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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.
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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.
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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
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Miller CL, O JM, Allan JS, Madsen JC. Novel approaches for long-term lung transplant survival. Front Immunol 2022; 13:931251. [PMID: 35967365 PMCID: PMC9363671 DOI: 10.3389/fimmu.2022.931251] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 07/04/2022] [Indexed: 11/16/2022] Open
Abstract
Allograft failure remains a major barrier in the field of lung transplantation and results primarily from acute and chronic rejection. To date, standard-of-care immunosuppressive regimens have proven unsuccessful in achieving acceptable long-term graft and patient survival. Recent insights into the unique immunologic properties of lung allografts provide an opportunity to develop more effective immunosuppressive strategies. Here we describe advances in our understanding of the mechanisms driving lung allograft rejection and highlight recent progress in the development of novel, lung-specific strategies aimed at promoting long-term allograft survival, including tolerance.
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Affiliation(s)
- Cynthia L. Miller
- Center for Transplantation Sciences, Massachusetts General Hospital, Boston, MA, United States
| | - Jane M. O
- Center for Transplantation Sciences, Massachusetts General Hospital, Boston, MA, United States
| | - James S. Allan
- Center for Transplantation Sciences, Massachusetts General Hospital, Boston, MA, United States
- Division of Thoracic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA, United States
| | - Joren C. Madsen
- Center for Transplantation Sciences, Massachusetts General Hospital, Boston, MA, United States
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA, United States
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Patrono D, Roggio D, Mazzeo AT, Catalano G, Mazza E, Rizza G, Gambella A, Rigo F, Leone N, Elia V, Dondossola D, Lonati C, Fanelli V, Romagnoli R. Clinical assessment of liver metabolism during hypothermic oxygenated machine perfusion using microdialysis. Artif Organs 2021; 46:281-295. [PMID: 34516020 PMCID: PMC9292750 DOI: 10.1111/aor.14066] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 08/17/2021] [Accepted: 09/05/2021] [Indexed: 12/12/2022]
Abstract
Background While growing evidence supports the use of hypothermic oxygenated machine perfusion (HOPE) in liver transplantation, its effects on liver metabolism are still incompletely understood. Methods To assess liver metabolism during HOPE using microdialysis (MD), we conducted an open‐label, observational pilot study on 10 consecutive grafts treated with dual‐HOPE (D‐HOPE). Microdialysate and perfusate levels of glucose, lactate, pyruvate, glutamate, and flavin mononucleotide (FMN) were measured during back table preparation and D‐HOPE and correlated to graft function and patient outcome. Results Median (IQR) MD and D‐HOPE time was 228 (210, 245) and 116 (103, 143) min. Three grafts developed early allograft dysfunction (EAD), with one requiring retransplantation. During D‐HOPE, MD glucose and lactate levels increased (ANOVA = 9.88 [p = 0.01] and 3.71 [p = 0.08]). Their 2nd‐hour levels were higher in EAD group and positively correlated with L‐GrAFT score. 2nd‐hour MD glucose and lactate were also positively correlated with cold ischemia time, macrovesicular steatosis, weight gain during D‐HOPE, and perfusate FMN. These correlations were not apparent when perfusate levels were considered. In contrast, MD FMN levels invariably dropped steeply after D‐HOPE start, whereas perfusate FMN was higher in dysfunctioning grafts. Conclusion MD glucose and lactate during D‐HOPE are markers of hepatocellular injury and could represent additional elements of the viability assessment.
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Affiliation(s)
- Damiano Patrono
- General Surgery 2U - Liver Transplant Unit, Department of Surgical Sciences, A.O.U. Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Dorotea Roggio
- General Surgery 2U - Liver Transplant Unit, Department of Surgical Sciences, A.O.U. Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy.,Department of Molecular Biotechnology and Health Sciences, University of Turin, Turin, Italy
| | - Anna Teresa Mazzeo
- Anaesthesia, Critical Care and Emergency, A.O.U. Department of Surgical Sciences, Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy.,Anesthesia and Intensive Care, Department of Adult and Pediatric Pathology, University of Messina, Messina, Italy
| | - Giorgia Catalano
- General Surgery 2U - Liver Transplant Unit, Department of Surgical Sciences, A.O.U. Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Elena Mazza
- General Surgery 2U - Liver Transplant Unit, Department of Surgical Sciences, A.O.U. Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Giorgia Rizza
- General Surgery 2U - Liver Transplant Unit, Department of Surgical Sciences, A.O.U. Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Alessandro Gambella
- Pathology Unit, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Federica Rigo
- General Surgery 2U - Liver Transplant Unit, Department of Surgical Sciences, A.O.U. Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Nicola Leone
- General Surgery 2U - Liver Transplant Unit, Department of Surgical Sciences, A.O.U. Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Vincenzo Elia
- Anaesthesia, Critical Care and Emergency, A.O.U. Department of Surgical Sciences, Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Daniele Dondossola
- General and Liver Transplant Surgery Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, Università degli Studi of Milan, Milan, Italy
| | - Caterina Lonati
- Center for Preclinical Research, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Vito Fanelli
- Anaesthesia, Critical Care and Emergency, A.O.U. Department of Surgical Sciences, Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Renato Romagnoli
- General Surgery 2U - Liver Transplant Unit, Department of Surgical Sciences, A.O.U. Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
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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.
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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.
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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
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Commentary: Maintaining the pHysiological equilibrium. J Thorac Cardiovasc Surg 2020; 161:1977-1978. [PMID: 33246565 DOI: 10.1016/j.jtcvs.2020.08.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 08/11/2020] [Accepted: 08/12/2020] [Indexed: 11/22/2022]
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Cyclosporin A Administration During Ex Vivo Lung Perfusion Preserves Lung Grafts in Rat Transplant Model. Transplantation 2020; 104:e252-e259. [PMID: 32217944 DOI: 10.1097/tp.0000000000003237] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Despite the benefits of ex vivo lung perfusion (EVLP) such as lung reconditioning, preservation, and evaluation before transplantation, deleterious effects, including activation of proinflammatory cascades and alteration of metabolic profiles have been reported. Although patient outcomes have been favorable, further studies addressing optimal conditions are warranted. In this study, we investigated the role of the immunosuppressant drug cyclosporine A (CyA) in preserving mitochondrial function and subsequently preventing proinflammatory changes in lung grafts during EVLP. METHODS Using rat heart-lung blocks after 1-hour cold preservation, an acellular normothermic EVLP system was established for 4 hours. CyA was added into perfusate at a final concentration of 1 μM. The evaluation included lung graft function, lung compliance, and pulmonary vascular resistance as well as biochemical marker measurement in the perfusate at multiple time points. After EVLP, single orthotopic lung transplantation was performed, and the grafts were assessed 2 hours after reperfusion. RESULTS Lung grafts on EVLP with CyA exhibited significantly better functional and physiological parameters as compared with those without CyA treatment. CyA administration attenuated proinflammatory changes and prohibited glucose consumption during EVLP through mitigating mitochondrial dysfunction in lung grafts. CyA-preconditioned lungs showed better posttransplant lung early graft function and less inflammatory events compared with control. CONCLUSIONS During EVLP, CyA administration can have a preconditioning effect through both its anti-inflammatory and mitochondrial protective properties, leading to improved lung graft preservation, which may result in enhanced graft quality after transplantation.
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Fanelli V, Del Sorbo L, Boffini M, Costamagna A, Balzano S, Musso T, Scutera S, Cappello P, Mazzeo A, Solidoro P, Baietto L, D'avolio A, Derosa FG, Brazzi L, Mascia L, Rinaldi M, Ranieri VM. Impact of imipenem concentration in lung perfusate and tissue biopsy during clinical ex-vivo lung perfusion of high-risk lung donors. Minerva Anestesiol 2020; 86:617-626. [DOI: 10.23736/s0375-9393.20.13840-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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10
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Günther M, Sondén A, Gustavsson J, Arborelius UP, Rocksén D. Feasibility of pleural and perilesional subcutaneous microdialysis to assess porcine experimental pulmonary contusion. Exp Lung Res 2020; 46:117-127. [DOI: 10.1080/01902148.2020.1742252] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- Mattias Günther
- Department of Clinical Science and Education, Södersjukhuset, Stockholm, Sweden
| | - Anders Sondén
- Department of Clinical Science and Education, Södersjukhuset, Stockholm, Sweden
| | - Jenny Gustavsson
- Department of Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Ulf P. Arborelius
- Department of Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - David Rocksén
- Department of Neuroscience, Karolinska Institutet, Stockholm, Sweden
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Spratt JR, Mattison LM, Kerns NK, Huddleston SJ, Meyer L, Iles TL, Loor G, Iaizzo PA. Prolonged extracorporeal preservation and evaluation of human lungs with portable normothermic ex vivo perfusion. Clin Transplant 2020; 34:e13801. [DOI: 10.1111/ctr.13801] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 01/24/2020] [Indexed: 01/16/2023]
Affiliation(s)
- John R. Spratt
- Department of Surgery University of Minnesota Minneapolis Minnesota
| | - Lars M. Mattison
- Department of Surgery University of Minnesota Minneapolis Minnesota
- Department of Biomedical Engineering University of Minnesota Minneapolis Minnesota
| | - Natalie K. Kerns
- Division of Cardiothoracic Surgery Department of Surgery University of Minnesota Minneapolis Minnesota
| | - Stephen J. Huddleston
- Division of Cardiothoracic Surgery Department of Surgery University of Minnesota Minneapolis Minnesota
| | | | - Tinen L. Iles
- Department of Surgery University of Minnesota Minneapolis Minnesota
| | - Gabriel Loor
- Division of Cardiothoracic Surgery Department of Surgery University of Minnesota Minneapolis Minnesota
- Division of Cardiothoracic Transplantation and Circulatory Support Michael E. DeBakey Department of Surgery Baylor College of Medicine Houston Texas
| | - Paul A. Iaizzo
- Department of Surgery University of Minnesota Minneapolis Minnesota
- Department of Biomedical Engineering University of Minnesota Minneapolis Minnesota
- Institute for Engineering in Medicine University of Minnesota Minneapolis Minnesota
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