1
|
Vu Manh TP, Gouin C, De Wolf J, Jouneau L, Pascale F, Bevilacqua C, Ar Gouilh M, Da Costa B, Chevalier C, Glorion M, Hannouche L, Urien C, Estephan J, Magnan A, Le Guen M, Marquant Q, Descamps D, Dalod M, Schwartz-Cornil I, Sage E. SARS-CoV2 infection in whole lung primarily targets macrophages that display subset-specific responses. Cell Mol Life Sci 2024; 81:351. [PMID: 39147987 DOI: 10.1007/s00018-024-05322-z] [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: 11/09/2023] [Revised: 05/22/2024] [Accepted: 06/05/2024] [Indexed: 08/17/2024]
Abstract
Deciphering the initial steps of SARS-CoV-2 infection, that influence COVID-19 outcomes, is challenging because animal models do not always reproduce human biological processes and in vitro systems do not recapitulate the histoarchitecture and cellular composition of respiratory tissues. To address this, we developed an innovative ex vivo model of whole human lung infection with SARS-CoV-2, leveraging a lung transplantation technique. Through single-cell RNA-seq, we identified that alveolar and monocyte-derived macrophages (AMs and MoMacs) were initial targets of the virus. Exposure of isolated lung AMs, MoMacs, classical monocytes and non-classical monocytes (ncMos) to SARS-CoV-2 variants revealed that while all subsets responded, MoMacs produced higher levels of inflammatory cytokines than AMs, and ncMos contributed the least. A Wuhan lineage appeared to be more potent than a D614G virus, in a dose-dependent manner. Amidst the ambiguity in the literature regarding the initial SARS-CoV-2 cell target, our study reveals that AMs and MoMacs are dominant primary entry points for the virus, and suggests that their responses may conduct subsequent injury, depending on their abundance, the viral strain and dose. Interfering on virus interaction with lung macrophages should be considered in prophylactic strategies.
Collapse
Affiliation(s)
- Thien-Phong Vu Manh
- Aix-Marseille University, CNRS, INSERM, CIML, Centre d'Immunologie de Marseille-Luminy, Turing Center for Living Systems, 13009, Marseille, France.
| | - Carla Gouin
- Université Paris-Saclay, INRAE, UVSQ, VIM, 78350, Jouy-en-Josas, France
| | - Julien De Wolf
- Université Paris-Saclay, INRAE, UVSQ, VIM, 78350, Jouy-en-Josas, France
- Department of Thoracic Surgery and Lung Transplantation, Foch Hospital, 92150, Suresnes, France
| | - Luc Jouneau
- Université Paris-Saclay, INRAE, UVSQ, VIM, 78350, Jouy-en-Josas, France
- Université Paris-Saclay, INRAE, UVSQ, BREED, 78350, Jouy-en-Josas, France
| | - Florentina Pascale
- Université Paris-Saclay, INRAE, UVSQ, VIM, 78350, Jouy-en-Josas, France
- Department of Thoracic Surgery and Lung Transplantation, Foch Hospital, 92150, Suresnes, France
| | - Claudia Bevilacqua
- Université Paris-Saclay, INRAE, AgroParisTech, GABI, 78350, Jouy-en-Josas, France
| | - Meriadeg Ar Gouilh
- Department of Virology, Univ Caen Normandie, Dynamicure INSERM UMR 1311, CHU Caen, 14000, Caen, France
| | - Bruno Da Costa
- Université Paris-Saclay, INRAE, UVSQ, VIM, 78350, Jouy-en-Josas, France
| | | | - Matthieu Glorion
- Université Paris-Saclay, INRAE, UVSQ, VIM, 78350, Jouy-en-Josas, France
- Department of Thoracic Surgery and Lung Transplantation, Foch Hospital, 92150, Suresnes, France
| | - Laurent Hannouche
- Aix-Marseille University, CNRS, INSERM, CIML, Centre d'Immunologie de Marseille-Luminy, Turing Center for Living Systems, 13009, Marseille, France
- Université Paris-Saclay, INRAE, UVSQ, VIM, 78350, Jouy-en-Josas, France
| | - Céline Urien
- Université Paris-Saclay, INRAE, UVSQ, VIM, 78350, Jouy-en-Josas, France
| | - Jérôme Estephan
- Université Paris-Saclay, INRAE, UVSQ, VIM, 78350, Jouy-en-Josas, France
| | - Antoine Magnan
- Université Paris-Saclay, INRAE, UVSQ, VIM, 78350, Jouy-en-Josas, France
- Department of Pulmonology, Foch Hospital, 92150, Suresnes, France
| | - Morgan Le Guen
- Université Paris-Saclay, INRAE, UVSQ, VIM, 78350, Jouy-en-Josas, France
- Department of Anesthesiology, Foch Hospital, 92150, Suresnes, France
| | - Quentin Marquant
- Université Paris-Saclay, INRAE, UVSQ, VIM, 78350, Jouy-en-Josas, France
- Department of Pulmonology, Foch Hospital, 92150, Suresnes, France
- Delegation to Clinical Research and Innovation, Foch Hospital, 92150, Suresnes, France
| | - Delphyne Descamps
- Université Paris-Saclay, INRAE, UVSQ, VIM, 78350, Jouy-en-Josas, France
| | - Marc Dalod
- Aix-Marseille University, CNRS, INSERM, CIML, Centre d'Immunologie de Marseille-Luminy, Turing Center for Living Systems, 13009, Marseille, France
| | | | - Edouard Sage
- Université Paris-Saclay, INRAE, UVSQ, VIM, 78350, Jouy-en-Josas, France
- Department of Thoracic Surgery and Lung Transplantation, Foch Hospital, 92150, Suresnes, France
| |
Collapse
|
2
|
Forgie K, Fialka N, Watkins A, Du K, Himmat S, Hatami S, Khan M, Wang X, Edgar R, Buswell-Zuk KM, Freed DH, Nagendran J. Normothermic Perfusion is Superior to Cold Perfusion in Porcine Ex Situ Lung Perfusion. Transplant Proc 2024:S0041-1345(24)00316-6. [PMID: 39019761 DOI: 10.1016/j.transproceed.2024.04.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 03/24/2024] [Accepted: 04/26/2024] [Indexed: 07/19/2024]
Abstract
BACKGROUND Cold ex situ lung perfusion (ESLP) has demonstrated improved preservation in small animal ESLP compared to normothermic ESLP and cold static preservation. We hypothesized that cold negative pressure ventilation (NPV)-ESLP would improve graft function in a porcine transplantation model. METHODS Four perfusate temperatures were examined with 12 hours NPV-ESLP in a large animal transplantation model. Pig lungs were allotted to four groups: (1) Normothermia (38°C, n = 6); (2) profound hypothermia (10°C, n = 6); (3) moderate hypothermia (20°C, n = 3); (4) subnormothermia (32°C, n = 3). A fifth group subnormothermic low-flow (SNLF) perfusion was examined to assess the effect of reduced cardiac output with cold perfusion (32°C, 10% cardiac output, n = 6). RESULTS Only Normothermic and SNLF groups demonstrated acceptable oxygenation after 12 hours NPV-ESLP and were transplanted. All other groups failed prematurely. After 12 hours of ESLP, Normothermic lungs demonstrated significantly greater dynamic compliance compared to SNLF lungs (P = .03). Edema formation post-ESLP was significantly worse in the SNLF group (P = .01). There was no significant difference in pulmonary artery pressures after ESLP (P = .10); however, pulmonary vascular resistance was significantly greater in the SNLF (P = .04). Isolated left lung oxygenation 4-hours post-transplant and left lung edema formation was not significantly different between Normothermic and SNLF post-transplant (P = .09). Proinflammatory cytokines were significantly greater during SNLF-ESLP (tumor necrosis factor alpha, P < .05). CONCLUSIONS Prolonged normothermic (38°C) NPV-ESLP is superior to 10, 20, and 32°C perfusion. Normothermic ESLP of porcine lungs results in superior graft function and reduced inflammation versus SNLF-ESLP.
Collapse
Affiliation(s)
- Keir Forgie
- Department of Surgery, Division of Cardiac Surgery, Faculty of Medicine, University of Alberta, Edmonton, AB, Canada; Mazankowski Alberta Heart Institute, Edmonton, AB, Canada
| | - Nicholas Fialka
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Abeline Watkins
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Katie Du
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Sayed Himmat
- Department of Surgery, Faculty of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Sanaz Hatami
- Department of Surgery, Faculty of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Mubashir Khan
- Department of Surgery, Faculty of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Xiuhua Wang
- Department of Surgery, Faculty of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Ryan Edgar
- Ray Rajotte Surgical Medical Research Institute (SMRI), Edmonton, AB, Canada
| | | | - Darren H Freed
- Department of Surgery, Division of Cardiac Surgery, Faculty of Medicine, University of Alberta, Edmonton, AB, Canada; Mazankowski Alberta Heart Institute, Edmonton, AB, Canada; Alberta Transplant Institute, Edmonton, AB, Canada; Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
| | - Jayan Nagendran
- Department of Surgery, Division of Cardiac Surgery, Faculty of Medicine, University of Alberta, Edmonton, AB, Canada; Mazankowski Alberta Heart Institute, Edmonton, AB, Canada; Alberta Transplant Institute, Edmonton, AB, Canada; Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada.
| |
Collapse
|
3
|
Iskender I. Technical Advances Targeting Multiday Preservation of Isolated Ex Vivo Lung Perfusion. Transplantation 2024; 108:1319-1332. [PMID: 38499501 DOI: 10.1097/tp.0000000000004992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/20/2024]
Abstract
Indications for ex vivo lung perfusion (EVLP) have evolved from assessment of questionable donor lungs to treatment of some pathologies and the logistics. Yet up to 3 quarters of donor lungs remain discarded across the globe. Multiday preservation of discarded human lungs on EVLP platforms would improve donor lung utilization rates via application of sophisticated treatment modalities, which could eventually result in zero waitlist mortality. The purpose of this article is to summarize advances made on the technical aspects of the protocols in achieving a stable multiday preservation of isolated EVLP. Based on the evidence derived from large animal and/or human studies, the following advances have been considered important in achieving this goal: ability to reposition donor lungs during EVLP; perfusate adsorption/filtration modalities; perfusate enrichment with plasma and/or donor whole blood, nutrients, vitamins, and amino acids; low-flow, pulsatile, and subnormothermic perfusion; positive outflow pressure; injury specific personalized ventilation strategies; and negative pressure ventilation. Combination of some of these advances in an automatized EVLP device capable of managing perfusate biochemistry and ventilation would likely speed up the processes of achieving multiday preservation of isolated EVLP.
Collapse
Affiliation(s)
- Ilker Iskender
- Department of Cardiac Surgery, East Limburg Hospital, Genk, Belgium
| |
Collapse
|
4
|
Nykänen AI, Keshavjee S, Liu M. Creating superior lungs for transplantation with next-generation gene therapy during ex vivo lung perfusion. J Heart Lung Transplant 2024; 43:838-848. [PMID: 38310996 DOI: 10.1016/j.healun.2024.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Revised: 12/23/2023] [Accepted: 01/29/2024] [Indexed: 02/06/2024] Open
Abstract
Engineering donor organs to better tolerate the harmful non-immunological and immunological responses inherently related to solid organ transplantation would improve transplant outcomes. Our enhanced knowledge of ischemia-reperfusion injury, alloimmune responses and pathological fibroproliferation after organ transplantation, and the advanced toolkit available for gene therapies, have brought this goal closer to clinical reality. Ex vivo organ perfusion has evolved rapidly especially in the field of lung transplantation, where clinicians routinely use ex vivo lung perfusion (EVLP) to confirm the quality of marginal donor lungs before transplantation, enabling safe transplantation of organs originally considered unusable. EVLP would also be an attractive platform to deliver gene therapies, as treatments could be administered to an isolated organ before transplantation, thereby providing a window for sophisticated organ engineering while minimizing off-target effects to the recipient. Here, we review the status of lung transplant first-generation gene therapies that focus on inducing transgene expression in the target cells. We also highlight recent advances in next-generation gene therapies, that enable gene editing and epigenetic engineering, that could be used to permanently change the donor organ genome and to induce widespread transcriptional gene expression modulation in the donor lung. In a future vision, dedicated organ repair and engineering centers will use gene editing and epigenetic engineering, to not only increase the donor organ pool, but to create superior organs that will function better and longer in the recipient.
Collapse
Affiliation(s)
- Antti I Nykänen
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada; Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Cardiothoracic Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Shaf Keshavjee
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada; Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Division of Thoracic Surgery, Department of Surgery, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Mingyao Liu
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada; Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
| |
Collapse
|
5
|
Ponholzer F, Dumfarth J, Krapf C, Pircher A, Hautz T, Wolf D, Augustin F, Schneeberger S. The impact and relevance of techniques and fluids on lung injury in machine perfusion of lungs. Front Immunol 2024; 15:1358153. [PMID: 38510260 PMCID: PMC10950925 DOI: 10.3389/fimmu.2024.1358153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 02/26/2024] [Indexed: 03/22/2024] Open
Abstract
Primary graft dysfunction (PGD) is a common complication after lung transplantation. A plethora of contributing factors are known and assessment of donor lung function prior to organ retrieval is mandatory for determination of lung quality. Specialized centers increasingly perform ex vivo lung perfusion (EVLP) to further assess lung functionality and improve and extend lung preservation with the aim to increase lung utilization. EVLP can be performed following different protocols. The impact of the individual EVLP parameters on PGD development, organ function and postoperative outcome remains to be fully investigated. The variables relate to the engineering and function of the respective perfusion devices, such as the type of pump used, functional, like ventilation modes or physiological (e.g. perfusion solutions). This review reflects on the individual technical and fluid components relevant to EVLP and their respective impact on inflammatory response and outcome. We discuss key components of EVLP protocols and options for further improvement of EVLP in regard to PGD. This review offers an overview of available options for centers establishing an EVLP program and for researchers looking for ways to adapt existing protocols.
Collapse
Affiliation(s)
- Florian Ponholzer
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Julia Dumfarth
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Christoph Krapf
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Andreas Pircher
- Department of Haematology and Oncology, Internal Medicine V, Medical University of Innsbruck, Innsbruck, Austria
| | - Theresa Hautz
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Dominik Wolf
- Department of Haematology and Oncology, Internal Medicine V, Medical University of Innsbruck, Innsbruck, Austria
| | - Florian Augustin
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Stefan Schneeberger
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| |
Collapse
|
6
|
Quiros KAM, Nelson TM, Ulu A, Dominguez EC, Biddle TA, Lo DD, Nordgren TM, Eskandari M. A Comparative Study of Ex-Vivo Murine Pulmonary Mechanics Under Positive- and Negative-Pressure Ventilation. Ann Biomed Eng 2024; 52:342-354. [PMID: 37906375 PMCID: PMC10808462 DOI: 10.1007/s10439-023-03380-1] [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: 12/07/2022] [Accepted: 10/03/2023] [Indexed: 11/02/2023]
Abstract
Increased ventilator use during the COVID-19 pandemic resurrected persistent questions regarding mechanical ventilation including the difference between physiological and artificial breathing induced by ventilators (i.e., positive- versus negative-pressure ventilation, PPV vs NPV). To address this controversy, we compare murine specimens subjected to PPV and NPV in ex vivo quasi-static loading and quantify pulmonary mechanics via measures of quasi-static and dynamic compliances, transpulmonary pressure, and energetics when varying inflation frequency and volume. Each investigated mechanical parameter yields instance(s) of significant variability between ventilation modes. Most notably, inflation compliance, percent relaxation, and peak pressure are found to be consistently dependent on the ventilation mode. Maximum inflation volume and frequency note varied dependencies contingent on the ventilation mode. Contradictory to limited previous clinical investigations of oxygenation and end-inspiratory measures, the mechanics-focused comprehensive findings presented here indicate lung properties are dependent on loading mode, and importantly, these dependencies differ between smaller versus larger mammalian species despite identical custom-designed PPV/NPV ventilator usage. Results indicate that past contradictory findings regarding ventilation mode comparisons in the field may be linked to the chosen animal model. Understanding the differing fundamental mechanics between PPV and NPV may provide insights for improving ventilation strategies and design to prevent associated lung injuries.
Collapse
Affiliation(s)
- K A M Quiros
- Department of Mechanical Engineering, University of California Riverside, 900 University Ave., Riverside, CA, 92506, USA
| | - T M Nelson
- Department of Mechanical Engineering, University of California Riverside, 900 University Ave., Riverside, CA, 92506, USA
| | - A Ulu
- Division of Biomedical Sciences, Riverside School of Medicine, University of California, Riverside, CA, USA
| | - E C Dominguez
- Division of Biomedical Sciences, Riverside School of Medicine, University of California, Riverside, CA, USA
- Environmental Toxicology Graduate Program, University of California, Riverside, CA, USA
| | - T A Biddle
- Division of Biomedical Sciences, Riverside School of Medicine, University of California, Riverside, CA, USA
- Environmental Toxicology Graduate Program, University of California, Riverside, CA, USA
- School of Medicine, BREATHE Center, University of California, Riverside, CA, USA
| | - D D Lo
- Division of Biomedical Sciences, Riverside School of Medicine, University of California, Riverside, CA, USA
- School of Medicine, BREATHE Center, University of California, Riverside, CA, USA
- Center for Health Disparities Research, University of California, Riverside, CA, USA
| | - T M Nordgren
- Division of Biomedical Sciences, Riverside School of Medicine, University of California, Riverside, CA, USA
- Environmental Toxicology Graduate Program, University of California, Riverside, CA, USA
- School of Medicine, BREATHE Center, University of California, Riverside, CA, USA
- Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, CO, USA
| | - M Eskandari
- Department of Mechanical Engineering, University of California Riverside, 900 University Ave., Riverside, CA, 92506, USA.
- School of Medicine, BREATHE Center, University of California, Riverside, CA, USA.
- Department of Bioengineering, University of California, Riverside, CA, USA.
| |
Collapse
|
7
|
Iske J, Schroeter A, Knoedler S, Nazari-Shafti TZ, Wert L, Roesel MJ, Hennig F, Niehaus A, Kuehn C, Ius F, Falk V, Schmelzle M, Ruhparwar A, Haverich A, Knosalla C, Tullius SG, Vondran FWR, Wiegmann B. Pushing the boundaries of innovation: the potential of ex vivo organ perfusion from an interdisciplinary point of view. Front Cardiovasc Med 2023; 10:1272945. [PMID: 37900569 PMCID: PMC10602690 DOI: 10.3389/fcvm.2023.1272945] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 09/22/2023] [Indexed: 10/31/2023] Open
Abstract
Ex vivo machine perfusion (EVMP) is an emerging technique for preserving explanted solid organs with primary application in allogeneic organ transplantation. EVMP has been established as an alternative to the standard of care static-cold preservation, allowing for prolonged preservation and real-time monitoring of organ quality while reducing/preventing ischemia-reperfusion injury. Moreover, it has paved the way to involve expanded criteria donors, e.g., after circulatory death, thus expanding the donor organ pool. Ongoing improvements in EVMP protocols, especially expanding the duration of preservation, paved the way for its broader application, in particular for reconditioning and modification of diseased organs and tumor and infection therapies and regenerative approaches. Moreover, implementing EVMP for in vivo-like preclinical studies improving disease modeling raises significant interest, while providing an ideal interface for bioengineering and genetic manipulation. These approaches can be applied not only in an allogeneic and xenogeneic transplant setting but also in an autologous setting, where patients can be on temporary organ support while the diseased organs are treated ex vivo, followed by reimplantation of the cured organ. This review provides a comprehensive overview of the differences and similarities in abdominal (kidney and liver) and thoracic (lung and heart) EVMP, focusing on the organ-specific components and preservation techniques, specifically on the composition of perfusion solutions and their supplements and perfusion temperatures and flow conditions. Novel treatment opportunities beyond organ transplantation and limitations of abdominal and thoracic EVMP are delineated to identify complementary interdisciplinary approaches for the application and development of this technique.
Collapse
Affiliation(s)
- Jasper Iske
- Department of Cardiothoracic Surgery, Deutsches Herzzentrum der Charité, Berlin, Germany
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Andreas Schroeter
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
- Division of Transplant Surgery, Department of Surgery, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, United States
| | - Samuel Knoedler
- Division of Plastic Surgery, Department of Surgery, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, United States
- Department of Plastic Surgery and Hand Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Timo Z. Nazari-Shafti
- Department of Cardiothoracic Surgery, Deutsches Herzzentrum der Charité, Berlin, Germany
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Leonard Wert
- Department of Cardiothoracic Surgery, Deutsches Herzzentrum der Charité, Berlin, Germany
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Maximilian J. Roesel
- Department of Cardiothoracic Surgery, Deutsches Herzzentrum der Charité, Berlin, Germany
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Division of Transplant Surgery, Department of Surgery, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, United States
| | - Felix Hennig
- Department of Cardiothoracic Surgery, Deutsches Herzzentrum der Charité, Berlin, Germany
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Adelheid Niehaus
- Department for Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Christian Kuehn
- Department for Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
- German Center for Lung Research (DZL), Hannover, Germany
- Lower Saxony Center for Biomedical Engineering, Implant Research and Development (NIFE), Hannover, Germany
| | - Fabio Ius
- Department for Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
- German Center for Lung Research (DZL), Hannover, Germany
| | - Volkmar Falk
- Department of Cardiothoracic Surgery, Deutsches Herzzentrum der Charité, Berlin, Germany
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site, Berlin, Germany
- Department of Health Science and Technology, Translational Cardiovascular Technology, ETH Zurich, Zürich, Switzerland
| | - Moritz Schmelzle
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Arjang Ruhparwar
- Department for Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
- German Center for Lung Research (DZL), Hannover, Germany
- Lower Saxony Center for Biomedical Engineering, Implant Research and Development (NIFE), Hannover, Germany
| | - Axel Haverich
- Department for Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
- German Center for Lung Research (DZL), Hannover, Germany
- Lower Saxony Center for Biomedical Engineering, Implant Research and Development (NIFE), Hannover, Germany
| | - Christoph Knosalla
- Department of Cardiothoracic Surgery, Deutsches Herzzentrum der Charité, Berlin, Germany
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site, Berlin, Germany
| | - Stefan G. Tullius
- Division of Transplant Surgery, Department of Surgery, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, United States
| | - Florian W. R. Vondran
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Bettina Wiegmann
- Department for Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
- German Center for Lung Research (DZL), Hannover, Germany
- Lower Saxony Center for Biomedical Engineering, Implant Research and Development (NIFE), Hannover, Germany
| |
Collapse
|
8
|
Gouin C, Vu Manh TP, Jouneau L, Bevilacqua C, De Wolf J, Glorion M, Hannouche L, Urien C, Estephan J, Roux A, Magnan A, Le Guen M, Da Costa B, Chevalier C, Descamps D, Schwartz-Cornil I, Dalod M, Sage E. Cell type- and time-dependent biological responses in ex vivo perfused lung grafts. Front Immunol 2023; 14:1142228. [PMID: 37465668 PMCID: PMC10351384 DOI: 10.3389/fimmu.2023.1142228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 06/13/2023] [Indexed: 07/20/2023] Open
Abstract
In response to the increasing demand for lung transplantation, ex vivo lung perfusion (EVLP) has extended the number of suitable donor lungs by rehabilitating marginal organs. However despite an expanding use in clinical practice, the responses of the different lung cell types to EVLP are not known. In order to advance our mechanistic understanding and establish a refine tool for improvement of EVLP, we conducted a pioneer study involving single cell RNA-seq on human lungs declined for transplantation. Functional enrichment analyses were performed upon integration of data sets generated at 4 h (clinical duration) and 10 h (prolonged duration) from two human lungs processed to EVLP. Pathways related to inflammation were predicted activated in epithelial and blood endothelial cells, in monocyte-derived macrophages and temporally at 4 h in alveolar macrophages. Pathways related to cytoskeleton signaling/organization were predicted reduced in most cell types mainly at 10 h. We identified a division of labor between cell types for the selected expression of cytokine and chemokine genes that varied according to time. Immune cells including CD4+ and CD8+ T cells, NK cells, mast cells and conventional dendritic cells displayed gene expression patterns indicating blunted activation, already at 4 h in several instances and further more at 10 h. Therefore despite inducing inflammatory responses, EVLP appears to dampen the activation of major lung immune cell types, what may be beneficial to the outcome of transplantation. Our results also support that therapeutics approaches aiming at reducing inflammation upon EVLP should target both the alveolar and vascular compartments.
Collapse
Affiliation(s)
- Carla Gouin
- Université Paris-Saclay, INRAE, UVSQ, VIM, 78350, Jouy-en-Josas, France
| | - Thien-Phong Vu Manh
- Aix-Marseille University, CNRS, INSERM, CIML, Centre d'Immunologie de Marseille-Luminy, Turing Center for Living Systems, Marseille, France
| | - Luc Jouneau
- Université Paris-Saclay, INRAE, UVSQ, VIM, 78350, Jouy-en-Josas, France
- Université Paris-Saclay, INRAE, UVSQ, BREED, 78350, Jouy-en-Josas, France
| | - Claudia Bevilacqua
- Université Paris-Saclay, INRAE, AgroParisTech, GABI, 78350, Jouy-en-Josas, France
| | - Julien De Wolf
- Université Paris-Saclay, INRAE, UVSQ, VIM, 78350, Jouy-en-Josas, France
- Department of Thoracic Surgery and Lung Transplantation, Foch Hospital, Suresnes, France
| | - Matthieu Glorion
- Université Paris-Saclay, INRAE, UVSQ, VIM, 78350, Jouy-en-Josas, France
- Department of Thoracic Surgery and Lung Transplantation, Foch Hospital, Suresnes, France
| | - Laurent Hannouche
- Université Paris-Saclay, INRAE, UVSQ, VIM, 78350, Jouy-en-Josas, France
- Aix-Marseille University, CNRS, INSERM, CIML, Centre d'Immunologie de Marseille-Luminy, Turing Center for Living Systems, Marseille, France
| | - Céline Urien
- Université Paris-Saclay, INRAE, UVSQ, VIM, 78350, Jouy-en-Josas, France
| | - Jérôme Estephan
- Université Paris-Saclay, INRAE, UVSQ, VIM, 78350, Jouy-en-Josas, France
| | - Antoine Roux
- Université Paris-Saclay, INRAE, UVSQ, VIM, 78350, Jouy-en-Josas, France
- Department of Pulmonology, Foch Hospital, Suresnes, France
| | - Antoine Magnan
- Université Paris-Saclay, INRAE, UVSQ, VIM, 78350, Jouy-en-Josas, France
- Department of Pulmonology, Foch Hospital, Suresnes, France
| | - Morgan Le Guen
- Université Paris-Saclay, INRAE, UVSQ, VIM, 78350, Jouy-en-Josas, France
- Department of Anesthesiology, Foch Hospital, Suresnes, France
| | - Bruno Da Costa
- Université Paris-Saclay, INRAE, UVSQ, VIM, 78350, Jouy-en-Josas, France
| | | | - Delphyne Descamps
- Université Paris-Saclay, INRAE, UVSQ, VIM, 78350, Jouy-en-Josas, France
| | | | - Marc Dalod
- Aix-Marseille University, CNRS, INSERM, CIML, Centre d'Immunologie de Marseille-Luminy, Turing Center for Living Systems, Marseille, France
| | - Edouard Sage
- Université Paris-Saclay, INRAE, UVSQ, VIM, 78350, Jouy-en-Josas, France
- Department of Thoracic Surgery and Lung Transplantation, Foch Hospital, Suresnes, France
| |
Collapse
|
9
|
Noda K, Furukawa M, Chan EG, Sanchez PG. Expanding Donor Options for Lung Transplant: Extended Criteria, Donation After Circulatory Death, ABO Incompatibility, and Evolution of Ex Vivo Lung Perfusion. Transplantation 2023; 107:1440-1451. [PMID: 36584375 DOI: 10.1097/tp.0000000000004480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Only using brain-dead donors with standard criteria, the existing donor shortage has never improved in lung transplantation. Currently, clinical efforts have sought the means to use cohorts of untapped donors, such as extended criteria donors, donation after circulatory death, and donors that are ABO blood group incompatible, and establish the evidence for their potential contribution to the lung transplant needs. Also, technical maturation for using those lungs may eliminate immediate concerns about the early posttransplant course, such as primary graft dysfunction or hyperacute rejection. In addition, recent clinical and preclinical advances in ex vivo lung perfusion techniques have allowed the safer use of lungs from high-risk donors and graft modification to match grafts to recipients and may improve posttransplant outcomes. This review summarizes recent trends and accomplishments and future applications for expanding the donor pool in lung transplantation.
Collapse
Affiliation(s)
- Kentaro Noda
- Division of Lung Transplant and Lung Failure, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | | | | | | |
Collapse
|
10
|
Taje R, Fabbi E, Sorge R, Elia S, Dauri M, Pompeo E. Adjuvant Transthoracic Negative-Pressure Ventilation in Nonintubated Thoracoscopic Surgery. J Clin Med 2023; 12:4234. [PMID: 37445268 DOI: 10.3390/jcm12134234] [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: 05/22/2023] [Revised: 06/15/2023] [Accepted: 06/20/2023] [Indexed: 07/15/2023] Open
Abstract
BACKGROUND To minimize the risks of barotrauma during nonintubated thoracoscopic-surgery under spontaneous ventilation, we investigated an adjuvant transthoracic negative-pressure ventilation (NPV) method in patients operated on due to severe emphysema or interstitial lung disease. METHODS In this retrospective study, NPV was employed for temporary low oxygen saturation and to achieve end-operative lung re-expansion during nonintubated lung volume reduction surgery (LVRS) for severe emphysema (30 patients, LVRS group) and in the nonintubated wedge resection of undetermined interstitial lung disease (30 patients, wedge-group). The results were compared following 1:1 propensity score matching with equivalent control groups undergoing the same procedures under spontaneous ventilation, with adjuvant positive-pressure ventilation (PPV) performed on-demand through the laryngeal mask. The primary outcomes were changes (preoperative-postoperative value) in the arterial oxygen tension/fraction of the inspired oxygen ratio (ΔPO2/FiO2;) and ΔPaCO2, and lung expansion completeness on a 24 h postoperative chest radiograph (CXR-score, 2: full or 1: incomplete). RESULTS Intergroup comparisons (NPV vs. PPV) showed no differences in demographic and pulmonary function. NPV could be accomplished in all instances with no conversion to general anesthesia with intubation. In the LVRS group, NPV improved ΔPO2/FiO2 (9.3 ± 16 vs. 25.3 ± 30.5, p = 0.027) and ΔPaCO2 (-2.2 ± 3.15 mmHg vs. 0.03 ± 0.18 mmHg, p = 0.008) with no difference in the CXR score, whereas in the wedge group, both ΔPO2/FiO2 (3.1 ± 8.2 vs. 9.9 ± 13.8, p = 0.035) and the CXR score (1.9 ± 0.3 vs. 1.6 ± 0.5, p = 0.04) were better in the NPV subgroup. There was no mortality and no intergroup difference in morbidity. CONCLUSIONS In this retrospective study, NITS with adjuvant transthoracic NPV resulted in better 24 h oxygenation measures than PPV in both the LVRS and wedge groups, and in better lung expansion according to the CXR score in the wedge group.
Collapse
Affiliation(s)
- Riccardo Taje
- Department of Thoracic Surgery, Policlinico Tor Vergata University, V.le Oxford 81, 00133 Rome, Italy
| | - Eleonora Fabbi
- Department of Anesthesia and Intensive Care, Policlinico Tor Vergata University, V.le Oxford 81, 00133 Rome, Italy
| | - Roberto Sorge
- Department of Biostatistics, Tor Vergata University of Rome, 00133 Rome, Italy
| | - Stefano Elia
- Department of Medicine and Health Sciences V. Tiberio, University of Molise, 86100 Campobasso, Italy
| | - Mario Dauri
- Department of Anesthesia and Intensive Care, Policlinico Tor Vergata University, V.le Oxford 81, 00133 Rome, Italy
| | - Eugenio Pompeo
- Department of Thoracic Surgery, Policlinico Tor Vergata University, V.le Oxford 81, 00133 Rome, Italy
| |
Collapse
|
11
|
Braithwaite SA, van Hooijdonk E, van der Kaaij NP. Ventilation during ex vivo lung perfusion, a review. Transplant Rev (Orlando) 2023; 37:100762. [PMID: 37099887 DOI: 10.1016/j.trre.2023.100762] [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: 11/21/2022] [Revised: 04/11/2023] [Accepted: 04/12/2023] [Indexed: 04/28/2023]
Abstract
Evidence suggests that ventilation during ex vivo lung perfusion (EVLP) with a 'one-size-fits-all' strategy has the potential to cause lung injury which may only become clinically relevant in marginal lung allografts. EVLP induced- or accelerated lung injury is a dynamic and cumulative process reflecting the interplay of a number of factors. Stress and strain in lung tissue caused by positive pressure ventilation may be exacerbated by the altered properties of lung tissue in an EVLP setting. Any pre-existing injury may alter the ability of lung allografts to accommodate set ventilation and perfusion techniques on EVLP leading to further injury. This review will examine the effects of ventilation on donor lungs in the setting of EVLP. A framework for developing a protective ventilation technique will be proposed.
Collapse
Affiliation(s)
- Sue A Braithwaite
- Department of Anesthesiology, University Medical Center Utrecht, Q04.2.317, Postbus 85500, Utrecht 3508, GA, the Netherlands.
| | - Elise van Hooijdonk
- Department of Cardiothoracic Surgery, University Medical Center Utrecht, Room E03.511, Heidelberglaan 100, Utrecht 3584, CX, the Netherlands
| | - Niels P van der Kaaij
- Department of Cardiothoracic Surgery, University Medical Center Utrecht, Room E03.511, Heidelberglaan 100, Utrecht 3584, CX, the Netherlands
| |
Collapse
|
12
|
Diagnostic and Therapeutic Implications of Ex Vivo Lung Perfusion in Lung Transplantation: Potential Benefits and Inherent Limitations. Transplantation 2023; 107:105-116. [PMID: 36508647 DOI: 10.1097/tp.0000000000004414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Ex vivo lung perfusion (EVLP), a technique in which isolated lungs are continually ventilated and perfused at normothermic temperature, is emerging as a promising platform to optimize donor lung quality and increase the lung graft pool. Over the past few decades, the EVLP technique has become recognized as a significant achievement and gained much attention in the field of lung transplantation. EVLP has been demonstrated to be an effective platform for various targeted therapies to optimize donor lung function before transplantation. Additionally, some physical parameters during EVLP and biological markers in the EVLP perfusate can be used to evaluate graft function before transplantation and predict posttransplant outcomes. However, despite its advantages, the clinical practice of EVLP continuously encounters multiple challenges associated with both intrinsic and extrinsic limitations. It is of utmost importance to address the advantages and disadvantages of EVLP for its broader clinical usage. Here, the pros and cons of EVLP are comprehensively discussed, with a focus on its benefits and potential approaches for overcoming the remaining limitations. Directions for future research to fully explore the clinical potential of EVLP in lung transplantation are also discussed.
Collapse
|
13
|
Yu J, Zhang N, Zhang Z, Li Y, Gao J, Chen C, Wen Z. Exploring predisposing factors and pathogenesis contributing to injuries of donor lungs. Expert Rev Respir Med 2022; 16:1191-1203. [PMID: 36480922 DOI: 10.1080/17476348.2022.2157264] [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: 12/13/2022]
Abstract
INTRODUCTION Lung transplantation (LTx) remains the only therapeutic strategy for patients with incurable lung diseases. However, its use has been severely limited by the narrow donor pool and potential concerns of inferior quality of donor lungs, which are more susceptible to external influence than other transplant organs. Multiple insults, including various causes of death and a series of perimortem events, may act together on donor lungs and eventually culminate in primary graft dysfunction (PGD) after transplantation as well as other poor short-term outcomes. AREAS COVERED This review focuses on the predisposing factors contributing to injuries to the donor lungs, specifically focusing on the pathogenesis of these injuries and their impact on post-transplant outcomes. Additionally, various maneuvers to mitigate donor lung injuries have been proposed. EXPERT OPINION The selection criteria for eligible donors vary and may be poor discriminators of lung injury. Not all transplanted lungs are in ideal condition. With the rapidly increasing waiting list for LTx, the trend of using marginal donors has become more apparent, underscoring the need to gain a deeper understanding of donor lung injuries and discover more donor resources.
Collapse
Affiliation(s)
- Jing Yu
- Department of Anesthesiology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, 200433, Shanghai, Zhejiang, China
| | - Nan Zhang
- Department of Anesthesiology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, 200433, Shanghai, Zhejiang, China
| | - Zhiyuan Zhang
- Department of Anesthesiology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, 200433, Shanghai, Zhejiang, China
| | - Yuping Li
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, 200433, Shanghai, Zhejiang, China
| | - Jiameng Gao
- Department of Anesthesiology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, 200433, Shanghai, Zhejiang, China
| | - Chang Chen
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, 200433, Shanghai, Zhejiang, China
| | - Zongmei Wen
- Department of Anesthesiology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, 200433, Shanghai, Zhejiang, China
| |
Collapse
|
14
|
Dong S, Wang L, Chitano P, Coxson HO, Vasilescu DM, Paré PD, Seow CY. Lung resistance and elastance are different in ex vivo sheep lungs ventilated by positive and negative pressures. Am J Physiol Lung Cell Mol Physiol 2022; 322:L673-L682. [PMID: 35272489 DOI: 10.1152/ajplung.00464.2021] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Lung resistance (RL) and elastance (EL) can be measured during positive or negative pressure ventilation. Whether the different modes of ventilation produce different RL and EL is still being debated. Although negative pressure ventilation (NPV) is more physiological, positive pressure ventilation (PPV) is more commonly used for treating respiratory failure. In the present study we measured lung volume, airway diameter and airway volume, as well as RL and EL with PPV and NPV in explanted sheep lungs. We found that lung volume under a static pressure, either positive or negative, was not different. However, RL and EL were significantly higher in NPV at high inflation pressures. Interestingly, diameters of smaller airways (diameters < 3.5 mm) and total airway volume were significantly greater at high negative inflation pressures compared with those at high positive inflation pressures. This suggests that NPV is more effective in distending the peripheral airways, likely due to the fact that negative pressure is applied through the pleural membrane and reaches the central airways via the peripheral airways, whereas positive pressure is applied in the opposite direction. More distension of lung periphery could explain why RL is higher in NPV (vs. PPV), because the peripheral parenchyma is a major source of tissue resistance, which is a part of the RL that increases with pressure. This explanation is consistent with the finding that during high frequency ventilation (>1 Hz, where RL reflects airway resistance more than tissue resistance), the difference in RL between NPV and PPV disappeared.
Collapse
Affiliation(s)
- Shoujin Dong
- The UBC Centre for Heart Lung Innovation, St. Paul's Hospital, Vancouver, BC, Canada.,Respiratory Department, Chengdu First People's Hospital, Chengdu, China
| | - Lu Wang
- The UBC Centre for Heart Lung Innovation, St. Paul's Hospital, Vancouver, BC, Canada
| | - Pasquale Chitano
- The UBC Centre for Heart Lung Innovation, St. Paul's Hospital, Vancouver, BC, Canada
| | - Harvey O Coxson
- The UBC Centre for Heart Lung Innovation, St. Paul's Hospital, Vancouver, BC, Canada
| | | | - Peter D Paré
- The UBC Centre for Heart Lung Innovation, St. Paul's Hospital, Vancouver, BC, Canada.,Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Chun Y Seow
- The UBC Centre for Heart Lung Innovation, St. Paul's Hospital, Vancouver, BC, Canada.,Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
| |
Collapse
|
15
|
Hatami S, Hefler J, Freed DH. Inflammation and Oxidative Stress in the Context of Extracorporeal Cardiac and Pulmonary Support. Front Immunol 2022; 13:831930. [PMID: 35309362 PMCID: PMC8931031 DOI: 10.3389/fimmu.2022.831930] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 02/08/2022] [Indexed: 12/12/2022] Open
Abstract
Extracorporeal circulation (ECC) systems, including cardiopulmonary bypass, and extracorporeal membrane oxygenation have been an irreplaceable part of the cardiothoracic surgeries, and treatment of critically ill patients with respiratory and/or cardiac failure for more than half a century. During the recent decades, the concept of extracorporeal circulation has been extended to isolated machine perfusion of the donor organ including thoracic organs (ex-situ organ perfusion, ESOP) as a method for dynamic, semi-physiologic preservation, and potential improvement of the donor organs. The extracorporeal life support systems (ECLS) have been lifesaving and facilitating complex cardiothoracic surgeries, and the ESOP technology has the potential to increase the number of the transplantable donor organs, and to improve the outcomes of transplantation. However, these artificial circulation systems in general have been associated with activation of the inflammatory and oxidative stress responses in patients and/or in the exposed tissues and organs. The activation of these responses can negatively affect patient outcomes in ECLS, and may as well jeopardize the reliability of the organ viability assessment, and the outcomes of thoracic organ preservation and transplantation in ESOP. Both ECLS and ESOP consist of artificial circuit materials and components, which play a key role in the induction of these responses. However, while ECLS can lead to systemic inflammatory and oxidative stress responses negatively affecting various organs/systems of the body, in ESOP, the absence of the organs that play an important role in oxidant scavenging/antioxidative replenishment of the body, such as liver, may make the perfused organ more susceptible to inflammation and oxidative stress during extracorporeal circulation. In the present manuscript, we will review the activation of the inflammatory and oxidative stress responses during ECLP and ESOP, mechanisms involved, clinical implications, and the interventions for attenuating these responses in ECC.
Collapse
Affiliation(s)
- Sanaz Hatami
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
- Canadian National Transplant Research Program, Edmonton, AB, Canada
| | - Joshua Hefler
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Darren H. Freed
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
- Canadian National Transplant Research Program, Edmonton, AB, Canada
- Department of Biomedical Engineering, University of Alberta, Edmonton, AB, Canada
- Alberta Transplant Institute, Edmonton, AB, Canada
- Department of Physiology, University of Alberta, Edmonton, AB, Canada
- *Correspondence: Darren H. Freed,
| |
Collapse
|
16
|
Raredon MSB, Engler AJ, Yuan Y, Greaney AM, Niklason LE. Microvascular fluid flow in ex vivo and engineered lungs. J Appl Physiol (1985) 2021; 131:1444-1459. [PMID: 34554016 PMCID: PMC8616606 DOI: 10.1152/japplphysiol.00286.2020] [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: 04/15/2020] [Revised: 08/23/2021] [Accepted: 09/15/2021] [Indexed: 11/22/2022] Open
Abstract
In recent years, it has become common to experiment with ex vivo perfused lungs for organ transplantation and to attempt regenerative pulmonary engineering using decellularized lung matrices. However, our understanding of the physiology of ex vivo organ perfusion is imperfect; it is not currently well understood how decreasing microvascular barrier affects the perfusion of pulmonary parenchyma. In addition, protocols for lung perfusion and organ culture fluid-handling are far from standardized, with widespread variation on both basic methods and on ideally controlled parameters. To address both of these deficits, a robust, noninvasive, and mechanistic model is needed which is able to predict microvascular resistance and permeability in perfused lungs while providing insight into capillary recruitment. Although validated mathematical models exist for fluid flow in native pulmonary tissue, previous models generally assume minimal intravascular leak from artery to vein and do not assess capillary bed recruitment. Such models are difficult to apply to both ex vivo lung perfusions, in which edema can develop over time and microvessels can become blocked, and to decellularized ex vivo organomimetic cultures, in which microvascular recruitment is variable and arterially perfused fluid enters into the alveolar space. Here, we develop a mathematical model of pulmonary microvascular fluid flow which is applicable in both instances, and we apply our model to data from native, decellularized, and regenerating lungs under ex vivo perfusion. The results provide substantial insight into microvascular pressure-flow mechanics, while producing previously unknown output values for tissue-specific capillary-alveolar hydraulic conductivity, microvascular recruitment, and total organ barrier resistance.NEW & NOTEWORTHY We present a validated model of pulmonary microvascular fluid mechanics and apply this model to study the effects of increased capillary permeability in decellularized and regenerating lungs. We find that decellularization alters microvascular steady-state mechanics and that re-endothelialization partially rescues key biologic parameters. The described model provides powerful insight into intraorgan microvascular dynamics and may be used to guide regenerative engineering experiments. We include all data and derivations necessary to replicate this work.
Collapse
Affiliation(s)
- Micha Sam Brickman Raredon
- Department of Biomedical Engineering, Yale University, New Haven, Connecticut
- Vascular Biology and Therapeutics, Yale University, New Haven, Connecticut
- Medical Scientist Training Program, Yale University, New Haven, Connecticut
| | - Alexander J Engler
- Department of Biomedical Engineering, Yale University, New Haven, Connecticut
- Vascular Biology and Therapeutics, Yale University, New Haven, Connecticut
| | - Yifan Yuan
- Vascular Biology and Therapeutics, Yale University, New Haven, Connecticut
- Department of Anesthesiology, Yale University, New Haven, Connecticut
| | - Allison M Greaney
- Department of Biomedical Engineering, Yale University, New Haven, Connecticut
- Vascular Biology and Therapeutics, Yale University, New Haven, Connecticut
| | - Laura E Niklason
- Department of Biomedical Engineering, Yale University, New Haven, Connecticut
- Vascular Biology and Therapeutics, Yale University, New Haven, Connecticut
- Department of Anesthesiology, Yale University, New Haven, Connecticut
| |
Collapse
|
17
|
Ex Vivo Lung Perfusion: A Platform for Donor Lung Assessment, Treatment and Recovery. TRANSPLANTOLOGY 2021. [DOI: 10.3390/transplantology2040037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Lung transplantation offers a lifesaving therapy for patients with end-stage lung disease but its availability is presently limited by low organ utilization rates with donor lungs frequently excluded due to unsuitability at assessment. When transplantation does occur, recipients are then vulnerable to primary graft dysfunction (PGD), multitudinous short-term complications, and chronic lung allograft dysfunction. The decision whether to use donor lungs is made rapidly and subjectively with limited information and means many lungs that might have been suitable are lost to the transplant pathway. Compared to static cold storage (SCS), ex vivo lung perfusion (EVLP) offers clinicians unrivalled opportunity for rigorous objective assessment of donor lungs in conditions replicating normal physiology, thus allowing for better informed decision-making in suitability assessments. EVLP additionally offers a platform for the delivery of intravascular or intrabronchial therapies to metabolically active tissue aiming to treat existing lung injuries. In the future, EVLP may be employed to provide a pre-transplant environment optimized to prevent negative outcomes such as primary graft dysfunction (PGD) or rejection post-transplant.
Collapse
|
18
|
Challenging the Ex Vivo Lung Perfusion Procedure With Continuous Dialysis in a Pig Model. Transplantation 2021; 106:979-987. [PMID: 34468431 DOI: 10.1097/tp.0000000000003931] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Normothermic ex vivo lung perfusion (EVLP) increases the pool of donor lungs by requalifying marginal lungs refused for transplantation through the recovery of macroscopic and functional properties. However the cell response and metabolism occurring during EVLP generate a nonphysiological accumulation of electrolytes, metabolites, cytokines and other cellular byproducts which may have deleterious effects both at the organ and cell levels, with impact on transplantation outcomes. METHODS We analyzed the physiological, metabolic and genome-wide response of lungs undergoing a 6-hour EVLP procedure in a pig model in 4 experimental conditions: without perfusate modification, with partial replacement of fluid, and with adult or pediatric dialysis filters. RESULTS Adult and pediatric dialysis stabilized the electrolytic and metabolic profiles while maintaining acid-base and gas exchanges. Pediatric dialysis increased the level of IL-10 and IL-6 in the perfusate. Despite leading to modification of the perfusate composition, the 4 EVLP conditions did not affect the gene expression profiles which were associated in all cases with increased cell survival, cell proliferation, inflammatory response and cell movement, and with inhibition of bleeding. CONCLUSIONS Management of EVLP perfusate by periodic replacement and continuous dialysis has no significant effect on the lung function nor on the gene expression profiles ex vivo. These results suggest that the accumulation of dialysable cell products does not significantly alter the lung cell response during EVLP, a finding that may have impact on EVLP management in the clinic.
Collapse
|
19
|
Lung Transplantation, Pulmonary Endothelial Inflammation, and Ex-Situ Lung Perfusion: A Review. Cells 2021; 10:cells10061417. [PMID: 34200413 PMCID: PMC8229792 DOI: 10.3390/cells10061417] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 06/01/2021] [Accepted: 06/02/2021] [Indexed: 12/31/2022] Open
Abstract
Lung transplantation (LTx) is the gold standard treatment for end-stage lung disease; however, waitlist mortality remains high due to a shortage of suitable donor lungs. Organ quality can be compromised by lung ischemic reperfusion injury (LIRI). LIRI causes pulmonary endothelial inflammation and may lead to primary graft dysfunction (PGD). PGD is a significant cause of morbidity and mortality post-LTx. Research into preservation strategies that decrease the risk of LIRI and PGD is needed, and ex-situ lung perfusion (ESLP) is the foremost technological advancement in this field. This review addresses three major topics in the field of LTx: first, we review the clinical manifestation of LIRI post-LTx; second, we discuss the pathophysiology of LIRI that leads to pulmonary endothelial inflammation and PGD; and third, we present the role of ESLP as a therapeutic vehicle to mitigate this physiologic insult, increase the rates of donor organ utilization, and improve patient outcomes.
Collapse
|
20
|
Hasenauer A, Bédat B, Parapanov R, Lugrin J, Debonneville A, Abdelnour-Berchtold E, Gonzalez M, Perentes JY, Piquilloud L, Szabo C, Krueger T, Liaudet L. Effects of cold or warm ischemia and ex-vivo lung perfusion on the release of damage associated molecular patterns and inflammatory cytokines in experimental lung transplantation. J Heart Lung Transplant 2021; 40:905-916. [PMID: 34193360 DOI: 10.1016/j.healun.2021.05.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 05/14/2021] [Accepted: 05/24/2021] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Lung transplantation (LTx) is associated with sterile inflammation, possibly related to the release of damage associated molecular patterns (DAMPs) by injured allograft cells. We have measured cellular damage and the release of DAMPs and cytokines in an experimental model of LTx after cold or warm ischemia and examined the effect of pretreatment with ex-vivo lung perfusion (EVLP). METHODS Rat lungs were exposed to cold ischemia alone (CI group) or with 3h EVLP (CI-E group), warm ischemia alone (WI group) or with 3 hour EVLP (WI-E group), followed by LTx (2 hour). Bronchoalveolar lavage (BAL) was performed before (right lung) or after (left lung) LTx to measure LDH (marker of cellular injury), the DAMPs HMGB1, IL-33, HSP-70 and S100A8, and the cytokines IL-1β, IL-6, TNFα, and CXCL-1. Graft oxygenation capacity and static compliance after LTx were also determined. RESULTS Compared to CI, WI displayed cellular damage and inflammation without any increase of DAMPs after ischemia alone, but with a significant increase of HMGB1 and functional impairment after LTx. EVLP promoted significant inflammation in both cold (CI-E) and warm (WI-E) groups, which was not associated with cell death or DAMP release at the end of EVLP, but with the release of S100A8 after LTx. EVLP reduced graft damage and dysfunction in warm ischemic, but not cold ischemic, lungs. CONCLUSIONS The pathomechanisms of sterile lung inflammation during LTx are significantly dependent on the conditions. The release of HMGB1 (in the absence of EVLP) and S100A8 (following EVLP) may be important factors in the pathogenesis of LTx.
Collapse
Affiliation(s)
- Arpad Hasenauer
- Service of Thoracic Surgery, Lausanne University Hospital, Lausanne, Switzerland
| | - Benoît Bédat
- Service of Thoracic Surgery, Lausanne University Hospital, Lausanne, Switzerland
| | - Roumen Parapanov
- Service of Thoracic Surgery, Lausanne University Hospital, Lausanne, Switzerland; Service of Thoracic Surgery and Department of Adult Intensive Care Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | - Jérôme Lugrin
- Service of Thoracic Surgery and Department of Adult Intensive Care Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | - Anne Debonneville
- Service of Thoracic Surgery, Lausanne University Hospital, Lausanne, Switzerland
| | | | - Michel Gonzalez
- Service of Thoracic Surgery, Lausanne University Hospital, Lausanne, Switzerland
| | - Jean Y Perentes
- Service of Thoracic Surgery, Lausanne University Hospital, Lausanne, Switzerland
| | - Lise Piquilloud
- Department of Adult Intensive Care Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | - Csaba Szabo
- Department of Pharmacology, Faculty of Science and Medicine, University of Fribourg, Fribourg, Switzerland
| | - Thorsten Krueger
- Service of Thoracic Surgery, Lausanne University Hospital, Lausanne, Switzerland
| | - Lucas Liaudet
- Department of Adult Intensive Care Medicine, Lausanne University Hospital, Lausanne, Switzerland.
| |
Collapse
|
21
|
Lyu Q, Wen Y, Zhang X, Addinsall AB, Cacciani N, Larsson L. Multi-omics reveals age-related differences in the diaphragm response to mechanical ventilation: a pilot study. Skelet Muscle 2021; 11:11. [PMID: 33941271 PMCID: PMC8089133 DOI: 10.1186/s13395-021-00267-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 04/13/2021] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Old age is associated with a significantly increased mortality in COVID-19 patients exposed to long-term controlled mechanical ventilation (CMV) and suggested to be due to the hyperinflammatory response associated with the viral infection. However, our understanding of age-related differences in the response to CMV in the absence of a viral infection remains insufficient. METHODS Young (7-8 months) and old (28-32 months) F344 BN hybrid rats were exposed to the ICU condition for 5 days, i.e., complete immobilization, mechanical ventilation, and extensive monitoring. Transcriptomic (RNA-Seq) and proteomics (Proximity Extension Assay) analyses of the diaphragm and proteomics analysis of plasma were conducted to investigate the molecular differences between young and old rats exposed to the ICU condition. RESULTS According to multi-omics analyses, significant differences were observed in the diaphragm between young and old rats in response to 5 days CMV and immobilization. In young rats, metabolic pathways were primarily downregulated in response to immobilization (post-synaptic blockade of neuromuscular transmission). In old rats, on the other hand, dramatic immune and inflammatory responses were observed, i.e., an upregulation of specific related pathways such as "IL-17 signaling pathway", along with a higher level of inflammatory factors and cytokine/chemokine in plasma. CONCLUSIONS The dramatically increased mortality in old ICU patients with COVID-19-associated hyperinflammation and cytokine storm need not only reflect the viral infection but may also be associated with the ventilator induced diaphragm dysfunction (VIDD) and hyperinflammatory responses induced by long-term CMV per se. Although mechanical ventilation is a life-saving intervention in COVID-19 ICU patients, CMV should be cautiously used especially in old age and other means of respiratory support may be considered, such as negative pressure ventilation.
Collapse
Affiliation(s)
- Qiong Lyu
- Department of Physiology and Pharmacology, Karolinska Institutet, Bioclinicum, J8:30, SE-171 77, Stockholm, Sweden
- Department of General Practice, The First Affiliated Hospital of Chongqing Medical University, 400016, Chongqing, China
| | - Ya Wen
- Department of Physiology and Pharmacology, Karolinska Institutet, Bioclinicum, J8:30, SE-171 77, Stockholm, Sweden
| | - Xiang Zhang
- Department of Physiology and Pharmacology, Karolinska Institutet, Bioclinicum, J8:30, SE-171 77, Stockholm, Sweden
| | - Alex B Addinsall
- Department of Physiology and Pharmacology, Karolinska Institutet, Bioclinicum, J8:30, SE-171 77, Stockholm, Sweden
| | - Nicola Cacciani
- Department of Physiology and Pharmacology, Karolinska Institutet, Bioclinicum, J8:30, SE-171 77, Stockholm, Sweden
- Department of Clinical Neuroscience, Karolinska Institutet, Bioclinicum, J8:30, SE-171 77, Stockholm, Sweden
| | - Lars Larsson
- Department of Physiology and Pharmacology, Karolinska Institutet, Bioclinicum, J8:30, SE-171 77, Stockholm, Sweden.
- Department of Clinical Neuroscience, Karolinska Institutet, Bioclinicum, J8:30, SE-171 77, Stockholm, Sweden.
| |
Collapse
|
22
|
Prasad NK, Pasrija C, Talaie T, Krupnick AS, Zhao Y, Lau CL. Ex Vivo Lung Perfusion: Current Achievements and Future Directions. Transplantation 2021; 105:979-985. [PMID: 33044428 PMCID: PMC8792510 DOI: 10.1097/tp.0000000000003483] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
There is a severe shortage in the availability of donor organs for lung transplantation. Novel strategies are needed to optimize usage of available organs to address the growing global needs. Ex vivo lung perfusion has emerged as a powerful tool for the assessment, rehabilitation, and optimization of donor lungs before transplantation. In this review, we discuss the history of ex vivo lung perfusion, current evidence on its use for standard and extended criteria donors, and consider the exciting future opportunities that this technology provides for lung transplantation.
Collapse
Affiliation(s)
- Nikhil K. Prasad
- Department of Surgery, University of Maryland School of Medicine
| | - Chetan Pasrija
- Department of Surgery, University of Maryland School of Medicine
| | - Tara Talaie
- Department of Surgery, University of Maryland School of Medicine
| | | | - Yunge Zhao
- Department of Surgery, University of Maryland School of Medicine
| | - Christine L. Lau
- Department of Surgery, University of Maryland School of Medicine
| |
Collapse
|
23
|
Bobba CM, Nelson K, Dumond C, Eren E, Black SM, Englert JA, Ghadiali SN, Whitson BA. A Novel Negative Pressure-Flow Waveform to Ventilate Lungs for Normothermic Ex Vivo Lung Perfusion. ASAIO J 2021; 67:96-103. [PMID: 32404613 PMCID: PMC9218878 DOI: 10.1097/mat.0000000000001168] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Ex vivo lung perfusion (EVLP) is increasingly used to treat and assess lungs before transplant. Minimizing ventilator induced lung injury (VILI) during EVLP is an important clinical need, and negative pressure ventilation (NPV) may reduce VILI compared with conventional positive pressure ventilation (PPV). However, it is not clear if NPV is intrinsically lung protective or if differences in respiratory pressure-flow waveforms are responsible for reduced VILI during NPV. In this study, we quantified lung injury using novel pressure-flow waveforms during normothermic EVLP. Rat lungs were ventilated-perfused ex vivo for 2 hours using tidal volume, positive end-expiratory pressure (PEEP), and respiratory rate matched PPV or NPV protocols. Airway pressures and flow rates were measured in real time and lungs were assessed for changes in compliance, pulmonary vascular resistance, oxygenation, edema, and cytokine secretion. Negative pressure ventilation lungs demonstrated reduced proinflammatory cytokine secretion, reduced weight gain, and reduced pulmonary vascular resistance (p < 0.05). Compliance was higher in NPV lungs (p < 0.05), and there was no difference in oxygenation between the two groups. Respiratory pressure-flow waveforms during NPV and PPV were significantly different (p < 0.05), especially during the inspiratory phase, where the NPV group exhibited rapid time-dependent changes in pressure and airflow whereas the PPV group exhibited slower changes in airflow/pressures. Lungs ventilated with PPV also had a greater transpulmonary pressure (p < 0.05). Greater improvement in lung function during NPV EVLP may be caused by favorable airflow patterns and/or pressure dynamics, which may better mimic human respiratory patterns.
Collapse
Affiliation(s)
- Christopher M Bobba
- From the Division of Pulmonary, Critical Care, and Sleep Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
- Dorothy M. Davis Heart and Lung Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Kevin Nelson
- From the Division of Pulmonary, Critical Care, and Sleep Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
- Dorothy M. Davis Heart and Lung Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Curtis Dumond
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio; and
- Department of Surgery, Collaboration for Organ Perfusion, Protection, Engineering and Regeneration (COPPER) Laboratory, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Emre Eren
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio; and
- Department of Surgery, Collaboration for Organ Perfusion, Protection, Engineering and Regeneration (COPPER) Laboratory, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Sylvester M Black
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio; and
- Department of Surgery, Collaboration for Organ Perfusion, Protection, Engineering and Regeneration (COPPER) Laboratory, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Joshua A Englert
- From the Division of Pulmonary, Critical Care, and Sleep Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
- Dorothy M. Davis Heart and Lung Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Samir N Ghadiali
- From the Division of Pulmonary, Critical Care, and Sleep Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
- Dorothy M. Davis Heart and Lung Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Bryan A Whitson
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio; and
- Department of Surgery, Collaboration for Organ Perfusion, Protection, Engineering and Regeneration (COPPER) Laboratory, The Ohio State University Wexner Medical Center, Columbus, Ohio
| |
Collapse
|
24
|
Buchko MT, Boroumand N, Cheng JC, Hirji A, Halloran K, Freed DH, Nagendran J. Clinical transplantation using negative pressure ventilation ex situ lung perfusion with extended criteria donor lungs. Nat Commun 2020; 11:5765. [PMID: 33188221 PMCID: PMC7666579 DOI: 10.1038/s41467-020-19581-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Accepted: 10/22/2020] [Indexed: 01/09/2023] Open
Abstract
Lung transplantation remains the best treatment option for end-stage lung disease; however, is limited by a shortage of donor grafts. Ex situ lung perfusion, also known as ex vivo lung perfusion, has been shown to allow for the safe evaluation and reconditioning of extended criteria donor lungs, increasing donor utilization. Negative pressure ventilation ex situ lung perfusion has been shown, preclinically, to result in less ventilator-induced lung injury than positive pressure ventilation. Here we demonstrate that, in a single-arm interventional study (ClinicalTrials.gov number NCT03293043) of 12 extended criteria donor human lungs, negative pressure ventilation ex situ lung perfusion allows for preservation and evaluation of donor lungs with all grafts and patients surviving to 30 days and recovered to discharge from hospital. This trial also demonstrates that ex situ lung perfusion is safe and feasible with no patients demonstrating primary graft dysfunction scores grade 3 at 72 h or requiring post-operative extracorporeal membrane oxygenation.
Collapse
Affiliation(s)
- Max T Buchko
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada
- Mazankowski Alberta Heart Institute, Edmonton, AB, Canada
| | - Nasim Boroumand
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada
- Mazankowski Alberta Heart Institute, Edmonton, AB, Canada
| | - Jeffrey C Cheng
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada
- Mazankowski Alberta Heart Institute, Edmonton, AB, Canada
| | - Alim Hirji
- Division of Pulmonary Medicine, Department of Medicine, University of Alberta, Edmonton, AB, Canada
- Alberta Transplant Institute, Edmonton, AB, Canada
- Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
| | - Kieran Halloran
- Division of Pulmonary Medicine, Department of Medicine, University of Alberta, Edmonton, AB, Canada
- Alberta Transplant Institute, Edmonton, AB, Canada
- Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
| | - Darren H Freed
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada
- Mazankowski Alberta Heart Institute, Edmonton, AB, Canada
- Alberta Transplant Institute, Edmonton, AB, Canada
- Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
| | - Jayan Nagendran
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada.
- Mazankowski Alberta Heart Institute, Edmonton, AB, Canada.
- Alberta Transplant Institute, Edmonton, AB, Canada.
- Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada.
| |
Collapse
|
25
|
Jin Z, Hana Z, Alam A, Rajalingam S, Abayalingam M, Wang Z, Ma D. Review 1: Lung transplant-from donor selection to graft preparation. J Anesth 2020; 34:561-574. [PMID: 32476043 PMCID: PMC7261511 DOI: 10.1007/s00540-020-02800-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 05/17/2020] [Indexed: 12/16/2022]
Abstract
For various end-stage lung diseases, lung transplantation remains one of the only viable treatment options. While the demand for lung transplantation has steadily risen over the last few decades, the availability of donor grafts is limited, which have resulted in progressively longer waiting lists. In the early years of lung transplantation, only the 'ideal' donor grafts are considered for transplantation. Due to the donor shortages, there is ongoing discussion about the safe use of 'suboptimal' grafts to expand the donor pool. In this review, we will discuss the considerations around donor selection, donor-recipient matching, graft preparation and graft optimisation.
Collapse
Affiliation(s)
- Zhaosheng Jin
- Division of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Chelsea and Westminster Hospital, London, SW10 9NH, UK
| | - Zac Hana
- Division of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Chelsea and Westminster Hospital, London, SW10 9NH, UK
| | - Azeem Alam
- Division of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Chelsea and Westminster Hospital, London, SW10 9NH, UK
| | - Shamala Rajalingam
- Division of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Chelsea and Westminster Hospital, London, SW10 9NH, UK
| | - Mayavan Abayalingam
- Division of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Chelsea and Westminster Hospital, London, SW10 9NH, UK
| | - Zhiping Wang
- Department of Anesthesiology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China
| | - Daqing Ma
- Division of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Chelsea and Westminster Hospital, London, SW10 9NH, UK.
| |
Collapse
|
26
|
Buchko MT, Himmat S, Aboelnazar NS, Stewart CJ, Hatami S, Dromparis P, Adam B, Freed DH, Nagendran J. A Low-Cost Perfusate Alternative for Ex Vivo Lung Perfusion. Transplant Proc 2020; 52:2941-2946. [PMID: 32624230 DOI: 10.1016/j.transproceed.2020.05.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 05/12/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Normothermic ex vivo lung perfusion (EVLP) has been used successfully to evaluate and recondition marginal donor lungs; however, multiple barriers continue to prevent its widespread adoption. We sought to develop a common hospital ingredient-derived perfusate (CHIP) with equivalent functional and inflammatory characteristics to a standard Krebs-Henseleit buffer with 8% serum albumin-derived perfusate (KHB-Alb) to improve access and reduce costs of ex vivo organ perfusion. METHODS Sixteen porcine lungs were perfused using negative pressure ventilation (NPV) EVLP for 12 hours in a normothermic state and were allocated equally to 2 groups: KHB-Alb vs CHIP. Physiological parameters, cytokine profiles, and edema formation were compared between treatment groups. RESULTS Perfused lungs in both groups demonstrated equivalent oxygenation (partial pressure of arterial oxygen/fraction of inspired oxygen ratio >350 mm Hg) and physiological parameters. There was equivalent generation of tumor necrosis factor-α and IL-6, irrespective of perfusate solution used, when comparing CHIP vs KHB-Alb. Pig lungs developed equivalent edema formation between groups (CHIP: 15.8 ± 4.8%, KHB-Alb 19.5 ± 4.4%, P > .05). CONCLUSION A perfusate derived of common hospital ingredients provides equivalent results to a standard Krebs-Henseleit buffer with 8% serum albumin-based perfusate in NPV-EVLP.
Collapse
Affiliation(s)
- Max T Buchko
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada; Mazankowski Alberta Heart Institute, Edmonton, AB, Canada
| | - Sayed Himmat
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Nader S Aboelnazar
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Catherine J Stewart
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Sanaz Hatami
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Peter Dromparis
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, AB, Canada
| | - Benjamin Adam
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, AB, Canada
| | - Darren H Freed
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada; Mazankowski Alberta Heart Institute, Edmonton, AB, Canada; Alberta Transplant Institute, Edmonton, AB, Canada; Canadian National Transplant Research Program, Edmonton, AB, Canada
| | - Jayan Nagendran
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada; Mazankowski Alberta Heart Institute, Edmonton, AB, Canada; Alberta Transplant Institute, Edmonton, AB, Canada; Canadian National Transplant Research Program, Edmonton, AB, Canada.
| |
Collapse
|
27
|
Abstract
The pig is an omnivorous, monogastric species with many advantages to serve as an animal model for human diseases. There are very high similarities to humans in anatomy and functions of the immune system, e g., the presence of tonsils, which are absent in rodents. The porcine immune system resembles man for more than 80% of analyzed parameters in contrast to the mouse with only about 10%. The pig can easily be bred, and there are less emotional problems to use them as experimental animals than dogs or monkeys. Indwelling cannulas in a vein or lymphatic vessel enable repetitive stress-free sampling. Meanwhile, there are many markers available to characterize immune cells. Lymphoid organs, their function, and their role in lymphocyte kinetics (proliferation and migration) are reviewed. For long-term experiments, minipigs (e.g., Göttingen minipig) are available. Pigs can be kept under gnotobiotic (germfree) conditions for some time after birth to study the effects of microbiota. The effects of probiotics can be tested on the gut immune system. The lung has been used for extracorporeal preservation and immune engineering. After genetic modifications are established, the pig is the best animal model for future xenotransplantation to reduce the problem of organ shortage for organ transplantation. Autotransplantation of particles of lymphnodes regenerates in the subcutaneous tissue. This is a model to treat secondary lymphedema patients. There are pigs with cystic fibrosis and severe combined immune deficiency available.
Collapse
Affiliation(s)
- Reinhard Pabst
- Institute of Immunomorphology, Centre of Anatomy, Medical School Hannover, Hanover, Germany.
| |
Collapse
|
28
|
Abstract
Although lung transplant remains the only option for patients suffering from end-stage lung failure, donor supply is insufficient to meet demand. Static cold preservation is the most common method to preserve lungs in transport to the recipient; however, this method does not improve lung quality and only allows for 8 h of storage. This results in lungs which become available for donation but cannot be used due to failure to meet physiologic criteria or an inability to store them for a sufficient time to find a suitable recipient. Therefore, lungs lost due to failure to meet physiological or compatibility criteria may be mitigated through preservation methods which improve lung function and storage durations. Ex situ lung perfusion (ESLP) is a recently developed method which allows for longer storage times and has been demonstrated to improve lung function such that rejected lungs can be accepted for donation. Although greater use of ESLP will help to improve donor lung utilization, the ability to cryopreserve lungs would allow for organ banking to better utilize donor lungs. However, lung cryopreservation research remains underrepresented in the literature despite its unique advantages for cryopreservation over other organs. Therefore, this review will discuss the current techniques for lung preservation, static cold preservation and ESLP, and provide a review of the cryopreservation challenges and advantages unique to lungs.
Collapse
|
29
|
Normothermic machine perfusion of donor-lungs ex-vivo: promoting clinical adoption. Curr Opin Organ Transplant 2020; 25:285-292. [PMID: 32304426 DOI: 10.1097/mot.0000000000000765] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Lung transplantation offers the only realistic therapeutic option for patients with end-stage lung disease. However, this is impacted by a shortfall in availability of suitable donor-lungs. Normothermic machine perfusion of donor-lungs outside the donor body also known as ex-vivo lung perfusion (EVLP) offers a potential solution through objective assessment, reconditioning and treatment of donor-lungs initially deemed unsuitable for use. This review discusses key advances and challenges in the wider clinical adoption of this technology. RECENT FINDINGS This review will summarize key research within the following areas: recent clinical trials utilizing EVLP, logistical challenges, EVLP protocol innovations, novel assessment methods and current research into therapeutic modulation of lung function during EVLP. SUMMARY Normothermic machine perfusion of donor-lungs ex-vivo offers a promising platform to assess and modulate donor-lung quality prior to transplantation. Consensus on how and when to best utilize EVLP is yet to be reached, meaning that widespread clinical adoption of the technology has not yet become a reality. Further work is needed on agreed indications, perfusion protocols and organization of services before becoming a regularly used procedure prior to lung transplantation.
Collapse
|
30
|
Iskender I, Arni S, Maeyashiki T, Citak N, Sauer M, Rodriguez JM, Frauenfelder T, Opitz I, Weder W, Inci I. Perfusate adsorption during ex vivo lung perfusion improves early post-transplant lung function. J Thorac Cardiovasc Surg 2020; 161:e109-e121. [PMID: 32201002 DOI: 10.1016/j.jtcvs.2019.12.128] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 11/29/2019] [Accepted: 12/05/2019] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Improvement in ex vivo lung perfusion protocols could increase the number of donors available for transplantation and protect the lungs from primary graft dysfunction. We hypothesize that perfusate adsorption during ex vivo lung perfusion reconditions the allograft to ischemia-reperfusion injury after lung transplantation. METHODS Donor pig lungs were preserved for 24 hours at 4°C, followed by 6 hours of ex vivo lung perfusion according to the Toronto protocol. The perfusate was additionally adsorbed through a CytoSorb adsorber (CytoSorbents, Berlin, Germany) in the treatment group, whereas control lungs were perfused according to the standard protocol (n = 5, each). Ex vivo lung perfusion physiology and biochemistry were monitored. Upon completion of ex vivo lung perfusion, a left single lung transplantation was performed. Oxygenation function and lung mechanics were assessed during a 4-hour reperfusion period. The inflammatory response was determined during ex vivo lung perfusion and reperfusion. RESULTS The cytokine concentrations in the perfusate were markedly lower with the adsorber, resulting in improved ex vivo lung perfusion physiology and biochemistry during the 6-hour perfusion period. Post-transplant dynamic lung compliance was markedly better during the 4-hour reperfusion period in the treatment group. Isolated allograft oxygenation function and dynamic compliance continued to be superior in the adsorber group at the end of reperfusion, accompanied by a markedly decreased local inflammatory response. CONCLUSIONS Implementation of an additional cytokine adsorber has refined the standard ex vivo lung perfusion protocol. Furthermore, cytokine removal during ex vivo lung perfusion improved immediate post-transplant graft function together with a less intense inflammatory response to reperfusion in pigs. Further studies are warranted to understand the beneficial effects of perfusate adsorption during ex vivo lung perfusion in the clinical setting.
Collapse
Affiliation(s)
- Ilker Iskender
- Department of Thoracic Surgery, University Hospital Zurich-University of Zurich, Zurich, Switzerland
| | - Stephan Arni
- Department of Thoracic Surgery, University Hospital Zurich-University of Zurich, Zurich, Switzerland
| | - Tatsuo Maeyashiki
- Department of Thoracic Surgery, University Hospital Zurich-University of Zurich, Zurich, Switzerland
| | - Necati Citak
- Department of Thoracic Surgery, University Hospital Zurich-University of Zurich, Zurich, Switzerland
| | - Mareike Sauer
- Department of Surgical Research, University Hospital Zurich-University of Zurich, Zurich, Switzerland
| | | | - Thomas Frauenfelder
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich-University of Zurich, Zurich, Switzerland
| | - Isabelle Opitz
- Department of Thoracic Surgery, University Hospital Zurich-University of Zurich, Zurich, Switzerland
| | - Walter Weder
- Department of Thoracic Surgery, University Hospital Zurich-University of Zurich, Zurich, Switzerland
| | - Ilhan Inci
- Department of Thoracic Surgery, University Hospital Zurich-University of Zurich, Zurich, Switzerland.
| |
Collapse
|
31
|
Abstract
PURPOSE OF REVIEW Ex-vivo lung perfusion (EVLP) has been developed to expand the donor pool for lung transplantation recipients. The role of EVLP in organ preservation, evaluation and potential reconditioning is reviewed. RECENT FINDINGS EVLP has been shown to significantly increase the utilization of donor lungs for transplantation. Evidence suggests that patient outcomes from EVLP lungs are comparable to standard procurement technique. Novel strategies are being developed to treat and recondition injured donor lungs. EVLP may also prove to be a tool for translational research of lung diseases. SUMMARY EVLP has been shown to be an effective system to expand donor pool for lung transplantation without detriment to recipients. Future potential ex-vivo developments may further improve patient outcomes as well as increasing availability of donor organs.
Collapse
|
32
|
Buchko MT, Stewart CJ, Hatami S, Himmat S, Freed DH, Nagendran J. Total parenteral nutrition in ex vivo lung perfusion: Addressing metabolism improves both inflammation and oxygenation. Am J Transplant 2019; 19:3390-3397. [PMID: 31420938 DOI: 10.1111/ajt.15572] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 07/15/2019] [Accepted: 08/04/2019] [Indexed: 01/25/2023]
Abstract
Ex vivo lung perfusion (EVLP) protocols generally limit metabolic supplementation to insulin and glucose. We sought to determine whether the addition of total parenteral nutrition (TPN) would improve lung function in EVLP. Ten porcine lungs were perfused using EVLP for 24 hours and supplemented with insulin and glucose. In the treatment group (n = 5), the perfusate was also supplemented with a continuous infusion of TPN containing lipids, amino acids, essential vitamins, and cofactors. Physiologic parameters and perfusate electrolytes were continuously evaluated. Perfusate lactate, lipid and branch chain amino acid (BCAA) concentrations were also analyzed to elucidate how substrates were being utilized over time. Lungs in the TPN group exhibited significantly better oxygenation. Perfusate sodium was more stable in the TPN group. In the control group, free fatty acids (FFA) were quickly depleted, reaching negligible levels early in the perfusion. Alternatively, BCAA in the control group rose continually over the perfusion demonstrating a shift toward proteolysis for energy substrate. In the TPN group, both FFA and BCAA concentrations remained stable at in vivo levels after initial stabilization. TNF-α concentrations were lower in the TPN group. The addition of TPN in EVLP allows for better electrolyte composition, decreased inflammation, and improved graft performance.
Collapse
Affiliation(s)
- Max T Buchko
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada.,Mazankowski Alberta Heart Institute, Edmonton, AB, Canada
| | - Catherine J Stewart
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Sanaz Hatami
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Sayed Himmat
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Darren H Freed
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada.,Mazankowski Alberta Heart Institute, Edmonton, AB, Canada.,Alberta Transplant Institute, Edmonton, AB, Canada.,Canadian National Transplant Research Program, Edmonton, AB, Canada
| | - Jayan Nagendran
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada.,Mazankowski Alberta Heart Institute, Edmonton, AB, Canada.,Alberta Transplant Institute, Edmonton, AB, Canada.,Canadian National Transplant Research Program, Edmonton, AB, Canada
| |
Collapse
|
33
|
Okamoto T, Niikawa H, Ayyat K, Sakanoue I, Said S, McCurry KR. Machine Perfusion of Lungs. CURRENT TRANSPLANTATION REPORTS 2019. [DOI: 10.1007/s40472-019-00258-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
|
34
|
Hozain AE, Tipograf Y, Pinezich MR, Cunningham KM, Donocoff R, Queen D, Fung K, Marboe CC, Guenthart BA, O'Neill JD, Vunjak-Novakovic G, Bacchetta M. Multiday maintenance of extracorporeal lungs using cross-circulation with conscious swine. J Thorac Cardiovasc Surg 2019; 159:1640-1653.e18. [PMID: 31761338 PMCID: PMC7094131 DOI: 10.1016/j.jtcvs.2019.09.121] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 09/05/2019] [Accepted: 09/09/2019] [Indexed: 12/11/2022]
Abstract
Objectives Lung remains the least-utilized solid organ for transplantation. Efforts to recover donor lungs with reversible injuries using ex vivo perfusion systems are limited to <24 hours of support. Here, we demonstrate the feasibility of extending normothermic extracorporeal lung support to 4 days using cross-circulation with conscious swine. Methods A swine behavioral training program and custom enclosure were developed to enable multiday cross-circulation between extracorporeal lungs and recipient swine. Lungs were ventilated and perfused in a normothermic chamber for 4 days. Longitudinal analyses of extracorporeal lungs (ie, functional assessments, multiscale imaging, cytokine quantification, and cellular assays) and recipient swine (eg, vital signs and blood and tissue analyses) were performed. Results Throughout 4 days of normothermic support, extracorporeal lung function was maintained (arterial oxygen tension/inspired oxygen fraction >400 mm Hg; compliance >20 mL/cm H2O), and recipient swine were hemodynamically stable (lactate <3 mmol/L; pH, 7.42 ± 0.05). Radiography revealed well-aerated lower lobes and consolidation in upper lobes of extracorporeal lungs, and bronchoscopy showed healthy airways without edema or secretions. In bronchoalveolar lavage fluid, granulocyte-macrophage colony-stimulating factor, interleukin (IL) 4, IL-6, and IL-10 levels increased less than 6-fold, whereas interferon gamma, IL-1α, IL-1β, IL-1ra, IL-2, IL-8, IL-12, IL-18, and tumor necrosis factor alpha levels decreased from baseline to day 4. Histologic evaluations confirmed an intact blood–gas barrier and outstanding preservation of airway and alveolar architecture. Cellular viability and metabolism in extracorporeal lungs were confirmed after 4 days. Conclusions We demonstrate feasibility of normothermic maintenance of extracorporeal lungs for 4 days by cross-circulation with conscious swine. Cross-circulation approaches could support the recovery of damaged lungs and enable organ bioengineering to improve transplant outcomes.
Collapse
Affiliation(s)
- Ahmed E Hozain
- Department of Biomedical Engineering, Columbia University Medical Center, Columbia University, New York, NY; Department of Surgery, Columbia University Medical Center, Columbia University, New York, NY
| | - Yuliya Tipograf
- Department of Surgery, Columbia University Medical Center, Columbia University, New York, NY; Departments of Thoracic and Cardiac Surgery, Vanderbilt University, Nashville, Tenn
| | - Meghan R Pinezich
- Department of Biomedical Engineering, Columbia University Medical Center, Columbia University, New York, NY
| | - Katherine M Cunningham
- Department of Biomedical Engineering, Columbia University Medical Center, Columbia University, New York, NY
| | - Rachel Donocoff
- Institute of Comparative Medicine, Columbia University Medical Center, Columbia University, New York, NY
| | - Dawn Queen
- Vagelos College of Physicians and Surgeons, Columbia University Medical Center, Columbia University, New York, NY
| | - Kenmond Fung
- Department of Clinical Perfusion, Columbia University Medical Center, Columbia University, New York, NY
| | - Charles C Marboe
- Department of Pathology and Cell Biology, Columbia University Medical Center, Columbia University, New York, NY
| | - Brandon A Guenthart
- Department of Biomedical Engineering, Columbia University Medical Center, Columbia University, New York, NY
| | - John D O'Neill
- Department of Biomedical Engineering, Columbia University Medical Center, Columbia University, New York, NY
| | - Gordana Vunjak-Novakovic
- Department of Biomedical Engineering, Columbia University Medical Center, Columbia University, New York, NY; Department of Medicine, Columbia University Medical Center, Columbia University, New York, NY.
| | - Matthew Bacchetta
- Department of Biomedical Engineering, Columbia University Medical Center, Columbia University, New York, NY; Departments of Thoracic and Cardiac Surgery, Vanderbilt University, Nashville, Tenn.
| |
Collapse
|
35
|
Buchko MT, Himmat S, Stewart CJ, Hatami S, Dromparis P, Adam BA, Freed DH, Nagendran J. Continuous Hemodialysis Does Not Improve Graft Function During Ex Vivo Lung Perfusion Over 24 Hours. Transplant Proc 2019; 51:2022-2028. [PMID: 31303418 DOI: 10.1016/j.transproceed.2019.03.042] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Accepted: 03/13/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Extended periods of ex vivo lung perfusion (EVLP) lead to several inadvertent consequences including accumulation of lactate and increasing electrolyte concentrations in the perfusate. We sought to determine whether continuous hemodialysis (CHD) of the perfusate would be a suitable modality for improving ionic homeostasis in extended EVLP without compromising functional outcomes. METHODS Twelve porcine lungs were perfused using EVLP for 24 hours. All lungs were ventilated with negative pressure ventilation. Lungs in the treatment group (n = 6) underwent continuous hemodialysis of the perfusate. Functional parameters, edema formation, and histopathologic analysis were used to assess graft function. Electrolyte and lactate profiles were also followed to assess the efficiency of hemodialysis. RESULTS Lungs in both treatment and control groups demonstrated stable and acceptable oxygenation to 24 hours. Lungs demonstrated a decrease in compliance over time. There was no difference in oxygenation and compliance between groups. CHD-EVLP lungs had higher pulmonary vascular resistance and pulmonary artery pressures. Despite increased perfusion pressures, weight gain at both 11 and 23 hours was not different between groups. Perfusate sodium and lactate concentrations were significantly lower in the CHD-EVLP group. CONCLUSION The addition of continuous hemodialysis to EVLP did not improve graft function up to 24 hours despite improved maintenance of perfusate composition.
Collapse
Affiliation(s)
- Max T Buchko
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada; Mazankowski Alberta Heart Institute, Edmonton, AB, Canada
| | - Sayed Himmat
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Catherine J Stewart
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Sanaz Hatami
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Peter Dromparis
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, AB, Canada
| | - Benjamin A Adam
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, AB, Canada
| | - Darren H Freed
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada; Mazankowski Alberta Heart Institute, Edmonton, AB, Canada; Alberta Transplant Institute, Edmonton, AB, Canada; Canadian National Transplant Research Program, Edmonton, AB, Canada
| | - Jayan Nagendran
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada; Mazankowski Alberta Heart Institute, Edmonton, AB, Canada; Alberta Transplant Institute, Edmonton, AB, Canada; Canadian National Transplant Research Program, Edmonton, AB, Canada.
| |
Collapse
|
36
|
Dromparis P, Aboelnazar NS, Wagner S, Himmat S, White CW, Hatami S, Luc JGY, Rotich S, Freed DH, Nagendran J, Mengel M, Adam BA. Ex vivo perfusion induces a time- and perfusate-dependent molecular repair response in explanted porcine lungs. Am J Transplant 2019; 19:1024-1036. [PMID: 30230229 DOI: 10.1111/ajt.15123] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Revised: 09/13/2018] [Accepted: 09/14/2018] [Indexed: 01/25/2023]
Abstract
Ex vivo lung perfusion (EVLP) shows promise in ameliorating pretransplant acute lung injury (ALI) and expanding the donor organ pool, but the mechanisms of ex vivo repair remain poorly understood. We aimed to assess the utility of gene expression for characterizing ALI during EVLP. One hundred sixty-nine porcine lung samples were collected in vivo (n = 25), after 0 (n = 11) and 12 (n = 11) hours of cold static preservation (CSP), and after 0 (n = 57), 6 (n = 8), and 12 (n = 57) hours of EVLP, utilizing various ventilation and perfusate strategies. The expression of 53 previously described ALI-related genes was measured and correlated with function and histology. Twenty-eight genes were significantly upregulated and 6 genes downregulated after 12 hours of EVLP. Aggregate gene sets demonstrated differential expression with EVLP (P < .001) but not CSP. Upregulated 28-gene set expression peaked after 6 hours of EVLP, whereas downregulated 6-gene set expression continued to decline after 12 hours. Cellular perfusates demonstrated a greater reduction in downregulated 6-gene set expression vs acellular perfusate (P < .038). Gene set expression correlated with relevant functional and histologic parameters, including P/F ratio (P < .001) and interstitial inflammation (P < .005). Further studies with posttransplant results are warranted to evaluate the clinical significance of this novel molecular approach for assessing organ quality during EVLP.
Collapse
Affiliation(s)
- Peter Dromparis
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - Nader S Aboelnazar
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Siegfried Wagner
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - Sayed Himmat
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Christopher W White
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Sanaz Hatami
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Jessica G Y Luc
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Silas Rotich
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - Darren H Freed
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Jayan Nagendran
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Michael Mengel
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - Benjamin A Adam
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| |
Collapse
|
37
|
Steinmeyer J, Becker S, Avsar M, Salman J, Höffler K, Haverich A, Warnecke G, Mühlfeld C, Ochs M, Schnapper-Isl A. Cellular and acellular ex vivo lung perfusion preserve functional lung ultrastructure in a large animal model: a stereological study. Respir Res 2018; 19:238. [PMID: 30509256 PMCID: PMC6278069 DOI: 10.1186/s12931-018-0942-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Accepted: 11/19/2018] [Indexed: 01/07/2023] Open
Abstract
Background Ex vivo lung perfusion (EVLP) is used by an increasing number of transplant centres. It is still controversial whether an acellular or cellular (erythrocyte enriched) perfusate is preferable. The aim of this paper was to evaluate whether acellular (aEVLP) or cellular EVLP (cEVLP) preserves functional lung ultrastructure better and to generate a hypothesis regarding possible underlying mechanisms. Methods Lungs of 20 pigs were assigned to 4 groups: control, ischaemia (24 h), aEVLP and cEVLP (both EVLP groups: 24 h ischaemia + 12 h EVLP). After experimental procedures, whole lungs were perfusion fixed, samples for light and electron microscopic stereology were taken, and ventilation, diffusion and perfusion related parameters were estimated. Results Lung structure was well preserved in all groups. Lungs had less atelectasis and higher air content after EVLP. No significant group differences were found in alveolar septum composition or blood-air barrier thickness. Small amounts of intraalveolar oedema were detected in both EVLP groups but significantly more in aEVLP than in cEVLP. Conclusions Both EVLP protocols supported lungs well for up to 12 h and could largely prevent ischaemia ex vivo reperfusion associated lung injury. In both EVLP groups, oedema volume remained below the level of functional relevance. The group difference in oedema formation was possibly due to inferior septal perfusion in aEVLP. Electronic supplementary material The online version of this article (10.1186/s12931-018-0942-5) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Jasmin Steinmeyer
- Institute of Functional and Applied Anatomy, Hannover Medical School, Hannover, Germany
| | - Simon Becker
- Institute of Functional and Applied Anatomy, Hannover Medical School, Hannover, Germany.,REBIRTH Cluster of Excellence, Hannover, Germany.,Department of Anesthesiology, Intensive Care, Palliative Care and Pain Medicine, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, Germany
| | - Murat Avsar
- Department of Cardiothoracic, Transplantation and Vascular Surgery (HTTG), Hannover Medical School, Hannover, Germany
| | - Jawad Salman
- Department of Cardiothoracic, Transplantation and Vascular Surgery (HTTG), Hannover Medical School, Hannover, Germany
| | - Klaus Höffler
- Department of Cardiothoracic, Transplantation and Vascular Surgery (HTTG), Hannover Medical School, Hannover, Germany
| | - Axel Haverich
- REBIRTH Cluster of Excellence, Hannover, Germany.,Department of Cardiothoracic, Transplantation and Vascular Surgery (HTTG), Hannover Medical School, Hannover, Germany.,Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Member of the German Center for Lung Research (DZL), Hannover, Germany
| | - Gregor Warnecke
- REBIRTH Cluster of Excellence, Hannover, Germany.,Department of Cardiothoracic, Transplantation and Vascular Surgery (HTTG), Hannover Medical School, Hannover, Germany.,Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Member of the German Center for Lung Research (DZL), Hannover, Germany
| | - Christian Mühlfeld
- Institute of Functional and Applied Anatomy, Hannover Medical School, Hannover, Germany.,REBIRTH Cluster of Excellence, Hannover, Germany.,Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Member of the German Center for Lung Research (DZL), Hannover, Germany
| | - Matthias Ochs
- Institute of Functional and Applied Anatomy, Hannover Medical School, Hannover, Germany.,REBIRTH Cluster of Excellence, Hannover, Germany.,Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Member of the German Center for Lung Research (DZL), Hannover, Germany
| | - Anke Schnapper-Isl
- Institute of Functional and Applied Anatomy, Hannover Medical School, Hannover, Germany. .,REBIRTH Cluster of Excellence, Hannover, Germany.
| |
Collapse
|
38
|
Abstract
This article summarizes recent knowledge and clinical advances in machine perfusion (MP) of thoracic organs. MP of thoracic organs has gained much attention during the last decade. Clinical studies are investigating the role of MP to preserve, resuscitate, and assess heart and lungs prior to transplantation. Currently, MP of the cardiac allograft is essential in all type DCD heart transplantation while MP of the pulmonary allograft is mandatory in uncontrolled DCD lung transplantation. MP of thoracic organs also offers an exciting platform to further investigate downregulation of the innate and adaptive immunity prior to reperfusion of the allograft in recipients. MP provides a promising technology that allows pre-transplant preservation, resuscitation, assessment, repair, and conditioning of cardiac and pulmonary allografts outside the body in a near physiologic state prior to planned transplantation. Results of ongoing clinical trials are awaited to estimate the true clinical value of this new technology in advancing the field of heart and lung transplantation by increasing the total number and the quality of available organs and by further improving recipient early and long-term outcome.
Collapse
Affiliation(s)
- Dirk Van Raemdonck
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Chronic Diseases, KU Leuven University, Leuven, Belgium
| | - Filip Rega
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Cardiovascular Sciences, KU Leuven University, Leuven, Belgium
| | - Steffen Rex
- Department of Cardiovascular Sciences, KU Leuven University, Leuven, Belgium.,Department of Anaesthesiology, University Hospitals Leuven, Leuven, Belgium
| | - Arne Neyrinck
- Department of Cardiovascular Sciences, KU Leuven University, Leuven, Belgium.,Department of Anaesthesiology, University Hospitals Leuven, Leuven, Belgium
| |
Collapse
|