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Lau NS, Ly M, Ewenson K, Toomath S, Ly H, Mestrovic N, Liu K, McCaughan G, Crawford M, Pulitano C. Indocyanine green: A novel marker for assessment of graft quality during ex situ normothermic machine perfusion of human livers. Artif Organs 2024; 48:472-483. [PMID: 38132848 DOI: 10.1111/aor.14696] [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: 09/10/2023] [Revised: 11/27/2023] [Accepted: 12/06/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Ex situ machine perfusion facilitates the assessment of livers prior to transplantation. However, currently available markers of liver function poorly predict long-term graft function. Indocyanine green (ICG) is a liver-specific dye which, although common in vivo, has never been comprehensively evaluated for the assessment of graft quality during ex situ machine perfusion. This study aimed to assess the utility of ICG in the ex situ setting. METHODS Using a customized long-term perfusion system, human livers that were not suitable for transplantation were perfused using a red cell-based perfusate. ICG was delivered into the perfusate on days 0, 1, and 4 to assess ICG clearance (spectrophotometric absorbance at 805 nm) and ICG fluorescence (near-infrared camera). RESULTS Sixteen partial livers were perfused for a median duration of 172 h (7.2 days). On day 0, the median ICG perfusate disappearance rate (PDR) was 7.5%/min and the median ICG retention at 15 min was 9.9%. Grafts that survived ≥7 days had a significantly higher median ICG PDR on day 0 (14.5%/min vs. 6.5%/min, p = 0.005) but not on days 1 or 4. ICG perfusion demonstrated that long-surviving grafts had a significantly lower median red-value (89.8 vs. 118.6, p = 0.011) and a significantly lower median blue-value (12.9 vs. 22.6, p = 0.045) than short-surviving grafts. CONCLUSION ICG is a novel marker for the assessment of liver function during ex situ normothermic machine perfusion. ICG PDR and quantitative ICG perfusion can distinguish between long- and short-surviving grafts and demonstrate the utility of ICG in the assessment of graft quality prior to transplant.
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Affiliation(s)
- Ngee-Soon Lau
- Centre for Organ Assessment, Repair and Optimisation, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Mark Ly
- Centre for Organ Assessment, Repair and Optimisation, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Kasper Ewenson
- Centre for Organ Assessment, Repair and Optimisation, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Shamus Toomath
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Hayden Ly
- Centre for Organ Assessment, Repair and Optimisation, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Nicole Mestrovic
- Centre for Organ Assessment, Repair and Optimisation, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Ken Liu
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Geoff McCaughan
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Michael Crawford
- Centre for Organ Assessment, Repair and Optimisation, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Carlo Pulitano
- Centre for Organ Assessment, Repair and Optimisation, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
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Halle-Smith JM, Hall L, Hann A, Arshad A, Armstrong MJ, Bangash MN, Murphy N, Cuell J, Isaac JL, Ferguson J, Roberts KJ, Mirza DF, Perera MTPR. Low C-reactive Protein and Urea Distinguish Primary Nonfunction From Early Allograft Dysfunction Within 48 Hours of Liver Transplantation. Transplant Direct 2023; 9:e1484. [PMID: 37250485 PMCID: PMC10212614 DOI: 10.1097/txd.0000000000001484] [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: 02/08/2023] [Accepted: 03/03/2023] [Indexed: 05/31/2023] Open
Abstract
Primary nonfunction (PNF) is a life-threatening complication of liver transplantation (LT), but in the early postoperative period, it can be difficult to differentiate from early allograft dysfunction (EAD). The aim of this study was to determine if serum biomarkers can distinguish PNF from EAD in the initial 48 h following LT. Materials and Methods A retrospective study of adult patients that underwent LT between January 2010 and April 2020 was performed. Clinical parameters, absolute values and trends of C-reactive protein (CRP), blood urea, creatinine, liver function tests, platelets, and international normalized ratio in the initial 48 h after LT were compared between the EAD and PNF groups. Results There were 1937 eligible LTs, with PNF and EAD occurring in 38 (2%) and 503 (26%) patients, respectively. A low serum CRP and urea were associated with PNF. CRP was able to differentiate between the PNF and EAD on postoperative day (POD)1 (20 versus 43 mg/L; P < 0.001) and POD2 (24 versus 77; P < 0.001). The area under the receiver operating characteristic curve (AUROC) of POD2 CRP was 0.770 (95% confidence interval [CI] 0.645-0.895). The urea value on POD2 (5.05 versus 9.0 mmol/L; P = 0.002) and trend of POD2:1 ratio (0.71 versus 1.32 mmol/L; P < 0.001) were significantly different between the groups. The AUROC of the change in urea from POD1 to 2 was 0.765 (95% CI 0.645-0.885). Aspartate transaminase was significantly different between the groups, with an AUROC of 0.884 (95% CI 0.753-1.00) on POD2. Discussion The biochemical profile immediately following LT can distinguish PNF from EAD; CRP, urea, and aspartate transaminase are more effective than ALT and bilirubin in distinguishing PNF from EAD in the initial postoperative 48 h. Clinicians should consider the values of these markers when making treatment decisions.
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Affiliation(s)
- James M. Halle-Smith
- Liver Unit, Queen Elizabeth Hospital, Birmingham, United Kingdom
- College of Medical and Dental Sciences, University of Birmingham, Edgbaston, United Kingdom
| | - Lewis Hall
- College of Medical and Dental Sciences, University of Birmingham, Edgbaston, United Kingdom
| | - Angus Hann
- Liver Unit, Queen Elizabeth Hospital, Birmingham, United Kingdom
- College of Medical and Dental Sciences, University of Birmingham, Edgbaston, United Kingdom
| | - Asif Arshad
- Liver Unit, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Matthew J. Armstrong
- Liver Unit, Queen Elizabeth Hospital, Birmingham, United Kingdom
- College of Medical and Dental Sciences, University of Birmingham, Edgbaston, United Kingdom
| | - Mansoor N. Bangash
- Liver Unit, Queen Elizabeth Hospital, Birmingham, United Kingdom
- College of Medical and Dental Sciences, University of Birmingham, Edgbaston, United Kingdom
| | - Nick Murphy
- Liver Unit, Queen Elizabeth Hospital, Birmingham, United Kingdom
- College of Medical and Dental Sciences, University of Birmingham, Edgbaston, United Kingdom
| | - James Cuell
- Liver Unit, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - John L. Isaac
- Liver Unit, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - James Ferguson
- Liver Unit, Queen Elizabeth Hospital, Birmingham, United Kingdom
- College of Medical and Dental Sciences, University of Birmingham, Edgbaston, United Kingdom
| | - Keith J. Roberts
- Liver Unit, Queen Elizabeth Hospital, Birmingham, United Kingdom
- College of Medical and Dental Sciences, University of Birmingham, Edgbaston, United Kingdom
| | - Darius F. Mirza
- Liver Unit, Queen Elizabeth Hospital, Birmingham, United Kingdom
- College of Medical and Dental Sciences, University of Birmingham, Edgbaston, United Kingdom
| | - M. Thamara P. R. Perera
- Liver Unit, Queen Elizabeth Hospital, Birmingham, United Kingdom
- College of Medical and Dental Sciences, University of Birmingham, Edgbaston, United Kingdom
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Current and Potential Applications for Indocyanine Green in Liver Transplantation. Transplantation 2021; 106:1339-1350. [PMID: 34966106 DOI: 10.1097/tp.0000000000004024] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Indocyanine green (ICG) is a fluorescent dye taken up and almost exclusively cleared by the liver. Measurement of its clearance and visualization of its fluorescence make it suitable for a number of potential applications in liver transplantation including assessment of liver function and real-time assessment of arterial, venous, and biliary structures. ICG clearance can be used to assess donor graft quality before procurement and graft metabolic function before transplant using normothermic ex vivo machine perfusion. ICG clearance in the post-liver transplantation period is able to predict recipient outcomes with correlations to early allograft dysfunction and postoperative complications. After absorbing light in the near-infrared spectrum, ICG also emits fluorescence at 835 nm. This allows the assessment of vascular patency after reconstruction and patterns of liver perfusion in real time. ICG perfusion patterns after revascularization are also associated with posttransplant graft function and survival. ICG fluorescence cholangiography is routine in a number of centers and acts as an aid to identifying the optimal point of bile duct division during living donor liver transplantation to optimize safety for both donor and recipient. In summary, ICG is a versatile tool and has a number of useful applications in the liver transplantation journey including assessment of liver function, perfusion assessment, and cholangiography. Further research and clinical trials are required to validate and standardize its routine use in liver transplantation.
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