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Abbas SH, Ceresa CDL, Pollok JM. Steatotic Donor Transplant Livers: Preservation Strategies to Mitigate against Ischaemia-Reperfusion Injury. Int J Mol Sci 2024; 25:4648. [PMID: 38731866 PMCID: PMC11083584 DOI: 10.3390/ijms25094648] [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: 03/12/2024] [Revised: 04/21/2024] [Accepted: 04/22/2024] [Indexed: 05/13/2024] Open
Abstract
Liver transplantation (LT) is the only definitive treatment for end-stage liver disease, yet the UK has seen a 400% increase in liver disease-related deaths since 1970, constrained further by a critical shortage of donor organs. This shortfall has necessitated the use of extended criteria donor organs, including those with evidence of steatosis. The impact of hepatic steatosis (HS) on graft viability remains a concern, particularly for donor livers with moderate to severe steatosis which are highly sensitive to the process of ischaemia-reperfusion injury (IRI) and static cold storage (SCS) leading to poor post-transplantation outcomes. This review explores the pathophysiological predisposition of steatotic livers to IRI, the limitations of SCS, and alternative preservation strategies, including novel organ preservation solutions (OPS) and normothermic machine perfusion (NMP), to mitigate IRI and improve outcomes for steatotic donor livers. By addressing these challenges, the liver transplant community can enhance the utilisation of steatotic donor livers which is crucial in the context of the global obesity crisis and the growing need to expand the donor pool.
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Affiliation(s)
- Syed Hussain Abbas
- Oxford Transplant Centre, Nuffield Department of Surgical Sciences, University of Oxford, Oxford OX1 2JD, UK;
| | - Carlo Domenico Lorenzo Ceresa
- Department of Hepatopancreatobiliary and Liver Transplant Surgery, Royal Free Hospital, Pond Street, Hampstead, London NW3 2QG, UK;
| | - Joerg-Matthias Pollok
- Department of Hepatopancreatobiliary and Liver Transplant Surgery, Royal Free Hospital, Pond Street, Hampstead, London NW3 2QG, UK;
- Division of Surgery & Interventional Science, University College London, Gower Street, London WC1E 6BT, UK
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2
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Abdominal Organ Preservation Solutions in the Age of Machine Perfusion. Transplantation 2023; 107:326-340. [PMID: 35939388 DOI: 10.1097/tp.0000000000004269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The past decade has been the foreground for a radical revolution in the field of preservation in abdominal organ transplantation. Perfusion has increasingly replaced static cold storage as the preferred and even gold standard preservation method for marginal-quality organs. Perfusion is dynamic and offers several advantages in comparison with static cold storage. These include the ability to provide a continuous supply of new metabolic substrates, clear metabolic waste products, and perform some degree of organ viability assessment before actual transplantation in the recipient. At the same time, the ongoing importance of static cold storage cannot be overlooked, in particular when it comes to logistical and technical convenience and cost, not to mention the fact that it continues to work well for the majority of transplant allografts. The present review article provides an overview of the fundamental concepts of organ preservation, providing a brief history of static cold preservation and description of the principles behind and basic components of cold preservation solutions. An evaluation of current evidence supporting the use of different preservation solutions in abdominal organ transplantation is provided. As well, the range of solutions used for machine perfusion of abdominal organs is described, as are variations in their compositions related to changing metabolic needs paralleling the raising of the temperature of the perfusate from hypothermic to normothermic range. Finally, appraisal of new preservation solutions that are on the horizon is provided.
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3
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Malekhosseini SA, Ghasemi Y, Rousta J, Aghaei R, Kianpour S, Negahdaripour M, Heidari R, Shamsaeefar A, Gholami S, Nikeghbalian S. Clinical Evaluation of an HTK Solution for Liver Transplantation: A Phase 3 Randomized Pilot Clinical Trial Study. ARCHIVES OF IRANIAN MEDICINE 2022; 25:617-623. [PMID: 37543887 PMCID: PMC10685771 DOI: 10.34172/aim.2022.97] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 02/27/2022] [Indexed: 08/07/2023]
Abstract
BACKGROUND Organ preservation solutions are not easily accessible in Iran, similar to many resource-limited countries. We aimed to evaluate the efficacy of a locally-produced HTK solution among adult liver transplantation candidates in a pilot clinical trial study. METHODS Adult patients undergoing liver transplantation were randomly allocated into two groups. One received the HTK solution (PharMedCina Inc., Shiraz, Iran), and the second received the commercially available HTK solution (Custodiol ®). RESULTS Overall, 28 individuals entered the study, including 11 and 9 males (78.6% and 64.3%) in the Custodiol® and local HTK groups, respectively. Clinical characteristics, including postoperative biliary complications, reperfusion syndrome, infection and primary non-function (PNF) rates, amount of intraoperative bleeding, length of hospital and ICU stay, peak aspartate aminotransferase (AST) and alanine aminotransferase (ALT), and duration of follow-up were similar between the two groups (P>0.05). One patient died in the locally-produced HTK group. The patient underwent re-transplantation 20 days after his first liver transplantation due to PNF. Two patients died in the Custodiol group, both due to PNF of the liver, which occurred five and three days after transplantation. The two groups did not show any difference regarding serum levels of AST, ALT, alkaline phosphatase (ALP), bilirubin, platelet count, prothrombin time and international normalized ratio, white blood cell count, blood urea nitrogen, and creatinine on the first postoperative day and on the day of discharge (P>0.05). CONCLUSION Based on the findings of this pilot study with the current sample size, no statistically significant difference was found between our locally-produced HTK solution and Custodiol® regarding clinical outcomes.
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Affiliation(s)
- Seyed Ali Malekhosseini
- Shiraz Transplant Center, Abu Ali Sina Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Younes Ghasemi
- Pharmaceutical Sciences Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
- Department of Pharmaceutical Biotechnology, School of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Javad Rousta
- Pharmaceutical Sciences Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Roghayyeh Aghaei
- Pharmaceutical Sciences Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Sedigheh Kianpour
- Pharmaceutical Sciences Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Manica Negahdaripour
- Pharmaceutical Sciences Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
- Department of Pharmaceutical Biotechnology, School of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Reza Heidari
- Pharmaceutical Sciences Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Alireza Shamsaeefar
- Shiraz Transplant Center, Abu Ali Sina Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Siavash Gholami
- Shiraz Transplant Center, Abu Ali Sina Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Saman Nikeghbalian
- Shiraz Transplant Center, Abu Ali Sina Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
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4
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Van den Eynde J, Achtergaele J, Fieuws S, Jochmans I, Sainz-Barriga M, Monbaliu D, Pirenne J, Gilbo N. The effect of organ preservation solutions on short-term outcomes after liver transplantation: a single-center retrospective study. Transpl Int 2021; 34:327-338. [PMID: 33280170 DOI: 10.1111/tri.13799] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 09/22/2020] [Accepted: 12/02/2020] [Indexed: 12/30/2022]
Abstract
The effect of preservation solutions on outcomes has been subject of many debates but the relative benefits of the various solutions remain unclear. We retrospectively compared short-term outcomes of 885 liver transplantations performed between 1/2000 and 12/2017 and preserved with either Histidine-Tryptophan-Ketoglutarate (HTK, n = 190), University of Wisconsin (UW, n = 557), or Institute George Lopez 1 preservation solution (IGL-1, n = 139). Inverse probability of treatment weighting (IPTW) was performed to account for baseline differences between groups and analyses were adjusted for confounders. In the IPTW analyses, peak AST within 7 days was 44% higher (95% CI 15-81%, P < 0.001) in HTK than in UW. Mean model of early allograft function (MEAF) score was 0.61 points (95% CI 0.12-1.10, P = 0.01) higher in HTK than in UW. Early allograft dysfunction (EAD) was more likely to occur with HTK compared to IGL-1 (IPTW OR = 2.87, 95% CI = 1.00-8.19, P = 0.049) and UW (IPTW OR = 1.75, 95% CI = 1.06-2.88, P = 0.023). The type of preservation solution had no impact on hospital stay, ICU stay, incidence of biliary strictures, or graft and recipient survival. HTK was the least effective on reducing graft injury and increased the probability of graft dysfunction after transplantation. UW and IGL-1 were equally effective in reducing graft injury and dysfunction.
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Affiliation(s)
- Jef Van den Eynde
- Department of Abdominal Transplantation Surgery, University Hospitals Leuven, Leuven, Belgium.,Laboratory of Abdominal Transplant Surgery, Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium
| | - Jannick Achtergaele
- Department of Abdominal Transplantation Surgery, University Hospitals Leuven, Leuven, Belgium.,Laboratory of Abdominal Transplant Surgery, Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium
| | - Steffen Fieuws
- Leuven Biostatistics and Statistical Bioinformatics Centre (L-BioStat), KU Leuven, Leuven, Belgium
| | - Ina Jochmans
- Department of Abdominal Transplantation Surgery, University Hospitals Leuven, Leuven, Belgium.,Laboratory of Abdominal Transplant Surgery, Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium
| | - Mauricio Sainz-Barriga
- Department of Abdominal Transplantation Surgery, University Hospitals Leuven, Leuven, Belgium.,Laboratory of Abdominal Transplant Surgery, Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium
| | - Diethard Monbaliu
- Department of Abdominal Transplantation Surgery, University Hospitals Leuven, Leuven, Belgium.,Laboratory of Abdominal Transplant Surgery, Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium
| | - Jacques Pirenne
- Department of Abdominal Transplantation Surgery, University Hospitals Leuven, Leuven, Belgium.,Laboratory of Abdominal Transplant Surgery, Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium
| | - Nicholas Gilbo
- Department of Abdominal Transplantation Surgery, University Hospitals Leuven, Leuven, Belgium.,Laboratory of Abdominal Transplant Surgery, Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium
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5
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Abbas SH, Friend PJ. Principles and current status of abdominal organ preservation for transplantation. SURGERY IN PRACTICE AND SCIENCE 2020. [DOI: 10.1016/j.sipas.2020.100020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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6
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Carnevale ME, Lausada N, Juan de Paz L, Stringa P, Machuca M, Rumbo M, Guibert EE, Tiribelli C, Gondolesi GE, Rodriguez JV. The Novel N,N-bis-2-Hydroxyethyl-2-Aminoethanesulfonic Acid-Gluconate-Polyethylene Glycol-Hypothermic Machine Perfusion Solution Improves Static Cold Storage and Reduces Ischemia/Reperfusion Injury in Rat Liver Transplant. Liver Transpl 2019; 25:1375-1386. [PMID: 31121085 DOI: 10.1002/lt.25573] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 05/16/2019] [Indexed: 01/19/2023]
Abstract
Organ transplantation is the treatment of choice against terminal and irreversible organ failure. Optimal preservation of the graft is crucial to counteract cold ischemia effects. As we developed an N,N-bis-2-hydroxyethyl-2-aminoethanesulfonic acid-gluconate-polyethylene glycol (BGP)-based solution (hypothermic machine perfusion [HMP]), we aimed to analyze the use of this solution on static cold storage (SCS) of rat livers for transplantation as compared with the histidine tryptophan ketoglutarate (HTK) preservation solution. Livers procured from adult male Sprague Dawley rats were preserved with BGP-HMP or HTK solutions. Liver total water content and metabolites were measured during the SCS at 0°C for 24 hours. The function and viability of the preserved rat livers were first assessed ex vivo after rewarming (90 minutes at 37°C) and in vivo using the experimental model of reduced-size heterotopic liver transplantation. After SCS, the water and glycogen content in both groups remained unchanged as well as the tissue glutathione concentration. In the ex vivo studies, livers preserved with the BGP-HMP solution were hemodynamically more efficient and the O2 consumption rate was higher than in livers from the HTK group. Bile production and glycogen content after 90 minutes of normothermic reperfusion was diminished in both groups compared with the control group. Cellular integrity of the BGP-HMP group was better, and the histological damage was reversible. In the in vivo model, HTK-preserved livers showed a greater degree of histological injury and higher apoptosis compared with the BGP-HMP group. In conclusion, our results suggest a better role of the BGP-HMP solution compared with HTK in preventing ischemia/reperfusion injury in the rat liver model.
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Affiliation(s)
- Matías E Carnevale
- Centro Binacional (Argentina-Italia) de Investigaciones en Criobiología Clínica y Aplicada, Universidad Nacional de Rosario, Rosario, Argentina.,Consejo Nacional de Investigaciones Científicas y Técnicas, Universidad Nacional de la Plata, La Plata, Argentina
| | - Natalia Lausada
- Cátedra de Trasplante, Facultad de Ciencias Médicas, Universidad Nacional de la Plata, La Plata, Argentina
| | - Leonardo Juan de Paz
- Centro Binacional (Argentina-Italia) de Investigaciones en Criobiología Clínica y Aplicada, Universidad Nacional de Rosario, Rosario, Argentina
| | - Pablo Stringa
- Cátedra de Trasplante, Facultad de Ciencias Médicas, Universidad Nacional de la Plata, La Plata, Argentina.,Consejo Nacional de Investigaciones Científicas y Técnicas, Universidad Nacional de la Plata, La Plata, Argentina
| | - Mariana Machuca
- Laboratorio de Patología Especial, Facultad de Ciencias Veterinarias, Universidad Nacional de la Plata, La Plata, Argentina
| | - Martin Rumbo
- Instituto de Estudios Inmunológicos y Fisiopatológicos, Universidad Nacional de la Plata, La Plata, Argentina.,Consejo Nacional de Investigaciones Científicas y Técnicas, Universidad Nacional de la Plata, La Plata, Argentina
| | - Edgardo E Guibert
- Centro Binacional (Argentina-Italia) de Investigaciones en Criobiología Clínica y Aplicada, Universidad Nacional de Rosario, Rosario, Argentina.,Consejo Nacional de Investigaciones Científicas y Técnicas, Universidad Nacional de la Plata, La Plata, Argentina
| | | | - Gabriel E Gondolesi
- Consejo Nacional de Investigaciones Científicas y Técnicas, Universidad Nacional de la Plata, La Plata, Argentina.,Servicio de Cirugía General, Trasplante Hepático, Pancreático e Intestinal, Hospital Universitario Fundación Favaloro, Laboratorio de Microcirugía Experimental, Instituto de Medicina Traslacional, Trasplante y Bioengeniería, Consejo Nacional de Investigaciones Científicas y Técnicas, Universidad Favaloro, Buenos Aires, Argentina
| | - Joaquin V Rodriguez
- Centro Binacional (Argentina-Italia) de Investigaciones en Criobiología Clínica y Aplicada, Universidad Nacional de Rosario, Rosario, Argentina.,Consejo Nacional de Investigaciones Científicas y Técnicas, Universidad Nacional de la Plata, La Plata, Argentina
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7
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Organ preservation solutions: linking pharmacology to survival for the donor organ pathway. Curr Opin Organ Transplant 2019; 23:361-368. [PMID: 29697461 DOI: 10.1097/mot.0000000000000525] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
PURPOSE OF REVIEW To provide an understanding of the scientific principles, which underpinned the development of organ preservation solutions, and to bring into context new strategies and challenges for solution development against the background of changing preservation technologies and expanded criteria donor access. RECENT FINDINGS Improvements in organ preservation solutions continue to be made with new pharmacological approaches. New solutions have been developed for dynamic perfusion preservation and are now in clinical application. Principles defining organ preservation solution pharmacology are being applied for cold chain logistics in tissue engineering and regenerative medicine. SUMMARY Organ preservation solutions support the donor organ pathway. The solution compositions allow additives and pharmacological agents to be delivered direct to the target organ to mitigate preservation injury. Changing preservation strategies provide further challenges and opportunities to improve organ preservation solutions.
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8
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Extracorporeal Perfusion in Vascularized Composite Allotransplantation: Current Concepts and Future Prospects. Ann Plast Surg 2019; 80:669-678. [PMID: 29746324 DOI: 10.1097/sap.0000000000001477] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Severe injuries of the face and limbs remain a major challenge in today's reconstructive surgery. Vascularized composite allotransplantation (VCA) has emerged as a promising approach to restore these defects. Yet, there are major obstacles preventing VCA from broad clinical application. Two key restrictions are (1) the graft's limited possible ischemia time, keeping the potential donor radius extremely small, and (2) the graft's immunogenicity, making extensive lifelong monitoring and immunosuppressive treatment mandatory. Machine perfusion systems have demonstrated clinical success addressing these issues in solid organ transplantation by extending possible ischemia times and decreasing immunogenicity. Despite many recent promising preclinical trials, machine perfusion has not yet been utilized in clinical VCA. This review presents latest perfusion strategies in clinical solid organ transplantation and experimental VCA in light of the specific requirements by the vascularized composite allograft's unique tissue composition. It discusses optimal settings for temperature, oxygenation, and flow types, as well as perfusion solutions and the most promising additives. Moreover, it highlights the implications for the utility of VCA as therapeutic measure in plastic surgery, if machine perfusion can be successfully introduced in a clinical setting.
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9
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Analysis of Interactions Between Components of Selected Solution for Organ Perfusion and Preservation. Transplant Proc 2018; 50:1967-1970. [PMID: 30177089 DOI: 10.1016/j.transproceed.2018.02.166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Accepted: 02/06/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND In the literature there is a great deal of information about the activity of liquid preservatives and the solutions used to modify them; however, there is no information about the possibility of interactions between them during multiorgan retrieval. The aim of the study was to analyze the possibility of reactions between the components of Biolasol and histidine-tryptophan-ketoglutarate (HTK). Biolasol is the first Polish liquid preservative intended for rinsing kidneys, livers, and pancreases by simple hypothermia. HTK is a cardioplegic fluid used in organ preservation of hearts, livers, kidneys, pancreases, and lungs. METHODS Biolasol and HTK solution were used for the tests. The preservatives were mixed together at 1:1, 0.25:0.75, and 0.75:0.25 ratios. The volume of mixtures to be analyzed was 500 mL. The prepared systems were stored in a refrigerator (4°C) protecting against light. The systems were subjected to physicochemical analysis involving pH, density, viscosity, buffer capacity, osmolarity, and absorbance measurements as well as visual and microscopic assessment at time intervals: immediately after mixing (t = 0) and after 12, 24, 48, and 72 hours. RESULTS The analysis suggests that interactions between solution components can occur and have a positive effect on storage time and effectiveness of organ rinsing. CONCLUSIONS The use of Biolasol and HTK in multiorgan retrieval is safe.
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10
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Panisello-Rosello A, Castro-Benítez C, Lopez A, Balloji S, Folch-Puy E, Adam R, Roselló-Catafau J. Graft Protection Against Cold Ischemia Preservation: An Institute George Lopez 1 and Histidine-tryptophan-ketoglutarate Solution Appraisal. Transplant Proc 2018; 50:714-718. [PMID: 29661422 DOI: 10.1016/j.transproceed.2018.02.044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Cold storage of organs in preservation solutions, such as Institute George Lopez 1 (IGL-1) or histidine-tryptophan-ketoglutarate (HTK), is a mandatory step for organ transplantation. This preservation leads to an ischemic injury that affects the outcome of the organ. This article studies the liver graft eluate after organ recovery using IGL-1 or HTK solutions. We explore the influence of the volume used for washing out the liver and the consequences in the graft preservation when both solutions are used. Livers were washed out with different volumes of HTK and IGL-1 according to manufacturers' instructions and then preserved in both solutions for 24 hours at 4°C. Tissue and eluates were collected for subsequent analyses. We measured transaminases (aspartate aminotransferase and alanine aminotransferase), histology by hematoxylin/eosin staining, and red blood cell and hemoglobin counts, respectively. After washing out and cold storage, the IGL-1 processed livers showed better preservation than those with HTK solution; however, in this latter case, an important accumulation of erythrocytes was found when compared to IGL-1. These data were consistent with the higher hemoglobin and red blood cell counts observed for IGL-1 eluates after 24 hours. The volume used for washing out the organ depends on the composition and properties of the organ preservation solutions (ie, IGL-1 and HTK); this is an important factor for the graft cold preservation. The total volume used for washing out the graft should be considered because it has a direct impact on the total cost for clinical transplantations.
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Affiliation(s)
- A Panisello-Rosello
- Institut d'Investigacions Biomèdiques de Barcelona (IIBB), CSIC-IDIBAPS, Catalonia, Barcelona, Spain
| | - C Castro-Benítez
- Centre Hepato-Biliare, AP-P-HP Hôpital Paul Brousse, Inserm U776, Univesité Paris-Sud, Villejuif, Paris, France
| | - A Lopez
- Centre Hepato-Biliare, AP-P-HP Hôpital Paul Brousse, Inserm U776, Univesité Paris-Sud, Villejuif, Paris, France
| | - S Balloji
- Institut d'Investigacions Biomèdiques de Barcelona (IIBB), CSIC-IDIBAPS, Catalonia, Barcelona, Spain
| | - E Folch-Puy
- Institut d'Investigacions Biomèdiques de Barcelona (IIBB), CSIC-IDIBAPS, Catalonia, Barcelona, Spain
| | - R Adam
- Centre Hepato-Biliare, AP-P-HP Hôpital Paul Brousse, Inserm U776, Univesité Paris-Sud, Villejuif, Paris, France
| | - J Roselló-Catafau
- Institut d'Investigacions Biomèdiques de Barcelona (IIBB), CSIC-IDIBAPS, Catalonia, Barcelona, Spain.
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Szilágyi ÁL, Mátrai P, Hegyi P, Tuboly E, Pécz D, Garami A, Solymár M, Pétervári E, Balaskó M, Veres G, Czopf L, Wobbe B, Szabó D, Wagner J, Hartmann P. Compared efficacy of preservation solutions on the outcome of liver transplantation: Meta-analysis. World J Gastroenterol 2018; 24:1812-1824. [PMID: 29713134 PMCID: PMC5922999 DOI: 10.3748/wjg.v24.i16.1812] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 04/02/2018] [Accepted: 04/09/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To compare the effects of the four most commonly used preservation solutions on the outcome of liver transplantations. METHODS A systematic literature search was performed using MEDLINE, Scopus, EMBASE and the Cochrane Library databases up to January 31st, 2017. The inclusion criteria were comparative, randomized controlled trials (RCTs) for deceased donor liver (DDL) allografts with adult and pediatric donors using the gold standard University of Wisconsin (UW) solution or histidine-tryptophan-ketoglutarate (HTK), Celsior (CS) and Institut Georges Lopez (IGL-1) solutions. Fifteen RCTs (1830 livers) were included; the primary outcomes were primary non-function (PNF) and one-year post-transplant graft survival (OGS-1). RESULTS All trials were homogenous with respect to donor and recipient characteristics. There was no statistical difference in the incidence of PNF with the use of UW, HTK, CS and IGL-1 (RR = 0.02, 95%CI: 0.01-0.03, P = 0.356). Comparing OGS-1 also failed to reveal any difference between UW, HTK, CS and IGL-1 (RR = 0.80, 95%CI: 0.80-0.80, P = 0.369). Two trials demonstrated higher PNF levels for UW in comparison with the HTK group, and individual studies described higher rates of biliary complications where HTK and CS were used compared to the UW and IGL-1 solutions. However, the meta-analysis of the data did not prove a statistically significant difference: the UW, CS, HTK and IGL-1 solutions were associated with nearly equivalent outcomes. CONCLUSION Alternative solutions for UW yield the same degree of safety and effectiveness for the preservation of DDLs, but further well-designed clinical trials are warranted.
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Affiliation(s)
| | - Péter Mátrai
- Institute of Bioanalysis, University of Pécs, Pécs H-7624, Hungary
| | - Péter Hegyi
- Institute for Translational Medicine and First Department of Medicine, University of Pécs, Pécs H-7624, Hungary
- MTA-SZTE Translational Gastroenterology Research Group, Szeged H-6720, Hungary
- János Szentágothai Research Center, University of Pécs, Pécs H-7624, Hungary
| | - Eszter Tuboly
- Institute of Surgical Research, University of Szeged, Szeged H-6720, Hungary
| | - Daniella Pécz
- Institute of Surgical Research, University of Szeged, Szeged H-6720, Hungary
| | - András Garami
- Institute for Translational Medicine and First Department of Medicine, University of Pécs, Pécs H-7624, Hungary
| | - Margit Solymár
- Institute for Translational Medicine and First Department of Medicine, University of Pécs, Pécs H-7624, Hungary
| | - Erika Pétervári
- Institute for Translational Medicine and First Department of Medicine, University of Pécs, Pécs H-7624, Hungary
| | - Márta Balaskó
- Institute for Translational Medicine and First Department of Medicine, University of Pécs, Pécs H-7624, Hungary
| | - Gábor Veres
- 1st Department of Paediatrics, University of Semmelweis, Budapest H-1085, Hungary
| | - László Czopf
- Department of Cardiology, 1st Department of Medicine, University of Pécs, Pécs H-7624, Hungary
| | - Bastian Wobbe
- Department of Cardiology, 1st Department of Medicine, University of Pécs, Pécs H-7624, Hungary
| | - Dorottya Szabó
- Department of Cardiology, 1st Department of Medicine, University of Pécs, Pécs H-7624, Hungary
| | - Juliane Wagner
- Department of Cardiology, 1st Department of Medicine, University of Pécs, Pécs H-7624, Hungary
| | - Petra Hartmann
- Institute of Surgical Research, University of Szeged, Szeged H-6720, Hungary
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12
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Rao F, Yang J, Gong C, Huang R, Wang Q, Shen J. Systematic review of preservation solutions for allografts for liver transplantation based on a network meta-analysis. Int J Surg 2018; 54:1-6. [PMID: 29684666 DOI: 10.1016/j.ijsu.2018.04.024] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 04/09/2018] [Accepted: 04/12/2018] [Indexed: 01/20/2023]
Abstract
AIMS The aim of this work was to determine the best preservation solutions for allografts for liver transplantation by quantitative network meta-analysis. METHODS Global electronic databases including PubMed, EMBASE, and Cochrane Library were searched for relevant randomized controlled trials. Seven pieces of parametric data were extracted from included studies for pooled estimation. A consistency model was used for direct and indirect comparisons. The cumulative probability P value was utilized to rank the solutions. A node-splitting model was utilized for testing the consistency of final data. Quality of evidence was assessed using the GRADE (Grades of Recommendations Assessment, Development and Evaluation) system. RESULTS Eleven 2-arm trials including 1319 patients and 5 different solutions were finally included. HTK (Histidine-tryptophan-ketoglutarate) solution exhibited the best efficacy for decreasing the primary dysfunction rate, biliary complications and ICU-stay time (probability P = 0.43, 0.45 and 0.58, respectively). Celsior solution significantly decreased the rate of rejection and early retransplantation (probability P = 0.73 and 0.38, respectively), and enhanced patient and graft survival (probability P = 0.90 and 0.98, respectively) more than did other solutions. Overall, the quality of evidence was rated high or moderate. CONCLUSIONS We suggested that HTK solution may offer the best safety during the perioperative period. However, Celsior solution led to better graft tolerance and exhibited greater benefit for long-term outcomes. And our conclusions still need to be further validated.
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Affiliation(s)
- Fengying Rao
- School of Nursing, Huanggang Polytechnic College, Huanggang, 438002, PR China
| | - Jian Yang
- School of Nursing, Huanggang Polytechnic College, Huanggang, 438002, PR China
| | - Cheng Gong
- Department of General Surgery, Zhongnan Hospital of Wuhan University, Wuhan, 430071, PR China
| | - Rong Huang
- School of Nursing, Huanggang Polytechnic College, Huanggang, 438002, PR China
| | - Qi Wang
- The 1st Department of Gastrointestinal Surgery, Renmin Hospital of Wuhan University, Wuhan, 430060, Hubei Province, PR China.
| | - Jun Shen
- Emergency Center, Zhongnan Hospital of Wuhan University, 430071, Hubei Province, PR China.
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13
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DCD Liver Transplant: a Meta-review of the Evidence and Current Optimization Strategies. CURRENT TRANSPLANTATION REPORTS 2018. [DOI: 10.1007/s40472-018-0193-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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14
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Panisello-Roselló A, Verde E, Lopez A, Flores M, Folch-Puy E, Rolo A, Palmeira C, Hotter G, Carbonell T, Adam R, Roselló-Catafau J. Cytoprotective Mechanisms in Fatty Liver Preservation against Cold Ischemia Injury: A Comparison between IGL-1 and HTK. Int J Mol Sci 2018; 19:ijms19020348. [PMID: 29364854 PMCID: PMC5855570 DOI: 10.3390/ijms19020348] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Revised: 01/16/2018] [Accepted: 01/19/2018] [Indexed: 12/17/2022] Open
Abstract
Institute Goeorges Lopez 1 (IGL-1) and Histidine-Tryptophan-Ketoglutarate (HTK) preservation solutions are regularly used in clinical for liver transplantation besides University of Wisconsin (UW) solution and Celsior. Several clinical trials and experimental works have been carried out comparing all the solutions, however the comparative IGL-1 and HTK appraisals are poor; especially when they deal with the underlying protection mechanisms of the fatty liver graft during cold storage. Fatty livers from male obese Zücker rats were conserved for 24 h at 4 °C in IGL-1 or HTK preservation solutions. After organ recovery and rinsing of fatty liver grafts with Ringer Lactate solution, we measured the changes in mechanistic target of rapamycin (mTOR) signaling activation, liver autophagy markers (Beclin-1, Beclin-2, LC3B and ATG7) and apoptotic markers (caspase 3, caspase 9 and TUNEL). These determinations were correlated with the prevention of liver injury (aspartate and alanine aminostransferase (AST/ALT), histology) and mitochondrial damage (glutamate dehydrogenase (GLDH) and confocal microscopy findings). Liver grafts preserved in IGL-1 solution showed a marked reduction on p-TOR/mTOR ratio when compared to HTK. This was concomitant with significant increased cyto-protective autophagy and prevention of liver apoptosis, including inflammatory cytokines such as HMGB1. Together, our results revealed that IGL-1 preservation solution better protected fatty liver grafts against cold ischemia damage than HTK solution. IGL-1 protection was associated with a reduced liver damage, higher induced autophagy and decreased apoptosis. All these effects would contribute to limit the subsequent extension of reperfusion injury after graft revascularization in liver transplantation procedures.
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Affiliation(s)
- Arnau Panisello-Roselló
- Experimental Hepatic Ischemia-Reperfusion Unit, Institut d'Investigacions Biomèdiques de Barcelona (IIBB), Spanish National Research Council (CSIC), 08036 Barcelona, Catalonia, Spain.
| | - Eva Verde
- Department of Cell Biology, Physiology and Immunology, Universitat de Barcelona, Barcelona, 08028 Catalonia, Spain.
| | - Alexandre Lopez
- Centre Hépato-Biliaire, AP-PH, Hôpital Paul Brousse, 94800 Villejuif, France.
| | - Marta Flores
- Department of Cell Biology, Physiology and Immunology, Universitat de Barcelona, Barcelona, 08028 Catalonia, Spain.
| | - Emma Folch-Puy
- Experimental Hepatic Ischemia-Reperfusion Unit, Institut d'Investigacions Biomèdiques de Barcelona (IIBB), Spanish National Research Council (CSIC), 08036 Barcelona, Catalonia, Spain.
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Catalonia, Spain.
| | - Anabela Rolo
- Center for Neuroscience and Cell Biology, Universidade Coimbra, 3000-370 Coimbra, Portugal.
| | - Carlos Palmeira
- Center for Neuroscience and Cell Biology, Universidade Coimbra, 3000-370 Coimbra, Portugal.
| | - Georgina Hotter
- Experimental Hepatic Ischemia-Reperfusion Unit, Institut d'Investigacions Biomèdiques de Barcelona (IIBB), Spanish National Research Council (CSIC), 08036 Barcelona, Catalonia, Spain.
| | - Teresa Carbonell
- Department of Cell Biology, Physiology and Immunology, Universitat de Barcelona, Barcelona, 08028 Catalonia, Spain.
| | - René Adam
- Centre Hépato-Biliaire, AP-PH, Hôpital Paul Brousse, 94800 Villejuif, France.
| | - Joan Roselló-Catafau
- Experimental Hepatic Ischemia-Reperfusion Unit, Institut d'Investigacions Biomèdiques de Barcelona (IIBB), Spanish National Research Council (CSIC), 08036 Barcelona, Catalonia, Spain.
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Catalonia, Spain.
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15
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Chedid MF, Bosi HR, Chedid AD, Alvares-da-Silva MR, Leipnitz I, Grezzana-Filho TJM, Reis MJ, Filho GM, Ghissi AJ, Neto PR, de Araujo A, Arruda S, Lopes AB, Michalczuk MT, Backes AN, Kruel CDP, Kruel CRP. One Hundred Consecutive Liver Transplants Using Institutes Georges Lopez-1 Preservation Solution: Outcomes and Prognostic Factors. Transplant Proc 2017; 49:848-851. [PMID: 28457409 DOI: 10.1016/j.transproceed.2017.01.061] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND There are only 4 prior studies reporting on outcomes of liver transplantation (LT) using Institutes Georges Lopez-1 (IGL-1) preservation solution. Detection of negative predictors of LT using IGL-1 may help finding strategies to protect selected recipients at higher risk of graft failure and death. METHODS Review of all consecutive adult patients who underwent a first whole-graft LT using IGL-1 at authors' institution from 2013 to 2016. Primary end point was graft failure within the first 90 postoperative days (PODs). Graft losses due to any cause (including all deaths with a functioning graft) were recorded as graft failures. RESULTS Of all 100 patients included in this study, 37 were women; median age was 58 years (range 18-71). There were 12 graft losses during the first 90 PODs (including 3 cases of primary nonfunction of the liver allograft), and 10 of the 12 graft losses occurred on first 30 PODs. All 12 patients who experienced graft loss (including 1 patient who underwent liver retransplantation) died within the first 90 PODs. Of the total 100 patients, 14 experienced biliary complications. Univariate analysis revealed prolonged warm ischemic time (WIT) as the only predictor of 90-day graft failure (odds ratio = 23.5, confidence interval = 1.29-430.18, P = .03). The cutoff by receiver operating characteristic curve for WIT was 38 minutes (area under the curve = 0.70). Positive predictive value for WIT >38 minutes was 94.3%. CONCLUSIONS LT using IGL-1 can be performed safely. Similar to prior reports on LT using other preservation solutions, prolonged WIT was associated with adverse outcomes.
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Affiliation(s)
- M F Chedid
- Liver Transplant Program, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil.
| | - H R Bosi
- Liver Transplant Program, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - A D Chedid
- Liver Transplant Program, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - M R Alvares-da-Silva
- Liver Transplant Program, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - I Leipnitz
- Liver Transplant Program, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - T J M Grezzana-Filho
- Liver Transplant Program, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - M J Reis
- Liver Transplant Program, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - G M Filho
- Liver Transplant Program, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - A J Ghissi
- Liver Transplant Program, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - P R Neto
- Liver Transplant Program, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - A de Araujo
- Liver Transplant Program, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - S Arruda
- Liver Transplant Program, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - A B Lopes
- Liver Transplant Program, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - M T Michalczuk
- Liver Transplant Program, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - A N Backes
- Liver Transplant Program, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - C D P Kruel
- Liver Transplant Program, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - C R P Kruel
- Liver Transplant Program, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
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16
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Hameed AM, Laurence JM, Lam VWT, Pleass HC, Hawthorne WJ. A systematic review and meta-analysis of cold in situ perfusion and preservation of the hepatic allograft: Working toward a unified approach. Liver Transpl 2017; 23:1615-1627. [PMID: 28734125 PMCID: PMC5725662 DOI: 10.1002/lt.24829] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 05/03/2017] [Accepted: 07/16/2017] [Indexed: 01/01/2023]
Abstract
The efficacy of cold in situ perfusion and static storage of the liver is a possible determinant of transplantation outcomes. The aim of this study was to determine whether there is evidence to substantiate a preference for a particular perfusion route (aortic or dual) or perfusion/preservation solution in donation after brain death (DBD) liver transplantation. The Embase, MEDLINE, and Cochrane databases were used (1980-2017). Random effects modeling was used to estimate effects on transplantation outcomes based on (1) aortic or dual in situ perfusion and (2) the use of University of Wisconsin (UW), histidine tryptophan ketoglutarate (HTK), Celsior, and/or Institut Georges Lopez-1 (IGL-1) solutions for perfusion/preservation. A total of 22 articles were included (2294 liver transplants). The quality of evidence ranged from very low to moderate Grading of Recommendations, Assessment, Development and Evaluations score. Meta-analyses were conducted for 14 eligible studies. Although there was no difference in the primary nonfunction (PNF) rate, a higher peak alanine aminotransferase (ALT) was recorded in dual compared with aortic-only UW-perfused livers (standardized mean difference, 0.24; 95% confidence interval, 0.01-0.47); a back-table portal venous flush was undertaken in the majority of aortic-only perfused livers. There were no relevant differences in peak enzymes, PNF, thrombotic graft loss, biliary complications, or 1-year graft survival in comparisons between dual-perfused livers using UW, HTK, Celsior, or IGL-1. In conclusion, there is no significant evidence that aortic-only perfusion of the DBD liver compromises transplantation outcomes, and it may be favored because of its simplicity. However, there is currently insufficient evidence to advocate for the use of any particular perfusion/preservation fluid over the others. Liver Transplantation 23 1615-1627 2017 AASLD.
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Affiliation(s)
- Ahmer M. Hameed
- Centre for Transplant and Renal Research, Westmead Institute for Medical ResearchWestmeadNew South WalesAustralia,Department of SurgeryWestmead HospitalWestmeadNew South WalesAustralia,Sydney Medical SchoolUniversity of SydneySydneyNew South WalesAustralia
| | - Jerome M. Laurence
- Sydney Medical SchoolUniversity of SydneySydneyNew South WalesAustralia,Department of Surgery,Institute of Academic Surgery, Royal Prince Alfred HospitalUniversity of SydneyCamperdownNew South WalesAustralia
| | - Vincent W. T. Lam
- Department of SurgeryWestmead HospitalWestmeadNew South WalesAustralia,Sydney Medical SchoolUniversity of SydneySydneyNew South WalesAustralia
| | - Henry C. Pleass
- Department of SurgeryWestmead HospitalWestmeadNew South WalesAustralia,Sydney Medical SchoolUniversity of SydneySydneyNew South WalesAustralia,Department of Surgery
| | - Wayne J. Hawthorne
- Centre for Transplant and Renal Research, Westmead Institute for Medical ResearchWestmeadNew South WalesAustralia,Department of SurgeryWestmead HospitalWestmeadNew South WalesAustralia,Sydney Medical SchoolUniversity of SydneySydneyNew South WalesAustralia
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17
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The Relevance of the UPS in Fatty Liver Graft Preservation: A New Approach for IGL-1 and HTK Solutions. Int J Mol Sci 2017; 18:ijms18112287. [PMID: 29088097 PMCID: PMC5713257 DOI: 10.3390/ijms18112287] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Revised: 10/23/2017] [Accepted: 10/25/2017] [Indexed: 12/17/2022] Open
Abstract
The 26S proteasome is the central proteolytic machinery of the ubiquitin proteasome system (UPS), which is involved in the degradation of ubiquitinated protein substrates. Recently, UPS inhibition has been shown to be a key factor in fatty liver graft preservation during organ cold storage using University of Wisconsin solution (UW) and Institute Georges Lopez (IGL-1) solutions. However, the merits of IGL-1 and histidine-tryptophan-ketoglutarate (HTK) solutions for fatty liver preservation have not been compared. Fatty liver grafts from obese Zücker rats were preserved for 24 h at 4 °C. Aspartate aminotransferase and alanine aminotransferase (AST/ALT), glutamate dehydrogenase (GLDH), ATP, adenosine monophosphate protein kinase (AMPK), e-NOS, proteasome activity and liver polyubiquitinated proteins were determined. IGL-1 solution prevented ATP breakdown during cold-storage preservation of steatotic livers to a greater extent than HTK solution. There were concomitant increases in AMPK activation, e-NOS (endothelial NOS (NO synthase)) expression and UPS inhibition. UPS activity is closely related to the composition of the solution used to preserve the organ. IGL-1 solution provided significantly better protection against ischemia-reperfusion for cold-stored fatty liver grafts than HTK solution. The effect is exerted through the activation of the protective AMPK signaling pathway, an increase in e-NOS expression and a dysregulation of the UPS.
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18
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Nickkholgh A, Maluf D. Emerging graft protective strategies in clinical liver transplantation. Expert Rev Gastroenterol Hepatol 2017; 11:623-631. [PMID: 28438069 DOI: 10.1080/17474124.2017.1322901] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
There have been remarkable efforts to characterize the key responsible pathophysiologic mechanisms, as well as to ameliorate the organ preservation and ischemia reperfusion injury with the ultimate goal of expanding the donor pool and further improvement of the outcomes of liver transplantation. Attempts to translate the experimental results from bench to bedside have yielded no valid protective concepts in the field of clinical liver transplantation yet. Nonetheless, there has been a considerable amount of ongoing clinical research to develop clinically relevant graft protective strategies. Areas covered: This review focuses on the most recent evidence based findings and ongoing clinical trials that might lead to emerging graft protective strategies in the field of clinical liver transplantation. New evidence-based findings in the donor preconditioning, organ preservation, and perioperative pharmacologic graft protection strategies in the recipient are reviewed. Expert commentary: Few strategies have been shown to exert some graft protective effects against ischemia reperfusion injury in recent clinical trials in liver transplantation. Among others, 'dynamic graft preservation' techniques have been emerging as more promising graft optimization strategies.
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Affiliation(s)
- Arash Nickkholgh
- a Department of Surgery , University of Virginia , Charlottesville , VA , USA
| | - Daniel Maluf
- a Department of Surgery , University of Virginia , Charlottesville , VA , USA
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