (I.L.); (M.S.); (W.S.); (R.Ö.); (N.R.); (I.M.S.); (J.P.)
| | - Robert Öllinger
- Department of Surgery, Campus Charité Mitte | Campus Virchow-Klinikum—Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany; (I.L.); (M.S.); (W.S.); (R.Ö.); (N.R.); (I.M.S.); (J.P.)
| | - Nathanael Raschzok
- Department of Surgery, Campus Charité Mitte | Campus Virchow-Klinikum—Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany; (I.L.); (M.S.); (W.S.); (R.Ö.); (N.R.); (I.M.S.); (J.P.)
| | - Igor M. Sauer
- Department of Surgery, Campus Charité Mitte | Campus Virchow-Klinikum—Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany; (I.L.); (M.S.); (W.S.); (R.Ö.); (N.R.); (I.M.S.); (J.P.)
| | - Frank Tacke
- Department of Hepatology and Gastroenterology, Campus Charité Mitte | Campus Virchow-Klinikum—Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany;
| | - Pavel Strnad
- Department of Gastroenterology, Metabolic Disorders and Intensive Care, University Hospital RWTH Aachen, 52074 Aachen, Germany; (P.S.); (C.T.)
| | - Christian Trautwein
- Department of Gastroenterology, Metabolic Disorders and Intensive Care, University Hospital RWTH Aachen, 52074 Aachen, Germany; (P.S.); (C.T.)
| | - Ulf Peter Neumann
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, 52074 Aachen, Germany; (Z.C.); (U.P.N.)
| | - Jiri Fronek
- Department of Transplant Surgery, Institute for Clinical and Experimental Medicine, 140 21 Prague, Czech Republic;
| | - Arianeb Mehrabi
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, 69120 Heidelberg, Germany;
| | - Johann Pratschke
- Department of Surgery, Campus Charité Mitte | Campus Virchow-Klinikum—Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany; (I.L.); (M.S.); (W.S.); (R.Ö.); (N.R.); (I.M.S.); (J.P.)
| | - Andrea Schlegel
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham B15 2TH, UK;
| | - Georg Lurje
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, 52074 Aachen, Germany; (Z.C.); (U.P.N.)
- Department of Surgery, Campus Charité Mitte | Campus Virchow-Klinikum—Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany; (I.L.); (M.S.); (W.S.); (R.Ö.); (N.R.); (I.M.S.); (J.P.)
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Boteon YL, Laing RW, Schlegel A, Wallace L, Smith A, Attard J, Bhogal RH, Reynolds G, PR Perera MT, Muiesan P, Mirza DF, Mergental H, Afford SC. The impact on the bioenergetic status and oxidative-mediated tissue injury of a combined protocol of hypothermic and normothermic machine perfusion using an acellular haemoglobin-based oxygen carrier: The cold-to-warm machine perfusion of the liver. PLoS One 2019; 14:e0224066. [PMID: 31644544 PMCID: PMC6808429 DOI: 10.1371/journal.pone.0224066] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 10/04/2019] [Indexed: 01/12/2023] Open
Abstract
Introduction The combination of hypothermic and normothermic machine perfusion (HMP+NMP) of the liver provides individual benefits of both techniques, improving the rescue of marginal organs. The aim of this study was to investigate the effect on the bioenergetic status and the oxidative-mediated tissue injury of an uninterrupted combined protocol of HMP+NMP using a single haemoglobin-based oxygen carrier (HBOC)-based perfusate. Methods Ten discarded human donor livers had either 2 hours of dual hypothermic oxygenated perfusion (D-HOPE) with sequential controlled rewarming (COR) and then NMP using the HBOC-based perfusate uninterruptedly (cold-to-warm group); or 2 hours of hypothermic oxygenated perfusion (HOPE) with an oxygen carrier-free perfusate, followed by perfusate exchange and then NMP with an HBOC-based perfusate. Markers of liver function, tissue adenosine triphosphate (ATP) levels and tissue injury were systematically assessed. Results The hypothermic phase downregulated mitochondrial respiration and increased ATP levels in both groups. The cold-to-warm group presented higher arterial vascular resistance during rewarming/NMP (p = 0.03) with a trend of lower arterial flow (p = 0.09). At the end of NMP tissue expression of markers of reactive oxygen species production, oxidative injury and inflammation were comparable between the groups. Conclusion The uninterrupted combined protocol of HMP+NMP using an HBOC-based perfusate—cold-to-warm MP—mitigated the oxidative-mediated tissue injury and enhanced hepatic energy stores, similarly to an interrupted combined protocol; however, it simplified the logistics of this combination and may favour its clinical applicability.
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Affiliation(s)
- Yuri L. Boteon
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
- National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Richard W. Laing
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
- National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Andrea Schlegel
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Lorraine Wallace
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
- National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Amanda Smith
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Joseph Attard
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
- National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Ricky H. Bhogal
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
- National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Gary Reynolds
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
- National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - M. Thamara PR Perera
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Paolo Muiesan
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Darius F. Mirza
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
- National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Hynek Mergental
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
- National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Simon C. Afford
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
- National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
- * E-mail:
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Bellini MI, Yiu J, Nozdrin M, Papalois V. The Effect of Preservation Temperature on Liver, Kidney, and Pancreas Tissue ATP in Animal and Preclinical Human Models. J Clin Med 2019; 8:jcm8091421. [PMID: 31505880 PMCID: PMC6780500 DOI: 10.3390/jcm8091421] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 08/30/2019] [Accepted: 09/02/2019] [Indexed: 02/06/2023] Open
Abstract
The recent advances in machine perfusion (MP) technology involve settings ranging between hypothermic, subnormothermic, and normothermic temperatures. Tissue level adenosine triphosphate (ATP) is a long-established marker of viability and functionality and is universal for all organs. In the midst of a growing number of complex clinical parameters for the quality assessment of graft prior to transplantation, a revisit of ATP may shed light on the underlying reconditioning mechanisms of different perfusion temperatures in the form of restoration of metabolic and energy status. This article aims to review and critically analyse animal and preclinical human studies (discarded grafts) during MP of three abdominal organs (liver, kidney, and pancreas) in which ATP was a primary endpoint. A selective review of recent novel reconditioning approaches relevant to mitigation of graft ischaemia-reperfusion injury via MP and for different perfusion temperatures was also conducted. With a current reiterated interest for oxygenation during MP, a re-introduction of tissue ATP levels may be valuable for graft viability assessment prior to transplantation. Further studies may help delineate the benefits of selective perfusion temperatures on organs viability.
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Affiliation(s)
| | - Janice Yiu
- School of Medicine, University College London, London WC1E 6BT, UK
| | - Mikhail Nozdrin
- School of Medicine, Imperial College London, London SW72AZ, UK
| | - Vassilios Papalois
- Renal and Transplant Directorate, Imperial College Healthcare NHS Trust, London W120HS, UK
- Department of Surgery and Cancer, Imperial College London, London SW72AZ, UK
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20
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Kaminski J, Delpech PO, Kaaki-Hosni S, Promeyrat X, Hauet T, Hannaert P. Oxygen Consumption by Warm Ischemia-Injured Porcine Kidneys in Hypothermic Static and Machine Preservation. J Surg Res 2019; 242:78-86. [PMID: 31071608 DOI: 10.1016/j.jss.2019.04.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 03/26/2019] [Accepted: 04/04/2019] [Indexed: 01/20/2023]
Abstract
Static cold storage (SCS) and hypothermic machine perfusion (HMP) are currently standard methods for renal grafts clinical preservation. Both methods are predominantly implemented without the active delivery of oxygen, even for donation after circulatory death-like kidneys. However, even under severe hypothermia (4°C-6°C), kidneys can consume oxygen and produce ATP. What is not established, though, is to what extent and how SCS and HMP compare in terms of oxygen. Using a porcine preclinical model of renal warm ischemia (WI) to compare SCS and HMP methods, we continuously monitored and quantified oxygen level and consumption along preservation; we also determined prepreservation and postpreservation cortical ATP level; values were given as median and [min; max] range. One-hour WI reduced ATP by ∼90% (from 3.3 [1.7; 4.5] mmol/L tissue in Controls). Oxygen consumption (QO2, μmol/min per 100 g) was determined from initial solution PO2 decrease (SCS and HMP) and from arterio-venous difference (HMP). In SCS and HMP, PO2 decreased rapidly (t1/2 ∼1 h) from atmospheric levels to 52.9 [38.0; 65.9] and 8.2 [3.0, 16.0] mmHg, respectively. In HMP, QO2 was 2.7 [0.4; 3.9] versus 0.5 [0.0; 1.3] in SCS (P < 0.05); postpreservation ATP amounted to 5.8 [3.2; 6.5] in HMP versus 0.1 [0.0; 0.2] in SCS. Despite hypothermic conditions in SCS or HMP, donation after circulatory death-like renal grafts require oxygen. Increased oxygen consumption, restored ATP level, and improved histological profile in HMP might explain the established HMP superiority over SCS. These results establish a rational basis for the use of oxygen in hypothermic preservation. Optimal levels required for preservation and graft-type variants remain to be determined.
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Affiliation(s)
| | - Pierre-Olivier Delpech
- INSERM U1082-IRTOMIT, CHU de Poitiers, Poitiers, France; Service d'Urologie, CHU de Poitiers, Poitiers, France
| | | | - Xavier Promeyrat
- Service d'Urologie et de Chirurgie de la Transplantation, Hôpital Édouard-Herriot, Université Claude-Bernard Lyon 1, Lyon, France
| | - Thierry Hauet
- INSERM U1082-IRTOMIT, CHU de Poitiers, Poitiers, France; Service de Biochimie, CHU de Poitiers, Poitiers, France
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Hypothermic Oxygenated Perfusion: A Simple and Effective Method to Modulate the Immune Response in Kidney Transplantation. Transplantation 2019; 103:e128-e136. [DOI: 10.1097/tp.0000000000002634] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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22
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Moeckli B, Sun P, Lazeyras F, Morel P, Moll S, Pascual M, Bühler LH. Evaluation of donor kidneys prior to transplantation: an update of current and emerging methods. Transpl Int 2019; 32:459-469. [PMID: 30903673 DOI: 10.1111/tri.13430] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 03/18/2019] [Indexed: 02/06/2023]
Abstract
The lack of suitable kidney donor organs has led to rising numbers of patients with end stage renal disease waiting for kidney transplantation. Despite decades of clinical experience and research, no evaluation process that can reliably predict the outcome of an organ has yet been established. This review is an overview of current methods and emerging techniques in the field of donor kidney evaluation prior to transplantation. Established techniques like histological evaluation, clinical scores, and machine perfusion systems offer relatively reliable predictions of delayed graft function but are unable to consistently predict graft survival. Emerging techniques including molecular biomarkers, new imaging technologies, and normothermic machine perfusion offer innovative approaches toward a more global evaluation of an organ with better outcome prediction and possibly even identification of targets for therapeutic interventions prior to transplantation. These techniques should be studied in randomized controlled trials to determine whether they can be safely used in routine clinical practice to ultimately reduce the discard rate and improve graft outcomes.
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Affiliation(s)
- Beat Moeckli
- Department of Surgery and Transplantation, Zurich University Hospital, Zurich, Switzerland
| | - Pamela Sun
- Department of Surgery, Geneva University Hospital, Geneva, Switzerland
| | - François Lazeyras
- Department of Radiology and Medical Informatics, CIBM, Geneva University Hospital, Geneva, Switzerland
| | - Philippe Morel
- Department of Surgery, Geneva University Hospital, Geneva, Switzerland
| | - Solange Moll
- Department of Pathology, Geneva University Hospital, Geneva, Switzerland
| | - Manuel Pascual
- Transplantation Center Lausanne, University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Léo H Bühler
- Department of Surgery, Geneva University Hospital, Geneva, Switzerland
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23
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Schlegel A, Dutkowski P. Impact of Machine Perfusion on Biliary Complications after Liver Transplantation. Int J Mol Sci 2018; 19:ijms19113567. [PMID: 30424553 PMCID: PMC6274934 DOI: 10.3390/ijms19113567] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 11/01/2018] [Accepted: 11/05/2018] [Indexed: 12/13/2022] Open
Abstract
We describe in this review the different types of injuries caused to the biliary tree after liver transplantation. Furthermore, we explain underlying mechanisms and why oxygenated perfusion concepts could not only protect livers, but also repair high-risk grafts to prevent severe biliary complications and graft loss. Accordingly, we summarize experimental studies and clinical applications of machine liver perfusion with a focus on biliary complications after liver transplantation. Key points: (1) Acute inflammation with subsequent chronic ongoing liver inflammation and injury are the main triggers for cholangiocyte injury and biliary tree transformation, including non-anastomotic strictures; (2) Hypothermic oxygenated perfusion (HOPE) protects livers from initial oxidative injury at normothermic reperfusion after liver transplantation. This is a unique feature of a cold oxygenation approach, which is effective also end-ischemically, e.g., after cold storage, due to mitochondrial repair mechanisms. In contrast, normothermic oxygenated perfusion concepts protect by reducing cold ischemia, and are therefore most beneficial when applied instead of cold storage; (3) Due to less downstream activation of cholangiocytes, hypothermic oxygenated perfusion also significantly reduces the development of biliary strictures after liver transplantation.
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Affiliation(s)
- Andrea Schlegel
- Department of Surgery & Transplantation, University Hospital Zurich, 8091 Zurich, Switzerland.
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham B15 2TH, UK.
- NIHR Liver Biomedical Research Unit, University Hospitals Birmingham, Birmingham B15 2TH, UK.
| | - Philipp Dutkowski
- Department of Surgery & Transplantation, University Hospital Zurich, 8091 Zurich, Switzerland.
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Li X, Wang Y, Deng S. Meeting report: The first international conference on xenotransplantation in Chengdu, China. Xenotransplantation 2017; 24. [PMID: 29171695 DOI: 10.1111/xen.12376] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Affiliation(s)
- Xiang Li
- School of Medicine; University of Electronic Science and Technology of China; Chengdu Sichuan China
| | - Yi Wang
- Institute of Organ Transplantation; Sichuan Academy of Medical Science & Sichuan Provincial People's Hospital; Chengdu Sichuan China
| | - Shaoping Deng
- Institute of Organ Transplantation; Sichuan Academy of Medical Science & Sichuan Provincial People's Hospital; Chengdu Sichuan China
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Nuclear Magnetic Resonance Strategies for Metabolic Analysis. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2017; 965:45-76. [DOI: 10.1007/978-3-319-47656-8_3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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26
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Should Pulsatile Preservation Be the Gold Standard in Kidney Transplantation? CURRENT TRANSPLANTATION REPORTS 2015. [DOI: 10.1007/s40472-015-0063-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Wang H, Xu Z, Wu A, Dong Y, Zhang Y, Yue Y, Xie Z. 2-deoxy-D-glucose enhances anesthetic effects in mice. Anesth Analg 2015; 120:312-9. [PMID: 25390277 DOI: 10.1213/ane.0000000000000520] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND The mechanisms of general anesthesia by volatile drugs remain largely unknown. Mitochondrial dysfunction and reduction in energy levels have been suggested to be associated with general anesthesia status. 2-Deoxy-D-glucose (2-DG), an analog of glucose, inhibits hexokinase and reduces cellular levels of adenosine triphosphate (ATP). 3-Nitropropionic acid is another compound which can deplete ATP levels. In contrast, idebenone and L-carnitine could rescue deficits of energy. We therefore sought to determine whether 2-DG and/or 3-nitropropionic acid can enhance the anesthetic effects of isoflurane, and whether idebenone and L-carnitine can reverse the actions of 2-DG. METHODS C57BL/6J mice (8 months old) received different concentrations of isoflurane with and without the treatments of 2-DG, 3-nitropropionic acid, idebenone, and L-carnitine. Isoflurane-induced loss of righting reflex (LORR) was determined in the mice. ATP levels in H4 human neuroglioma cells were assessed after these treatments. Finally, 31P-magnetic resonance spectroscopy was used to determine the effects of isoflurane on brain ATP levels in the mice. RESULTS 2-DG enhanced isoflurane-induced LORR (P = 0.002, N = 15). 3-Nitropropionic acid also enhanced the anesthetic effects of isoflurane (P = 0.005, N = 15). Idebenone (idebenone + saline versus idebenone + 2-DG: P = 0.165, N = 15), but not L-carnitine (L-carnitine + saline versus L-carnitine + 2-DG: P < 0.0001, N = 15), inhibited the effects of 2-DG on enhancing isoflurane-induced LORR in the mice, as evidenced by 2-DG not enhancing isoflurane-induced LORR in the mice pretreated with idebenone. Idebenone (idebenone + saline versus idebenone + 2-DG: P = 0.177, N = 6), but not L-carnitine (L-carnitine + saline versus L-carnitine + 2-DG: P = 0.029, N = 6), also mitigated the effects of 2-DG on reducing ATP levels in cells, as evidenced by 2-DG not decreasing ATP levels in the cells pretreated with idebenone. Finally, isoflurane decreased ATP levels in both cultured cells and mouse brains (β-ATP: P = 0.003, N = 10; β-ATP/phosphocreatine: P = 0.006, N = 10; β-ATP/inorganic phosphate: P = 0.001, N = 10). CONCLUSIONS These results from our pilot studies have established a system and generated a hypothesis that 2-DG enhances anesthetic effects via reducing energy levels. These findings should promote further studies to investigate anesthesia mechanisms.
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Affiliation(s)
- Hui Wang
- From the *Department of Anesthesia, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; †Geriatric Anesthesia Research Unit, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Charlestown, Massachusetts; and ‡Anesthesia and Operation Center, Chinese PLA General Hospital, Beijing, China
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Abstract
BACKGROUND Magnetic resonance imaging (MRI) gadolinium-perfusion was applied in simulated Donation after Cardiac Death (DCD) in porcine kidneys to measure intrarenal perfusion. Adenosine triphosphate (ATP) resynthesis during oxygenated hypothermic perfusion was compared to evaluate the "ex vivo organ viability". Adenine nucleotide (AN) was measured by P nuclear magnetic resonance (NMR) spectroscopy. Whereas this latter technique requires sophisticated hardware, gadolinium-perfusion can be realized using any standard proton-MRI scanner. The aim of this work was to establish a correlation between the two methods. METHODS Twenty-two porcine kidneys presenting up to 90 min warm ischemia were perfused with oxygenation at 4 °C using our magnetic resonance-compatible machine. During the perfusion, P NMR spectroscopy and gadolinium-perfusion sequences were performed. Measures obtained from the gadolinium-perfusion were the speed of elimination of the cortical gadolinium and the presence or absence of a corticomedullar shunt. For ATP resynthesis analysis, P chemical shift imaging was acquired and analyzed. All the kidneys have been submitted to histologic examination. RESULTS ATP resynthesis was observed in all organs presenting a cortical gadolinium elimination slope of (-) 23° or greater. In organs with lower gadolinium elimination, no AN or only precursors were detected. This study reveals a link between the two methods and demonstrates ex vivo viability in 93% of the analyzed kidneys. Benefits and side effects of both methods are discussed. CONCLUSION Oxygenated hypothermic perfusion enables the evaluation of kidneys in DCD simulated situation; gadolinium-perfusion can be introduced into any center equipped with a proton-MRI scanner allowing results superposable with ATP measurement.
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Bruinsma BG, Yarmush ML, Uygun K. Organomatics and organometrics: Novel platforms for long-term whole-organ culture. TECHNOLOGY 2014; 2:13. [PMID: 25035864 PMCID: PMC4097862 DOI: 10.1142/s2339547814300029] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
Organ culture systems are instrumental as experimental whole-organ models of physiology and disease, as well as preservation modalities facilitating organ replacement therapies such as transplantation. Nevertheless, a coordinated system of machine perfusion components and integrated regulatory control has yet to be fully developed to achieve long-term maintenance of organ function ex vivo. Here we outline current strategies for organ culture, or organomatics, and how these systems can be regulated by means of computational algorithms, or organometrics, to achieve the organ culture platforms anticipated in modern-day biomedicine.
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Abstract
PURPOSE OF REVIEW Pretransplant assessment of kidney graft viability may help clinicians to decide whether to accept or discard a kidney for transplantation. With the increasing demand for donor kidneys and the increased use of marginal kidneys, the need of viability markers has increased to pursue superior transplant outcomes. Hypothermic machine perfusion (HMP) provides the theoretical opportunity to assess the viability of donor kidneys. We discuss the novel developments in viability testing during HMP and address the future prospects. RECENT FINDINGS HMP viability testing has focused on the analysis of machine perfusion parameters and perfusate biomarkers. Renal resistance and the biomarkers lactate dehydrogenase, aspartate transaminase, glutathione-S-transferase, N-acetyl-β-D-glucosaminidase, heart-type fatty acid binding protein, lipid peroxidation products, redox-active iron and IL-18 are correlated with transplant outcome in terms of development of delayed graft function or graft survival. However, they all lack adequate predictive value for transplant outcome. New techniques including contrast-enhanced ultrasound, three-dimensional ultrasound and magnetic resonance spectrometry are promising methods to test kidney viability during HMP, but their value has to be established. The introduction of normothermic machine perfusion offers other promising opportunities for viability testing. SUMMARY Machine perfusion characteristics and perfusate biomarkers have been extensively studied. They often correlate with the transplant outcome, but the present viability tests are not reliable predictors of transplant outcome. New developments in kidney graft viability assessment are necessary to have a chance of being clinically useful in the future.
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