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Ray S, Parmentier C, Kawamura M, Ganesh S, Nogueira E, Novoa FC, Hobeika C, Chu T, Kalimuthu SN, Selzner M, Reichman TW. Reanimating Pancreatic Grafts Subjected to Prolonged Cold Ischemic Injury Using Normothermic Ex Vivo Perfusion. Transplant Direct 2024; 10:e1620. [PMID: 38617463 PMCID: PMC11013695 DOI: 10.1097/txd.0000000000001620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 02/08/2024] [Accepted: 02/10/2024] [Indexed: 04/16/2024] Open
Abstract
Background Pancreas transplant volumes are limited because of poor utilization of "extended criteria grafts." Prolonged cold ischemia is a risk factor associated with poor allograft survival. We aimed to establish the feasibility of transplantation using grafts subjected to prolonged cold ischemia and determine whether these grafts could be optimized using normothermic ex vivo perfusion (NEVP) in a porcine model. Methods The study population consisted of 35 to 40 kg male Yorkshire pigs in an allotransplantation model with a 3-d survival plan for recipients. Control grafts were subjected to cold storage (CS) in a University of Wisconsin solution for 21 to 24 h (n = 6), whereas the test group received an additional 3 h NEVP after CS of 21 h (n = 5). Results The 3-d survival was 60% in the NEVP arm versus 0% in the control arm (P = 0.008; log rank). Graft parenchyma was 60% to 70% preserved in the NEVP arm at necropsy on gross appearance. In addition, the islet function was well preserved, and both the pancreas (including the islets) and the duodenal morphology were maintained histologically. The intravenous glucose tolerance test on the day of euthanasia was in the normoglycemic range for 80% of cases in the NEVP arm. Conclusions Optimization of pancreas grafts exposed to extended CS with NEVP seems promising at rescuing and reanimating these grafts for transplantation, resulting in significantly improved survival in a porcine pancreas transplant model.
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Affiliation(s)
- Samrat Ray
- Department of Multiorgan Transplantation, Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Catherine Parmentier
- Department of Multiorgan Transplantation, Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Masataka Kawamura
- Department of Multiorgan Transplantation, Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Sujani Ganesh
- Department of Multiorgan Transplantation, Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Emmanuel Nogueira
- Department of Multiorgan Transplantation, Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Francisco Calderon Novoa
- Department of Multiorgan Transplantation, Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Christian Hobeika
- Department of Multiorgan Transplantation, Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Tunpang Chu
- Department of Multiorgan Transplantation, Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Sangeetha N. Kalimuthu
- Department of Laboratory Medicine and Pathobiology, University Health Network, Toronto, ON, Canada
| | - Markus Selzner
- Department of Multiorgan Transplantation, Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Trevor W. Reichman
- Department of Multiorgan Transplantation, Ajmera Transplant Centre, Toronto General Hospital, University Health Network, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
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2
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López-Martínez S, Simón C, Santamaria X. Normothermic Machine Perfusion Systems: Where Do We Go From Here? Transplantation 2024; 108:22-44. [PMID: 37026713 DOI: 10.1097/tp.0000000000004573] [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: 04/08/2023]
Abstract
Normothermic machine perfusion (NMP) aims to preserve organs ex vivo by simulating physiological conditions such as body temperature. Recent advancements in NMP system design have prompted the development of clinically effective devices for liver, heart, lung, and kidney transplantation that preserve organs for several hours/up to 1 d. In preclinical studies, adjustments to circuit structure, perfusate composition, and automatic supervision have extended perfusion times up to 1 wk of preservation. Emerging NMP platforms for ex vivo preservation of the pancreas, intestine, uterus, ovary, and vascularized composite allografts represent exciting prospects. Thus, NMP may become a valuable tool in transplantation and provide significant advantages to biomedical research. This review recaps recent NMP research, including discussions of devices in clinical trials, innovative preclinical systems for extended preservation, and platforms developed for other organs. We will also discuss NMP strategies using a global approach while focusing on technical specifications and preservation times.
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Affiliation(s)
- Sara López-Martínez
- Carlos Simon Foundation, Centro de Investigación Príncipe Felipe, Valencia, Spain
| | - Carlos Simón
- Carlos Simon Foundation, Centro de Investigación Príncipe Felipe, Valencia, Spain
- Department of Obstetrics and Gynecology, Universidad de Valencia, Valencia, Spain
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Harvard University, Boston, MA
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX
| | - Xavier Santamaria
- Carlos Simon Foundation, Centro de Investigación Príncipe Felipe, Valencia, Spain
- INCLIVA Biomedical Research Institute, Valencia, Spain
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3
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Panconesi R, Carvalho MF, Eden J, Fazi M, Ansari F, Mancina L, Navari N, Sousa Da Silva RX, Dondossola D, Borrego LB, Pietzke M, Peris A, Meierhofer D, Muiesan P, Galkin A, Marra F, Dutkowski P, Schlegel A. Mitochondrial injury during normothermic regional perfusion (NRP) and hypothermic oxygenated perfusion (HOPE) in a rodent model of DCD liver transplantation. EBioMedicine 2023; 98:104861. [PMID: 37924707 PMCID: PMC10660010 DOI: 10.1016/j.ebiom.2023.104861] [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: 03/04/2023] [Revised: 10/15/2023] [Accepted: 10/16/2023] [Indexed: 11/06/2023] Open
Abstract
BACKGROUND Normothermic regional perfusion (NRP) and hypothermic-oxygenated-perfusion (HOPE), were both shown to improve outcomes after liver transplantation from donors after circulatory death (DCD). Comparative clinical and mechanistical studies are however lacking. METHODS A rodent model of NRP and HOPE, both in the donor, was developed. Following asystolic donor warm ischemia time (DWIT), the abdominal compartment was perfused either with a donor-blood-based-perfusate at 37 °C (NRP) or with oxygenated Belzer-MPS at 10 °C (donor-HOPE) for 2 h. Livers were then procured and underwent 5 h static cold storage (CS), followed by transplantation. Un-perfused and HOPE-treated DCD-livers (after CS) and healthy livers (DBD) with direct implantation after NRP served as controls. Endpoints included the entire spectrum of ischemia-reperfusion-injury. FINDINGS Healthy control livers (DBD) showed minimal signs of inflammation during 2 h NRP and achieved 100% posttransplant recipient survival. In contrast, DCD livers with 30 and 60 min DWIT suffered from greater mitochondrial injury and inflammation as measured by increased perfusate Lactate, FMN- and HMGB-1-levels with subsequent Toll-like-receptor activation during NRP. In contrast, donor-HOPE (instead of NRP) led to significantly less mitochondrial-complex-I-injury and inflammation. Results after donor-HOPE were comparable to ex-situ HOPE after CS. Most DCD-liver recipients survived when treated with one HOPE-technique (86%), compared to only 40% after NRP (p = 0.0053). Following a reduction of DWIT (15 min), DCD liver recipients achieved comparable survivals with NRP (80%). INTERPRETATION High-risk DCD livers benefit more from HOPE-treatment, either immediately in the donor or after cold storage. Comparative prospective clinical studies are required to translate the results. FUNDING Funding was provided by the Swiss National Science Foundation (grant no: 32003B-140776/1, 3200B-153012/1, 320030-189055/1, and 31IC30-166909) and supported by University Careggi (grant no 32003B-140776/1) and the OTT (grant No.: DRGT641/2019, cod.prog. 19CT03) and the Max Planck Society. Work in the A.G. laboratory was partially supported by the NIH R01NS112381 and R21NS125466 grants.
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Affiliation(s)
- Rebecca Panconesi
- Hepatobiliary Unit, Careggi University Hospital, University of Florence, Florence, Italy; Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy; Department of Surgery, A.O.U. Città della Salute e della Scienza di Torino, University of Turin, 10124, Turin, Italy; Department of Visceral Surgery and Transplantation, University Hospital Zurich, Swiss HPB and Transplant Center, Zurich, Switzerland
| | | | - Janina Eden
- Department of Visceral Surgery and Transplantation, University Hospital Zurich, Swiss HPB and Transplant Center, Zurich, Switzerland
| | - Marilena Fazi
- Hepatobiliary Unit, Careggi University Hospital, University of Florence, Florence, Italy; Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Fariha Ansari
- Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, 407 East 61st Street, New York, NY, 10065, USA
| | - Leandro Mancina
- Department of Visceral Surgery and Transplantation, University Hospital Zurich, Swiss HPB and Transplant Center, Zurich, Switzerland
| | - Nadia Navari
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Richard Xavier Sousa Da Silva
- Department of Visceral Surgery and Transplantation, University Hospital Zurich, Swiss HPB and Transplant Center, Zurich, Switzerland
| | - Daniele Dondossola
- General and Liver Transplant Surgery Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico and University of Milan, Centre of Preclinical Research, 20122, Italy
| | - Lucia Bautista Borrego
- Department of Visceral Surgery and Transplantation, University Hospital Zurich, Swiss HPB and Transplant Center, Zurich, Switzerland
| | - Matthias Pietzke
- Max Planck Institute for Molecular Genetics, Mass Spectrometry Facility, 14195, Berlin, Germany
| | - Adriano Peris
- Tuscany Regional Transplant Authority, Centro Regionale Allocazione Organi e Tessuti (CRAOT), Florence, Italy
| | - David Meierhofer
- Max Planck Institute for Molecular Genetics, Mass Spectrometry Facility, 14195, Berlin, Germany
| | - Paolo Muiesan
- Hepatobiliary Unit, Careggi University Hospital, University of Florence, Florence, Italy; Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy; Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, 407 East 61st Street, New York, NY, 10065, USA
| | - Alexander Galkin
- Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, 407 East 61st Street, New York, NY, 10065, USA
| | - Fabio Marra
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy; Center for Research, High Education and Transfer DENOThe, University of Florence, Florence, Italy
| | - Philipp Dutkowski
- Department of Visceral Surgery and Transplantation, University Hospital Zurich, Swiss HPB and Transplant Center, Zurich, Switzerland
| | - Andrea Schlegel
- Hepatobiliary Unit, Careggi University Hospital, University of Florence, Florence, Italy; Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy; Department of Visceral Surgery and Transplantation, University Hospital Zurich, Swiss HPB and Transplant Center, Zurich, Switzerland; General and Liver Transplant Surgery Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico and University of Milan, Centre of Preclinical Research, 20122, Italy; Transplantation Center, Digestive Disease and Surgery Institute and Department of Immunology, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA.
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4
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Parmentier C, Ray S, Mazilescu LI, Kawamura M, Noguchi Y, Nogueira E, Ganesh S, Arulratnam B, Kalimuthu SN, Selzner M, Reichman TW. Normothermic Ex Vivo Machine Perfusion of Discarded Human Pancreas Allografts: A Feasibility Study. Transpl Int 2023; 36:10936. [PMID: 37252614 PMCID: PMC10210159 DOI: 10.3389/ti.2023.10936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 04/28/2023] [Indexed: 05/31/2023]
Abstract
Pancreas transplantation is the only curative treatment for patients with complicated diabetes, and organ shortage is a common and increasing problem. Strategies to expand the donor pool are needed, and normothermic ex vivo perfusion of the pancreas has the potential to test and repair grafts before implantation. Between January 2021 and April 2022, six human pancreases, declined for transplantation or islet isolation, were perfused using a previously established method by our group. All 6 cases were successfully perfused for 4 h, with minimal edema. The mean age of the donors was 44.16 ± 13.8 years. Five grafts were obtained from neurological death donors, and one was obtained from a donation after cardiac death. The mean glucose and lactate levels decreased throughout perfusion and insulin levels increased. All 6 grafts were metabolically active during perfusion and histopathology showed minimal tissue injury and no edema. Human normothermic ex vivo perfusion of the pancreas is feasible and safe and has the potential to expand the donor pool. Future studies will focus on tests and biomarkers for the assessment of grafts.
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Affiliation(s)
- Catherine Parmentier
- Toronto General Hospital, Toronto, ON, Canada
- University Health Network (UHN), Toronto, ON, Canada
| | - Samrat Ray
- Toronto General Hospital, Toronto, ON, Canada
- University Health Network (UHN), Toronto, ON, Canada
| | - Laura I. Mazilescu
- Toronto General Hospital, Toronto, ON, Canada
- University Health Network (UHN), Toronto, ON, Canada
- Essen University Hospital, Essen, North Rhine-Westphalia, Germany
| | - Masataka Kawamura
- Toronto General Hospital, Toronto, ON, Canada
- University Health Network (UHN), Toronto, ON, Canada
| | - Yuki Noguchi
- Toronto General Hospital, Toronto, ON, Canada
- University Health Network (UHN), Toronto, ON, Canada
| | - Emmanuel Nogueira
- Toronto General Hospital, Toronto, ON, Canada
- University Health Network (UHN), Toronto, ON, Canada
| | - Sujani Ganesh
- Toronto General Hospital, Toronto, ON, Canada
- University Health Network (UHN), Toronto, ON, Canada
| | - Bhranavi Arulratnam
- Toronto General Hospital, Toronto, ON, Canada
- University Health Network (UHN), Toronto, ON, Canada
| | - Sangeetha N. Kalimuthu
- Toronto General Hospital, Toronto, ON, Canada
- University Health Network (UHN), Toronto, ON, Canada
| | - Markus Selzner
- Toronto General Hospital, Toronto, ON, Canada
- University Health Network (UHN), Toronto, ON, Canada
| | - Trevor W. Reichman
- Toronto General Hospital, Toronto, ON, Canada
- University Health Network (UHN), Toronto, ON, Canada
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5
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Tripathy S, Das SK. Strategies for organ preservation: Current prospective and challenges. Cell Biol Int 2023; 47:520-538. [PMID: 36626269 DOI: 10.1002/cbin.11984] [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: 07/25/2022] [Revised: 11/02/2022] [Accepted: 11/09/2022] [Indexed: 01/11/2023]
Abstract
In current therapeutic approaches, transplantation of organs provides the best available treatment for a myriad of end-stage organ failures. However, shortage of organ donors, lacunae in preservation methods, and lack of a suitable match are the major constraints in advocating this life-sustaining therapy. There has been continuous progress in the strategies for organ preservation since its inception. Current strategies for organ preservation are based on the University of Wisconsin (UW) solution using the machine perfusion technique, which allows successful preservation of intra-abdominal organs (kidney and liver) but not intra-thoracic organs (lungs and heart). However, novel concepts with a wide range of adapted preservation technologies that can increase the shelf life of retrieved organs are still under investigation. The therapeutic interventions of in vitro-cultured stem cells could provide novel strategies for replacement of nonfunctional cells of damaged organs with that of functional ones. This review describes existing strategies, highlights recent advances, discusses challenges and innovative approaches for effective organ preservation, and describes application of stem cells to restore the functional activity of damaged organs for future clinical practices.
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Affiliation(s)
- Seema Tripathy
- School of Biological Sciences, National Institute of Science Education and Research (NISER), Bhubaneshwar, India
| | - Saroj Kumar Das
- Neurobiology Laboratory, Centre for Biotechnology, Siksha 'O' Anusandhan (Deemed to be University), Bhubaneswar, India
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6
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Ferrer-Fàbrega J, Folch-Puy E, Llaves-López A, García-Pérez R, Fuster J. Breaking the limits of experimental pancreas transplantation: Working toward the clinical ideal graft. FRONTIERS IN TRANSPLANTATION 2022; 1:1035480. [PMID: 38994386 PMCID: PMC11235275 DOI: 10.3389/frtra.2022.1035480] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 09/27/2022] [Indexed: 07/13/2024]
Abstract
Pancreas transplantation is, at present, the only curative treatment for type-1 diabetes that maintains normoglycemia thus avoiding complications arising from poor glycemic control. Despite its great benefits, the number of pancreas transplants has decreased significantly since its inception in the late 1960s, largely due to demographic changes and the consequent suboptimal quality of donors. The selection criteria for pancreas donors mainly depend on morphological variables such as fatty infiltration, fibrosis, or edema, as well as both functional (amylase and lipase) and clinical variables of the donor. However, the final criterion in the decision-making process is the somewhat subjective assessment of a trained surgeon. That being said, the recent incorporation of graft perfusion machines into clinical practice seems to be changing the work dynamics of the donor organ retrieval team, facilitating decision-making based on objective morphological and functional criteria. Normothermic perfusion using perfusate with supplemental oxygen replicates near physiological parameters thus being a promising strategy for organ preservation. Nevertheless, optimum perfusion parameters are difficult to establish in pancreas transplantation given its complex vascular anatomy combined with an intrinsically low blood flow. The objective of this work is to analyze the results published in the recent literature relating to the considerations of ex-vivo normothermic graft perfusion machines and their usefulness in the field of pancreas transplantation.
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Affiliation(s)
- Joana Ferrer-Fàbrega
- Hepatobiliopancreatic Surgery and Liver and Pancreatic Transplantation Unit, Clinic Institute of Digestive and Metabolic Diseases (ICMDiM), Hospital Clínic, University of Barcelona, Barcelona, Spain
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
- Network for Biomedical Research in Hepatic and Digestive Diseases (CIBEREHD), Barcelona, Spain
| | - Emma Folch-Puy
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
- Experimental Pathology Department, Institut d'Investigacions Biomèdiques de Barcelona-Consejo Superior de Investigaciones Científicas (IIBB-CSIC), Barcelona, Spain
| | - Andrea Llaves-López
- Experimental Pathology Department, Institut d'Investigacions Biomèdiques de Barcelona-Consejo Superior de Investigaciones Científicas (IIBB-CSIC), Barcelona, Spain
| | - Rocío García-Pérez
- Hepatobiliopancreatic Surgery and Liver and Pancreatic Transplantation Unit, Clinic Institute of Digestive and Metabolic Diseases (ICMDiM), Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Josep Fuster
- Hepatobiliopancreatic Surgery and Liver and Pancreatic Transplantation Unit, Clinic Institute of Digestive and Metabolic Diseases (ICMDiM), Hospital Clínic, University of Barcelona, Barcelona, Spain
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
- Network for Biomedical Research in Hepatic and Digestive Diseases (CIBEREHD), Barcelona, Spain
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7
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Mazilescu LI, Parmentier C, Kalimuthu SN, Ganesh S, Kawamura M, Goto T, Noguchi Y, Selzner M, Reichman TW. Normothermic ex situ pancreas perfusion for the preservation of porcine pancreas grafts. Am J Transplant 2022; 22:1339-1349. [PMID: 35258859 PMCID: PMC9314088 DOI: 10.1111/ajt.17019] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 01/28/2022] [Accepted: 02/23/2022] [Indexed: 01/25/2023]
Abstract
Pancreas transplantation improves and extends the life of patients with insulin-dependent diabetes. Pancreata from extended criteria donors have been increasingly used due to the scarcity of available grafts. Normothermic ex situ pancreas perfusion (NESPP) can keep grafts metabolically active, potentially allowing for assessment and organ repair, and could improve outcomes of marginal grafts. A novel NESPP technique was developed and tested. Porcine pancreata were removed after a short period of warm ischemia and subjected to 6 h of NESPP. Perfusion parameters, potential graft assessment markers and graft injury were measured. Next, pancreata subjected to 3 h of NESPP were transplanted and animals were followed for up to 3 days. Graft function and injury post-transplantation were evaluated. Using this novel system of perfusion, pancreata were perfused for an extended period of time with minimal edema. Histology at the end of perfusion showed intact islet cells with only mild signs of tissue injury. NESPP transplanted grafts showed immediate function after transplantation, with glucose levels in normal range. NESPP maintains a physiologic environment and excellent graft function without causing significant graft injury. Porcine pancreas transplantation is feasible and allows for in vivo graft assessment of pancreas function and injury after NESPP.
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Affiliation(s)
- Laura I. Mazilescu
- Ajmera Transplant ProgramToronto General HospitalTorontoOntarioCanada,Division of NephrologyThe Hospital for Sick ChildrenTorontoOntarioCanada,Department of General, Visceral, and Transplantation SurgeryUniversity Hospital EssenEssenGermany,Division of General SurgeryToronto General HospitalUniversity Health NetworkTorontoOntarioCanada
| | | | - Sangeetha N. Kalimuthu
- Department of PathologyUniversity Health Network and University of TorontoTorontoOntarioCanada
| | - Sujani Ganesh
- Ajmera Transplant ProgramToronto General HospitalTorontoOntarioCanada
| | - Masataka Kawamura
- Ajmera Transplant ProgramToronto General HospitalTorontoOntarioCanada
| | - Toru Goto
- Ajmera Transplant ProgramToronto General HospitalTorontoOntarioCanada
| | - Yuki Noguchi
- Ajmera Transplant ProgramToronto General HospitalTorontoOntarioCanada
| | - Markus Selzner
- Ajmera Transplant ProgramToronto General HospitalTorontoOntarioCanada,Division of General SurgeryToronto General HospitalUniversity Health NetworkTorontoOntarioCanada
| | - Trevor W. Reichman
- Ajmera Transplant ProgramToronto General HospitalTorontoOntarioCanada,Division of General SurgeryToronto General HospitalUniversity Health NetworkTorontoOntarioCanada
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8
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Kirste G. Cold but not too cold: advances in hypothermic and normothermic organ perfusion. KOREAN JOURNAL OF TRANSPLANTATION 2022; 36:2-14. [PMID: 35769433 PMCID: PMC9235527 DOI: 10.4285/kjt.22.0008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 02/21/2022] [Indexed: 11/24/2022] Open
Abstract
Transplantation is the method of choice and, in many cases, the only method of treatment for patients with end-stage organ disease. Excellent results have been achieved, and the main focus today is to extend the number of available donors. The use of extended-criteria donors or donors after circulatory death is standard, but is accompanied by an increased risk of ischemia reperfusion injury. This review presents newly developed machine perfusion techniques using hypothermic, subnormothermic, or normothermic conditions, with or without oxygenation. Possibilities for treatment and quality assessment in decision-making about organ acceptability are also discussed.
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Affiliation(s)
- Guenter Kirste
- Department of Surgery, University Hospital of Freiburg, Albert Ludwig University of Freiburg, Freiburg im Breisgau, Germany
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9
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Ogbemudia AE, Hakim G, Dengu F, El-Gilani F, Dumbill R, Mulvey J, Sayal K, Prudhomme T, Mesnard B, Rozenberg K, Lo Faro L, James T, Oliver J, Sharples E, Mittal S, Johnson P, Friend PJ, Ploeg R, Hunter J, Branchereau J. Development of ex situ normothermic reperfusion as an innovative method to assess pancreases after preservation. Transpl Int 2021; 34:1630-1642. [PMID: 34448276 DOI: 10.1111/tri.13990] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 07/07/2021] [Indexed: 12/26/2022]
Abstract
Static cold storage (SCS) is the standard method for pancreas preservation prior to transplantation; however, it does not permit organ assessment. Normothermic reperfusion (NR) is utilized clinically for other organs to assess viability. Our aim was to develop NR using normothermic machine perfusion technique to simulate reperfusion at the time of transplantation, enabling evaluation of oxygenated hypothermic machine perfusion (HMPO2) as a newer strategy to optimize pancreas preservation. 13 porcine pancreases procured after circulatory death were divided into 3 groups: 4 pancreases preserved using SCS, and 2 groups preserved by HMPO2 (n = 4 and n = 5, differing by type of preservation solution). Duration of perfusion or cold storage was 6 hours before the 1-hour assessment using NR. Outcome measures were perfusion characteristics, biochemistry and change in tissue water mass as oedema assessment. During NR, the HMPO2 groups demonstrated better perfusion characteristics, normal macroscopic appearances, decreased water mass and one HMPO2 group demonstrated a response to glucose stimulation. Conversely, the SCS group showed an increased water mass and developed early macroscopic appearances of oedema, interstitial haemorrhage and minimal portal outflow. This study suggests that ex situ assessment of pancreases by NR is promising, and that HMPO2 may be better than SCS.
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Affiliation(s)
- Ann Etohan Ogbemudia
- Nuffield Department of Surgical Sciences, Oxford Transplant Centre, University of Oxford, Oxford, UK.,Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Gabriella Hakim
- Nuffield Department of Surgical Sciences, Oxford Transplant Centre, University of Oxford, Oxford, UK
| | - Fungai Dengu
- Nuffield Department of Surgical Sciences, Oxford Transplant Centre, University of Oxford, Oxford, UK.,Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Faysal El-Gilani
- Nuffield Department of Surgical Sciences, Oxford Transplant Centre, University of Oxford, Oxford, UK.,Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Richard Dumbill
- Nuffield Department of Surgical Sciences, Oxford Transplant Centre, University of Oxford, Oxford, UK.,Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - John Mulvey
- Nuffield Department of Surgical Sciences, Oxford Transplant Centre, University of Oxford, Oxford, UK
| | - Karen Sayal
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,CRUK, Oxford Cancer Centre, University of Oxford, Oxford, UK
| | - Thomas Prudhomme
- Department Urology, Kidney Transplantation and Andrology, Toulouse Rangueil University, Toulouse, France
| | - Benoit Mesnard
- Institut de Transplantation Urologie Néphrologie (ITUN), CHU Nantes, Nantes, France
| | - Kaithlyn Rozenberg
- Nuffield Department of Surgical Sciences, Oxford Transplant Centre, University of Oxford, Oxford, UK
| | - Letizia Lo Faro
- Nuffield Department of Surgical Sciences, Oxford Transplant Centre, University of Oxford, Oxford, UK
| | - Timothy James
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Joshua Oliver
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Edward Sharples
- Nuffield Department of Surgical Sciences, Oxford Transplant Centre, University of Oxford, Oxford, UK.,Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Shruti Mittal
- Nuffield Department of Surgical Sciences, Oxford Transplant Centre, University of Oxford, Oxford, UK.,Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Paul Johnson
- Nuffield Department of Surgical Sciences, Oxford Transplant Centre, University of Oxford, Oxford, UK.,DRWF Human Islet Isolation Facility, Oxford, UK
| | - Peter J Friend
- Nuffield Department of Surgical Sciences, Oxford Transplant Centre, University of Oxford, Oxford, UK.,Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Rutger Ploeg
- Nuffield Department of Surgical Sciences, Oxford Transplant Centre, University of Oxford, Oxford, UK.,Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - James Hunter
- Nuffield Department of Surgical Sciences, Oxford Transplant Centre, University of Oxford, Oxford, UK.,Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,University Hospitals Coventry and Warwickshire NHS Trust, Oxford, UK
| | - Julien Branchereau
- Nuffield Department of Surgical Sciences, Oxford Transplant Centre, University of Oxford, Oxford, UK.,Institut de Transplantation Urologie Néphrologie (ITUN), CHU Nantes, Nantes, France.,Centre de Recherche en Transplantation Et Immunologie (CRTI), UMR1064, INSERM, Université de Nantes, Nantes, France
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10
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Doppenberg JB, Leemkuil M, Engelse MA, Krikke C, de Koning EJP, Leuvenink HGD. Hypothermic oxygenated machine perfusion of the human pancreas for clinical islet isolation: a prospective feasibility study. Transpl Int 2021; 34:1397-1407. [PMID: 34036616 PMCID: PMC8456912 DOI: 10.1111/tri.13927] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 05/14/2021] [Accepted: 05/16/2021] [Indexed: 11/28/2022]
Abstract
Due to an increasing scarcity of pancreases with optimal donor characteristics, islet isolation centers utilize pancreases from extended criteria donors, such as from donation after circulatory death (DCD) donors, which are particularly susceptible to prolonged cold ischemia time (CIT). We hypothesized that hypothermic machine perfusion (HMP) can safely increase CIT. Five human DCD pancreases were subjected to 6 h of oxygenated HMP. Perfusion parameters, apoptosis, and edema were measured prior to islet isolation. Five human DBD pancreases were evaluated after static cold storage (SCS). Islet viability, and in vitro and in vivo functionality in diabetic mice were analyzed. Islets were isolated from HMP pancreases after 13.4 h [12.9–14.5] CIT and after 9.2 h [6.5–12.5] CIT from SCS pancreases. Histological analysis of the pancreatic tissue showed that HMP did not induce edema nor apoptosis. Islets maintained >90% viable during culture, and an appropriate in vitro and in vivo function in mice was demonstrated after HMP. The current study design does not permit to demonstrate that oxygenated HMP allows for cold ischemia extension; however, the successful isolation of functional islets from discarded human DCD pancreases after performing 6 h of oxygenated HMP indicates that oxygenated HMP may be a useful technology for better preservation of pancreases.
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Affiliation(s)
- Jason B Doppenberg
- Transplantation Center, Leiden University Medical Center, Leiden, the Netherlands
| | - Marjolein Leemkuil
- Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands
| | - Marten A Engelse
- Transplantation Center, Leiden University Medical Center, Leiden, the Netherlands
| | - Christina Krikke
- Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands
| | - Eelco J P de Koning
- Transplantation Center, Leiden University Medical Center, Leiden, the Netherlands
| | - Henri G D Leuvenink
- Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands
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11
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Elango M, Papalois V. Working towards an ERAS Protocol for Pancreatic Transplantation: A Narrative Review. J Clin Med 2021; 10:1418. [PMID: 33915899 PMCID: PMC8036565 DOI: 10.3390/jcm10071418] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 03/24/2021] [Accepted: 03/27/2021] [Indexed: 12/11/2022] Open
Abstract
Enhanced recovery after surgery (ERAS) initially started in the early 2000s as a series of protocols to improve the perioperative care of surgical patients. They aimed to increase patient satisfaction while reducing postoperative complications and postoperative length of stay. Despite these protocols being widely adopted in many fields of surgery, they are yet to be adopted in pancreatic transplantation: a high-risk surgery with often prolonged length of postoperative stay and high rate of complications. We have analysed the literature in pancreatic and transplantation surgery to identify the necessary preoperative, intra-operative and postoperative components of an ERAS pathway in pancreas transplantation.
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Affiliation(s)
- Madhivanan Elango
- Department of Surgery and Cancer, Imperial College London, London SW7 2AZ, UK;
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12
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Kattner N, Dyson N, Bury Y, Tiniakos D, White K, Davey T, Eliasson L, Tindale L, Wagner BE, Honkanen-Scott M, Doyle J, Ploeg RJ, Shaw JA, Scott WE. Development and validation of a quantitative electron microscopy score to assess acute cellular stress in the human exocrine pancreas. JOURNAL OF PATHOLOGY CLINICAL RESEARCH 2020; 7:173-187. [PMID: 33225596 PMCID: PMC7869933 DOI: 10.1002/cjp2.185] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 09/21/2020] [Accepted: 09/28/2020] [Indexed: 12/11/2022]
Abstract
The pancreas is particularly sensitive to acute cellular stress, but this has been difficult to evaluate using light microscopy. Pancreatic ischaemia associated with deceased organ donation negatively impacts whole‐organ and isolated‐islet transplantation outcomes. Post‐mortem changes have also hampered accurate interpretation of ante‐mortem pancreatic pathology. A rigorous histological scoring system accurately quantifying ischaemia is required to experimentally evaluate innovations in organ preservation and to increase rigour in clinical/research evaluation of underlying pancreatic pathology. We developed and validated an unbiased electron microscopy (EM) score of acute pancreatic exocrine cellular stress in deceased organ donor cohorts (development [n = 28] and validation [n = 16]). Standardised assessment led to clearly described numerical scores (0–3) for nuclear, mitochondrial and endoplasmic reticulum (ER) morphology and intracellular vacuolisation; with a maximum (worst) aggregate total score of 12. In the Validation cohort, a trend towards higher scores was observed for tail versus head regions (nucleus score following donation after brainstem death [DBD]: head 0.67 ± 0.19; tail 0.86 ± 0.11; p = 0.027) and donation after circulatory death (DCD) versus DBD (mitochondrial score: DCD (head + tail) 2.59 ± 0.16; DBD (head + tail) 2.38 ± 0.21; p = 0.004). Significant mitochondrial changes were seen ubiquitously even with short cold ischaemia, whereas nuclear and vacuolisation changes remained mild even after prolonged ischaemia. ER score correlated with cold ischaemia time (CIT) following DBD (pancreatic tail region: r = 0.796; p = 0.018). No relationships between CIT and EM scores were observed following DCD. In conclusion, we have developed and validated a novel EM score providing standardised quantitative assessment of subcellular ultrastructural morphology in pancreatic acinar cells. This provides a robust novel tool for gold standard measurement of acute cellular stress in studies evaluating surrogate measures of peri‐transplant ischaemia, organ preservation technologies and in samples obtained for detailed pathological examination of underlying pancreatic pathology.
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Affiliation(s)
- Nicole Kattner
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Nicola Dyson
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Yvonne Bury
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK.,Department of Cellular Pathology, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Dina Tiniakos
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK.,Department of Pathology, Aretaieion Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Kathryn White
- Electron Microscopy Research Services, Newcastle University, Newcastle upon Tyne, UK
| | - Tracey Davey
- Electron Microscopy Research Services, Newcastle University, Newcastle upon Tyne, UK
| | - Lena Eliasson
- Department of Clinical Sciences Malmö, Islet Cell Exocytosis, Lund University Diabetes Centre, Lund University, Malmö, Sweden
| | - Lynn Tindale
- Department of Cellular Pathology, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Bart E Wagner
- Histopathology Department, Royal Hallamshire Hospital, Sheffield, UK
| | - Minna Honkanen-Scott
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Jennifer Doyle
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Rutger J Ploeg
- Nuffield Department of Surgical Science, University of Oxford, BRC Oxford and NHS Blood and Transplant, Oxford, UK
| | - James Am Shaw
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK.,Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - William E Scott
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
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13
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Abstract
Because of the high demand of organs, the usage of marginal grafts has increased. These marginal organs have a higher risk of developing ischemia-reperfusion injury, which can lead to posttransplant complications. Ex situ machine perfusion (MP), compared with the traditional static cold storage, may better protect these organs from ischemia-reperfusion injury. In addition, MP can also act as a platform for dynamic administration of pharmacological agents or gene therapy to further improve transplant outcomes. Numerous therapeutic agents have been studied under both hypothermic (1-8°C) and normothermic settings. Here, we review all the therapeutics used during MP in different organ systems (lung, liver, kidney, heart). The major categories of therapeutic agents include vasodilators, mesenchymal stem cells, antiinflammatory agents, antiinfection agents, siRNA, and defatting agents. Numerous animal and clinical studies have examined MP therapeutic agents, some of which have even led to the successful reconditioning of discarded grafts. More clinical studies, especially randomized controlled trials, will need to be conducted in the future to solidify these promising results and to define the role of MP therapeutic agents in solid organ transplantation.
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14
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Resch T, Cardini B, Oberhuber R, Weissenbacher A, Dumfarth J, Krapf C, Boesmueller C, Oefner D, Grimm M, Schneeberger S. Transplanting Marginal Organs in the Era of Modern Machine Perfusion and Advanced Organ Monitoring. Front Immunol 2020; 11:631. [PMID: 32477321 PMCID: PMC7235363 DOI: 10.3389/fimmu.2020.00631] [Citation(s) in RCA: 75] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 03/19/2020] [Indexed: 12/11/2022] Open
Abstract
Organ transplantation is undergoing profound changes. Contraindications for donation have been revised in order to better meet the organ demand. The use of lower-quality organs and organs with greater preoperative damage, including those from donation after cardiac death (DCD), has become an established routine but increases the risk of graft malfunction. This risk is further aggravated by ischemia and reperfusion injury (IRI) in the process of transplantation. These circumstances demand a preservation technology that ameliorates IRI and allows for assessment of viability and function prior to transplantation. Oxygenated hypothermic and normothermic machine perfusion (MP) have emerged as valid novel modalities for advanced organ preservation and conditioning. Ex vivo prolonged lung preservation has resulted in successful transplantation of high-risk donor lungs. Normothermic MP of hearts and livers has displayed safe (heart) and superior (liver) preservation in randomized controlled trials (RCT). Normothermic kidney preservation for 24 h was recently established. Early clinical outcomes beyond the market entry trials indicate bioenergetics reconditioning, improved preservation of structures subject to IRI, and significant prolongation of the preservation time. The monitoring of perfusion parameters, the biochemical investigation of preservation fluids, and the assessment of tissue viability and bioenergetics function now offer a comprehensive assessment of organ quality and function ex situ. Gene and protein expression profiling, investigation of passenger leukocytes, and advanced imaging may further enhance the understanding of the condition of an organ during MP. In addition, MP offers a platform for organ reconditioning and regeneration and hence catalyzes the clinical realization of tissue engineering. Organ modification may include immunological modification and the generation of chimeric organs. While these ideas are not conceptually new, MP now offers a platform for clinical realization. Defatting of steatotic livers, modulation of inflammation during preservation in lungs, vasodilatation of livers, and hepatitis C elimination have been successfully demonstrated in experimental and clinical trials. Targeted treatment of lesions and surgical treatment or graft modification have been attempted. In this review, we address the current state of MP and advanced organ monitoring and speculate about logical future steps and how this evolution of a novel technology can result in a medial revolution.
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Affiliation(s)
- Thomas Resch
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Benno Cardini
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Rupert Oberhuber
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Annemarie Weissenbacher
- Department of Visceral, Transplant and Thoracic Surgery, 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
| | - Claudia Boesmueller
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Dietmar Oefner
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Michael Grimm
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Sefan Schneeberger
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
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15
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Moving the Margins: Updates on the Renaissance in Machine Perfusion for Organ Transplantation. CURRENT TRANSPLANTATION REPORTS 2020. [DOI: 10.1007/s40472-020-00277-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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16
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Kvietkauskas M, Leber B, Strupas K, Stiegler P, Schemmer P. Machine Perfusion of Extended Criteria Donor Organs: Immunological Aspects. Front Immunol 2020; 11:192. [PMID: 32180769 PMCID: PMC7057848 DOI: 10.3389/fimmu.2020.00192] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Accepted: 01/24/2020] [Indexed: 12/20/2022] Open
Abstract
Due to higher vulnerability and immunogenicity of extended criteria donor (ECD) organs used for organ transplantation (Tx), the discovery of new treatment strategies, involving tissue allorecognition pathways, is important. The implementation of machine perfusion (MP) led to improved estimation of the organ quality and introduced the possibility to achieve graft reconditioning prior to Tx. A significant number of experimental and clinical trials demonstrated increasing support for MP as a promising method of ECD organ preservation compared to classical static cold storage. MP reduced ischemia-reperfusion injury resulting in the protection from inadequate activation of innate immunity. However, there are no general agreements on MP protocols, and clinical application is limited. The objective of this comprehensive review is to summarize literature on immunological effects of MP of ECD organs based on experimental studies and clinical trials.
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Affiliation(s)
- Mindaugas Kvietkauskas
- Department of General, Visceral and Transplant Surgery, Medical University of Graz, Graz, Austria.,Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Bettina Leber
- Department of General, Visceral and Transplant Surgery, Medical University of Graz, Graz, Austria
| | | | - Philipp Stiegler
- Department of General, Visceral and Transplant Surgery, Medical University of Graz, Graz, Austria
| | - Peter Schemmer
- Department of General, Visceral and Transplant Surgery, Medical University of Graz, Graz, Austria
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17
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Prudhomme T, Renaudin K, Lo Faro ML, Cantarovich D, Kervella D, Minault D, Hervouet J, Le Bas-Bernardet S, Karam G, Blancho G, Branchereau J. Ex situ hypothermic perfusion of nonhuman primate pancreas: A feasibility study. Artif Organs 2020; 44:736-743. [PMID: 31995645 DOI: 10.1111/aor.13655] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 01/16/2020] [Accepted: 01/23/2020] [Indexed: 12/15/2022]
Abstract
Pancreatic static cold storage (SCS) is the gold-standard method for pancreas preservation. Our main objective was to evaluate feasibility of hypothermic perfusion (HP) of nonhuman primates' pancreases for potential organ transplantation. Seven baboon pancreases were tested. Animals were included in a study approved by the French Research Ministry of Health. Two groups were compared: the control group (n = 2) was preserved using conventional SCS for 24-h and the perfusion group (n = 5) used HP for 24-h, with three different perfusion pressures (PP): 15 (n = 3), 20 (n = 1), and 25 mm Hg (n = 1). In the control group, focal congestion of islets was observed after 6-h. At 24-h, ischemic necrosis and multifocal congestion also occurred. In the HP group, at 15 mm Hg PP, multifocal congestion of islets was present at 24-h. At 20 mm Hg PP, no ischemic necrosis was found after 6-h. At 12-h and 24-h, focal congestion of islets was seen. At 25 mm Hg PP, focal congestion of islets appeared after 12-h. Immunostaining for insulin, glucagon, and somatostatin was normal and similar in controls and perfused pancreas transplants even after 24-h. Apoptosis index represented by cleaved caspase 3 activity, was less than 1% in perfusion and control groups, even after 24-h. HP of nonhuman primate pancreas is feasible and not deleterious as far as 24-h compared to SCS. SCS for more than 12-h was harmful for the transplants. Systolic perfusion pressure between 15-20 mm Hg did not cause any pathological injury of the tested organs.
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Affiliation(s)
- Thomas Prudhomme
- Institut de Transplantation Urologie Néphrologie (ITUN), CHU Nantes, Nantes, France.,Centre de Recherche en Transplantation et Immunologie (CRTI), UMR1064, INSERM, Université de Nantes, Nantes, France
| | - Karine Renaudin
- Département d'anatomie et cytologie pathologique, CHU Nantes, Nantes, France
| | - Maria Letizia Lo Faro
- Oxford Transplant Centre, Nuffield Department of Surgical Sciences, Churchill Hospital, Oxford, United Kingdom
| | - Diego Cantarovich
- Institut de Transplantation Urologie Néphrologie (ITUN), CHU Nantes, Nantes, France
| | - Delphine Kervella
- Institut de Transplantation Urologie Néphrologie (ITUN), CHU Nantes, Nantes, France.,Centre de Recherche en Transplantation et Immunologie (CRTI), UMR1064, INSERM, Université de Nantes, Nantes, France
| | - David Minault
- Centre de Recherche en Transplantation et Immunologie (CRTI), UMR1064, INSERM, Université de Nantes, Nantes, France
| | - Jérémy Hervouet
- Centre de Recherche en Transplantation et Immunologie (CRTI), UMR1064, INSERM, Université de Nantes, Nantes, France
| | - Stéphanie Le Bas-Bernardet
- Centre de Recherche en Transplantation et Immunologie (CRTI), UMR1064, INSERM, Université de Nantes, Nantes, France
| | - Georges Karam
- Institut de Transplantation Urologie Néphrologie (ITUN), CHU Nantes, Nantes, France
| | - Gilles Blancho
- Institut de Transplantation Urologie Néphrologie (ITUN), CHU Nantes, Nantes, France.,Centre de Recherche en Transplantation et Immunologie (CRTI), UMR1064, INSERM, Université de Nantes, Nantes, France
| | - Julien Branchereau
- Institut de Transplantation Urologie Néphrologie (ITUN), CHU Nantes, Nantes, France.,Centre de Recherche en Transplantation et Immunologie (CRTI), UMR1064, INSERM, Université de Nantes, Nantes, France.,Oxford Transplant Centre, Nuffield Department of Surgical Sciences, Churchill Hospital, Oxford, United Kingdom
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18
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Abstract
Composite tissue (CT) preservation is important to outcomes after replant or transplant. Since the first limb replant, the mainstay of preservation has been static cold storage with the amputated part being placed in moistened gauze over ice. Historically, the gold-standard in solid organ preservation has been static cold storage with specialized solution, but this has recently evolved in the last few decades to develop technologies such as machine perfusion and even persufflation. This review explores the impact of cooling and oxygenation on CT, summarizes the work done in the area of CT preservation, discusses lessons learned from our experience in solid organ preservation, and proposes future directions.
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19
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Novel Organ Perfusion and Preservation Strategies in Transplantation – Where Are We Going in the United Kingdom? Transplantation 2020; 104:1813-1824. [DOI: 10.1097/tp.0000000000003106] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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20
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Prudhomme T, Kervella D, Le Bas-Bernardet S, Cantarovich D, Karam G, Blancho G, Branchereau J. Ex situ Perfusion of Pancreas for Whole-Organ Transplantation: Is it Safe and Feasible? A Systematic Review. J Diabetes Sci Technol 2020; 14:120-134. [PMID: 31409133 PMCID: PMC7189158 DOI: 10.1177/1932296819869312] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Pancreas transplantation is currently one of the best treatments proposed in highly selected patients with unstable and brittle type 1 diabetes. The objective of pancreas transplantation is to restore normoglycemia and avoid the occurrence of complications associated with diabetes. Graft pancreatitis and thrombosis, arising from ischemia reperfusion injuries, are major causes of graft loss in the postoperative period. Ex situ perfusion, in hypothermic or normothermic settings, allowed to improve ischemic reperfusion injury in other organ transplantations (kidney, liver, or lung). The development of pancreatic graft perfusion techniques would limit these ischemic reperfusion injuries. OBJECTIVE Evaluation of the safety and feasibility of ex situ perfusion of pancreas for whole-organ transplantation. METHODS English literature about pancreas perfusion was analyzed using electronic database Medline via PubMed (1950-2018). Exclusion criteria were studies that did not specify the technical aspects of machine perfusion and studies focused only on pancreas perfusion for islet isolation. RESULTS Hypothermic machine perfusion for pancreas preservation has been evaluated in nine studies and normothermic machine perfusion in ten studies. We evaluated machine perfusion model, types of experimental model, anatomy, perfusion parameters, flushing and perfusion solution, length of perfusion, and comparison between static cold storage and perfusion. CONCLUSIONS This review compared ex vivo machine perfusion of experimental pancreas for whole-organ transplantation. Pancreas perfusion is feasible and could be a helpful tool to evaluate pancreas prior to transplantation. Pancreas perfusion (in hypothermic or normothermic settings) could reduce ischemic reperfusion injuries, and maybe could avoid pancreas thrombosis and reduce morbidity of pancreas transplantation.
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Affiliation(s)
- Thomas Prudhomme
- Centre de Recherche en Transplantation
et Immunologie UMR 1064, INSERM, Université de Nantes, France
- Institut de Transplantation Urologie
Néphrologie (ITUN), CHU Nantes, France
| | - Delphine Kervella
- Centre de Recherche en Transplantation
et Immunologie UMR 1064, INSERM, Université de Nantes, France
- Institut de Transplantation Urologie
Néphrologie (ITUN), CHU Nantes, France
| | - Stéphanie Le Bas-Bernardet
- Centre de Recherche en Transplantation
et Immunologie UMR 1064, INSERM, Université de Nantes, France
- Institut de Transplantation Urologie
Néphrologie (ITUN), CHU Nantes, France
| | - Diego Cantarovich
- Institut de Transplantation Urologie
Néphrologie (ITUN), CHU Nantes, France
| | - Georges Karam
- Institut de Transplantation Urologie
Néphrologie (ITUN), CHU Nantes, France
| | - Gilles Blancho
- Centre de Recherche en Transplantation
et Immunologie UMR 1064, INSERM, Université de Nantes, France
- Institut de Transplantation Urologie
Néphrologie (ITUN), CHU Nantes, France
| | - Julien Branchereau
- Centre de Recherche en Transplantation
et Immunologie UMR 1064, INSERM, Université de Nantes, France
- Institut de Transplantation Urologie
Néphrologie (ITUN), CHU Nantes, France
- Julien Branchereau, Centre de Recherche en
Transplantation et Immunologie UMR 1064, INSERM, 30 Bd Jean Monnet, Nantes
44035, France.
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21
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Abstract
PURPOSE OF REVIEW Beta-cell replacement is the best therapeutic option for patients with type 1 diabetes. Because of donor scarcity, more extended criteria donors are used for transplantation. Donation after circulatory death donors (DCD) are not commonly used for pancreas transplantation, because of the supposed higher risk of complications. This review gives an overview on the pathophysiology, risk factors, and outcome in DCD transplantation and discusses different preservation methods. RECENT FINDINGS Studies on outcomes of DCD pancreata show similar results compared with those of donation after brain death (DBD), when accumulation of other risk factors is avoided. Hypothermic machine perfusion is shown to be a safe method to improve graft viability in experimental settings. DCD should not be the sole reason to decline a pancreas for transplantation. Adequate donor selection and improved preservation techniques can lead to enhanced pancreas utilization and outcome.
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Affiliation(s)
- M. Leemkuil
- 0000 0000 9558 4598grid.4494.dDepartment of Surgery, University of Groningen, University Medical Center Groningen, P.O. Box 30 001, 9700 RB Groningen, The Netherlands
| | - H. G. D. Leuvenink
- 0000 0000 9558 4598grid.4494.dDepartment of Surgery, University of Groningen, University Medical Center Groningen, P.O. Box 30 001, 9700 RB Groningen, The Netherlands
| | - R. A. Pol
- 0000 0000 9558 4598grid.4494.dDepartment of Surgery, University of Groningen, University Medical Center Groningen, P.O. Box 30 001, 9700 RB Groningen, The Netherlands
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22
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Optimizing organs for transplantation; advancements in perfusion and preservation methods. Transplant Rev (Orlando) 2019; 34:100514. [PMID: 31645271 DOI: 10.1016/j.trre.2019.100514] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 06/20/2019] [Accepted: 10/11/2019] [Indexed: 02/06/2023]
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23
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Mensink JW, de Vries KM, Huurman VAL, Pol RA, Alwayn IPJ, Braat AE. Risk analysis of extended pancreas donor selection criteria. Pancreatology 2019; 19:994-999. [PMID: 31495709 DOI: 10.1016/j.pan.2019.08.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 07/04/2019] [Accepted: 08/25/2019] [Indexed: 12/11/2022]
Abstract
INTRODUCTION The success of pancreas transplantation, in combination with a stable number of available allografts has resulted in an increasing waiting list. This study investigated donor potential by expanding age and Body Mass Index (BMI) criteria. METHODS All reported donors in the Netherlands between 2013 and 2017 were analysed. Risk assessment of extended criteria donors was done by in-depth analysis of donor reports and calculation of the Pancreas Donor Risk Index (PDRI). The PDRI of these extended criteria donors was compared to standard criteria donors to evaluate the increased risk on graft failure. RESULTS A total of 1273 donors were reported. Of these donors, 405 donors were reported as pancreas donor, of which 93 (23%) pancreata were transplanted. Extending age criterion with 5 years could result in additional 40 Donation after Brain Death donors and 37 Donation after Circulatory Death donors reported. In 24 (31%) extended age criteria donors the PDRI was below the upper limit of currently transplanted pancreata. Extending BMI criteria to 35 kg/m2 could result in an additional 19 (6%) donors reported. CONCLUSIONS Extending BMI criteria could result in a slight increase of reported donors. Extending age criteria increased significantly the number of reported donors. In 24 (31%) of the older donors the PDRI showed a reduced risk compared to currently transplanted pancreata. This study suggest that, if other risk factors are absent, pancreata of extended age and/or BMI criteria donors should be considered for transplantation.
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Affiliation(s)
- Jacobus W Mensink
- Department of Transplant Surgery, LUMC, Leiden University, the Netherlands; Dutch Transplant Foundation, Leiden, the Netherlands.
| | | | | | - Robert A Pol
- Department of Transplant Surgery, UMCG, Groningen University, the Netherlands
| | - Ian P J Alwayn
- Department of Transplant Surgery, LUMC, Leiden University, the Netherlands
| | - Andries E Braat
- Department of Transplant Surgery, LUMC, Leiden University, the Netherlands
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24
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Abstract
PURPOSE OF REVIEW Pancreas transplantation enables complete patient independence from exogenous insulin administration and increases both patient survival and quality of life. Despite this, there has been a decline in pancreas transplantation for the past 20 years, influenced by changing donor demographics with more high-risk extended criteria (ECD) and donation after cardiac death (DCD) donors. This review discusses whether the advent of machine perfusion (MP), if extended to the pancreas, can increase the pool of suitable donor organs. RECENT FINDINGS Hypothermic and normothermic MP, as forms of preservation deemed superior to cold storage for high-risk kidney and liver donor organs, have opened the avenue for translation of this work into the pancreas. Recent experimental models of porcine and human ex-vivo pancreatic MP are promising. Applications of MP to the pancreas however need refinement-focusing on perfusion protocols and viability assessment tools. Emerging research shows pancreatic MP can potentially offer superior preservation capacity, the ability to both resuscitate and manipulate organs, and assess functional and metabolic organ viability. The future of MP will lie in organ assessment and resuscitation after retrieval, where ultimately organs initially considered high risk and unsuitable for transplantation will be optimised and transformed, making them then available for clinical use, thus increasing the pool of suitably viable pancreata for transplantation.
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Affiliation(s)
- Karim Hamaoui
- 0000 0001 2113 8111grid.7445.2Department of Surgery, Imperial College London, London, UK
| | - Vassilios Papalois
- 0000 0001 2113 8111grid.7445.2Department of Surgery, Imperial College London, London, UK
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25
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Weissenbacher A, Vrakas G, Nasralla D, Ceresa CDL. The future of organ perfusion and re-conditioning. Transpl Int 2019; 32:586-597. [PMID: 30980772 PMCID: PMC6850430 DOI: 10.1111/tri.13441] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 01/25/2019] [Accepted: 04/09/2019] [Indexed: 12/14/2022]
Abstract
Organ preservation and re‐conditioning using machine perfusion technologies continue to generate promising results in terms of viability assessment, organ utilization and improved initial graft function. Here, we summarize the latest findings and study the results of ex‐vivo/ex‐situ hypothermic (HMP) and normothermic machine perfusion (NMP) in the area of abdominal organ transplantation (kidney, liver, pancreas and intestine). We also consider the potential role of normothermic regional perfusion (NRP) to re‐condition donors after circulatory death organs before retrieval. The findings from clinical studies reported to date suggest that machine perfusion will offer real benefits when compared with conventional cold preservation. Several randomized trials are expected to report their findings within the next 2 years which may shed light on the relative merits of different perfusion methods and could indicate which perfusion parameters may be most useful to predict organ quality and viability. Further work is needed to identify composite endpoints that are relevant for transplanted organs that have undergone machine preservation. Multi‐centre trials to compare and analyse the combinations of NRP followed by HMP and/or NMP, either directly after organ retrieval using transportable devices or when back‐to‐base, are needed. The potential applications of machine preservation technology beyond the field of solid organ transplantation are also considered.
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Affiliation(s)
- Annemarie Weissenbacher
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria.,Nuffield Department of Surgical Sciences, Oxford Transplant Centre, Churchill Hospital, Oxford University Hospitals, University of Oxford, Oxford, UK
| | - Georgios Vrakas
- Nuffield Department of Surgical Sciences, Oxford Transplant Centre, Churchill Hospital, Oxford University Hospitals, University of Oxford, Oxford, UK
| | - David Nasralla
- Nuffield Department of Surgical Sciences, Oxford Transplant Centre, Churchill Hospital, Oxford University Hospitals, University of Oxford, Oxford, UK
| | - Carlo D L Ceresa
- Nuffield Department of Surgical Sciences, Oxford Transplant Centre, Churchill Hospital, Oxford University Hospitals, University of Oxford, Oxford, UK
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Messner F, Guo Y, Etra JW, Brandacher G. Emerging technologies in organ preservation, tissue engineering and regenerative medicine: a blessing or curse for transplantation? Transpl Int 2019; 32:673-685. [PMID: 30920056 DOI: 10.1111/tri.13432] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 01/18/2019] [Accepted: 03/21/2019] [Indexed: 02/06/2023]
Abstract
Since the beginning of transplant medicine in the 1950s, advances in surgical technique and immunosuppressive therapy have created the success story of modern organ transplantation. However, today more than ever, we are facing a huge discrepancy between organ supply and demand, limiting the potential for transplantation to save and improve the lives of millions. To address the current limitations and shortcomings, a variety of emerging new technologies focusing on either maximizing the availability of organs or on generating new organs and organ sources hold great potential to eventully overcoming these hurdles. These advances are mainly in the field of regenerative medicine and tissue engineering. This review gives an overview of this emerging field and its multiple sub-disciplines and highlights recent advances and existing limitations for widespread clinical application and potential impact on the future of transplantation.
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Affiliation(s)
- Franka Messner
- Vascularized Composite Allotransplantation (VCA) Laboratory, Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Yinan Guo
- Vascularized Composite Allotransplantation (VCA) Laboratory, Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Orthopedics, Xiangya Hospital of Central South University, Changsha, Hunan Province, China
| | - Joanna W Etra
- Vascularized Composite Allotransplantation (VCA) Laboratory, Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Gerald Brandacher
- Vascularized Composite Allotransplantation (VCA) Laboratory, Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Tchilikidi KY. Liver graft preservation methods during cold ischemia phase and normothermic machine perfusion. World J Gastrointest Surg 2019; 11:126-142. [PMID: 31057698 PMCID: PMC6478595 DOI: 10.4240/wjgs.v11.i3.126] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 03/21/2019] [Accepted: 03/24/2019] [Indexed: 02/06/2023] Open
Abstract
The growing demand for donor organs requires measures to expand donor pool. Those include extended criteria donors, such as elderly people, steatotic livers, donation after cardiac death, etc. Static cold storage to reduce metabolic requirements developed by Collins in late 1960s is the mainstay and the golden standard for donated organ protection. Hypothermic machine perfusion provides dynamic organ preservation at 4°C with protracted infusion of metabolic substrates to the graft during the ex vivo period. It has been used instead of static cold storage or after it as short perfusion in transplant center. Normothermic machine perfusion (NMP) delivers oxygen, and nutrition at physiological temperature mimicking regular environment in order to support cellular function. This would minimize effects of ischemia/reperfusion injury. Potentially, NMP may help to estimate graft functionality before implantation into a recipient. Clinical studies demonstrated at least its non-inferiority or better outcomes vs static cold storage. Regular grafts donated after brain death could be safely preserved with convenient static cold storage. Except for prolonged ischemia time where hypothermic machine perfusion started in transplant center could be estimated to provide possible positive reconditioning effect. Use of hypothermic machine perfusion in regular donation instead of static cold storage or in extended criteria donors requires further investigation. Multicenter randomized clinical trial supposed to be completed in December 2021. Extended criteria donors need additional measures for graft storage and assessment until its implantation. NMP is actively evaluating promising method for this purpose. Future studies are necessary for precise estimation and confirmation to issue clinical practice recommendations.
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