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Iskender I. Technical Advances Targeting Multiday Preservation of Isolated Ex Vivo Lung Perfusion. Transplantation 2024; 108:1319-1332. [PMID: 38499501 DOI: 10.1097/tp.0000000000004992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/20/2024]
Abstract
Indications for ex vivo lung perfusion (EVLP) have evolved from assessment of questionable donor lungs to treatment of some pathologies and the logistics. Yet up to 3 quarters of donor lungs remain discarded across the globe. Multiday preservation of discarded human lungs on EVLP platforms would improve donor lung utilization rates via application of sophisticated treatment modalities, which could eventually result in zero waitlist mortality. The purpose of this article is to summarize advances made on the technical aspects of the protocols in achieving a stable multiday preservation of isolated EVLP. Based on the evidence derived from large animal and/or human studies, the following advances have been considered important in achieving this goal: ability to reposition donor lungs during EVLP; perfusate adsorption/filtration modalities; perfusate enrichment with plasma and/or donor whole blood, nutrients, vitamins, and amino acids; low-flow, pulsatile, and subnormothermic perfusion; positive outflow pressure; injury specific personalized ventilation strategies; and negative pressure ventilation. Combination of some of these advances in an automatized EVLP device capable of managing perfusate biochemistry and ventilation would likely speed up the processes of achieving multiday preservation of isolated EVLP.
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Affiliation(s)
- Ilker Iskender
- Department of Cardiac Surgery, East Limburg Hospital, Genk, Belgium
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Chao BT, McInnis MC, Sage AT, Yeung JC, Cypel M, Liu M, Wang B, Keshavjee S. A radiographic score for human donor lungs on ex vivo lung perfusion predicts transplant outcomes. J Heart Lung Transplant 2024; 43:797-805. [PMID: 38211838 DOI: 10.1016/j.healun.2024.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 01/02/2024] [Accepted: 01/05/2024] [Indexed: 01/13/2024] Open
Abstract
BACKGROUND Ex vivo lung perfusion (EVLP) is an advanced platform for isolated lung assessment and treatment. Radiographs acquired during EVLP provide a unique opportunity to assess lung injury. The purpose of our study was to define and evaluate EVLP radiographic findings and their association with lung transplant outcomes. METHODS We retrospectively evaluated 113 EVLP cases from 2020-21. Radiographs were scored by a thoracic radiologist blinded to outcome. Six lung regions were scored for 5 radiographic features (consolidation, infiltrates, atelectasis, nodules, and interstitial lines) on a scale of 0 to 3 to derive a score. Spearman's correlation was used to correlate radiographic scores to biomarkers of lung injury. Machine learning models were developed using radiographic features and EVLP functional data. Predictive performance was assessed using the area under the curve. RESULTS Consolidation and infiltrates were the most frequent findings at 1 hour EVLP (radiographic lung score 2.6 (3.3) and 4.6 (4.3)). Consolidation (r = -0.536 and -0.608, p < 0.0001) and infiltrates (r = -0.492 and -0.616, p < 0.0001) were inversely correlated with oxygenation (∆pO2) at 1 hour and 3 hours of EVLP. First-hour consolidation and infiltrate lung scores predicted transplant suitability with an area under the curve of 87% and 88%, respectively. Prediction of transplant outcomes using a machine learning model yielded an area under the curve of 80% in the validation set. CONCLUSIONS EVLP radiographs provide valuable insight into donor lungs being assessed for transplantation. Consolidation and infiltrates were the most common abnormalities observed in EVLP lungs, and radiographic lung scores predicted the suitability of donor lungs for transplant.
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Affiliation(s)
- Bonnie T Chao
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada; Institute of Biomedical Engineering, University of Toronto, Toronto, Ontario, Canada
| | - Micheal C McInnis
- University Medical Imaging Toronto, Toronto General Hospital, University Health Network, Toronto, ON, Canada; Department of Medical Imaging, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Andrew T Sage
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada; Department of Surgery, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jonathan C Yeung
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Marcelo Cypel
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada; Department of Surgery, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Mingyao Liu
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada; Department of Surgery, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Bo Wang
- Vector Institute, University of Toronto, Toronto, Ontario, Canada; Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Shaf Keshavjee
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada; Institute of Biomedical Engineering, University of Toronto, Toronto, Ontario, Canada; Department of Surgery, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
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M M, Attawar S, BN M, Tisekar O, Mohandas A. Ex vivo lung perfusion and the Organ Care System: a review. CLINICAL TRANSPLANTATION AND RESEARCH 2024; 38:23-36. [PMID: 38725180 PMCID: PMC11075812 DOI: 10.4285/ctr.23.0057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 01/29/2024] [Accepted: 03/08/2024] [Indexed: 05/14/2024]
Abstract
With the increasing prevalence of heart failure and end-stage lung disease, there is a sustained interest in expanding the donor pool to alleviate the thoracic organ shortage crisis. Efforts to extend the standard donor criteria and to include donation after circulatory death have been made to increase the availability of suitable organs. Studies have demonstrated that outcomes with extended-criteria donors are comparable to those with standard-criteria donors. Another promising approach to augment the donor pool is the improvement of organ preservation techniques. Both ex vivo lung perfusion (EVLP) for the lungs and the Organ Care System (OCS, TransMedics) for the heart have shown encouraging results in preserving organs and extending ischemia time through the application of normothermic regional perfusion. EVLP has been effective in improving marginal or borderline lungs by preserving and reconditioning them. The use of OCS is associated with excellent short-term outcomes for cardiac allografts and has improved utilization rates of hearts from extended-criteria donors. While both EVLP and OCS have successfully transitioned from research to clinical practice, the costs associated with commercially available systems and consumables must be considered. The ex vivo perfusion platform, which includes both EVLP and OCS, holds the potential for diverse and innovative therapies, thereby transforming the landscape of thoracic organ transplantation.
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Affiliation(s)
- Menander M
- Institute of Heart and Lung Transplant, Krishna Institute of Medical Sciences (KIMS) Hospital, Secunderabad, India
| | - Sandeep Attawar
- Institute of Heart and Lung Transplant, Krishna Institute of Medical Sciences (KIMS) Hospital, Secunderabad, India
| | - Mahesh BN
- Institute of Heart and Lung Transplant, Krishna Institute of Medical Sciences (KIMS) Hospital, Secunderabad, India
| | - Owais Tisekar
- Institute of Heart and Lung Transplant, Krishna Institute of Medical Sciences (KIMS) Hospital, Secunderabad, India
| | - Anoop Mohandas
- Institute of Heart and Lung Transplant, Krishna Institute of Medical Sciences (KIMS) Hospital, Secunderabad, India
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Ponholzer F, Dumfarth J, Krapf C, Pircher A, Hautz T, Wolf D, Augustin F, Schneeberger S. The impact and relevance of techniques and fluids on lung injury in machine perfusion of lungs. Front Immunol 2024; 15:1358153. [PMID: 38510260 PMCID: PMC10950925 DOI: 10.3389/fimmu.2024.1358153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 02/26/2024] [Indexed: 03/22/2024] Open
Abstract
Primary graft dysfunction (PGD) is a common complication after lung transplantation. A plethora of contributing factors are known and assessment of donor lung function prior to organ retrieval is mandatory for determination of lung quality. Specialized centers increasingly perform ex vivo lung perfusion (EVLP) to further assess lung functionality and improve and extend lung preservation with the aim to increase lung utilization. EVLP can be performed following different protocols. The impact of the individual EVLP parameters on PGD development, organ function and postoperative outcome remains to be fully investigated. The variables relate to the engineering and function of the respective perfusion devices, such as the type of pump used, functional, like ventilation modes or physiological (e.g. perfusion solutions). This review reflects on the individual technical and fluid components relevant to EVLP and their respective impact on inflammatory response and outcome. We discuss key components of EVLP protocols and options for further improvement of EVLP in regard to PGD. This review offers an overview of available options for centers establishing an EVLP program and for researchers looking for ways to adapt existing protocols.
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Affiliation(s)
- Florian Ponholzer
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Julia Dumfarth
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Christoph Krapf
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Andreas Pircher
- Department of Haematology and Oncology, Internal Medicine V, Medical University of Innsbruck, Innsbruck, Austria
| | - Theresa Hautz
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Dominik Wolf
- Department of Haematology and Oncology, Internal Medicine V, Medical University of Innsbruck, Innsbruck, Austria
| | - Florian Augustin
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Stefan Schneeberger
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
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Sakanoue I, Okamoto T, Ayyat KS, Yun JJ, Farver CF, Fujioka H, Date H, McCurry KR. Intermittent Ex Vivo Lung Perfusion in a Porcine Model for Prolonged Lung Preservation. Transplantation 2024; 108:669-678. [PMID: 37726888 DOI: 10.1097/tp.0000000000004802] [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: 09/21/2023]
Abstract
BACKGROUND Ex vivo lung perfusion expands the lung transplant donor pool and extends preservation time beyond cold static preservation. We hypothesized that repeated regular ex vivo lung perfusion would better maintain lung grafts. METHODS Ten pig lungs were randomized into 2 groups. The control underwent 16 h of cold ischemic time and 2 h of cellular ex vivo lung perfusion. The intermittent ex vivo lung perfusion group underwent cold ischemic time for 4 h, ex vivo lung perfusion (first) for 2 h, cold ischemic time for 10 h, and 2 h of ex vivo lung perfusion (second). Lungs were assessed, and transplant suitability was determined after 2 h of ex vivo lung perfusion. RESULTS The second ex vivo lung perfusion was significantly associated with better oxygenation, limited extravascular water, higher adenosine triphosphate, reduced intraalveolar edema, and well-preserved mitochondria compared with the control, despite proinflammatory cytokine elevation. No significant difference was observed in the first and second perfusion regarding oxygenation and adenosine triphosphate, whereas the second was associated with lower dynamic compliance and higher extravascular lung water than the first. Transplant suitability was 100% for the first and 60% for the second ex vivo lung perfusion, and 0% for the control. CONCLUSIONS The second ex vivo lung perfusion had a slight deterioration in graft function compared to the first. Intermittent ex vivo lung perfusion created a better condition for lung grafts than cold static preservation, despite cytokine elevation. These results suggested that intermittent ex vivo lung perfusion may help prolong lung preservation.
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Affiliation(s)
- Ichiro Sakanoue
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH
- Department of Inflammation and Immunology, Lerner Research Institute, Cleveland Clinic, Cleveland, OH
- Department of Thoracic Surgery, Kyoto University, Kyoto, Japan
| | - Toshihiro Okamoto
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH
- Department of Inflammation and Immunology, Lerner Research Institute, Cleveland Clinic, Cleveland, OH
- Transplant Center, Cleveland Clinic, Cleveland, OH
| | - Kamal S Ayyat
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH
- Department of Inflammation and Immunology, Lerner Research Institute, Cleveland Clinic, Cleveland, OH
| | - James J Yun
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH
- Transplant Center, Cleveland Clinic, Cleveland, OH
| | - Carol F Farver
- Department of Pathology, Cleveland Clinic, Cleveland, OH
| | - Hisashi Fujioka
- Cryo-Electron Microscopy Core, Case Western Reserve University, Cleveland, OH
| | - Hiroshi Date
- Department of Thoracic Surgery, Kyoto University, Kyoto, Japan
| | - Kenneth R McCurry
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH
- Department of Inflammation and Immunology, Lerner Research Institute, Cleveland Clinic, Cleveland, OH
- Transplant Center, Cleveland Clinic, Cleveland, OH
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Michel SG, Hagl C, Kauke T, Kneidinger N, Schneider C. [Lung transplantation: current situation and developments]. CHIRURGIE (HEIDELBERG, GERMANY) 2024; 95:108-114. [PMID: 38191810 DOI: 10.1007/s00104-023-02023-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/11/2023] [Indexed: 01/10/2024]
Abstract
Lung transplantation is currently the gold standard treatment for end-stage lung diseases. Advances in the preservation of donor lungs, the surgical technique and immunosuppressive therapy have led to lung transplantation now being a routine procedure. Nevertheless, the shortage of donor organs, the acute and particularly chronic lung allograft dysfunction (CLAD) still represent major challenges even in experienced centers. Research in this area is still necessary to improve the long-term survival of lung recipients.
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Affiliation(s)
- S G Michel
- Herzchirurgische Klinik, LMU Klinikum, Marchioninistraße 15, 81377, München, Deutschland.
- Comprehensive Pneumology Center Munich, Deutsches Zentrum für Lungenforschung (DZL), München, Deutschland.
- Munich Heart Alliance, Deutsches Zentrum für Herz-Kreislaufforschung (DZHK), München, Deutschland.
| | - C Hagl
- Herzchirurgische Klinik, LMU Klinikum, Marchioninistraße 15, 81377, München, Deutschland
- Comprehensive Pneumology Center Munich, Deutsches Zentrum für Lungenforschung (DZL), München, Deutschland
- Munich Heart Alliance, Deutsches Zentrum für Herz-Kreislaufforschung (DZHK), München, Deutschland
| | - T Kauke
- Comprehensive Pneumology Center Munich, Deutsches Zentrum für Lungenforschung (DZL), München, Deutschland
- Abteilung für Thoraxchirurgie, LMU Klinikum, München, Deutschland
| | - N Kneidinger
- Comprehensive Pneumology Center Munich, Deutsches Zentrum für Lungenforschung (DZL), München, Deutschland
- Medizinische Klinik und Poliklinik V, Pneumologie, LMU Klinikum, München, Deutschland
| | - C Schneider
- Comprehensive Pneumology Center Munich, Deutsches Zentrum für Lungenforschung (DZL), München, Deutschland
- Abteilung für Thoraxchirurgie, LMU Klinikum, München, Deutschland
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Matsubara K, Miyoshi K, Kawana S, Kubo Y, Shimizu D, Tomioka Y, Shiotani T, Yamamoto H, Tanaka S, Kurosaki T, Ohara T, Okazaki M, Sugimoto S, Matsukawa A, Toyooka S. In vivo lung perfusion for prompt recovery from primary graft dysfunction after lung transplantation. J Heart Lung Transplant 2024; 43:284-292. [PMID: 37852513 DOI: 10.1016/j.healun.2023.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 10/03/2023] [Accepted: 10/11/2023] [Indexed: 10/20/2023] Open
Abstract
BACKGROUND No proven treatment after the development of primary graft dysfunction (PGD) is currently available. Here, we established a novel strategy of in vivo lung perfusion (IVLP) for the treatment of PGD. IVLP involves the application of an in vivo isolated perfusion circuit to an implanted lung. This study aimed to explore the effectiveness of IVLP vs conventional post-lung transplant (LTx) extracorporeal membrane oxygenation (ECMO) treatment using an experimental swine LTx PGD model. METHODS After 1.5-hour warm ischemia of the donor lungs, a left LTx was performed. Following the confirmation of PGD development, pigs were divided into 3 groups (n = 5 each): control (no intervention), ECMO, and IVLP. After 2 hours of treatment, a 4-hour functional assessment was conducted, and samples were obtained. RESULTS Significantly better oxygenation was achieved in the IVLP group (p ≤ 0.001). Recovery was confirmed immediately and maintained during the following 4-hour observation. The IVLP group also demonstrated better lung compliance than the control group (p = 0.045). A histologic evaluation showed that the lung injury score and terminal deoxynucleotidyl transferase dUTP nick end labeling assay showed significantly fewer injuries and a better result in the wet-to-dry weight ratio in the IVLP group. CONCLUSIONS A 2-hour IVLP is technically feasible and allows for prompt recovery from PGD after LTx. The posttransplant short-duration IVLP strategy can complement or overcome the limitations of the current practice for donor assessment and PGD management.
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Affiliation(s)
- Kei Matsubara
- Department of General Thoracic Surgery and Breast and Endocrinological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Kentaroh Miyoshi
- Department of General Thoracic Surgery and Breast and Endocrinological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan.
| | - Shinichi Kawana
- Department of General Thoracic Surgery and Breast and Endocrinological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Yujiro Kubo
- Department of General Thoracic Surgery and Breast and Endocrinological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Dai Shimizu
- Department of General Thoracic Surgery and Breast and Endocrinological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Yasuaki Tomioka
- Department of General Thoracic Surgery and Breast and Endocrinological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Toshio Shiotani
- Department of General Thoracic Surgery and Breast and Endocrinological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Haruchika Yamamoto
- Department of General Thoracic Surgery and Breast and Endocrinological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Shin Tanaka
- Department of General Thoracic Surgery and Breast and Endocrinological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Takeshi Kurosaki
- Department of General Thoracic Surgery and Breast and Endocrinological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Toshiaki Ohara
- Department of Pathology and Experimental Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Mikio Okazaki
- Department of General Thoracic Surgery and Breast and Endocrinological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Seiichiro Sugimoto
- Department of General Thoracic Surgery and Breast and Endocrinological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Akihiro Matsukawa
- Department of Pathology and Experimental Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Shinichi Toyooka
- Department of General Thoracic Surgery and Breast and Endocrinological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
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Lindstedt S, Niroomand A, Snell G. The devil is in the details: A commentary on registry analyses of characteristics and outcomes of lung transplants using ex vivo lung perfusion. J Heart Lung Transplant 2024; 43:226-228. [PMID: 37820946 DOI: 10.1016/j.healun.2023.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Revised: 10/04/2023] [Accepted: 10/05/2023] [Indexed: 10/13/2023] Open
Affiliation(s)
- Sandra Lindstedt
- Department of Cardiothoracic Surgery and Transplantation, Skåne University Hospital, Lund, Sweden; Wallenberg Center for Molecular Medicine, Lund University, Lund, Sweden; Department of Clinical Sciences, Lund University, Lund, Sweden; Lund Stem Cell Center, Lund University, Lund, Sweden
| | - Anna Niroomand
- Wallenberg Center for Molecular Medicine, Lund University, Lund, Sweden; Department of Clinical Sciences, Lund University, Lund, Sweden; Lund Stem Cell Center, Lund University, Lund, Sweden; Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Gregory Snell
- Lung Transplant Service, Alfred Hospital, Melbourne, Australia
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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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Pai V, Asgari E, Berman M, Callaghan C, Corris P, Large S, Messer S, Nasralla D, Parmar J, Watson C, O'Neill S. The British Transplantation Society guidelines on cardiothoracic organ transplantation from deceased donors after circulatory death. Transplant Rev (Orlando) 2023; 37:100794. [PMID: 37660415 DOI: 10.1016/j.trre.2023.100794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 08/29/2023] [Indexed: 09/05/2023]
Abstract
Maximising organ utilisation from donation after circulatory death (DCD) donors could help meet some of the shortfall in organ supply, but it represents a major challenge, particularly as organ donors and transplant recipients become older and more medically complex over time. Success is dependent upon establishing common practices and accepted protocols that allow the safe sharing of DCD organs and maximise the use of the DCD donor pool. The British Transplantation Society 'Guideline on transplantation from deceased donors after circulatory death' has recently been updated. This manuscript summarises the relevant recommendations from chapters specifically related to transplantation of cardiothoracic organs.
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Affiliation(s)
| | | | | | | | - Paul Corris
- Newcastle University and Institute of Transplantation, Freeman Hospital, Newcastle, UK
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11
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Gouchoe DA, Shukrallah B, Eggeman C, Igoe D, Ralston J, Mast D, Ganapathi AM, Whitson BA. XPS™ Jensen lung as a low-cost, high-fidelity training adjunct to ex-vivo lung perfusion. Artif Organs 2023; 47:1794-1797. [PMID: 37587902 DOI: 10.1111/aor.14623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 06/22/2023] [Accepted: 07/24/2023] [Indexed: 08/18/2023]
Abstract
BACKGROUND Ex vivo lung perfusion (EVLP) enables lung resuscitation before transplantation, and training is key, particularly in low-volume settings. To enable technique refinement and continuing education, we sought to demonstrate the value of a low-cost, high-fidelity EVLP simulator that would allow reproducible clinical scenarios. METHODS In partnership with our EVLP manufacturer, we utilized the XPS™ Jensen Lung with our clinical system. The Jensen Lung has two simulated lung bladders and an in-line polymethylpentene fiber oxygenator. It allows titration of ventilator support which aids in accurate clinical simulation. For simulations, blood gases (BGs) were obtained and compared with integrated in-line perfusate gas monitors (PGMs). PaO2 , PCO2 , and pH were measured and compared. RESULTS The PGM and BG values were not significantly different throughout the range of FiO2 and sweep gas flow rates evaluated. The "delta" PaO2 was measured between LA and PA and did not show any change between approaches. The pH measurement between BG and PGM was not significantly different. CONCLUSIONS The XPS™ Jensen Lung simulator allows for a high-fidelity simulator of clinical EVLP. The correlation of the PGM and the BG measurement of the PaO2 and pH allow for a low-cost simulation, as the PGMs are in line in the circuit, and enable real-time tracking of perfusate gas parameters with the PGM. Implementation of a standardized clinical EVLP training program allows the maintenance of technique and enables clinical simulation training without the need for costly animal perfusions and the use of multiple BG measurements.
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Affiliation(s)
- Doug A Gouchoe
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
- 88th Surgical Operations Squadron, Wright-Patterson Medical Center, WPAFB, Dayton, Ohio, USA
| | - Basam Shukrallah
- Department of Surgery, University of Alabama School of Medicine, Birmingham, Alabama, USA
| | | | - David Igoe
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - James Ralston
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - David Mast
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Asvin M Ganapathi
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Bryan A Whitson
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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12
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Zhou AL, Larson EL, Ruck JM, Ha JS, Casillan AJ, Bush EL. Current status and future potential of ex vivo lung perfusion in clinical lung transplantation. Artif Organs 2023; 47:1700-1709. [PMID: 37455548 DOI: 10.1111/aor.14607] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 05/29/2023] [Accepted: 06/19/2023] [Indexed: 07/18/2023]
Abstract
Lung transplantation is accepted as a well-established and effective treatment for patients with end-stage lung disease. While the number of candidates added to the waitlist continues to rise, the number of transplants performed remains limited by the number of suitable organ donors. Ex vivo lung perfusion (EVLP) emerged as a method of addressing the organ shortage by allowing the evaluation and potential reconditioning of marginal donor lungs or minimizing risks of prolonged ischemic time due to logistical challenges. The currently available FDA-approved EVLP systems have demonstrated excellent outcomes in clinical trials, and retrospective studies have demonstrated similar post-transplant survival between recipients who received marginal donor lungs perfused using EVLP and recipients who received standard criteria lungs stored using conventional methods. Despite this, widespread utilization has plateaued in the last few years, likely due to the significant costs associated with initiating EVLP programs. Centralized, dedicated EVLP perfusion centers are currently being investigated as a potential method of further expanding utilization of this technology. In the preclinical setting, potential applications of EVLP that are currently being studied include prolongation of organ preservation, reconditioning of unsuitable lungs, and further enhancement of already suitable lungs. As adoption of EVLP technology becomes more widespread, we may begin to see future implementation of these potential applications into the clinical setting.
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Affiliation(s)
- Alice L Zhou
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Emily L Larson
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Jessica M Ruck
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Jinny S Ha
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Alfred J Casillan
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Errol L Bush
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
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Janes LE, McAndrew C, Levin LS. Replantation versus transplantation: Where do we stand? EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023:10.1007/s00590-023-03737-1. [PMID: 37815630 DOI: 10.1007/s00590-023-03737-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 09/13/2023] [Indexed: 10/11/2023]
Abstract
PURPOSE Despite advances in extremity trauma care and reconstructive microsurgery, management of the traumatic amputations remains a challenge. The majority of patients will forever experience some level of disability even with replantation or advanced prosthetics. The goal of this article is to familiarize hand and reconstructive surgeons with the current state of upper extremity transplantation, so they better can educate their amputee patients regarding this as an option following limb loss. METHODS Current literature, in addition to the international registry on hand and composite tissue transplantation, was reviewed to assemble a summary of outcomes in upper extremity replantation and transplantation. RESULTS Sensory and functional outcomes of replantation and transplantation are comparable. Reported complications of immunosuppression are similar to those of other solid organ transplants. The financial cost of hand transplantation is high, but comparable to the lifetime cost of prosthesis use. CONCLUSION While the risk of immunosuppression is a serious consideration for patients pursuing hand transplantation, in the well-selected and informed patient, hand transplantation can dramatically improve patient reported to outcomes and quality of life.
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Affiliation(s)
- Lindsay E Janes
- Department of Orthopaedic Surgery, University of Pennsylvania, 3737 Market Street, Philadelphia, PA, 191904, USA
| | - Christine McAndrew
- Department of Orthopaedic Surgery, University of Pennsylvania, 3737 Market Street, Philadelphia, PA, 191904, USA
| | - L Scott Levin
- Department of Orthopaedic Surgery, University of Pennsylvania, 3737 Market Street, Philadelphia, PA, 191904, USA.
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Graeser K, Blanche PF, Zemtsovski M. Transplantation of initially rejected donor lungs using ex vivo lung perfusion: A 5-year experience. Acta Anaesthesiol Scand 2023; 67:1210-1218. [PMID: 37329167 DOI: 10.1111/aas.14296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 05/15/2023] [Accepted: 06/03/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND Ex vivo lung perfusion (EVLP) is a method for the evaluation and reconditioning of high-risk donor lungs to increase the pool of potential donor lungs. METHODS We reviewed all consecutive patients who received lung transplants from May 2012 to May 2017 with follow-up until July 2021. EVLP was used in lungs initially rejected due to inadequate oxygenation but without other contraindications. Lungs with improved oxygenation levels above the threshold were transplanted. The primary endpoint was the time to graft failure, which was defined as the time from surgery to death or re-transplantation, whichever occurred first. The secondary outcome was freedom from chronic lung allograft dysfunction. RESULTS A total of 157 patients underwent transplantation during the study period. Thirty-nine patients received EVLP-treated donor lungs. Restricted mean graft survival time up to 7 years is 5.14 years for non-EVLP and 4.19 for EVLP, the difference being -0.95 (confidence interval [CI]-1.93 to 0.04, p = .059). The hazard ratio is 1.66 (CI 1.00-2.75, p = .046). Chronic lung allograft dysfunction was the highest contributor to mortality in both groups. There were significant differences in freedom from chronic lung allograft dysfunction at 12 and 24 months of follow-up (p = .005 and p = .030, respectively). Subgroup analyses revealed that the first patients who received EVLP in 2012-2013 had a substantially worse 5-year graft survival than those who received EVLP more recently in 2016-2017 (14.3% vs. 60.0%). For the latter, the 5-year graft survival was observed to be remarkably close to the non-EVLP group (60.8%). CONCLUSION Long-term survival was significantly lower, and lung function was poorer among recipients in the EVLP group than in the non-EVLP group. However, the outcome of patients who received EVLP-treated lungs was observed to improve steadily after the first 2 years after EVLP was introduced in Denmark.
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Affiliation(s)
- Karin Graeser
- Department of Anesthesia and Intensive Care, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Paul F Blanche
- Department of Biostatistics, University of Copenhagen, Copenhagen, Denmark
| | - Mikhail Zemtsovski
- Department of Thoracic Anesthesiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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Kwon JH, Blanding WM, Shorbaji K, Scalea JR, Gibney BC, Baliga PK, Kilic A. Waitlist and Transplant Outcomes in Organ Donation After Circulatory Death: Trends in the United States. Ann Surg 2023; 278:609-620. [PMID: 37334722 DOI: 10.1097/sla.0000000000005947] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2023]
Abstract
OBJECTIVES To summarize waitlist and transplant outcomes in kidney, liver, lung, and heart transplantation using organ donation after circulatory death (DCD). BACKGROUND DCD has expanded the donor pool for solid organ transplantation, most recently for heart transplantation. METHODS The United Network for Organ Sharing registry was used to identify adult transplant candidates and recipients in the most recent allocation policy eras for kidney, liver, lung, and heart transplantation. Transplant candidates and recipients were grouped by acceptance criteria for DCD versus brain-dead donors [donation after brain death (DBD)] only and DCD versus DBD transplant, respectively. Propensity matching and competing-risks regression was used to model waitlist outcomes. Survival was modeled using propensity matching and Kaplan-Meier and Cox regression analysis. RESULTS DCD transplant volumes have increased significantly across all organs. Liver candidates listed for DCD organs were more likely to undergo transplantation compared with propensity-matched candidates listed for DBD only, and heart and liver transplant candidates listed for DCD were less likely to experience death or clinical deterioration requiring waitlist inactivation. Propensity-matched DCD recipients demonstrated an increased mortality risk up to 5 years after liver and kidney transplantation and up to 3 years after lung transplantation compared with DBD. There was no difference in 1-year mortality between DCD and DBD heart transplantation. CONCLUSIONS DCD continues to expand access to transplantation and improves waitlist outcomes for liver and heart transplant candidates. Despite an increased risk for mortality with DCD kidney, liver, and lung transplantation, survival with DCD transplant remains acceptable.
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Affiliation(s)
- Jennie H Kwon
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, SC
| | - Walker M Blanding
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, SC
| | - Khaled Shorbaji
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, SC
| | - Joseph R Scalea
- Division of Transplant Surgery, Medical University of South Carolina, Charleston, SC
| | - Barry C Gibney
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, SC
| | - Prabhakar K Baliga
- Division of Transplant Surgery, Medical University of South Carolina, Charleston, SC
| | - Arman Kilic
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, SC
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Radomsky L, Koch A, Olbertz C, Liu Y, Beushausen K, Keil J, Rauen U, Falk CS, Kühne JF, Kamler M. Composition of ex vivo perfusion solutions and kinetics define differential cytokine/chemokine secretion in a porcine cardiac arrest model of lung preservation. Front Cardiovasc Med 2023; 10:1245618. [PMID: 37808880 PMCID: PMC10556242 DOI: 10.3389/fcvm.2023.1245618] [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: 06/23/2023] [Accepted: 08/31/2023] [Indexed: 10/10/2023] Open
Abstract
Background Ex vivo lung perfusion (EVLP) uses continuous normothermic perfusion to reduce ischemic damage and to improve post-transplant outcomes, specifically for marginal donor lungs after the donation after circulatory death. Despite major efforts, the optimal perfusion protocol and the composition of the perfusate in clinical lung transplantation have not been identified. Our study aims to compare the concentration levels of cytokine/chemokine in different perfusion solutions during EVLP, after 1 and 9 h of cold static preservation (CSP) in a porcine cardiac arrest model, and to correlate inflammatory parameters to oxygenation capacities. Methods Following cardiac arrest, the lungs were harvested and were categorized into two groups: immediate (I-EVLP) and delayed EVLP (D-EVLP), after 1 and 9 h of CSP, respectively. The D-EVLP lungs were perfused with either Steen or modified Custodiol-N solution containing only dextran (CD) or dextran and albumin (CDA). The cytokine/chemokine levels were analyzed at baseline (0 h) and after 1 and 4 h of EVLP using Luminex-based multiplex assays. Results Within 4 h of EVLP, the concentration levels of TNF-α, IL-6, CXCL8, IFN-γ, IL-1α, and IL-1β increased significantly (P < 0.05) in all experimental groups. The CD solution contained lower concentration levels of TNF-α, IL-6, CXCL8, IFN-γ, IL-2, IL-12, IL-10, IL-4, IL-1RA, and IL-18 (P < 0.05) compared with those of the Steen solution. The concentration levels of all experimental groups have correlated negatively with the oxygenation capacity values (P < 0.05). Protein concentration levels did not reach statistical significance for I-EVLP vs. D-EVLP and CD vs. CDA solutions. Conclusion In a porcine cardiac arrest model, a longer period of CSP prior to EVLP did not result in an enhanced protein secretion into perfusates. The CD solution reduced the cytokine/chemokine secretion most probably by iron chelators and/or by the protecting effects of dextran. Supplementing with albumin did not further reduce the cytokine/chemokine secretion into perfusates. These findings may help in optimizing the preservation procedure of the lungs, thereby increasing the donor pool of organs.
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Affiliation(s)
- Lena Radomsky
- Institute of Transplant Immunology, Hannover Medical School, Hannover, Germany
| | - Achim Koch
- Department of Thoracic and Cardiovascular Surgery, West German Heart Center, University Hospital Essen, Essen, Germany
| | - Carolin Olbertz
- Department of Thoracic and Cardiovascular Surgery, West German Heart Center, University Hospital Essen, Essen, Germany
| | - Yongjie Liu
- Department of Thoracic and Cardiovascular Surgery, West German Heart Center, University Hospital Essen, Essen, Germany
| | - Kerstin Beushausen
- Institute of Transplant Immunology, Hannover Medical School, Hannover, Germany
| | - Jana Keil
- Institute of Transplant Immunology, Hannover Medical School, Hannover, Germany
| | - Ursula Rauen
- Institute of Biochemistry, University of Duisburg-Essen, Essen, Germany
| | - Christine S. Falk
- Institute of Transplant Immunology, Hannover Medical School, Hannover, Germany
- DZIF, German Center for Infectious Diseases, Germany, TTU-IICH, Hannover—Braunschweig site, Braunschweig,Germany
- DZL, German Center for Lung Diseases, BREATH site, Hannover, Germany
| | - Jenny F. Kühne
- Institute of Transplant Immunology, Hannover Medical School, Hannover, Germany
| | - Markus Kamler
- Department of Thoracic and Cardiovascular Surgery, West German Heart Center, University Hospital Essen, Essen, Germany
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Sage AT, Donahoe LL, Shamandy AA, Mousavi SH, Chao BT, Zhou X, Valero J, Balachandran S, Ali A, Martinu T, Tomlinson G, Del Sorbo L, Yeung JC, Liu M, Cypel M, Wang B, Keshavjee S. A machine-learning approach to human ex vivo lung perfusion predicts transplantation outcomes and promotes organ utilization. Nat Commun 2023; 14:4810. [PMID: 37558674 PMCID: PMC10412608 DOI: 10.1038/s41467-023-40468-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 07/26/2023] [Indexed: 08/11/2023] Open
Abstract
Ex vivo lung perfusion (EVLP) is a data-intensive platform used for the assessment of isolated lungs outside the body for transplantation; however, the integration of artificial intelligence to rapidly interpret the large constellation of clinical data generated during ex vivo assessment remains an unmet need. We developed a machine-learning model, termed InsighTx, to predict post-transplant outcomes using n = 725 EVLP cases. InsighTx model AUROC (area under the receiver operating characteristic curve) was 79 ± 3%, 75 ± 4%, and 85 ± 3% in training and independent test datasets, respectively. Excellent performance was observed in predicting unsuitable lungs for transplantation (AUROC: 90 ± 4%) and transplants with good outcomes (AUROC: 80 ± 4%). In a retrospective and blinded implementation study by EVLP specialists at our institution, InsighTx increased the likelihood of transplanting suitable donor lungs [odds ratio=13; 95% CI:4-45] and decreased the likelihood of transplanting unsuitable donor lungs [odds ratio=0.4; 95%CI:0.16-0.98]. Herein, we provide strong rationale for the adoption of machine-learning algorithms to optimize EVLP assessments and show that InsighTx could potentially lead to a safe increase in transplantation rates.
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Affiliation(s)
- Andrew T Sage
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Laura L Donahoe
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Alaa A Shamandy
- Department of Computer Science, University of Toronto, Toronto, ON, Canada
- Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - S Hossein Mousavi
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
| | - Bonnie T Chao
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
| | - Xuanzi Zhou
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
| | - Jerome Valero
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
| | - Sharaniyaa Balachandran
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
| | - Aadil Ali
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
| | - Tereza Martinu
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - George Tomlinson
- Department of Medicine, University Health Network, Toronto, ON, Canada
| | - Lorenzo Del Sorbo
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, Medical and Surgical Intensive Care Unit, University Health Network, Toronto, ON, Canada
| | - Jonathan C Yeung
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Mingyao Liu
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Marcelo Cypel
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Bo Wang
- Department of Computer Science, University of Toronto, Toronto, ON, Canada.
- Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada.
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada.
- Vector Institute, Toronto, ON, Canada.
| | - Shaf Keshavjee
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada.
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada.
- Department of Surgery, University of Toronto, Toronto, ON, Canada.
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada.
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Hunt ML, Cantu E. Primary graft dysfunction after lung transplantation. Curr Opin Organ Transplant 2023; 28:180-186. [PMID: 37053083 PMCID: PMC10214980 DOI: 10.1097/mot.0000000000001065] [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] [Indexed: 04/14/2023]
Abstract
PURPOSE OF REVIEW Primary graft dysfunction (PGD) is a clinical syndrome occurring within the first 72 h after lung transplantation and is characterized clinically by progressive hypoxemia and radiographically by patchy alveolar infiltrates. Resulting from ischemia-reperfusion injury, PGD represents a complex interplay between donor and recipient immunologic factors, as well as acute inflammation leading to alveolar cell damage. In the long term, chronic inflammation invoked by PGD can contribute to the development of chronic lung allograft dysfunction, an important cause of late mortality after lung transplant. RECENT FINDINGS Recent work has aimed to identify risk factors for PGD, focusing on donor, recipient and technical factors both inherent and potentially modifiable. Although no PGD-specific therapy currently exists, supportive care remains paramount and early initiation of ECMO can improve outcomes in select patients. Initial success with ex-vivo lung perfusion platforms has been observed with respect to decreasing PGD risk and increasing lung transplant volume; however, the impact on survival is not well delineated. SUMMARY This review will summarize the pathogenesis and clinical features of PGD, as well as highlight treatment strategies and emerging technologies to mitigate PGD risk in patients undergoing lung transplantation.
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Affiliation(s)
- Mallory L. Hunt
- Division of Cardiovascular Surgery, University of Pennsylvania Perelman School of Medicine, 1 Convention Avenue Pavilion 2 City, Philadelphia PA, 19104 USA
| | - Edward Cantu
- Division of Cardiovascular Surgery, University of Pennsylvania Perelman School of Medicine, 1 Convention Avenue Pavilion 2 City, Philadelphia PA, 19104 USA
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Peel JK, Keshavjee S, Naimark D, Liu M, Del Sorbo L, Cypel M, Barrett K, Pullenayegum EM, Sander B. Determining the impact of ex-vivo lung perfusion on hospital costs for lung transplantation: A retrospective cohort study. J Heart Lung Transplant 2023; 42:356-367. [PMID: 36411188 DOI: 10.1016/j.healun.2022.10.016] [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: 06/03/2022] [Revised: 10/04/2022] [Accepted: 10/20/2022] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Ex-vivo lung perfusion (EVLP) has improved organ utilization for lung transplantation, but it is not yet known whether the benefits of this technology offset its additional costs. We compared the institutional costs of lung transplantation before vs after EVLP was available to identify predictors of costs and determine the health-economic impact of EVLP. METHODS We performed a retrospective, before-after, propensity-score weighted cohort study of patients wait-listed for lung transplant at University Health Network (UHN) in Ontario, Canada, between January 2005 and December 2019 using institutional administrative data. We compared costs, in 2019 Canadian Dollars ($), between patients referred for transplant before EVLP was available (Pre-EVLP) to after (Modern EVLP). Cumulative costs were estimated using a novel application of multistate survival models. Predictors of costs were identified using weighted log-gamma generalized linear regression. RESULTS A total of 1,199 patients met inclusion criteria (352 Pre-EVLP; 847 Modern EVLP). Mean total costs for the transplant hospitalization were $111,878 ($94,123-$130,767) in the Pre-EVLP era and $110,969 ($87,714-$136,000) in the Modern EVLP era. Cumulative five-year costs since referral were $278,777 ($82,575-$298,135) in the Pre-EVLP era and $293,680 ($252,832-$317,599) in the Modern EVLP era. We observed faster progression to transplantation when EVLP was available. EVLP availability was not a predictor of waitlist (cost ratio [CR] 1.04 [0.81-1.37]; p = 0.354) or transplant costs (CR 1.02 [0.80-1.29]; p = 0.425) but was associated with lower costs during posttransplant years 1&2 (CR 0.75 [0.58-1.06]; p = 0.05) and posttransplant years 3+ (CR 0.43 [0.26-0.74]; p = 0.001). CONCLUSIONS At our center, EVLP availability was associated with faster progression to transplantation at no significant marginal cost.
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Affiliation(s)
- John Kenneth Peel
- Department of Anesthesiology, University Health Network, Toronto, Ontario, Canada; Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, Dalla Lana School for Public Health, University of Toronto, Toronto, Ontario, Canada.
| | - Shaf Keshavjee
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada; Division of Thoracic Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada; Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | - David Naimark
- Institute of Health Policy, Management and Evaluation, Dalla Lana School for Public Health, University of Toronto, Toronto, Ontario, Canada; Division of Nephrology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Mingyao Liu
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada; Division of Thoracic Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada; Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Lorenzo Del Sorbo
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada; Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Marcelo Cypel
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada; Division of Thoracic Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada; Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Kali Barrett
- Institute of Health Policy, Management and Evaluation, Dalla Lana School for Public Health, University of Toronto, Toronto, Ontario, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Eleanor M Pullenayegum
- Institute of Health Policy, Management and Evaluation, Dalla Lana School for Public Health, University of Toronto, Toronto, Ontario, Canada; The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Beate Sander
- Institute of Health Policy, Management and Evaluation, Dalla Lana School for Public Health, University of Toronto, Toronto, Ontario, Canada; Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada; ICES, Ontario, Canada; Public Health Ontario, Ontario, Canada.
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20
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Furukawa M, Noda K, Chan EG, Ryan JP, Coster JN, Sanchez PG. Lung transplantation from donation after circulatory death, evolution, and current status in the United States. Clin Transplant 2023; 37:e14884. [PMID: 36542414 DOI: 10.1111/ctr.14884] [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: 10/11/2022] [Revised: 12/05/2022] [Accepted: 12/11/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND The number of lung transplants from donors after circulatory death has increased over the last decade. This study aimed to describe the evolution and outcomes following lung transplantation donation after circulatory death (DCD) and report the practices and outcomes of ex vivo lung perfusion (EVLP) in this donor population. METHODS This was a retrospective study using a prospectively collected national registry. The United Network for Organ Sharing (UNOS) database was queried to identify adult patients who underwent lung transplantation between May 1, 2005, and December 31, 2021. Kaplan-Meier analysis and Weibull regression were used to compare survival in four cohorts (donation after brain death [DBD] with or without EVLP, and DCD with or without EVLP). The primary outcome of interest was patient survival. RESULTS Of the 21 356 recipients who underwent lung transplantation, 20 380 (95.4%) were from brain death donors and 976 (4.6%) from donors after circulatory death. Kaplan-Meier analysis showed no difference in the survival time between the two groups. In a multivariable analysis that controlled for baseline differences in donor and recipient characteristics, recipients who received lungs from cardiac death donors after EVLP had 28% shorter survival time relative to donor lungs after brain death without EVLP (hazard ratio [HR] 1.53, 95% confidence interval [CI] 1.10-2.15, p = .01). CONCLUSIONS The early survival differences observed after lung transplants from donors after circulatory death in lungs evaluated with EVLP deserves further investigation.
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Affiliation(s)
- Masashi Furukawa
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Kentaro Noda
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ernest G Chan
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - John P Ryan
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Jenalee N Coster
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Pablo G Sanchez
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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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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A Randomized, Multicenter, Blinded Pilot Study Assessing the Effects of Gaseous Nitric Oxide in an Ex Vivo System of Human Lungs. Pulm Ther 2022; 9:151-163. [PMID: 36510099 PMCID: PMC9744669 DOI: 10.1007/s41030-022-00209-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 11/14/2022] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Normothermic ex vivo lung perfusion (EVLP) is used to evaluate and condition donor lungs for transplantation. The objective of this study was to determine whether administration of exogenous nitric oxide during EVLP contributes to improvement of lung health. METHODS A multicenter, blinded, two-arm, randomized pilot study evaluated the effect of gaseous nitric oxide (gNO) administered during EVLP on donor lungs rejected for transplantation. gNO introduced into the perfusate at 80 parts per million (ppm) was compared with perfusate alone (P). An open-label substudy assessed inhaled nitric oxide gas (iNO) delivered into the lungs at 20 ppm via a ventilator. Primary endpoints were an aggregate score of lung physiology indicators and total duration of stable EVLP time. Secondary endpoints included assessments of lung weight and left atrium partial pressure of oxygen (LAPO2). RESULTS Twenty bilateral donor lungs (blinded study, n = 16; open-label substudy, n = 4) from three centers were enrolled. Median (min, max) total EVLP times for the gNO, P, and iNO groups were 12.4 (8.6, 12.6), 10.6 (6.0, 12.4), and 12.4 (8.7, 13.0) hours, respectively. In the blinded study, median aggregate scores were higher in the gNO group compared to the P group at most time points, suggesting better lung health with gNO (median score range [min, max], 0-3.5 [0, 7]) vs. P (0-2.0 [0, 5] at end of study). In the substudy, median aggregate scores did not improve for lungs in the iNO group. However, both the gNO and iNO groups showed improvements in lung weight and LAPO2 compared to the P group. CONCLUSIONS The data suggest that inclusion of gNO during EVLP may potentially prolong duration of organ stability and improve donor lung health, which warrants further investigation.
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Boffini M, Cassoni P, Gambella A, Simonato E, Delsedime L, Marro M, Fanelli V, Costamagna A, Lausi PO, Solidoro P, Scalini F, Barbero C, Brazzi L, Rinaldi M, Bertero L. Is there life on the airway tree? A pilot study of bronchial cell vitality and tissue morphology in the ex vivo lung perfusion (EVLP) era of lung transplantation. Artif Organs 2022; 46:2234-2243. [PMID: 35717633 PMCID: PMC9796079 DOI: 10.1111/aor.14342] [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: 03/31/2022] [Revised: 05/24/2022] [Accepted: 06/13/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Ex vivo lung perfusion (EVLP) is a relevant procedure to increase the lung donor pool but could potentially increase the airway tree ischemic injury risk. METHODS This study aimed to evaluate the direct effect of EVLP on the airway tree by evaluating bronchial cell vitality and tissue signs of injury on a series of 117 bronchial rings collected from 40 conventional and 19 EVLP-treated lung grafts. Bronchial rings and related scraped bronchial epithelial cells were collected before the EVLP procedure and surgical anastomosis. RESULTS The preimplantation interval was significantly increased in the EVLP graft group (p < 0.01). Conventional grafts presented cell viability percentages of 47.07 ± 23.41 and 49.65 ± 21.25 in the first and second grafts which did not differ significantly from the EVLP group (first graft 50.54 ± 25.83 and second graft 50.22 ± 20.90 cell viability percentage). No significant differences in terms of histopathological features (edema, inflammatory infiltrate, and mucosa ulceration) were observed comparing conventional and EVLP samples. A comparison of bronchial cell viability and histopathology of EVLP samples retrieved at different time intervals revealed no significant differences. Accordingly, major bronchial complications after lung transplant were not observed in both groups. CONCLUSIONS Based on these data, we observed that EVLP did not significantly impact bronchial cell vitality and airway tissue preservation nor interfere with bronchial anastomosis healing, further supporting it as a safe and useful procedure.
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Affiliation(s)
- Massimo Boffini
- Cardiac Surgery Division, Department of Surgical SciencesUniversity of TurinTurinItaly
| | - Paola Cassoni
- Pathology Unit, Department of Medical SciencesUniversity of TurinTurinItaly
| | | | - Erika Simonato
- Cardiac Surgery Division, Department of Surgical SciencesUniversity of TurinTurinItaly
| | - Luisa Delsedime
- Pathology Unit, AOU Città della Salute e della ScienzaUniversity HospitalTurinItaly
| | - Matteo Marro
- Cardiac Surgery Division, Department of Surgical SciencesUniversity of TurinTurinItaly
| | - Vito Fanelli
- Department of Anesthesia and Intensive Care Medicine, Department of Surgical SciencesUniversity of TurinTurinItaly
| | - Andrea Costamagna
- Department of Anesthesia and Intensive Care Medicine, Department of Surgical SciencesUniversity of TurinTurinItaly
| | - Paolo Olivo Lausi
- Thoracic Surgery Division, Department of Surgical SciencesUniversity of TurinTurinItaly
| | - Paolo Solidoro
- Pneumology Division, Department of Medical SciencesUniversity of TurinTurinItaly
| | - Fabrizio Scalini
- Cardiac Surgery Division, Department of Surgical SciencesUniversity of TurinTurinItaly
| | - Cristina Barbero
- Cardiac Surgery Division, Department of Surgical SciencesUniversity of TurinTurinItaly
| | - Luca Brazzi
- Department of Anesthesia and Intensive Care Medicine, Department of Surgical SciencesUniversity of TurinTurinItaly
| | - Mauro Rinaldi
- Cardiac Surgery Division, Department of Surgical SciencesUniversity of TurinTurinItaly
| | - Luca Bertero
- Pathology Unit, Department of Medical SciencesUniversity of TurinTurinItaly
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Priming of Cardiopulmonary Bypass with Human Albumin Decreases Endothelial Dysfunction after Pulmonary Ischemia-Reperfusion in an Animal Model. Int J Mol Sci 2022; 23:ijms23168938. [PMID: 36012201 PMCID: PMC9408928 DOI: 10.3390/ijms23168938] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 08/01/2022] [Accepted: 08/09/2022] [Indexed: 11/17/2022] Open
Abstract
The routine use of mechanical circulatory support during lung transplantation (LTx) is still controversial. The use of prophylactic human albumin (HA) or hypertonic sodium lactate (HSL) prime in mechanical circulatory support during LTx could prevent ischemia−reperfusion (IR) injuries and pulmonary endothelial dysfunction and thus prevent the development of pulmonary graft dysfunction. The objective was to investigate the impact of cardiopulmonary bypass (CPB) priming with HA and HSL compared to a CPB prime with Gelofusine (GF) on pulmonary endothelial dysfunction in a lung IR rat model. Rats were assigned to four groups: IR-CPB-GF group, IR-CPB-HA group, IR-CPB-HSL group and a sham group. The study of pulmonary vascular reactivity by wire myograph was the primary outcome. Glycocalyx degradation (syndecan-1 and heparan) was also assessed by ELISA and electron microscopy, systemic and pulmonary inflammation by ELISA (IL-1β, IL-10, and TNF-α) and immunohistochemistry. Clinical parameters were evaluated. We employed a CPB model with three different primings, permitting femoral−femoral assistance with left pulmonary hilum ischemia for IR. Pulmonary endothelium-dependent relaxation to acetylcholine was significantly decreased in the IR-CPB-GF group (11.9 ± 6.2%) compared to the IR-CPB-HA group (52.8 ± 5.2%, p < 0.0001), the IR-CPB-HSL group (57.7 ± 6.3%, p < 0.0001) and the sham group (80.8 ± 6.5%, p < 0.0001). We did not observe any difference between the groups concerning glycocalyx degradation, and systemic or tissular inflammation. The IR-CPB-HSL group needed more vascular filling and developed significantly more pulmonary edema than the IR-CPB-GF group and the IR-CPB-HA group. Using HA as a prime in CPB during Ltx could decrease pulmonary endothelial dysfunction’s IR-mediated effects. No effects of HA were found on inflammation.
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25
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Querrey M, Chiu S, Lecuona E, Wu Q, Sun H, Anderson M, Kelly M, Ravi S, Misharin AV, Kreisel D, Bharat A, Budinger GS. CD11b suppresses TLR activation of nonclassical monocytes to reduce primary graft dysfunction after lung transplantation. J Clin Invest 2022; 132:157262. [PMID: 35838047 PMCID: PMC9282933 DOI: 10.1172/jci157262] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 05/25/2022] [Indexed: 02/03/2023] Open
Abstract
Primary graft dysfunction (PGD) is the leading cause of postoperative mortality in lung transplant recipients and the most important risk factor for development of chronic lung allograft dysfunction. The mechanistic basis for the variability in the incidence and severity of PGD between lung transplant recipients is not known. Using a murine orthotopic vascularized lung transplant model, we found that redundant activation of Toll-like receptors 2 and 4 (TLR2 and -4) on nonclassical monocytes activates MyD88, inducing the release of the neutrophil attractant chemokine CXCL2. Deletion of Itgam (encodes CD11b) in nonclassical monocytes enhanced their production of CXCL2 and worsened PGD, while a CD11b agonist, leukadherin-1, administered only to the donor lung prior to lung transplantation, abrogated CXCL2 production and PGD. The damage-associated molecular pattern molecule HMGB1 was increased in peripheral blood samples from patients undergoing lung transplantation after reperfusion and induced CXCL2 production in nonclassical monocytes via TLR4/MyD88. An inhibitor of HMGB1 administered to the donor and recipient prior to lung transplantation attenuated PGD. Our findings suggest that CD11b acts as a molecular brake to prevent neutrophil recruitment by nonclassical monocytes following lung transplantation, revealing an attractive therapeutic target in the donor lung to prevent PGD in lung transplant recipients.
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Affiliation(s)
- Melissa Querrey
- Division of Pulmonary and Critical Care Medicine and,Division of Thoracic Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Stephen Chiu
- Division of Thoracic Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Emilia Lecuona
- Division of Thoracic Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Qiang Wu
- Division of Thoracic Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Haiying Sun
- Division of Thoracic Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Megan Anderson
- Division of Thoracic Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Megan Kelly
- Division of Thoracic Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Sowmya Ravi
- Division of Thoracic Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | | | - Daniel Kreisel
- Department of Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Ankit Bharat
- Division of Thoracic Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - G.R. Scott Budinger
- Division of Pulmonary and Critical Care Medicine and,Division of Thoracic Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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26
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Tanaka S, Hoyos Mejía L, Romero Román A, Campo-Cañaveral de la Cruz JL, Crowley Carrasco S, Naranjo Gómez JM, Córdoba Peláez MDM, Sánchez Calle Á, Gil Barturen M, Varela de Ugarte A, Gómez-de-Antonio D. Evaluation of Uncontrolled Donation After Circulatory Death Lungs by Conventional In Situ Effluent Gas Analysis and Ex Vivo Lung Perfusion. Arch Bronconeumol 2022; 58:569-571. [PMID: 35312549 DOI: 10.1016/j.arbres.2021.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 06/03/2021] [Accepted: 06/10/2021] [Indexed: 11/02/2022]
Affiliation(s)
- Shin Tanaka
- Department of Thoracic Surgery and Lung Transplantation, Hospital Universitario Puerta de Hierro-Majadahonda, Calle Manuel de Falla s/n, Majadahonda, Madrid 28222, Spain
| | - Lucas Hoyos Mejía
- Department of Thoracic Surgery and Lung Transplantation, Hospital Universitario Puerta de Hierro-Majadahonda, Calle Manuel de Falla s/n, Majadahonda, Madrid 28222, Spain.
| | - Alejandra Romero Román
- Department of Thoracic Surgery and Lung Transplantation, Hospital Universitario Puerta de Hierro-Majadahonda, Calle Manuel de Falla s/n, Majadahonda, Madrid 28222, Spain
| | - Jose Luis Campo-Cañaveral de la Cruz
- Department of Thoracic Surgery and Lung Transplantation, Hospital Universitario Puerta de Hierro-Majadahonda, Calle Manuel de Falla s/n, Majadahonda, Madrid 28222, Spain
| | - Silvana Crowley Carrasco
- Department of Thoracic Surgery and Lung Transplantation, Hospital Universitario Puerta de Hierro-Majadahonda, Calle Manuel de Falla s/n, Majadahonda, Madrid 28222, Spain
| | - Jose Manuel Naranjo Gómez
- Department of Thoracic Surgery and Lung Transplantation, Hospital Universitario Puerta de Hierro-Majadahonda, Calle Manuel de Falla s/n, Majadahonda, Madrid 28222, Spain
| | - Maria Del Mar Córdoba Peláez
- Department of Thoracic Surgery and Lung Transplantation, Hospital Universitario Puerta de Hierro-Majadahonda, Calle Manuel de Falla s/n, Majadahonda, Madrid 28222, Spain
| | - Álvaro Sánchez Calle
- Department of Thoracic Surgery and Lung Transplantation, Hospital Universitario Puerta de Hierro-Majadahonda, Calle Manuel de Falla s/n, Majadahonda, Madrid 28222, Spain
| | - Mariana Gil Barturen
- Department of Thoracic Surgery and Lung Transplantation, Hospital Universitario Puerta de Hierro-Majadahonda, Calle Manuel de Falla s/n, Majadahonda, Madrid 28222, Spain
| | - Andrés Varela de Ugarte
- Department of Thoracic Surgery and Lung Transplantation, Hospital Universitario Puerta de Hierro-Majadahonda, Calle Manuel de Falla s/n, Majadahonda, Madrid 28222, Spain
| | - David Gómez-de-Antonio
- Department of Thoracic Surgery and Lung Transplantation, Hospital Universitario Puerta de Hierro-Majadahonda, Calle Manuel de Falla s/n, Majadahonda, Madrid 28222, Spain
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Peterson DM, Beal EW, Reader BF, Dumond C, Black SM, Whitson BA. Electrical Impedance as a Noninvasive Metric of Quality in Allografts Undergoing Normothermic Ex Vivo Lung Perfusion. ASAIO J 2022; 68:964-971. [PMID: 35067581 PMCID: PMC9247000 DOI: 10.1097/mat.0000000000001591] [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] [Indexed: 11/26/2022] Open
Abstract
Ex vivo lung perfusion (EVLP) increases the pool of suitable organs for transplant by facilitating assessment and repair at normothermia, thereby improving identification of quality of marginal organs. However, there exists no current objective approach for assessing total organ edema. We sought to evaluate the use of electrical impedance as a metric to assess total organ edema in lungs undergoing EVLP. Adult porcine lungs (40 kg) underwent normothermic EVLP for 4 hours. To induce varying degrees of lung injury, the allografts were perfused with either Steen, a modified cell culture media, or 0.9% normal saline. Physiologic parameters (peak airway pressure and compliance), pulmonary artery and left atrial blood gases, and extravascular lung water measurements were evaluated over time. Wet-to-dry ratios were evaluated postperfusion. Modified Murray scoring was used to calculate lung injury. Impedance values were associated with lung injury scores ( p = 0.007). Peak airway pressure ( p = 0.01) and PaO 2 /FiO 2 ratios ( p = 0.005) were both significantly associated with reduced impedance. Compliance was not associated with impedance ( p = 0.07). Wet/dry ratios were significantly associated with impedance and Murray Scoring within perfusion groups of Steen, Saline, and Modified Cell Culture ( p = 0.0186, 0.0142, 0.0002, respectively). Electrical impedance offers a noninvasive modality for measuring lung quality as assessed by tissue edema in a porcine model of normothermic EVLP. Further studies evaluating the use of impedance to assess organ edema as a quality marker in human clinical models and abdominal organs undergoing ex vivo perfusion warrant investigation.
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Affiliation(s)
- Danielle M Peterson
- From the The Collaboration for Organ Perfusion, Protection, Engineering and Regeneration (COPPER) Laboratory, The Ohio State University, Columbus, Ohio
- The Ohio State University College of Medicine, Columbus, Ohio
- Penn State College of Medicine Department of Surgery, Hershey, Pennsylvania
| | - Eliza W Beal
- From the The Collaboration for Organ Perfusion, Protection, Engineering and Regeneration (COPPER) Laboratory, The Ohio State University, Columbus, Ohio
- The Ohio State University Wexner Medical Center Department of Surgery, Columbus Ohio
| | - Brenda F Reader
- From the The Collaboration for Organ Perfusion, Protection, Engineering and Regeneration (COPPER) Laboratory, The Ohio State University, Columbus, Ohio
- The Ohio State University Wexner Medical Center Department of Surgery, Columbus Ohio
| | - Curtis Dumond
- From the The Collaboration for Organ Perfusion, Protection, Engineering and Regeneration (COPPER) Laboratory, The Ohio State University, Columbus, Ohio
- The Ohio State University Wexner Medical Center Department of Surgery, Columbus Ohio
| | - Sylvester M Black
- From the The Collaboration for Organ Perfusion, Protection, Engineering and Regeneration (COPPER) Laboratory, The Ohio State University, Columbus, Ohio
- The Ohio State University Wexner Medical Center Department of Surgery, Columbus Ohio
| | - Bryan A Whitson
- From the The Collaboration for Organ Perfusion, Protection, Engineering and Regeneration (COPPER) Laboratory, The Ohio State University, Columbus, Ohio
- The Ohio State University Wexner Medical Center Department of Surgery, Columbus Ohio
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28
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Watanabe T, Kawashima M, Kohno M, Yeung J, Downar J, Healey A, Martinu T, Aversa M, Donahoe L, Pierre A, de Perrot M, Yasufuku K, Waddell TK, Keshavjee S, Cypel M. Outcomes of lung transplantation from organ donation after medical assistance in dying: First North American experience. Am J Transplant 2022; 22:1637-1645. [PMID: 35108446 DOI: 10.1111/ajt.16971] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 01/10/2022] [Accepted: 01/23/2022] [Indexed: 01/25/2023]
Abstract
Over 2.5% of deaths in Canada occur as a result from medical assisting in dying (MAID), and a subset of these deaths result in organ donation. However, detailed outcomes of lung transplant recipients using these donors is lacking. This is a retrospective single center cohort study comparing lung transplantation outcomes after donation using MAID donors compared to neurologically determined death and controlled donation after circulatory death (NDD/cDCD) donors from February 2018 to July 2021. Thirty-three patients received lungs from MAID donors, and 560 patients received lungs from NDD/cDCD donors. The donor diagnoses leading to MAID provision were degenerative neurological diseases (n = 33) and end stage organ failure (n = 5). MAID donors were significantly older than NDD/cDCD donors (56 [IQR 49-64] years vs. 48 [32-59]; p = .0009). Median ventilation period and 30 day mortality were not significantly different between MAID and NDD/cDCD lungs recipients (ventilation: 1 day [1-3] vs 2 days [1-3]; p = .37, deaths 0% [0/33] vs. 2% [11/560], p = .99 respectively). Intermediate-term outcomes were also similar. In summary, for lung transplantation using donors after MAID, recipient outcomes were excellent. Therefore, where this practice is permitted, donation after MAID should be strongly considered for lung transplantation as a way to respect donor wishes while substantially improving outcomes for recipients with end-stage lung disease.
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Affiliation(s)
- Tatsuaki Watanabe
- Division of Thoracic Surgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Ontario, Canada.,Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada.,Department of Thoracic Surgery, Institute of Development, Aging and Cancer, Tohoku University, Sendai, Japan
| | - Mitsuaki Kawashima
- Division of Thoracic Surgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Ontario, Canada.,Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Mikihiro Kohno
- Division of Thoracic Surgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Ontario, Canada.,Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Jonathan Yeung
- Division of Thoracic Surgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Ontario, Canada.,Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - James Downar
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Andrew Healey
- Trillium Gift of Life Network, Toronto, Ontario, Canada.,Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, Ontario, Canada.,Division of Critical Care, Department of Medicine, William Osler Health System, Brampton, Ontario, Canada
| | - Tereza Martinu
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada.,Division of Respirology, Department of Medicine, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Meghan Aversa
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada.,Division of Respirology, Department of Medicine, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - Laura Donahoe
- Division of Thoracic Surgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Ontario, Canada.,Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Andrew Pierre
- Division of Thoracic Surgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Ontario, Canada.,Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Marc de Perrot
- Division of Thoracic Surgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Ontario, Canada.,Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Kazuhiro Yasufuku
- Division of Thoracic Surgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Ontario, Canada.,Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Thomas K Waddell
- Division of Thoracic Surgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Ontario, Canada.,Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Shaf Keshavjee
- Division of Thoracic Surgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Ontario, Canada.,Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Marcelo Cypel
- Division of Thoracic Surgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Ontario, Canada.,Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
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29
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Venema LH, van Leeuwen LL, Posma RA, van Goor H, Ploeg RJ, Hannaert P, Hauet T, Minor T, Leuvenink HG. Impact of Red Blood Cells on Function and Metabolism of Porcine Deceased Donor Kidneys During Normothermic Machine Perfusion. Transplantation 2022; 106:1170-1179. [PMID: 34456268 PMCID: PMC9128616 DOI: 10.1097/tp.0000000000003940] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 08/05/2021] [Accepted: 08/06/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Normothermic machine perfusion (NMP) protocols using blood-based solutions are commonly used in the assessment of kidneys before transplantation. This procedure is, nevertheless, limited by blood availability and warrants the search for alternatives. We compared a blood-based solution with a serum-like preservation solution (Aqix) enriched with colloids with and without red blood cells (RBCs). METHODS Porcine kidneys retrieved from an abattoir were subjected to 30 min of warm ischemia, followed by 3 h of hypothermic oxygenated machine perfusion at 4 °C. Subsequently, kidneys (n = 6 per group) were evaluated with NMP for 4 h with 5 different solutions: diluted blood, Aqix with BSA ± RBCs, or Aqix with dextran 40 ± RBCs. RESULTS Throughout NMP, markers of renal function and tubular metabolism were favorable in groups with RBCs. The addition of RBCs resulted in 4- to 6-fold higher oxygen consumption rates. Controls had significantly higher ATP levels post-NMP, exhibited decreased production of oxidative stress markers, and had the highest creatinine clearance. In conclusion, this study shows that the addition of RBCs during NMP reduced renal injury, improved function, and was associated with increased renal metabolism. CONCLUSIONS Although the RBC-BSA-supplemented Aqix solution was also able to support metabolism and renal function, a blood-based perfusion solution remains superior.
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Affiliation(s)
- Leonie H. Venema
- Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - L. Leonie van Leeuwen
- Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Rene A. Posma
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Harry van Goor
- Department of Pathology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Rutger J. Ploeg
- Department of Surgery, Nuffield Department of Surgical Science, University of Oxford, Oxford, United Kingdom
| | - Patrick Hannaert
- IRTOMIT, INSERM U1082, Faculté de Médecine et de Pharmacie, Université de Poitiers, France
| | - Thierry Hauet
- IRTOMIT, INSERM U1082, Faculté de Médecine et de Pharmacie, Université de Poitiers, France
| | - Thomas Minor
- Department for Surgical Research/General Surgery, University Hospital Essen, Essen, Germany
| | - Henri G.D. Leuvenink
- Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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30
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Brenckmann V, Briot R, Ventrillard I, Romanini D, Barbado M, Jaulin K, Trocme C, De Wolf J, Glorion M, Sage É. Continuous Endogenous Exhaled CO Monitoring by Laser Spectrometer in Human EVLP Before Lung Transplantation. Transpl Int 2022; 35:10455. [PMID: 35711322 PMCID: PMC9192958 DOI: 10.3389/ti.2022.10455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 05/06/2022] [Indexed: 11/13/2022]
Abstract
Endogenous production of carbon monoxide (CO) is affected by inflammatory phenomena and ischemia-reperfusion injury. Precise measurement of exhaled endogenous CO (eCO) is possible thanks to a laser spectrometer (ProCeas® from AP2E company). We assessed eCO levels of human lung grafts during the normothermic Ex-Vivo Lung Perfusion (EVLP). ProCeas® was connected in bypass to the ventilation circuit. The surgical team took the decision to transplant the lungs without knowing eCO values. We compared eCO between accepted and rejected grafts. EVLP parameters and recipient outcomes were also compared with eCO values. Over 7 months, eCO was analyzed in 21 consecutive EVLP grafts. Two pairs of lungs were rejected by the surgical team. In these two cases, there was a tendency for higher eCO values (0.358 ± 0.52 ppm) compared to transplanted lungs (0.240 ± 0.76 ppm). During the EVLP procedure, eCO was correlated with glucose consumption and lactate production. However, there was no association of eCO neither with edema formation nor with the PO2/FiO2 ratio per EVLP. Regarding post-operative data, every patient transplanted with grafts exhaling high eCO levels (>0.235 ppm) during EVLP presented a Primary Graft Dysfunction score of 3 within the 72 h post-transplantation. There was also a tendency for a longer stay in ICU for recipients with grafts exhaling high eCO levels during EVLP. eCO can be continuously monitored during EVLP. It could serve as an additional and early marker in the evaluation of the lung grafts providing relevant information for post-operative resuscitation care.
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Affiliation(s)
- Vivien Brenckmann
- Emergency Department, Grenoble-Alpes University Hospital, Grenoble, France
- Université Grenoble Alpes, CNRS, TIMC-IMAG, Grenoble, France
| | - Raphael Briot
- Emergency Department, Grenoble-Alpes University Hospital, Grenoble, France
- Université Grenoble Alpes, CNRS, TIMC-IMAG, Grenoble, France
- *Correspondence: Raphael Briot,
| | | | | | - Maud Barbado
- Clinical Investigation Centre for Innovative Technology (CIC-IT), Grenoble-Alpes University Hospital, Grenoble, France
| | | | - Candice Trocme
- Biochemistry Proteins and Enzymes Laboratory, Grenoble-Alpes University Hospital, Grenoble, France
| | - Julien De Wolf
- Department of Thoracic Surgery, Foch Hospital, Suresnes, France
| | | | - Édouard Sage
- Department of Thoracic Surgery, Foch Hospital, Suresnes, France
- UMR 0892, Virologie et Immunologie Moléculaires, Université Versailles-Saint-Quentin-en-Yvelines, Versailles, France
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Necroptosis in Solid Organ Transplantation: A Literature Overview. Int J Mol Sci 2022; 23:ijms23073677. [PMID: 35409037 PMCID: PMC8998671 DOI: 10.3390/ijms23073677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 03/21/2022] [Accepted: 03/25/2022] [Indexed: 12/04/2022] Open
Abstract
Ischemia-reperfusion injury (IRI) is encountered in various stages during solid organ transplantation (SOT). IRI is known to be a multifactorial inflammatory condition involving hypoxia, metabolic stress, leukocyte extravasation, cellular death (including apoptosis, necrosis and necroptosis) and an activation of immune response. Although the cycle of sterile inflammation during IRI is consistent among different organs, the underlying mechanisms are poorly understood. Receptor-interacting protein kinase 3 (RIPK3) and mixed-lineage kinase domain-like pseudokinase (MLKL) are thought to be crucial in the implementation of necroptosis. Moreover, apart from “silent” apoptotic death, necrosis also causes sterile inflammation—necroinflammation, which is triggered by various damage-associated molecular patterns (DAMPs). Those DAMPs activate the innate immune system, causing local and systemic inflammatory responses, which can result in graft failure. In this overview we summarize knowledge on mechanisms of sterile inflammation processes during SOT with special focus on necroptosis and IRI and discuss protective strategies.
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Ex Vivo Lung Perfusion: A Review of Current and Future Application in Lung Transplantation. Pulm Ther 2022; 8:149-165. [PMID: 35316525 PMCID: PMC9098710 DOI: 10.1007/s41030-022-00185-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 01/25/2022] [Indexed: 12/23/2022] Open
Abstract
The number of waitlisted lung transplant candidates exceeds the availability of donor organs. Barriers to utilization of donor lungs include suboptimal lung allograft function, long ischemic times due to geographical distance between donor and recipient, and a wide array of other logistical and medical challenges. Ex vivo lung perfusion (EVLP) is a modality that allows donor lungs to be evaluated in a closed circuit outside of the body and extends lung donor assessment prior to final acceptance for transplantation. EVLP was first utilized successfully in 2001 in Lund, Sweden. Since its initial use, EVLP has facilitated hundreds of lung transplants that would not have otherwise happened. EVLP technology continues to evolve and improve, and currently there are multiple commercially available systems, and more under investigation worldwide. Although barriers to universal utilization of EVLP exist, the possibility for more widespread adaptation of this technology abounds. Not only does EVLP have diagnostic capabilities as an organ monitoring device but also the therapeutic potential to improve lung allograft quality when specific issues are encountered. Expanded treatment potential includes the use of immunomodulatory treatment to reduce primary graft dysfunction, as well as targeted antimicrobial therapy to treat infection. In this review, we will highlight the historical development, the current state of utilization/capability, and the future promise of this technology.
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Miceli V, Bertani A. Mesenchymal Stromal/Stem Cells and Their Products as a Therapeutic Tool to Advance Lung Transplantation. Cells 2022; 11:cells11050826. [PMID: 35269448 PMCID: PMC8909054 DOI: 10.3390/cells11050826] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 02/18/2022] [Accepted: 02/25/2022] [Indexed: 02/07/2023] Open
Abstract
Lung transplantation (LTx) has become the gold standard treatment for end-stage respiratory failure. Recently, extended lung donor criteria have been applied to decrease the mortality rate of patients on the waiting list. Moreover, ex vivo lung perfusion (EVLP) has been used to improve the number/quality of previously unacceptable lungs. Despite the above-mentioned progress, the morbidity/mortality of LTx remains high compared to other solid organ transplants. Lungs are particularly susceptible to ischemia-reperfusion injury, which can lead to graft dysfunction. Therefore, the success of LTx is related to the quality/function of the graft, and EVLP represents an opportunity to protect/regenerate the lungs before transplantation. Increasing evidence supports the use of mesenchymal stromal/stem cells (MSCs) as a therapeutic strategy to improve EVLP. The therapeutic properties of MSC are partially mediated by secreted factors. Hence, the strategy of lung perfusion with MSCs and/or their products pave the way for a new innovative approach that further increases the potential for the use of EVLP. This article provides an overview of experimental, preclinical and clinical studies supporting the application of MSCs to improve EVLP, the ultimate goal being efficient organ reconditioning in order to expand the donor lung pool and to improve transplant outcomes.
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Affiliation(s)
- Vitale Miceli
- Research Department, IRCCS ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), 90127 Palermo, Italy
- Correspondence: (V.M.); (A.B.); Tel.: +39-091-21-92-430 (V.M.); +39-091-21-92-111 (A.B.)
| | - Alessandro Bertani
- Thoracic Surgery and Lung Transplantation Unit, IRCCS ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), 90127 Palermo, Italy
- Correspondence: (V.M.); (A.B.); Tel.: +39-091-21-92-430 (V.M.); +39-091-21-92-111 (A.B.)
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Ex-vivo lung perfusion therapies. Curr Opin Organ Transplant 2022; 27:204-210. [DOI: 10.1097/mot.0000000000000961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Arjuna A, Olson MT, Walia R. Current trends in candidate selection, contraindications, and indications for lung transplantation. J Thorac Dis 2022; 13:6514-6527. [PMID: 34992831 PMCID: PMC8662491 DOI: 10.21037/jtd-2021-09] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 01/27/2021] [Indexed: 12/23/2022]
Abstract
Lung transplantation is an established treatment option that can improve quality of life and prolong survival for select patients diagnosed with end-stage lung disease. Given the gaps in organ donation and failures to make effective use of available organs, careful selection of candidates for lung transplant remains one of the most important considerations of the transplant community. Toward this end, we briefly reviewed recent trends in pretransplant evaluation, candidate selection, organ allocation, and organ preservation techniques. Since the latest consensus statement regarding appropriate selection of lung transplant candidates, many advances in the science and practice of lung transplantation have emerged and influenced our perspective of ‘contraindications’ to transplant. These advances have made it increasingly possible to pursue lung transplant in patients with risk factors for decreased survival—namely, older recipient age, increased body mass index, previous chest surgery, poorer nutritional status, and presence of chronic infection, cardiovascular disease, or extrapulmonary comorbid conditions. Therefore, we reviewed the updated evidence demonstrating the prognostic impact of these risk factors in lung transplant recipients. Lastly, we reviewed the salient evidence for current trends in disease-specific indications for lung transplantation, such as chronic obstructive pulmonary disease, idiopathic pulmonary fibrosis, cystic fibrosis, emphysema due to alpha-1 antitrypsin deficiency, and pulmonary arterial hypertension, among other less common end-stage diseases. Overall, lung transplant remains an exciting field with considerable hope for patients as they experience remarkable improvements in quality of life and survival in the modern era.
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Affiliation(s)
- Ashwini Arjuna
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Michael T Olson
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA.,University of Arizona College of Medicine - Phoenix, Phoenix, AZ, USA
| | - Rajat Walia
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
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Shukrallah B, Ganapathi AM, Whitson BA. Donor Aorta as Conduit for Ex Vivo Lung Perfusion. ASAIO J 2021; 67:e182-e183. [PMID: 33769345 PMCID: PMC8560012 DOI: 10.1097/mat.0000000000001361] [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] [Indexed: 12/14/2022] Open
Abstract
For ex vivo lung perfusion (EVLP), there is often inadequate pulmonary artery for effective EVLP. Creation of a neopulmonary artery conduit with donor aorta alleviates this shortcoming. This technique will become of more importance and need as there are more donation after circulatory death donor (DCD) heart procurements as this is a common source of EVLP. With the time constraints associated with the DCD recovery approach, there is a high likelihood of having a short native pulmonary artery with the lung block necessitating this approach.
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Affiliation(s)
- Bassam Shukrallah
- From the Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Asvin M Ganapathi
- Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Bryan A Whitson
- Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
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37
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Continuing progress toward improved lung assessment. J Heart Lung Transplant 2021; 40:696-697. [PMID: 34108110 PMCID: PMC9983802 DOI: 10.1016/j.healun.2021.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 04/26/2021] [Accepted: 04/28/2021] [Indexed: 11/20/2022] Open
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38
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Strategies to prolong homeostasis of ex vivo perfused lungs. J Thorac Cardiovasc Surg 2021; 161:1963-1973. [DOI: 10.1016/j.jtcvs.2020.07.104] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 06/30/2020] [Accepted: 07/26/2020] [Indexed: 01/08/2023]
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39
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Ischemia-Reperfusion Injury in Lung Transplantation. Cells 2021; 10:cells10061333. [PMID: 34071255 PMCID: PMC8228304 DOI: 10.3390/cells10061333] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 05/24/2021] [Accepted: 05/26/2021] [Indexed: 02/08/2023] Open
Abstract
Lung transplantation has been established worldwide as the last treatment for end-stage respiratory failure. However, ischemia–reperfusion injury (IRI) inevitably occurs after lung transplantation. The most severe form of IRI leads to primary graft failure, which is an important cause of morbidity and mortality after lung transplantation. IRI may also induce rejection, which is the main cause of mortality in recipients. Despite advances in donor management and graft preservation, most donor grafts are still unsuitable for transplantation. Although the pulmonary endothelium is the primary target site of IRI, the pathophysiology of lung IRI remains incompletely understood. It is essential to understand the mechanism of pulmonary IRI to improve the outcomes of lung transplantation. Therefore, we reviewed the state-of-the-art in the management of pulmonary IRI after lung transplantation. Recently, the ex vivo lung perfusion (EVLP) system has been clinically introduced worldwide. Various promising therapeutic strategies for the protection of the endothelium against IRI, including EVLP, inhalation therapy with therapeutic gases and substances, fibrinolytic treatment, and mesenchymal stromal cell therapy, are awaiting clinical application. We herein review the latest advances in the field of pulmonary IRI in lung transplantation.
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40
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Ex Vivo Mesenchymal Stem Cell Therapy to Regenerate Machine Perfused Organs. Int J Mol Sci 2021; 22:ijms22105233. [PMID: 34063399 PMCID: PMC8156338 DOI: 10.3390/ijms22105233] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Revised: 05/09/2021] [Accepted: 05/12/2021] [Indexed: 01/06/2023] Open
Abstract
Transplantation represents the treatment of choice for many end-stage diseases but is limited by the shortage of healthy donor organs. Ex situ normothermic machine perfusion (NMP) has the potential to extend the donor pool by facilitating the use of marginal quality organs such as those from donors after cardiac death (DCD) and extended criteria donors (ECD). NMP provides a platform for organ quality assessment but also offers the opportunity to treat and eventually regenerate organs during the perfusion process prior to transplantation. Due to their anti-inflammatory, immunomodulatory and regenerative capacity, mesenchymal stem cells (MSCs) are considered as an interesting tool in this model system. Only a limited number of studies have reported on the use of MSCs during ex situ machine perfusion so far with a focus on feasibility and safety aspects. At this point, no clinical benefits have been conclusively demonstrated, and studies with controlled transplantation set-ups are urgently warranted to elucidate favorable effects of MSCs in order to improve organs during ex situ machine perfusion.
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41
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Baciu C, Sage A, Zamel R, Shin J, Bai XH, Hough O, Bhat M, Yeung JC, Cypel M, Keshavjee S, Liu M. Transcriptomic investigation reveals donor-specific gene signatures in human lung transplants. Eur Respir J 2021; 57:13993003.00327-2020. [PMID: 33122335 DOI: 10.1183/13993003.00327-2020] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 10/05/2020] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Transplantation of lungs from donation after circulatory death (DCD) in addition to donation after brain death (DBD) became routine worldwide to address the global organ shortage. The development of ex vivo lung perfusion (EVLP) for donor lung assessment and repair contributed to the increased use of DCD lungs. We hypothesise that a better understanding of the differences between lungs from DBD and DCD donors, and between EVLP and directly transplanted (non-EVLP) lungs, will lead to the discovery of the injury-specific targets for donor lung repair and reconditioning. METHODS Tissue biopsies from human DBD (n=177) and DCD (n=65) donor lungs, assessed with or without EVLP, were collected at the end of cold ischaemic time. All samples were processed with microarray assays. Gene expression, network and pathway analyses were performed using R, Ingenuity Pathway Analysis and STRING. Results were validated with protein assays, multiple logistic regression and 10-fold cross-validation. RESULTS Our analyses showed that lungs from DBD donors have upregulation of inflammatory cytokines and pathways. In contrast, DCD lungs display a transcriptome signature of pathways associated with cell death, apoptosis and necrosis. Network centrality revealed specific drug targets to rehabilitate DBD lungs. Moreover, in DBD lungs, tumour necrosis factor receptor-1/2 signalling pathways and macrophage migration inhibitory factor-associated pathways were activated in the EVLP group. A panel of genes that differentiate the EVLP from the non-EVLP group in DBD lungs was identified. CONCLUSION The examination of gene expression profiling indicates that DBD and DCD lungs have distinguishable biological transcriptome signatures.
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Affiliation(s)
- Cristina Baciu
- Latner Thoracic Surgery Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
| | - Andrew Sage
- Latner Thoracic Surgery Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
| | - Ricardo Zamel
- Latner Thoracic Surgery Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
| | - Jason Shin
- Latner Thoracic Surgery Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
| | - Xiao-Hui Bai
- Latner Thoracic Surgery Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
| | - Olivia Hough
- Latner Thoracic Surgery Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
| | - Mamatha Bhat
- Multiorgan Transplant Program, University Health Network, Toronto, ON, Canada.,Division of Gastroenterology, University of Toronto, Toronto, ON, Canada
| | - Jonathan C Yeung
- Latner Thoracic Surgery Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada.,Multiorgan Transplant Program, University Health Network, Toronto, ON, Canada.,Toronto Lung Transplant Program, Dept of Surgery, University of Toronto, Toronto, ON, Canada
| | - Marcelo Cypel
- Latner Thoracic Surgery Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada.,Multiorgan Transplant Program, University Health Network, Toronto, ON, Canada.,Toronto Lung Transplant Program, Dept of Surgery, University of Toronto, Toronto, ON, Canada.,Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Shaf Keshavjee
- Latner Thoracic Surgery Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada.,Multiorgan Transplant Program, University Health Network, Toronto, ON, Canada.,Toronto Lung Transplant Program, Dept of Surgery, University of Toronto, Toronto, ON, Canada.,Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,These authors share senior authorship
| | - Mingyao Liu
- Latner Thoracic Surgery Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada.,Multiorgan Transplant Program, University Health Network, Toronto, ON, Canada.,Toronto Lung Transplant Program, Dept of Surgery, University of Toronto, Toronto, ON, Canada.,Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,These authors share senior authorship
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42
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Santini A, Fumagalli J, Merrino A, Protti I, Paleari MC, Montoli M, Dondossola D, Gori F, Righi I, Rosso L, Gatti S, Pesenti A, Grasselli G, Zanella A. Evidence of Air Trapping During Ex Vivo Lung Perfusion: A Swine Experimental Lung Imaging and Mechanics Study. Transplant Proc 2020; 53:457-465. [PMID: 33339649 DOI: 10.1016/j.transproceed.2020.10.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 09/21/2020] [Accepted: 10/19/2020] [Indexed: 11/17/2022]
Abstract
Ex vivo lung perfusion (EVLP) allows the ventilation and perfusion of lungs to evaluate their viability for transplantation. The aim of this study is to compare the mechanical, morphologic and functional properties of lungs during EVLP with values obtained in vivo to guide a safe mechanical ventilation strategy. Lungs from 5 healthy pigs were studied in vivo and during 4 hours of EVLP. Lung compliance, airway resistance, gas exchange, and hemodynamic parameters were collected at positive end-expiratory pressure (PEEP) of 5 cm H2O. Computed tomography was performed at PEEP 0, PEEP 5, and total lung capacity (TLC). Lung pressure-volume (PV) curves were performed from PEEP 0 to TLC. Lung compliance decreased during EVLP (53 ± 5 mL/cm H2O vs 29 ± 7 mL/cm H2O, P < .05), and the PV curve showed a lower inflection point. Gas content (528 ± 118 mL vs 892 ± 402 mL at PEEP 0) and airway resistance (25 ± 5 vs 44 ± 9 cmH2O/L∗s-1, P < .05) were higher during EVLP. Alveolar dead space (5% ± 2% vs 17% ± 6%, P < .05) and intrapulmonary shunt (9% ± 2% vs 28% ± 13%, P < .05) increased ex vivo compared to in vivo, while the partial pressure of oxygen to inspired oxygen fraction ratio (PO2/FiO2) did not differ (468 ± 52 mm Hg vs 536 ± 14 mm Hg). In conclusion, during EVLP lungs show signs of air trapping and bronchoconstriction, resulting in low compliance and increased alveolar dead space. Intrapulmonary shunt is high despite oxygenation levels acceptable for transplantation.
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Affiliation(s)
- A Santini
- Dipartimento di Anestesia, Rianimazione ed Emergenza, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Dipartimento di Anestesia e Terapie Intensive, Humanitas Clinical and Research Center, IRCCS, Rozzano, Milan, Italy
| | - J Fumagalli
- Dipartimento di Anestesia, Rianimazione ed Emergenza, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - A Merrino
- Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Milan, Italy
| | - I Protti
- Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Milan, Italy
| | - M C Paleari
- Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Milan, Italy
| | - M Montoli
- Dipartimento di Chirurgia Toracica, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - D Dondossola
- Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Milan, Italy; Dipartimento di Chirurgia Generale e dei Trapianti di Fegato, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - F Gori
- Dipartimento di Anestesia, Rianimazione ed Emergenza, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - I Righi
- Dipartimento di Chirurgia Toracica, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - L Rosso
- Dipartimento di Chirurgia Toracica, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - S Gatti
- Centro di Ricerche Precliniche, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - A Pesenti
- Dipartimento di Anestesia, Rianimazione ed Emergenza, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Milan, Italy
| | - G Grasselli
- Dipartimento di Anestesia, Rianimazione ed Emergenza, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Milan, Italy
| | - A Zanella
- Dipartimento di Anestesia, Rianimazione ed Emergenza, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Milan, Italy.
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Buchko MT, Boroumand N, Cheng JC, Hirji A, Halloran K, Freed DH, Nagendran J. Clinical transplantation using negative pressure ventilation ex situ lung perfusion with extended criteria donor lungs. Nat Commun 2020; 11:5765. [PMID: 33188221 PMCID: PMC7666579 DOI: 10.1038/s41467-020-19581-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Accepted: 10/22/2020] [Indexed: 01/09/2023] Open
Abstract
Lung transplantation remains the best treatment option for end-stage lung disease; however, is limited by a shortage of donor grafts. Ex situ lung perfusion, also known as ex vivo lung perfusion, has been shown to allow for the safe evaluation and reconditioning of extended criteria donor lungs, increasing donor utilization. Negative pressure ventilation ex situ lung perfusion has been shown, preclinically, to result in less ventilator-induced lung injury than positive pressure ventilation. Here we demonstrate that, in a single-arm interventional study (ClinicalTrials.gov number NCT03293043) of 12 extended criteria donor human lungs, negative pressure ventilation ex situ lung perfusion allows for preservation and evaluation of donor lungs with all grafts and patients surviving to 30 days and recovered to discharge from hospital. This trial also demonstrates that ex situ lung perfusion is safe and feasible with no patients demonstrating primary graft dysfunction scores grade 3 at 72 h or requiring post-operative extracorporeal membrane oxygenation.
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Affiliation(s)
- Max T Buchko
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada
- Mazankowski Alberta Heart Institute, Edmonton, AB, Canada
| | - Nasim Boroumand
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada
- Mazankowski Alberta Heart Institute, Edmonton, AB, Canada
| | - Jeffrey C Cheng
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada
- Mazankowski Alberta Heart Institute, Edmonton, AB, Canada
| | - Alim Hirji
- Division of Pulmonary Medicine, Department of Medicine, University of Alberta, Edmonton, AB, Canada
- Alberta Transplant Institute, Edmonton, AB, Canada
- Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
| | - Kieran Halloran
- Division of Pulmonary Medicine, Department of Medicine, University of Alberta, Edmonton, AB, Canada
- Alberta Transplant Institute, Edmonton, AB, Canada
- Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
| | - Darren H Freed
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada
- Mazankowski Alberta Heart Institute, Edmonton, AB, Canada
- Alberta Transplant Institute, Edmonton, AB, Canada
- Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
| | - Jayan Nagendran
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada.
- Mazankowski Alberta Heart Institute, Edmonton, AB, Canada.
- Alberta Transplant Institute, Edmonton, AB, Canada.
- Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada.
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Benazzo A, Schwarz S, Frommlet F, Sinn K, Schweiger T, Klikovits T, Hoda AM, Moser B, Matilla JR, Renyi Vamos F, Lang G, Jaksch P, Di Nardo M, Del Sorbo L, Taghavi S, Keshavjee S, Klepetko W, Cypel M, Hoetzenecker K. Donor ventilation parameters as predictors for length of mechanical ventilation after lung transplantation: Results of a prospective multicenter study. J Heart Lung Transplant 2020; 40:33-41. [PMID: 33246712 DOI: 10.1016/j.healun.2020.10.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 10/15/2020] [Accepted: 10/26/2020] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND The evaluation of donor lungs heavily depends on the subjective judgment of the retrieval surgeon. As a consequence, acceptance rates vary significantly among transplant centers. We aimed to determine donor ventilation parameters in a prospective study and test if they could be used as objective quality criteria during organ retrieval. METHODS A prospective evaluation of lung donors was performed in 3 transplant centers. Ventilation parameters were collected at the time of retrieval using a standardized ventilation protocol. Recipient length of mechanical ventilation (LMV) was defined as the primary end point, and collected data was used to build linear models predicting LMV. RESULTS In total, 166 donors were included in this study. Median LMV after transplantation was 32 hours (interquartile range: 20-63 hours). Peak inspiratory pressure and dynamic compliance (Cdyn) at the time of retrieval, but not the partial pressure of oxygen/fraction of inspired oxygen (P/F) ratio, correlated with recipient LMV in Spearman correlations (r = 0.280, p = 0.002; r = -0.245, p = 0.003; and r = 0.064, p = 0.432, respectively). Linear models were built to further evaluate the impact of donor ventilation parameters on LMV. The first model was based on donor P/F ratio, donor age, donor intubation time, donor smoking history, donor partial pressure of carbon dioxide, aspiration, chest trauma, and pathologic chest X-ray. This model performed poorly (multiple R-squared = 0.063). In a second model, donor ventilation parameters were included, and Cdyn was identified as the strongest predictor for LMV. The third model was extended by recipient factors, which significantly improved the robustness of the model (multiple R-squared = 0.293). CONCLUSION In this prospective evaluation of donor lung parameters, currently used donor quality criteria poorly predicted recipient LMV. Our data suggest that Cdyn is a strong donor-bound parameter to predict short-term graft performance; however, recipient factors are similarly relevant.
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Affiliation(s)
- Alberto Benazzo
- Division of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Stefan Schwarz
- Division of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Florian Frommlet
- Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Katharina Sinn
- Division of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Thomas Schweiger
- Division of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Thomas Klikovits
- Division of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Alireza Mir Hoda
- Division of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Bernhard Moser
- Division of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Jose Ramon Matilla
- Division of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Ferenc Renyi Vamos
- Department of Thoracic Surgery, Semmelweis University - National Institute of Oncology, Budapest, Hungary
| | - György Lang
- Division of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Peter Jaksch
- Division of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Matteo Di Nardo
- Pediatric Intensive Care Unit, Children's Hospital Bambino Gesù, Rome, Italy
| | - Lorenzo Del Sorbo
- Interdepartmental Division of Critical Care Medicine, University Health Network, Toronto, Ontario, Canada
| | - Shahrokh Taghavi
- Division of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Shaf Keshavjee
- Toronto Lung Transplant Program, Division of Thoracic Surgery, University Health Network, Toronto, Ontario, Canada
| | - Walter Klepetko
- Division of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Marcelo Cypel
- Toronto Lung Transplant Program, Division of Thoracic Surgery, University Health Network, Toronto, Ontario, Canada
| | - Konrad Hoetzenecker
- Division of Thoracic Surgery, Medical University of Vienna, Vienna, Austria.
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Schwarz S, Benazzo A, Dunkler D, Muckenhuber M, Sorbo LD, Di Nardo M, Sinn K, Moser B, Matilla JR, Lang G, Taghavi S, Vamos FR, Jaksch P, Cypel M, Keshavjee S, Klepetko W, Hoetzenecker K. Ventilation parameters and early graft function in double lung transplantation. J Heart Lung Transplant 2020; 40:4-11. [PMID: 33144029 DOI: 10.1016/j.healun.2020.10.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 09/01/2020] [Accepted: 10/07/2020] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Currently, the primary graft dysfunction (PGD) score is used to measure allograft function in the early post-lung transplant period. Although PGD grades at later time points (T48 hours and T72 hours) are useful to predict mid- and long-term outcomes, their predictive value is less relevant within the first 24 hours after transplantation. This study aimed to evaluate the capability of PGD grades to predict prolonged mechanical ventilation (MV) and compare it with a model derived from ventilation parameters measured on arrival at the intensive care unit (ICU). METHODS A retrospective single-center analysis of 422 double lung transplantations (LTxs) was performed. PGD was assessed 2 hours after arrival at ICU, and grades were associated with length of MV (LMV). In addition, peak inspiratory pressure (PIP), ratio of the arterial partial pressure of oxygen to fraction of inspired oxygen (P/F ratio), and dynamic compliance (cDyn) were collected, and a logistic regression model was created. The predictive capability for prolonged MV was calculated for both (the PGD score and the model). In a second step, the created model was externally validated using a prospective, international multicenter cohort including 102 patients from the lung transplant centers of Vienna, Toronto, and Budapest. RESULTS In the retrospective cohort, a high percentage of extubated patients was reported at 24 hours (35.1%), 48 hours (68.0%), and 72 hours (80.3%) after transplantation. At T0 (time point defined as 2 hours after arrival at the ICU), patients with PGD grade 0 had a shorter LMV with a median of 26 hours (interquartile range [IQR]: 16-47 hours) than those with PGD grade 1 (median: 42 hours, IQR: 27-50 hours), PGD grade 2 (median: 37.5 hours, IQR: 15.5-78.5 hours), and PGD grade 3 (median: 46 hours, IQR: 27-86 hours). However, IQRs largely overlapped for all grades, and the value of PGD to predict prolonged MV was poor. A total of 3 ventilation parameters (PIP, cDyn, and P/F ratio), determined at T0, were chosen on the basis of clinical reasoning. A logistic regression model including these parameters predicted prolonged MV (>72 hours) with an optimism-corrected area under the curve (AUC) of 0.727. In the prospective validation cohort, the model proved to be stable and achieved an AUC of 0.679. CONCLUSIONS The prediction model reported in this study combines 3 easily obtainable variables. It can be employed immediately after LTx to quantify the risk of prolonged MV, an important early outcome parameter.
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Affiliation(s)
- Stefan Schwarz
- Division of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Alberto Benazzo
- Division of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Daniela Dunkler
- Center for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Moritz Muckenhuber
- Division of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Lorenzo Del Sorbo
- Division of Thoracic Surgery, University Health Network, Toronto, Ontario, Canada
| | - Matteo Di Nardo
- Division of Thoracic Surgery, University Health Network, Toronto, Ontario, Canada
| | - Katharina Sinn
- Division of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Bernhard Moser
- Division of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - José Ramon Matilla
- Division of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Gyoergy Lang
- Division of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Shahrokh Taghavi
- Division of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Ferenc Renyi Vamos
- Department of Thoracic Surgery, Semmelweis University-National Institute of Oncology, Budapest, Hungary
| | - Peter Jaksch
- Division of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Marcelo Cypel
- Division of Thoracic Surgery, University Health Network, Toronto, Ontario, Canada
| | - Shaf Keshavjee
- Division of Thoracic Surgery, University Health Network, Toronto, Ontario, Canada
| | - Walter Klepetko
- Division of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Konrad Hoetzenecker
- Division of Thoracic Surgery, Medical University of Vienna, Vienna, Austria.
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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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Baidya R, Crawford DHG, Gautheron J, Wang H, Bridle KR. Necroptosis in Hepatosteatotic Ischaemia-Reperfusion Injury. Int J Mol Sci 2020; 21:ijms21165931. [PMID: 32824744 PMCID: PMC7460692 DOI: 10.3390/ijms21165931] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 08/12/2020] [Accepted: 08/12/2020] [Indexed: 02/07/2023] Open
Abstract
While liver transplantation remains the sole treatment option for patients with end-stage liver disease, there are numerous limitations to liver transplantation including the scarcity of donor livers and a rise in livers that are unsuitable to transplant such as those with excess steatosis. Fatty livers are susceptible to ischaemia-reperfusion (IR) injury during transplantation and IR injury results in primary graft non-function, graft failure and mortality. Recent studies have described new cell death pathways which differ from the traditional apoptotic pathway. Necroptosis, a regulated form of cell death, has been associated with hepatic IR injury. Receptor-interacting protein kinase 3 (RIPK3) and mixed-lineage kinase domain-like pseudokinase (MLKL) are thought to be instrumental in the execution of necroptosis. The study of hepatic necroptosis and potential therapeutic approaches to attenuate IR injury will be a key factor in improving our knowledge regarding liver transplantation with fatty donor livers. In this review, we focus on the effect of hepatic steatosis during liver transplantation as well as molecular mechanisms of necroptosis and its involvement during liver IR injury. We also discuss the immune responses triggered during necroptosis and examine the utility of necroptosis inhibitors as potential therapeutic approaches to alleviate IR injury.
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Affiliation(s)
- Raji Baidya
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland QLD 4006, Australia; (R.B.); (D.H.G.C.)
- Gallipoli Medical Research Institute, Brisbane, Queensland QLD 4120, Australia;
| | - Darrell H. G. Crawford
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland QLD 4006, Australia; (R.B.); (D.H.G.C.)
- Gallipoli Medical Research Institute, Brisbane, Queensland QLD 4120, Australia;
| | - Jérémie Gautheron
- Sorbonne University, Inserm, Centre de Recherche Saint-Antoine (CRSA), 75012 Paris, France;
- Institute of Cardiometabolism and Nutrition (ICAN), 75013 Paris, France
| | - Haolu Wang
- Gallipoli Medical Research Institute, Brisbane, Queensland QLD 4120, Australia;
- Diamantina Institute, The University of Queensland, Brisbane, Queensland QLD 4102, Australia
| | - Kim R. Bridle
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland QLD 4006, Australia; (R.B.); (D.H.G.C.)
- Gallipoli Medical Research Institute, Brisbane, Queensland QLD 4120, Australia;
- Correspondence: ; Tel.: +61-7-3346-0698
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Ayyat KS, Okamoto T, Niikawa H, Sakanoue I, Dugar S, Latifi SQ, Lebovitz DJ, Moghekar A, McCurry KR. A CLUE for better assessment of donor lungs: Novel technique in clinical ex vivo lung perfusion. J Heart Lung Transplant 2020; 39:1220-1227. [PMID: 32773324 DOI: 10.1016/j.healun.2020.07.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 07/13/2020] [Accepted: 07/16/2020] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND The direCt Lung Ultrasound Evaluation (CLUE) technique was proven to be an accurate method for monitoring extravascular lung water in donor lungs during ex vivo lung perfusion (EVLP) in an experimental model. The aim of this study was to examine the application of CLUE in the clinical setting. METHODS Lungs were evaluated using acellular EVLP protocol. Ultrasound images were obtained directly from the lung surface. Images were graded according to the percentage of B-lines seen on ultrasound. CLUE scores were calculated at the beginning and end of EVLP for the whole lung, each side, and lobe based on the number (No.) of images in each grade and the total No. of images taken and evaluated retrospectively. RESULTS A total of 23 EVLP cases were performed resulting in 13 lung transplants (LTxs) with no hospital mortality. Primary graft dysfunction (PGD) occurred in only 1 recipient (PGD3, no PGD2). Significant differences were found between suitable and non-suitable lungs in CLUE scores (1.03 vs 1.85, p < 0.001), unlike the partial pressure of oxygen/fraction of inspired oxygen ratio. CLUE had the highest area under the receiver operating characteristic curve (0.98) compared with other evaluation parameters. The initial CLUE score of standard donor lungs was significantly better than marginal lungs. The final CLUE score in proned lungs showed improvement when compared with initial CLUE score, especially in the upper lobes. CONCLUSIONS The CLUE technique shows the highest accuracy in evaluating donor lungs for LTx suitability compared with other parameters used in EVLP. CLUE can optimize the outcomes of LTx by guiding the decision making through the whole process of clinical EVLP.
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Affiliation(s)
- Kamal S Ayyat
- Department of Inflammation and Immunology, Lerner Research Institute and; Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio; Department of Cardiothoracic Surgery, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Toshihiro Okamoto
- Department of Inflammation and Immunology, Lerner Research Institute and; Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio; Transplant Center
| | - Hiromichi Niikawa
- Department of Inflammation and Immunology, Lerner Research Institute and; Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Ichiro Sakanoue
- Department of Inflammation and Immunology, Lerner Research Institute and; Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | | | - Samir Q Latifi
- Department of Pediatric Critical Care, Cleveland Clinic, Cleveland, Ohio; Lifebanc, Cleveland, Ohio
| | - Daniel J Lebovitz
- Lifebanc, Cleveland, Ohio; Department of Critical Care Medicine, Akron Children's Hospital, Akron, Ohio
| | | | - Kenneth R McCurry
- Department of Inflammation and Immunology, Lerner Research Institute and; Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio; Transplant Center.
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Kim JL, Reader BF, Dumond C, Lee Y, Mokadam NA, Black SM, Whitson BA. Pegylated-Catalase Is Protective in Lung Ischemic Injury and Oxidative Stress. Ann Thorac Surg 2020; 111:1019-1027. [PMID: 32710846 DOI: 10.1016/j.athoracsur.2020.05.131] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 05/04/2020] [Accepted: 05/18/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Lung transplant ischemia-reperfusion injury is typified by toxic metabolites and oxygen free radicals leading to worse graft function. Catalase is an enzyme involved in oxidative-stress detoxification. We hypothesize that direct delivery of highly concentrated polyethylene glycol-catalase (PEG-CAT) during normothermic ex vivo lung perfusion (EVLP) significantly reduces ischemia-reperfusion injury. METHODS To demonstrate protection, primary culture porcine endothelial cells were treated with PEG-CAT (0 to 1250 U/mL) in a model of oxidative stress (400 μM H2o2). In vivo, rat lungs were subjected to 0 hours or 1 hour of warm ischemic injury and 2 hours of EVLP with or without PEG-CAT. Perfusate was collected throughout the perfusion duration and tissue was collected at the end. Tissue and perfusate underwent analysis for markers of apoptosis and a biometric signature of lung health. RESULTS Uptake of PEG-CAT into primary endothelial cells was demonstrated with Alexa Fluor 488-labeled PEG-CAT. Oxidatively stressed cells pretreated with PEG-CAT had significantly decreased cytotoxicity and caspase 3/7 activity and increased cell viability and cell membrane integrity. In a rat model of warm ischemia with EVLP, PEG-CAT improved allograft viability as measured by indications of cell membrane integrity (lactate dehydrogenase and hyaluronic acid), presence of vasoconstrictive peptides (endothelin-1 and big endothelin-1) released from endothelial cells, and reduced apoptosis (terminal deoxynucleotidyl transferase dUTP nick-end labeling). CONCLUSIONS In vitro and ex vivo, PEG-CAT protects against oxidative stress-induced cytotoxicity, maintains cellular metabolism, and mitigates lung ischemia-reperfusion in an experimental model. Together, these data suggest that PEG-CAT is a potential therapeutic target for donor organs at risk for ischemia-reperfusion injury.
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Affiliation(s)
- Jung-Lye Kim
- COPPER Laboratory, Ohio State University Wexner Medical Center, Columbus, Ohio; Department of Surgery, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Brenda F Reader
- COPPER Laboratory, Ohio State University Wexner Medical Center, Columbus, Ohio; Comprehensive Transplant Center, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Curtis Dumond
- COPPER Laboratory, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Yonggyu Lee
- COPPER Laboratory, Ohio State University Wexner Medical Center, Columbus, Ohio; Department of Surgery, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Nahush A Mokadam
- Department of Surgery, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Sylvester M Black
- COPPER Laboratory, Ohio State University Wexner Medical Center, Columbus, Ohio; Department of Surgery, Ohio State University Wexner Medical Center, Columbus, Ohio; Comprehensive Transplant Center, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Bryan A Whitson
- COPPER Laboratory, Ohio State University Wexner Medical Center, Columbus, Ohio; Department of Surgery, Ohio State University Wexner Medical Center, Columbus, Ohio; Comprehensive Transplant Center, Ohio State University Wexner Medical Center, Columbus, Ohio.
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