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A Meta-Analysis and Systematic Review of Normothermic and Hypothermic Machine Perfusion in Liver Transplantation. J Clin Med 2022; 12:jcm12010235. [PMID: 36615037 PMCID: PMC9820958 DOI: 10.3390/jcm12010235] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 12/02/2022] [Accepted: 12/05/2022] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND The gap between the demand and supply of donor livers is still a considerable challenge. Since static cold storage is not sufficient in marginal livers, machine perfusion is being explored as an alternative. The objective of this study was to assess (dual) hypothermic oxygenated machine perfusion (HOPE/D-HOPE) and normothermic machine perfusion (NMP) in contrast to static cold storage (SCS). METHODS Three databases were searched to identify studies about machine perfusion. Graft and patient survival and postoperative complications were evaluated using the random effects model. RESULTS the incidence of biliary complications was lower in HOPE vs. SCS (OR: 0.59, 95% CI: 0.36-0.98, p = 0.04, I2: 0%). There was no significant difference in biliary complications between NMP and SCS (OR: 0.76, 95% CI: 0.41-1.40, p = 0.38, I2: 55%). Graft and patient survival were significantly better in HOPE than in SCS (HR: 0.40, 95% CI: 0.23-0.71, p = 0.002, I2: 0%) and (pooled HR: 0.43, 95% CI: 0.20-0.93, p = 0.03, I2: 0%). Graft and patient survival were not significantly different between NMP and SCS. CONCLUSION HOPE/D-HOPE and NMP are promising alternatives to SCS for donor liver preservation. They may help address the widening gap between the demand for and availability of donor livers by enabling the rescue and transplantation of marginal livers.
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Tessier SN, de Vries RJ, Pendexter CA, Cronin SEJ, Ozer S, Hafiz EOA, Raigani S, Oliveira-Costa JP, Wilks BT, Lopera Higuita M, van Gulik TM, Usta OB, Stott SL, Yeh H, Yarmush ML, Uygun K, Toner M. Partial freezing of rat livers extends preservation time by 5-fold. Nat Commun 2022; 13:4008. [PMID: 35840553 PMCID: PMC9287450 DOI: 10.1038/s41467-022-31490-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 06/20/2022] [Indexed: 02/04/2023] Open
Abstract
The limited preservation duration of organs has contributed to the shortage of organs for transplantation. Recently, a tripling of the storage duration was achieved with supercooling, which relies on temperatures between -4 and -6 °C. However, to achieve deeper metabolic stasis, lower temperatures are required. Inspired by freeze-tolerant animals, we entered high-subzero temperatures (-10 to -15 °C) using ice nucleators to control ice and cryoprotective agents (CPAs) to maintain an unfrozen liquid fraction. We present this approach, termed partial freezing, by testing gradual (un)loading and different CPAs, holding temperatures, and storage durations. Results indicate that propylene glycol outperforms glycerol and injury is largely influenced by storage temperatures. Subsequently, we demonstrate that machine perfusion enhancements improve the recovery of livers after freezing. Ultimately, livers that were partially frozen for 5-fold longer showed favorable outcomes as compared to viable controls, although frozen livers had lower cumulative bile and higher liver enzymes.
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Affiliation(s)
- Shannon N. Tessier
- grid.38142.3c000000041936754XCenter for Engineering in Medicine and Surgery, Harvard Medical School and Massachusetts General Hospital, Boston, MA USA ,grid.415829.30000 0004 0449 5362Shriners Hospitals for Children Boston, Boston, MA USA
| | - Reinier J. de Vries
- grid.38142.3c000000041936754XCenter for Engineering in Medicine and Surgery, Harvard Medical School and Massachusetts General Hospital, Boston, MA USA ,grid.415829.30000 0004 0449 5362Shriners Hospitals for Children Boston, Boston, MA USA ,grid.7177.60000000084992262Department of Surgery, Amsterdam University Medical Centers – location AMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Casie A. Pendexter
- grid.38142.3c000000041936754XCenter for Engineering in Medicine and Surgery, Harvard Medical School and Massachusetts General Hospital, Boston, MA USA ,grid.415829.30000 0004 0449 5362Shriners Hospitals for Children Boston, Boston, MA USA ,Present Address: Sylvatica Biotech Inc., North Charleston, SC USA
| | - Stephanie E. J. Cronin
- grid.38142.3c000000041936754XCenter for Engineering in Medicine and Surgery, Harvard Medical School and Massachusetts General Hospital, Boston, MA USA ,grid.415829.30000 0004 0449 5362Shriners Hospitals for Children Boston, Boston, MA USA
| | - Sinan Ozer
- grid.38142.3c000000041936754XCenter for Engineering in Medicine and Surgery, Harvard Medical School and Massachusetts General Hospital, Boston, MA USA ,grid.415829.30000 0004 0449 5362Shriners Hospitals for Children Boston, Boston, MA USA
| | - Ehab O. A. Hafiz
- grid.420091.e0000 0001 0165 571XDepartment of Electron Microscopy Research, Theodor Bilharz Research Institute, Giza, Egypt
| | - Siavash Raigani
- grid.415829.30000 0004 0449 5362Shriners Hospitals for Children Boston, Boston, MA USA ,grid.32224.350000 0004 0386 9924Department of Surgery, Division of Transplantation, Massachusetts General Hospital, Boston, MA USA
| | - Joao Paulo Oliveira-Costa
- grid.38142.3c000000041936754XCenter for Engineering in Medicine and Surgery, Harvard Medical School and Massachusetts General Hospital, Boston, MA USA ,grid.38142.3c000000041936754XDepartment of Medicine and Cancer Center, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA USA
| | - Benjamin T. Wilks
- grid.38142.3c000000041936754XCenter for Engineering in Medicine and Surgery, Harvard Medical School and Massachusetts General Hospital, Boston, MA USA ,grid.415829.30000 0004 0449 5362Shriners Hospitals for Children Boston, Boston, MA USA
| | - Manuela Lopera Higuita
- grid.38142.3c000000041936754XCenter for Engineering in Medicine and Surgery, Harvard Medical School and Massachusetts General Hospital, Boston, MA USA ,grid.415829.30000 0004 0449 5362Shriners Hospitals for Children Boston, Boston, MA USA
| | - Thomas M. van Gulik
- grid.7177.60000000084992262Department of Surgery, Amsterdam University Medical Centers – location AMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Osman Berk Usta
- grid.38142.3c000000041936754XCenter for Engineering in Medicine and Surgery, Harvard Medical School and Massachusetts General Hospital, Boston, MA USA ,grid.415829.30000 0004 0449 5362Shriners Hospitals for Children Boston, Boston, MA USA
| | - Shannon L. Stott
- grid.38142.3c000000041936754XCenter for Engineering in Medicine and Surgery, Harvard Medical School and Massachusetts General Hospital, Boston, MA USA ,grid.38142.3c000000041936754XDepartment of Medicine and Cancer Center, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA USA
| | - Heidi Yeh
- grid.32224.350000 0004 0386 9924Department of Surgery, Division of Transplantation, Massachusetts General Hospital, Boston, MA USA
| | - Martin L. Yarmush
- grid.38142.3c000000041936754XCenter for Engineering in Medicine and Surgery, Harvard Medical School and Massachusetts General Hospital, Boston, MA USA ,grid.415829.30000 0004 0449 5362Shriners Hospitals for Children Boston, Boston, MA USA ,grid.430387.b0000 0004 1936 8796Department of Biomedical Engineering, Rutgers University, Piscataway, NJ USA
| | - Korkut Uygun
- grid.38142.3c000000041936754XCenter for Engineering in Medicine and Surgery, Harvard Medical School and Massachusetts General Hospital, Boston, MA USA ,grid.415829.30000 0004 0449 5362Shriners Hospitals for Children Boston, Boston, MA USA
| | - Mehmet Toner
- grid.38142.3c000000041936754XCenter for Engineering in Medicine and Surgery, Harvard Medical School and Massachusetts General Hospital, Boston, MA USA ,grid.415829.30000 0004 0449 5362Shriners Hospitals for Children Boston, Boston, MA USA
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Recent Methods of Kidney Storage and Therapeutic Possibilities of Transplant Kidney. Biomedicines 2022; 10:biomedicines10051013. [PMID: 35625750 PMCID: PMC9139114 DOI: 10.3390/biomedicines10051013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 04/24/2022] [Accepted: 04/25/2022] [Indexed: 11/21/2022] Open
Abstract
Kidney transplantation is the standard procedure for the treatment of end-stage renal disease (ESRD). During kidney storage and before implantation, the organ is exposed to damaging factors which affect the decline in condition. The arrest of blood circulation results in oxygen and nutrient deficiency that lead to changes in the cell metabolism from aerobic to anaerobic, damaging organelles and cell structures. Currently, most kidney grafts are kept in a cold preservation solution to preserve low metabolism. However, there are numerous reports that machine perfusion is a better solution for organ preservation before surgery. The superiority of machine perfusion was proved in the case of marginal donor grafts, such as extended criteria donors (ECD) and donation after circulatory death (DCD). Different variant of kidney machine perfusions are evaluated. Investigators look for optimal conditions to protect kidneys from ischemia-reperfusion damage consequences by examining the best temperature conditions and comparing systems with constant or pulsatile flow. Moreover, machine perfusion brings additional advantages in clinical practice. Unlike cold static storage, machine perfusion allows the monitoring of the parameters of organ function, which gives a real possibility to make a decision prior to transplantation concerning whether the kidney is suitable for implantation. Moreover, new pharmacological therapies are sought to minimize organ damage. New components or cellular therapies can be applied, since perfusion solution flows through the organ. This review outlines the pros and cons of each machine perfusion technique and summarizes the latest achievements in the context of kidney transplantation using machine perfusion systems.
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Abraham N, Zhang M, Cray P, Gao Q, Samy KP, Neill R, Cywinska G, Migaly J, Kahan R, Pontula A, Halpern SE, Rush C, Penaflor J, Kesseli SJ, Krischak M, Song M, Hartwig MG, Pollara JJ, Barbas AS. Two Compartment Evaluation of Liver Grafts During Acellular Room Temperature Machine Perfusion (acRTMP) in a Rat Liver Transplant Model. Front Med (Lausanne) 2022; 9:804834. [PMID: 35280912 PMCID: PMC8907827 DOI: 10.3389/fmed.2022.804834] [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: 10/29/2021] [Accepted: 01/25/2022] [Indexed: 11/24/2022] Open
Abstract
Background Subnormothermic machine perfusion (SNMP) of liver grafts is currently less clinically developed than normothermic and hypothermic approaches, but may have logistical advantages. At intermediate temperatures, the oxygen demand of the graft is low enough to be satisfied with an acellular perfusate, obviating the need for oxygen carrying molecules. This intermediate metabolic rate, however, is sufficient to support the production of bile, which is emerging as an important indicator of graft injury and viability. In this study, we hypothesized that the biliary compartment would be more sensitive than perfusate in detecting graft injury during SNMP. Methods To test this hypothesis in a rat model, we performed liver transplants with DCD and control liver grafts after 1 h of acellular room temperature machine perfusion (acRTMP) or static cold storage (SCS). Point of care liver function tests were measured in biliary and perfusate samples after 1 h of machine perfusion. Following transplantation, rats were sacrificed at 24 h for assessment of post-transplant graft function and histology. Results All point-of-care liver function tests were significantly more concentrated in the biliary compartment than the perfusate compartment during acRTMP. DCD liver grafts could be distinguished from control liver grafts by significantly higher markers of hepatocyte injury (AST, ALT) in the biliary compartment, but not in the perfusate compartment. Classical markers of cholangiocyte injury, such as gammy-glut amyl transferase (GGT), amylase (AML), and alkaline phosphatase were detectable in the biliary compartment, but not in the perfusate compartment. In comparison to SCS, graft preservation by acRTMP produced a significant survival benefit in DCD liver transplantation (75 vs. 0%, p < 0.0030). Conclusion Together, these findings demonstrate that during acRTMP, the biliary compartment may be a more sensitive indicator of graft injury than the perfusate compartment. Moreover, acRTMP provides superior graft preservation to SCS in rat DCD liver transplantation.
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Affiliation(s)
- Nader Abraham
- Duke Ex-Vivo Organ Lab (DEVOL) - Division of Abdominal Transplant Surgery, Duke University, Durham, NC, United States
| | - Min Zhang
- Duke Ex-Vivo Organ Lab (DEVOL) - Division of Abdominal Transplant Surgery, Duke University, Durham, NC, United States
| | - Paul Cray
- Duke Ex-Vivo Organ Lab (DEVOL) - Division of Abdominal Transplant Surgery, Duke University, Durham, NC, United States
| | - Qimeng Gao
- Duke Ex-Vivo Organ Lab (DEVOL) - Division of Abdominal Transplant Surgery, Duke University, Durham, NC, United States
| | - Kannan P Samy
- Duke Ex-Vivo Organ Lab (DEVOL) - Division of Abdominal Transplant Surgery, Duke University, Durham, NC, United States
| | - Ryan Neill
- Duke Ex-Vivo Organ Lab (DEVOL) - Division of Abdominal Transplant Surgery, Duke University, Durham, NC, United States
| | - Greta Cywinska
- Duke Ex-Vivo Organ Lab (DEVOL) - Division of Abdominal Transplant Surgery, Duke University, Durham, NC, United States
| | - JonCarlo Migaly
- Duke Ex-Vivo Organ Lab (DEVOL) - Division of Abdominal Transplant Surgery, Duke University, Durham, NC, United States
| | - Riley Kahan
- Duke Ex-Vivo Organ Lab (DEVOL) - Division of Abdominal Transplant Surgery, Duke University, Durham, NC, United States
| | - Arya Pontula
- Duke Ex-Vivo Organ Lab (DEVOL) - Division of Abdominal Transplant Surgery, Duke University, Durham, NC, United States
| | - Samantha E Halpern
- Duke Ex-Vivo Organ Lab (DEVOL) - Division of Abdominal Transplant Surgery, Duke University, Durham, NC, United States
| | - Caroline Rush
- Duke Ex-Vivo Organ Lab (DEVOL) - Division of Abdominal Transplant Surgery, Duke University, Durham, NC, United States
| | - Jude Penaflor
- Duke Ex-Vivo Organ Lab (DEVOL) - Division of Abdominal Transplant Surgery, Duke University, Durham, NC, United States
| | - Samuel J Kesseli
- Duke Ex-Vivo Organ Lab (DEVOL) - Division of Abdominal Transplant Surgery, Duke University, Durham, NC, United States
| | - Madison Krischak
- Duke Ex-Vivo Organ Lab (DEVOL) - Division of Abdominal Transplant Surgery, Duke University, Durham, NC, United States
| | - Mingqing Song
- Duke Ex-Vivo Organ Lab (DEVOL) - Division of Abdominal Transplant Surgery, Duke University, Durham, NC, United States
| | - Matthew G Hartwig
- Duke Ex-Vivo Organ Lab (DEVOL) - Division of Abdominal Transplant Surgery, Duke University, Durham, NC, United States
| | - Justin J Pollara
- Duke Ex-Vivo Organ Lab (DEVOL) - Division of Abdominal Transplant Surgery, Duke University, Durham, NC, United States
| | - Andrew S Barbas
- Duke Ex-Vivo Organ Lab (DEVOL) - Division of Abdominal Transplant Surgery, Duke University, Durham, NC, United States
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Kvietkauskas M, Leber B, Strupas K, Stiegler P, Schemmer P. Machine Perfusion of Extended Criteria Donor Organs: Immunological Aspects. Front Immunol 2020; 11:192. [PMID: 32180769 PMCID: PMC7057848 DOI: 10.3389/fimmu.2020.00192] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Accepted: 01/24/2020] [Indexed: 12/20/2022] Open
Abstract
Due to higher vulnerability and immunogenicity of extended criteria donor (ECD) organs used for organ transplantation (Tx), the discovery of new treatment strategies, involving tissue allorecognition pathways, is important. The implementation of machine perfusion (MP) led to improved estimation of the organ quality and introduced the possibility to achieve graft reconditioning prior to Tx. A significant number of experimental and clinical trials demonstrated increasing support for MP as a promising method of ECD organ preservation compared to classical static cold storage. MP reduced ischemia-reperfusion injury resulting in the protection from inadequate activation of innate immunity. However, there are no general agreements on MP protocols, and clinical application is limited. The objective of this comprehensive review is to summarize literature on immunological effects of MP of ECD organs based on experimental studies and clinical trials.
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Affiliation(s)
- Mindaugas Kvietkauskas
- Department of General, Visceral and Transplant Surgery, Medical University of Graz, Graz, Austria.,Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Bettina Leber
- Department of General, Visceral and Transplant Surgery, Medical University of Graz, Graz, Austria
| | | | - Philipp Stiegler
- Department of General, Visceral and Transplant Surgery, Medical University of Graz, Graz, Austria
| | - Peter Schemmer
- Department of General, Visceral and Transplant Surgery, Medical University of Graz, Graz, Austria
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Ex Situ Liver Machine Perfusion as an Emerging Graft Protective Strategy in Clinical Liver Transplantation: the Dawn of a New Era. Transplantation 2019; 103:2003-2011. [DOI: 10.1097/tp.0000000000002772] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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7
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Abstract
Machine perfusion is a hot topic in liver transplantation and several new perfusion concepts are currently developed. Prior to introduction into routine clinical practice, however, such perfusion approaches need to demonstrate their impact on liver function, post-transplant complications, utilization rates of high-risk organs, and cost benefits. Therefore, based on results of experimental and clinical studies, the community has to recognize the limitations of this technology. In this review, we summarize current perfusion concepts and differences between protective mechanisms of ex- and in-situ perfusion techniques. Next, we discuss which graft types may benefit most from perfusion techniques, and highlight the current understanding of liver viability testing. Finally, we present results from recent clinical trials involving machine liver perfusion, and analyze the value of different outcome parameters, currently used as endpoints for randomized controlled trials in the field.
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Affiliation(s)
- Andrea Schlegel
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.,Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Xavier Muller
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Philipp Dutkowski
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
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8
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Laschke MW, Heß A, Scheuer C, Karschnia P, Kontaxi E, Menger MD. University of Wisconsin solution for the xeno-free storage of adipose tissue-derived microvascular fragments. Regen Med 2019; 14:681-691. [DOI: 10.2217/rme-2018-0164] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Aim: Adipose tissue-derived microvascular fragments (ad-MVF) are vascularization units for regenerative medicine. We investigated whether University of Wisconsin (UW) solution is suitable for their xeno-free storage. Materials & methods: Murine ad-MVF were cultivated for 24 h in 4°C or 20°C UW solution and 20°C endothelial cell growth medium (control). The ad-MVF were seeded onto collagen–glycosaminoglycan scaffolds, which were analyzed in dorsal skinfold chambers by intravital fluorescence microscopy and histology. Results: All implants exhibited microvascular networks on day 14 with the highest functional microvessel density in controls. Ad-MVF cultivation in UW solution at 4°C resulted in an improved scaffold vascularization compared with cultivation at 20°C. Conclusion: UW solution is suitable for the hypothermic storage of ad-MVF.
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Affiliation(s)
- Matthias W Laschke
- Institute for Clinical & Experimental Surgery, Saarland University, 66421 Homburg/Saar, Germany
| | - Alexander Heß
- Institute for Clinical & Experimental Surgery, Saarland University, 66421 Homburg/Saar, Germany
| | - Claudia Scheuer
- Institute for Clinical & Experimental Surgery, Saarland University, 66421 Homburg/Saar, Germany
| | - Philipp Karschnia
- Institute for Clinical & Experimental Surgery, Saarland University, 66421 Homburg/Saar, Germany
| | - Elena Kontaxi
- Institute for Clinical & Experimental Surgery, Saarland University, 66421 Homburg/Saar, Germany
| | - Michael D Menger
- Institute for Clinical & Experimental Surgery, Saarland University, 66421 Homburg/Saar, Germany
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Porcine Isolated Liver Perfusion for the Study of Ischemia Reperfusion Injury: A Systematic Review. Transplantation 2019; 102:1039-1049. [PMID: 29509572 DOI: 10.1097/tp.0000000000002156] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Understanding ischemia reperfusion injury (IRI) is essential to further improve outcomes after liver transplantation (LT). Porcine isolated liver perfusion (ILP) is increasingly used to reproduce LT-associated IRI in a strictly controlled environment. However, whether ILP is a reliable substitute of LT was never validated. METHODS We systematically reviewed the current experimental setups for ILP and parameters of interest reflecting IRI. RESULTS Isolated liver perfusion was never compared with transplantation in animals. Considerable variability exists between setups, and comparative data are unavailable. Experience so far suggests that centrifugal pump(s) with continuous flow are preferred to reduce the risk of embolism. Hepatic outflow can be established by cannulation of the inferior vena cava or freely drained in an open bath. Whole blood at approximately 38°C, hematocrit of 20% or greater, and the presence of leukocytes to trigger inflammation is considered the optimal perfusate. A number of parameters related to the 4 liver compartments (hepatocyte, cholangiocyte, endothelium, immune cells) are available; however, their significance and relation to clinical outcomes is not well described. CONCLUSIONS Porcine ILP provides a reproducible model to study early IRI events. As all models, it has its limitations. A standardization of the setup would allow comparison of data and progress in the field.
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Kim J, Zimmerman M, Hong J. Emerging Innovations in Liver Preservation and Resuscitation. Transplant Proc 2018; 50:2308-2316. [DOI: 10.1016/j.transproceed.2018.03.080] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Accepted: 03/02/2018] [Indexed: 12/18/2022]
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Optimizing Livers for Transplantation Using Machine Perfusion versus Cold Storage in Large Animal Studies and Human Studies: A Systematic Review and Meta-Analysis. BIOMED RESEARCH INTERNATIONAL 2018; 2018:9180757. [PMID: 30255101 PMCID: PMC6145150 DOI: 10.1155/2018/9180757] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 08/01/2018] [Accepted: 08/16/2018] [Indexed: 12/25/2022]
Abstract
Background Liver allograft preservation frequently involves static cold storage (CS) and machine perfusion (MP). With its increasing popularity, we investigated whether MP was superior to CS in terms of beneficial outcomes. Methods Human studies and large animal studies that optimized livers for transplantation using MP versus CS were assessed (PubMed/Medline/EMBASE). Meta-analyses were conducted for comparisons. Study quality was assessed according to the Newcastle-Ottawa quality assessment scale and SYRCLE's risk of bias tool. Results Nineteen studies were included. Among the large animal studies, lower levels of lactate dehydrogenase (SMD -3.16, 95% CI -5.14 to -1.18), alanine transferase (SMD -2.46, 95% CI -4.03 to -0.90), and hyaluronic acid (SMD -2.48, 95% CI -4.21 to -0.74) were observed in SNMP-preserved compared to CS-preserved livers. NMP-preserved livers showing lower level of hyaluronic acid (SMD -3.97, 95% CI -5.46 to -2.47) compared to CS-preserved livers. Biliary complications (RR 0.45, 95% CI 0.28 to 0.73) and early graft dysfunction (RR 0.56, 95% CI 0.34 to 0.92) also significantly reduced with HMP preservation in human studies. No evidence of publication bias was found. Conclusions MP preservation could improve short-term outcomes after transplantation compared to CS preservation. Additional randomized controlled trials (RCTs) are needed to develop clinical applications of MP preservation.
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Normothermic Ex Vivo Machine Perfusion for Liver Grafts Recovered from Donors after Circulatory Death: A Systematic Review and Meta-Analysis. HPB SURGERY : A WORLD JOURNAL OF HEPATIC, PANCREATIC AND BILIARY SURGERY 2018; 2018:6867986. [PMID: 29849531 PMCID: PMC5937385 DOI: 10.1155/2018/6867986] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 03/15/2018] [Indexed: 12/20/2022]
Abstract
As a result of donation after circulatory death liver grafts' poor tolerance to cold storage, there has been increasing research interest in normothermic machine perfusion. This study aims to systematically review the current literature comparing normothermic perfusion to cold storage in donation after circulatory death liver grafts and complete a meta-analysis of published large animal and human studies. A total of nine porcine studies comparing cold storage to normothermic machine perfusion for donation after circulatory death grafts were included for analysis. There was a significant reduction in AST (mean difference −2291 U/L, CI (−3019, −1563); P ≤ 0.00001) and ALT (mean difference −175 U/L, CI (−266, −85); P = 0.0001), for normothermic perfusion relative to static cold storage, with moderate (I2 = 61%) and high (I2 = 96%) heterogeneity, respectively. Total bile production was also significantly higher (mean difference = 174 ml, CI (155, 193); P ≤ 0.00001). Further research focusing on standardization, performance of this technology following periods of cold storage, economic implications, and clinical trial data focused on donation after circulatory death grafts will be helpful to advance this technology toward routine clinical utilization for these grafts.
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13
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Yoshikawa R, Obara H, Matsuno N, Morito N, Gouchi M, Otani M, Shonaka T, Takahashi H, Enosawa S, Hirano T, Furukawa H. Ex Vivo Reperfusion Model to Evaluate Utility of Machine Preservation for Porcine Liver Donated After Cardiac Death. Transplant Proc 2018; 50:2826-2829. [PMID: 30401405 DOI: 10.1016/j.transproceed.2018.04.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 03/22/2018] [Accepted: 04/06/2018] [Indexed: 12/27/2022]
Abstract
BACKGROUND Machine perfusion (MP) techniques are expected to prove useful for preserving the organ viability and recovering organ function for organ transplantation. Furthermore, an accurate assessment of organ viability using MP is important for expanding the donor criteria. In this study, an ex vivo reperfusion model (ERM) simulating transplantation using diluted autologous blood under normothermic conditions was evaluated for its utility of MP under subnormothermic conditions for livers donated after cardiac death (DCD). METHODS The liver preservation methods for DCD porcine livers were evaluated using the ERM. This investigation was performed using a novel perfusion system developed by our research group. Porcine livers were procured with a warm ischemia time (WIT) of 60 minutes. The organs were then preserved using subnormothemic machine perfusion (SNMP) or static cold storage (CS) for 4 hours. We also compared these tissues with SNMP livers procured under a WIT of 0 minutes. After the preservation, the livers were reperfused for 2 hours using the ERM with diluted autologous blood oxygenated by a membrane oxygenator under NMP conditions. Reperfusion was evaluated based on perfusion flow dynamics and outflow of deviating enzymes. RESULTS In the early stages of reperfusion, pressure in the blood vessels increased sharply in the CS group. Furthermore, the amount of aspartate aminotransferase accumulation was lower in the SNMP group than in the other groups. These results suggest ischemia-reperfusion injury is suppressed in SNMP conditions. CONCLUSION An ERM has use in evaluating the utility of MP for the DCD liver.
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Affiliation(s)
- R Yoshikawa
- Department of Mechanical Engineering, Tokyo Metropolitan University, Tokyo, Japan
| | - H Obara
- Department of Mechanical Engineering, Tokyo Metropolitan University, Tokyo, Japan; National Center for Child Health and Development, Tokyo, Japan
| | - N Matsuno
- Department of Mechanical Engineering, Tokyo Metropolitan University, Tokyo, Japan; National Center for Child Health and Development, Tokyo, Japan; Department of Surgery, Asahikawa Medical University, Hokkaido, Japan.
| | - N Morito
- Department of Mechanical Engineering, Tokyo Metropolitan University, Tokyo, Japan
| | - M Gouchi
- Department of Surgery, Asahikawa Medical University, Hokkaido, Japan
| | - M Otani
- Department of Surgery, Asahikawa Medical University, Hokkaido, Japan
| | - T Shonaka
- Department of Surgery, Asahikawa Medical University, Hokkaido, Japan
| | - H Takahashi
- Department of Surgery, Asahikawa Medical University, Hokkaido, Japan
| | - S Enosawa
- National Center for Child Health and Development, Tokyo, Japan
| | - T Hirano
- Department of Clinical Pharmacology, Tokyo University of Pharmacy and Life Sciences, Tokyo, Japan
| | - H Furukawa
- Department of Surgery, Asahikawa Medical University, Hokkaido, Japan
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14
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15
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Liver Graft Susceptibility during Static Cold Storage and Dynamic Machine Perfusion: DCD versus Fatty Livers. Int J Mol Sci 2017; 19:ijms19010109. [PMID: 29301219 PMCID: PMC5796058 DOI: 10.3390/ijms19010109] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 12/15/2017] [Accepted: 12/26/2017] [Indexed: 12/20/2022] Open
Abstract
We compared static preservation (cold storage, CS, 4 °C) with dynamic preservation (machine perfusion, MP, 20 °C) followed by reperfusion using marginal livers: a model of donation after cardiac death (DCD) livers and two models of fatty livers, the methionine-choline deficient (MCD) diet model, and obese Zucker (fa/fa) rats. CS injury in DCD livers was reversed by an oxygenated washout (OW): hepatic damage, bile flow, and the ATP/ADP ratio in the OW + CS group was comparable with the ratio obtained with MP. Using fatty livers, CS preservation induced a marked release in hepatic and biliary enzymes in obese Zucker rats when compared with the MCD group. The same trend occurred for bile flow. No difference was found when comparing MP in MCD and obese Zucker rats. Fatty acid analysis demonstrated that the total saturated (SFA)/polyunsaturated fatty acid (PUFA) ratio was, respectively, 1.5 and 0.71 in obese Zucker and MCD rats. While preservation damage in DCD livers is associated with the ATP/ADP recovered with OW, injury in fatty livers is linked to fatty acid constituents: livers from obese. Zucker rats, with greater content in saturated FA, might be more prone to CS injury. On the contrary, MCD livers with elevated PUFA content might be less susceptible to hypothermia.
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16
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Avruch JH, Bruinsma BG, Weeder PD, Sridharan GV, Porte RJ, Yeh H, Markmann JF, Uygun K. A novel model for ex situ reperfusion of the human liver following subnormothermic machine perfusion. TECHNOLOGY 2017; 5:196-200. [PMID: 31106253 PMCID: PMC6524532 DOI: 10.1142/s2339547817500108] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
Machine perfusion-based organ preservation techniques are prudently transitioning into clinical practice. Although experimental data is compelling, the outcomes in the highly variable clinical donation-transplantation setting are unpredictable. Here, we offer an intermediate tool for pre-clinical assessment of human donor livers. We present a model for ex situ reperfusion of discarded human livers and report on its application in three human livers that have undergone subnormothermic (21°C) machine perfusion as an experimental preservation method. During reperfusion, the livers macroscopically reperfused in the first 15 minutes, and remained visually well-perfused for 3 hours of ex situ reperfusion. Bile production and oxygen consumption were observed throughout ex situ reperfusion. ATP levels increased 4.25-fold during SNMP. Between the end of SNMP and the end of reperfusion ATP levels dropped 45%. ALT levels in blood increased rapidly in the first 30 minutes and ALT release continued to taper off towards the end of perfusion. Release of CRP, TNF-α, IL-1β, and IL-12, IFN-γ was sustained during reperfusion. These findings support the use of this model for the evaluation of novel human liver preservation techniques.
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Affiliation(s)
- James H Avruch
- Center for Engineering in Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Transplant Center, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Bote G Bruinsma
- Center for Engineering in Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Transplant Center, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Pepijn D Weeder
- Center for Engineering in Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Gautham V Sridharan
- Center for Engineering in Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Robert J Porte
- Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Heidi Yeh
- Transplant Center, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - James F Markmann
- Transplant Center, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Korkut Uygun
- Center for Engineering in Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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17
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Marecki H, Bozorgzadeh A, Porte RJ, Leuvenink HG, Uygun K, Martins PN. Liver ex situ machine perfusion preservation: A review of the methodology and results of large animal studies and clinical trials. Liver Transpl 2017; 23:679-695. [PMID: 28240817 DOI: 10.1002/lt.24751] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Accepted: 01/31/2017] [Indexed: 12/11/2022]
Abstract
Ex vivo machine perfusion (MP) is a promising way to better preserve livers prior to transplantation. Currently, no methodology has a verified benefit over simple cold storage. Before becoming clinically feasible, MP requires validation in models that reliably predict human performance. Such a model has been found in porcine liver, whose physiological, anatomical, and immunological characteristics closely resemble the human liver. Since the 1930s, researchers have explored MP as preservation, but only recently have clinical trials been performed. Making this technology clinically available holds the promise of expanding the donor pool through more effective preservation of extended criteria donor (ECD) livers. MP promises to decrease delayed graft function, primary nonfunction, and biliary strictures, which are all common failure modes of transplanted ECD livers. Although hypothermic machine perfusion (HMP) has become the standard for kidney ex vivo preservation, the precise settings and clinical role for liver MP have not yet been established. In research, there are 2 schools of thought: normothermic machine perfusion, closely mimicking physiologic conditions, and HMP, to maximize preservation. Here, we review the literature for porcine ex vivo MP, with an aim to summarize perfusion settings and outcomes pertinent to the clinical establishment of MP. Liver Transplantation 23 679-695 2017 AASLD.
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Affiliation(s)
- Hazel Marecki
- Transplant Division, Department of Surgery, University of Massachusetts, Worcester, MA
| | - Adel Bozorgzadeh
- Transplant Division, Department of Surgery, University of Massachusetts, Worcester, MA
| | - Robert J Porte
- Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands
| | - Henri G Leuvenink
- Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands
| | - Korkut Uygun
- Center of Engineering in Medicine, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Paulo N Martins
- Transplant Division, Department of Surgery, University of Massachusetts, Worcester, MA
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18
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Abstract
The demand of donor livers for transplantation exceeds the supply. In an attempt to maximize the number of potentially usable donor livers, several centers are exploring the role of machine perfusion. This review provides an update on machine perfusion strategies and basic concepts, based on current clinical issues, and discuss challenges, including currently used biomarkers for assessing the quality and viability of perfused organs. The potential benefits of machine perfusion on immunogenicity and the consequences on post-operative immunosuppression management are discussed.
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19
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Furukori M, Matsuno N, Meng LT, Shonaka T, Nishikawa Y, Imai K, Obara H, Furukawa H. Subnormothermic Machine Perfusion Preservation With Rewarming for Donation After Cardiac Death Liver Grafts in Pigs. Transplant Proc 2016; 48:1239-43. [PMID: 27320595 DOI: 10.1016/j.transproceed.2015.12.076] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Accepted: 12/07/2015] [Indexed: 01/15/2023]
Abstract
BACKGROUND The use of grafts from donors after cardiac death (DCD) would greatly contribute to the expansion of the donor organ pool. However, the implementation of such a strategy requires the development of novel preservation methods to recover from changes owing to warm ischemia. The aim of this study was to evaluate the effectiveness of subnormothermic machine perfusion (MP) preservation with rewarming for porcine DCD liver grafts for transplantation. METHODS Porcine livers were perfused with newly developed MP system. The livers were perfused for 4 hours with modified University of Wisconsin gluconate solution. Group 1 grafts were preserved with no warm ischemia time (WIT) and hypothermic MP (HMP) for 4 hours. Group 2 grafts were preserved with WIT 60 minutes and HMP for 4 hours. Group 3 grafts were preserved with WIT 60 minutes and rewarming up to 25°C by MP (RMP) for 4 hours. RESULTS The aspartate aminotransferase and lactate dehydrogenase in the effluent maintained at lower level in group 3 compared with group 2. However, tissue ATP levels did not recover in groups 2 and 3. Histologically, the fatty degenerate and swelling of the hepatocyte was slightly seen in all groups. The normal structure of the hepatocellular cords, the bile duct and the sinusoid endothelium were preserved in all groups. CONCLUSIONS Potentially, subnormothermic preservation with rewarming is expected to help the recovery of function for DCD liver grafts.
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Affiliation(s)
- M Furukori
- Department of Surgery, Asahikawa Medical University, Asahikawa, Japan
| | - N Matsuno
- Department of Surgery, Asahikawa Medical University, Asahikawa, Japan.
| | - L T Meng
- Department of Surgery, Asahikawa Medical University, Asahikawa, Japan
| | - T Shonaka
- Department of Surgery, Asahikawa Medical University, Asahikawa, Japan
| | - Y Nishikawa
- Department of Pathology, Asahikawa Medical University, Asahikawa, Japan
| | - K Imai
- Department of Surgery, Asahikawa Medical University, Asahikawa, Japan
| | - H Obara
- Mechanical Engineering, Tokyo Metropolitan University, Tokyo, Japan
| | - H Furukawa
- Department of Surgery, Asahikawa Medical University, Asahikawa, Japan
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20
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Abstract
BACKGROUND The high demand for livers for transplantation has led to organs of limited quality being accepted to expand the donor pool. This is associated with inferior outcomes due to more pronounced preservation injury. Accordingly, recent research has aimed to develop preservation modalities for improved preservation as well as strategies for liver viability assessment and liver reconditioning. METHODS The PubMed database was searched using the terms 'perfusion', 'liver', 'preservation', and 'reconditioning' in various combinations, and the according literature was reviewed. RESULTS Several perfusion techniques have been developed in recent years with the potential for liver reconditioning. Preclinical and first emerging clinical data suggest feasibility, safety, and superiority over the current gold standard of cold storage. CONCLUSION This review outlines current advances in the field of liver preservation with an emphasis on liver reconditioning methods.
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Affiliation(s)
- Dieter P Hoyer
- General, Visceral and Transplantation Surgery, University Hospital Essen, Essen, Germany
| | - Thomas Minor
- General, Visceral and Transplantation Surgery, University Hospital Essen, Essen, Germany
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21
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Karangwa SA, Dutkowski P, Fontes P, Friend PJ, Guarrera JV, Markmann JF, Mergental H, Minor T, Quintini C, Selzner M, Uygun K, Watson CJ, Porte RJ. Machine Perfusion of Donor Livers for Transplantation: A Proposal for Standardized Nomenclature and Reporting Guidelines. Am J Transplant 2016; 16:2932-2942. [PMID: 27129409 PMCID: PMC5132023 DOI: 10.1111/ajt.13843] [Citation(s) in RCA: 97] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Revised: 03/28/2016] [Accepted: 04/19/2016] [Indexed: 02/06/2023]
Abstract
With increasing demand for donor organs for transplantation, machine perfusion (MP) promises to be a beneficial alternative preservation method for donor livers, particularly those considered to be of suboptimal quality, also known as extended criteria donor livers. Over the last decade, numerous studies researching MP of donor livers have been published and incredible advances have been made in both experimental and clinical research in this area. With numerous research groups working on MP, various techniques are being explored, often applying different nomenclature. The objective of this review is to catalog the differences observed in the nomenclature used in the current literature to denote various MP techniques and the manner in which methodology is reported. From this analysis, we propose a standardization of nomenclature on liver MP to maximize consistency and to enable reliable comparison and meta-analyses of studies. In addition, we propose a standardized set of guidelines for reporting the methodology of future studies on liver MP that will facilitate comparison as well as clinical implementation of liver MP procedures.
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Affiliation(s)
- S. A. Karangwa
- Section of Hepatobiliary Surgery and Liver TransplantationDepartment of SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
- Surgical Research LaboratoryUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
| | - P. Dutkowski
- Department of Surgery & TransplantationUniversity Hospital ZurichZurichSwitzerland
| | - P. Fontes
- Thomas E. Starzl Transplantation Institute Department of SurgeryUniversity of Pittsburgh Medical CenterPittsburghPA
- McGowan Institute of Regenerative MedicineUniversity of PittsburghPittsburghPA
| | - P. J. Friend
- Nuffield Department of SurgeryOxford Transplant CentreUniversity of OxfordChurchill HospitalOxfordUK
| | - J. V. Guarrera
- Department of SurgeryCenter for Liver Disease and TransplantationColumbia University Medical CenterNew YorkNY
| | | | - H. Mergental
- Liver UnitUniversity Hospital BirminghamBirminghamUK
| | - T. Minor
- Department of Surgical ResearchClinic for General Visceral and Transplantation SurgeryUniversity Hospital EssenEssenGermany
| | - C. Quintini
- Department of SurgeryTransplant CenterDigestive Disease InstituteCleveland Clinic FoundationClevelandOH
| | - M. Selzner
- Department of SurgeryMulti Organ Transplant ProgramToronto General HospitalTorontoONCanada
| | - K. Uygun
- Department of SurgeryCenter for Engineering in MedicineMassachusetts General HospitalHarvard Medical SchoolBostonMA
| | - C. J. Watson
- University of Cambridge Department of Surgery and the NIHR Blood and Transplant Research Unit in Organ Donation and Transplantation University of CambridgeAddenbrooke's HospitalCambridgeUK
| | - R. J. Porte
- Section of Hepatobiliary Surgery and Liver TransplantationDepartment of SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
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22
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Jochmans I, Akhtar MZ, Nasralla D, Kocabayoglu P, Boffa C, Kaisar M, Brat A, O'Callaghan J, Pengel LHM, Knight S, Ploeg RJ. Past, Present, and Future of Dynamic Kidney and Liver Preservation and Resuscitation. Am J Transplant 2016; 16:2545-55. [PMID: 26946212 DOI: 10.1111/ajt.13778] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Revised: 02/03/2016] [Accepted: 02/23/2016] [Indexed: 01/25/2023]
Abstract
The increased demand for organs has led to the increased usage of "higher risk" kidney and liver grafts. These grafts from donation after circulatory death or expanded criteria donors are more susceptible to preservation injury and have a higher risk of unfavorable outcomes. Dynamic, instead of static, preservation could allow for organ optimization, offering a platform for viability assessment, active organ repair and resuscitation. Ex situ machine perfusion and in situ regional perfusion in the donor are emerging as potential tools to preserve and resuscitate vulnerable grafts. Preclinical findings have ignited clinical organ preservation research that investigates dynamic preservation, its various modes (continuous, preimplantation) and temperatures (hypo-, sub, or normothermic). This review outlines the current status of dynamic preservation of kidney and liver grafts and describes ongoing research and emerging clinical trials.
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Affiliation(s)
- I Jochmans
- Abdominal Transplant Surgery, KU Leuven, University Hospitals Leuven, Leuven, Belgium
| | - M Z Akhtar
- Biomedical Research Centre and Oxford Transplant Centre, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - D Nasralla
- Biomedical Research Centre and Oxford Transplant Centre, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - P Kocabayoglu
- Department of General, Visceral and Transplant Surgery, University Hospital Essen, Essen, Germany
| | - C Boffa
- Biomedical Research Centre and Oxford Transplant Centre, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - M Kaisar
- Biomedical Research Centre and Oxford Transplant Centre, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - A Brat
- Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - J O'Callaghan
- Biomedical Research Centre and Oxford Transplant Centre, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK.,Clinical Effectiveness Unit, Centre for Evidence in Transplantation, Royal College of Surgeons of England, London, University of Oxford, Oxford, UK
| | - L H M Pengel
- Biomedical Research Centre and Oxford Transplant Centre, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK.,Clinical Effectiveness Unit, Centre for Evidence in Transplantation, Royal College of Surgeons of England, London, University of Oxford, Oxford, UK
| | - S Knight
- Biomedical Research Centre and Oxford Transplant Centre, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK.,Clinical Effectiveness Unit, Centre for Evidence in Transplantation, Royal College of Surgeons of England, London, University of Oxford, Oxford, UK
| | - R J Ploeg
- Biomedical Research Centre and Oxford Transplant Centre, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
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23
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Barbas AS, Goldaracena N, Dib MJ, Selzner M. Ex-vivo liver perfusion for organ preservation: Recent advances in the field. Transplant Rev (Orlando) 2016; 30:154-60. [PMID: 27158081 DOI: 10.1016/j.trre.2016.03.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Revised: 02/15/2016] [Accepted: 03/01/2016] [Indexed: 01/13/2023]
Abstract
Liver transplantation is the optimal treatment for end-stage liver disease but is limited by the severe shortage of donor organs. This shortage has prompted increased utilization of marginal grafts from DCD and extended criteria donors, which poorly tolerate cold storage in comparison to standard criteria grafts. Ex-vivo liver perfusion (EVLP) technology has emerged as a potential alternative to cold storage for organ preservation, but there is no consensus regarding the optimal temperature or conditions for EVLP. Herein, we review recent advances in both pre-clinical and clinical studies, organized by perfusion temperature (hypothermic, subnormothermic, normothermic).
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Affiliation(s)
- A S Barbas
- University of Toronto, Multi-Organ Transplant Program, Department of Surgery, Canada.
| | - N Goldaracena
- University of Toronto, Multi-Organ Transplant Program, Department of Surgery, Canada
| | - M J Dib
- University of Toronto, Multi-Organ Transplant Program, Department of Surgery, Canada
| | - M Selzner
- University of Toronto, Multi-Organ Transplant Program, Department of Surgery, Canada
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24
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Utilization of Machine Perfusion and Nanotechnology for Liver Transplantation. CURRENT TRANSPLANTATION REPORTS 2015. [DOI: 10.1007/s40472-015-0076-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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25
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Karimian N, Matton APM, Westerkamp AC, Burlage LC, Op den Dries S, Leuvenink HGD, Lisman T, Uygun K, Markmann JF, Porte RJ. Ex Situ Normothermic Machine Perfusion of Donor Livers. J Vis Exp 2015:e52688. [PMID: 26067131 DOI: 10.3791/52688] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
In contrast to conventional static cold preservation (0-4 °C), ex situ machine perfusion may provide better preservation of donor livers. Continuous perfusion of organs provides the opportunity to improve organ quality and allows ex situ viability assessment of donor livers prior to transplantation. This video article provides a step by step protocol for ex situ normothermic machine perfusion (37 °C) of human donor livers using a device that provides a pressure and temperature controlled pulsatile perfusion of the hepatic artery and continuous perfusion of the portal vein. The perfusion fluid is oxygenated by two hollow fiber membrane oxygenators and the temperature can be regulated between 10 °C and 37 °C. During perfusion, the metabolic activity of the liver as well as the degree of injury can be assessed by biochemical analysis of samples taken from the perfusion fluid. Machine perfusion is a very promising tool to increase the number of livers that are suitable for transplantation.
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Affiliation(s)
- Negin Karimian
- Section of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University of Groningen, University Medical Center Groningen; Surgical Research Laboratory, Department of Surgery, University of Groningen, University Medical Center Groningen
| | - Alix P M Matton
- Section of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University of Groningen, University Medical Center Groningen; Surgical Research Laboratory, Department of Surgery, University of Groningen, University Medical Center Groningen
| | - Andrie C Westerkamp
- Section of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University of Groningen, University Medical Center Groningen; Surgical Research Laboratory, Department of Surgery, University of Groningen, University Medical Center Groningen
| | - Laura C Burlage
- Section of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University of Groningen, University Medical Center Groningen; Surgical Research Laboratory, Department of Surgery, University of Groningen, University Medical Center Groningen
| | - Sanna Op den Dries
- Section of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University of Groningen, University Medical Center Groningen; Surgical Research Laboratory, Department of Surgery, University of Groningen, University Medical Center Groningen
| | - Henri G D Leuvenink
- Surgical Research Laboratory, Department of Surgery, University of Groningen, University Medical Center Groningen
| | - Ton Lisman
- Section of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University of Groningen, University Medical Center Groningen; Surgical Research Laboratory, Department of Surgery, University of Groningen, University Medical Center Groningen
| | - Korkut Uygun
- Center of Engineering in Medicine/Surgical Services, Massachusetts General Hospital, Harvard Medical School, and Shriners Burns Hospital
| | - James F Markmann
- Division of Transplantation, Department of Surgery, Massachusetts General Hospital, Harvard Medical School
| | - Robert J Porte
- Section of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University of Groningen, University Medical Center Groningen; Surgical Research Laboratory, Department of Surgery, University of Groningen, University Medical Center Groningen;
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26
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Champigneulle B, Fieux F, Cheisson G, Dondero F, Savier E, Riou B, Langeron O, Nicolas-Robin A. French survey of the first three-years of liver transplantation activity from uncontrolled donors deceased after cardiac death. Anaesth Crit Care Pain Med 2015; 34:35-9. [PMID: 25829313 DOI: 10.1016/j.accpm.2014.05.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2013] [Accepted: 05/22/2014] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To assess the first three years of French activity related to liver transplantation from uncontrolled donation after cardiac death (uDCD). STUDY DESIGN Prospective and observational study in the three active centres authorized by the French Biomedicine Agency. PATIENTS AND METHODS All patients deceased between 2010 and 2012 after an uncontrolled cardiac arrest admitted to one of three centres (Pitié-Salpêtrière, Saint-Louis or Bicêtre hospitals, AP-HP, Paris, France) and potentially eligible for liver recovery were included. Abdominal normothermic oxygenated recirculation (ANOR) was used for graft preservation. RESULTS One hundred twenty-six potential uDCD donors were identified as eligible for liver recovery after hospital admission. The main causes of organ recovery failure were technical failure related to ANOR (29 patients, 23%), refusal of consent (39 patients, 31% of potential uDCD donors and 40% of asked relatives) and abnormal hepatic transaminases up to 200 UI.L(-1) during ANOR (24 patients, 19%). Finally, 11 livers were transplanted. Process efficiency was 9% [95% CI: 4-15%]. One-year recipient survival was 82%, [95% CI: 48-98%] and one-year graft survival was 64% [95% CI: 31-89%]. CONCLUSION Liver transplantation from uDCD donors is achievable in France, despite low process efficiency.
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Affiliation(s)
- B Champigneulle
- Department of Anesthesiology and Critical Care, groupe hospitalier Pitié-Salpêtrière, AP-HP, Paris, France
| | - F Fieux
- Department of Anesthesiology and Critical Care & Organ Transplant Coordination Team, hôpital Saint-Louis, AP-HP, Paris, France
| | - G Cheisson
- Department of Anesthesiology and Critical Care & Organ Transplant Coordination Team, hôpital Bicêtre, AP-HP, Le Kremlin-Bicêtre, France
| | - F Dondero
- Hepatobiliary Surgery and Liver Transplantation Department, hôpital Beaujon, AP-HP, Clichy, France
| | - E Savier
- Hepatobiliary Surgery and Liver Transplantation Department, groupe hospitalier Pitié-Salpêtrière, AP-HP, Paris, France
| | - B Riou
- Department of Emergency Medicine and Surgery, groupe hospitalier Pitié-Salpêtrière, AP-HP, Paris, France; UMRS Inserm 956, université médecine Pierre-et-Marie-Curie-Paris 6, 4, place Jussieu, 75005 Paris, France
| | - O Langeron
- Department of Anesthesiology and Critical Care, groupe hospitalier Pitié-Salpêtrière, AP-HP, Paris, France; UMRS Inserm 956, université médecine Pierre-et-Marie-Curie-Paris 6, 4, place Jussieu, 75005 Paris, France
| | - A Nicolas-Robin
- Department of Anesthesiology and Critical Care, groupe hospitalier Pitié-Salpêtrière, AP-HP, Paris, France; UMRS Inserm 956, université médecine Pierre-et-Marie-Curie-Paris 6, 4, place Jussieu, 75005 Paris, France.
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27
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Abstract
The current standard for liver preservation involves cooling of the organ on ice (0-4 °C). Although it is successful for shorter durations, this method of preservation does not allow long-term storage of the liver. The gradual loss of hepatic viability during preservation puts pressure on organ sharing and allocation, may limit the use of suboptimal grafts and necessitates rushed transplantation to achieve desirable post-transplantation outcomes. In an attempt to improve and prolong liver viability during storage, alternative preservation methods are under investigation. For instance, ex vivo machine perfusion systems aim to sustain and even improve viability by supporting hepatic function at warm temperatures, rather than simply slowing down deterioration by cooling. Here we describe a novel subzero preservation technique that combines ex vivo machine perfusion with cryoprotectants to facilitate long-term supercooled preservation. The technique improves the preservation of rat livers to prolong storage times as much as threefold, which is validated by successful long-term recipient survival after orthotopic transplantation. This protocol describes how to load rat livers with cryoprotectants to prevent both intracellular and extracellular ice formation and to protect against hypothermic injury. Cryoprotectants are loaded ex vivo using subnormothermic machine perfusion (SNMP), after which livers can be cooled to -6 °C without freezing and kept viable for up to 96 h. Cooling to a supercooled state is controlled, followed by 3 h of SNMP recovery and orthotopic liver transplantation.
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28
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Izamis ML, Efstathiades A, Keravnou C, Leen EL, Averkiou MA. Dynamic contrast-enhanced ultrasound of slaughterhouse porcine livers in machine perfusion. ULTRASOUND IN MEDICINE & BIOLOGY 2014; 40:2217-2230. [PMID: 25023101 DOI: 10.1016/j.ultrasmedbio.2014.03.031] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2013] [Revised: 03/28/2014] [Accepted: 03/31/2014] [Indexed: 06/03/2023]
Abstract
The aim of this study was to enable investigations into novel imaging and surgical techniques by developing a readily accessible, versatile liver machine perfusion system. Slaughterhouse pig livers were used, and dynamic contrast-enhanced ultrasound was introduced to optimize the procurement process and provide real-time perfusion monitoring. The system comprised a single pump, oxygenator, bubble trap and two flowmeters for pressure-controlled perfusion of the vessels using an off-the-shelf perfusate at room temperature. Successful livers exhibited homogeneous perfusion in both the portal vein and hepatic artery with dynamic contrast-enhanced ultrasound, which correlated with stable oxygen uptake, bile production and hepatic resistance and normal histology at the end of 3 h of perfusion. Dynamic contrast-enhanced ultrasound revealed perfusion abnormalities invisible to the naked eye, thereby providing context to the otherwise systemic biochemical/hemodynamic measurements and focal biopsy findings. The model developed here is a simple, cost-effective approach for stable ex vivo whole-organ machine perfusion.
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Affiliation(s)
- Maria-Louisa Izamis
- Department of Mechanical and Manufacturing Engineering, University of Cyprus, Nicosia, Cyprus
| | | | - Christina Keravnou
- Department of Mechanical and Manufacturing Engineering, University of Cyprus, Nicosia, Cyprus
| | - Edward L Leen
- Department of Medicine, Imperial College, London, United Kingdom
| | - Michalakis A Averkiou
- Department of Mechanical and Manufacturing Engineering, University of Cyprus, Nicosia, Cyprus.
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Tarantola E, Bertone V, Milanesi G, Gruppi C, Ferrigno A, Vairetti M, Barni S, Freitas I. Dipeptidylpeptidase-IV activity and expression reveal decreased damage to the intrahepatic biliary tree in fatty livers submitted to subnormothermic machine-perfusion respect to conventional cold storage. Eur J Histochem 2014; 58:2414. [PMID: 25308846 PMCID: PMC4194394 DOI: 10.4081/ejh.2014.2414] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Revised: 05/07/2014] [Accepted: 05/08/2014] [Indexed: 02/08/2023] Open
Abstract
Graft steatosis is a risk factor for poor initial function after liver transplantation. Biliary complications are frequent even after normal liver transplantation. A subnormothermic machine perfusion (MP20) preservation procedure was developed by our group with high potential for reducing injury to hepatocytes and sinusoidal cells of lean and fatty livers respect to conventional cold storage (CS). We report the response of the biliary tree to CS or MP20, in lean and obese Zucker rat liver. Dipeptidylpeptidase-IV (DPP-IV), crucial for the inactivation of incretins and neuropeptides, was used as a marker. Liver morphology and canalicular network of lean livers were similar after CS/reperfusion or MP20/reperfusion. CS preservation of fatty livers induced serious damage to the parenchyma and to the canalicular activity/ expression of DPP-IV, whereas with MP20 the morphology and canalicular network were similar to those of untreated lean liver. CS and MP20 had similar effects on DPP-IV activity and expression in the upper segments of the intrahepatic biliary tree of fatty livers. DPP-IV expression was significantly increased after MP20 respect to CS or to the controls, both for lean and obese animals. Our data support the superiority of MP20 over CS for preserving fatty livers. Dipeptidylpeptidase-IV activity and expression reveal decreased damage to the intrahepatic biliary tree in fatty livers submitted to subnormothermic machine-perfusion respect to conventional cold storage.
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Bruinsma BG, Yarmush ML, Uygun K. Organomatics and organometrics: Novel platforms for long-term whole-organ culture. TECHNOLOGY 2014; 2:13. [PMID: 25035864 PMCID: PMC4097862 DOI: 10.1142/s2339547814300029] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
Organ culture systems are instrumental as experimental whole-organ models of physiology and disease, as well as preservation modalities facilitating organ replacement therapies such as transplantation. Nevertheless, a coordinated system of machine perfusion components and integrated regulatory control has yet to be fully developed to achieve long-term maintenance of organ function ex vivo. Here we outline current strategies for organ culture, or organomatics, and how these systems can be regulated by means of computational algorithms, or organometrics, to achieve the organ culture platforms anticipated in modern-day biomedicine.
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op den Dries S, Sutton ME, Karimian N, de Boer MT, Wiersema-Buist J, Gouw ASH, Leuvenink HGD, Lisman T, Porte RJ. Hypothermic oxygenated machine perfusion prevents arteriolonecrosis of the peribiliary plexus in pig livers donated after circulatory death. PLoS One 2014; 9:e88521. [PMID: 24551114 PMCID: PMC3925142 DOI: 10.1371/journal.pone.0088521] [Citation(s) in RCA: 91] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2013] [Accepted: 01/07/2014] [Indexed: 12/14/2022] Open
Abstract
Background Livers derived from donation after circulatory death (DCD) are increasingly accepted for transplantation. However, DCD livers suffer additional donor warm ischemia, leading to biliary injury and more biliary complications after transplantation. It is unknown whether oxygenated machine perfusion results in better preservation of biliary epithelium and the peribiliary vasculature. We compared oxygenated hypothermic machine perfusion (HMP) with static cold storage (SCS) in a porcine DCD model. Methods After 30 min of cardiac arrest, livers were perfused in situ with HTK solution (4°C) and preserved for 4 h by either SCS (n = 9) or oxygenated HMP (10°C; n = 9), using pressure-controlled arterial and portal venous perfusion. To simulate transplantation, livers were reperfused ex vivo at 37°C with oxygenated autologous blood. Bile duct injury and function were determined by biochemical and molecular markers, and a systematic histological scoring system. Results After reperfusion, arterial flow was higher in the HMP group, compared to SCS (251±28 vs 166±28 mL/min, respectively, after 1 hour of reperfusion; p = 0.003). Release of hepatocellular enzymes was significantly higher in the SCS group. Markers of biliary epithelial injury (biliary LDH, gamma-GT) and function (biliary pH and bicarbonate, and biliary transporter expression) were similar in the two groups. However, histology of bile ducts revealed significantly less arteriolonecrosis of the peribiliary vascular plexus in HMP preserved livers (>50% arteriolonecrosis was observed in 7 bile ducts of the SCS preserved livers versus only 1 bile duct of the HMP preserved livers; p = 0.024). Conclusions Oxygenated HMP prevents arteriolonecrosis of the peribiliary vascular plexus of the bile ducts of DCD pig livers and results in higher arterial flow after reperfusion. Together this may contribute to better perfusion of the bile ducts, providing a potential advantage in the post-ischemic recovery of bile ducts.
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Affiliation(s)
- Sanna op den Dries
- Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Surgical Research Laboratory, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Michael E. Sutton
- Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Surgical Research Laboratory, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Negin Karimian
- Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Surgical Research Laboratory, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Marieke T. de Boer
- Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Janneke Wiersema-Buist
- Surgical Research Laboratory, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Annette S. H. Gouw
- Department of Pathology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Henri G. D. Leuvenink
- Surgical Research Laboratory, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Ton Lisman
- Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Surgical Research Laboratory, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Robert J. Porte
- Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- * E-mail:
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Machine perfusion in solid organ transplantation: where is the benefit? Langenbecks Arch Surg 2014; 399:421-7. [PMID: 24429900 DOI: 10.1007/s00423-014-1161-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Accepted: 01/01/2014] [Indexed: 12/26/2022]
Abstract
BACKGROUND Machine perfusion (MP) in solid organ transplantation has been a topic of variable importance for decades. At the dawn of organ transplantation, MP was one of the standard techniques for preservation; today's gold standard for organ preservation for transplantation is cold storage (CS). The outcome after transplantation of solid organs has tremendously improved over the last five decades. MP has been continuously under investigation and may be an option for organ preservation in selected cases; however, there is only little evidence from clinical trials that can be used to advocate for MP as a routine organ preservation method. METHODS This article reviews the current knowledge on MP in the field of solid organ transplantation with special focus on findings from clinical trials. CONCLUSION Especially in heart and lung transplantation, MP seems to be a promising tool to improve postoperative outcome, but a general evidence-based recommendation for or against an application of MP cannot be given due to the lack of the highest level of clinical evidence. Gold standards such as CS should not be left behind without good reason. Randomized clinical trials are desperately needed to further improve outcome and for better understanding of the underlying pathophysiological mechanisms.
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Schlegel A, Graf R, Clavien PA, Dutkowski P. Hypothermic oxygenated perfusion (HOPE) protects from biliary injury in a rodent model of DCD liver transplantation. J Hepatol 2013; 59:984-91. [PMID: 23820408 DOI: 10.1016/j.jhep.2013.06.022] [Citation(s) in RCA: 130] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Revised: 06/18/2013] [Accepted: 06/23/2013] [Indexed: 12/20/2022]
Abstract
BACKGROUND & AIMS The use of livers from donors after cardiac arrest (DCD) is increasing in many countries to overcome organ shortage. Due to additional warm ischemia before preservation, those grafts are at higher risk of failure and bile duct injury. Several competing rescue strategies by machine perfusion techniques have been developed with, however, unclear effects on biliary injury. We analyze the impact of an end-ischemic Hypothermic Oxygenated PErfusion (HOPE) approach applied only through the portal vein for 1h before graft implantation. METHODS Rat livers were subjected to 30-min in situ warm ischemia, followed by subsequent 4-h cold storage, mimicking DCD-organ procurement and conventional organ transport. Livers in the HOPE group underwent also passive cold storage for 4h, but were subsequently machine perfused for 1h before implantation. Outcome was tested by liver transplantation (LT) at 12h after implantation (n=10 each group) and after 4 weeks (n=10 each group), focusing on early reperfusion injury, immune response, and later intrahepatic biliary injury. RESULTS All animals survived after LT. However, reperfusion injury was significantly decreased by HOPE treatment as tested by hepatocyte injury, Kupffer cell activation, and endothelial cell activation. Recipients receiving non-perfused DCD livers disclosed less body weight gain, increased bilirubin, and severe intrahepatic biliary fibrosis. In contrast, HOPE treated DCD livers were protected from biliary injury, as detected by cholestasis parameter and histology. CONCLUSIONS We demonstrate in a DCD liver transplant model that end-ischemic hypothermic oxygenated perfusion is a powerful strategy for protection against biliary injury.
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Affiliation(s)
- Andrea Schlegel
- Department of Surgery, Laboratory of the Swiss HPB and Liver Transplantation Center, University Hospital Zurich, Switzerland
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Perfusion machines for liver transplantation: technology and multifunctionality. Updates Surg 2013; 66:101-8. [DOI: 10.1007/s13304-013-0234-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Accepted: 09/06/2013] [Indexed: 12/19/2022]
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