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Canizares S, Montalvan A, Chumdermpadetsuk R, Modest A, Eckhoff D, Lee DD. Liver machine perfusion technology: Expanding the donor pool to improve access to liver transplantation. Am J Transplant 2024:S1600-6135(24)00209-0. [PMID: 38508317 DOI: 10.1016/j.ajt.2024.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Revised: 03/01/2024] [Accepted: 03/11/2024] [Indexed: 03/22/2024]
Abstract
The imbalance between organ supply and demand continues to limit the broader benefits of organ transplantation. Machine perfusion (MP) may increase the supply of donor livers by expanding the use of extended-criteria donors. Using the United Network for Organ Sharing/Organ Procurement and Transplantation Network and the Standard Transplant Analysis and Research dataset, we reviewed the effect of MP implementation on the behavior of transplant centers. We identified 15 high-utilizing MP centers that were matched to suitable controls based on volume and geographical proximity. We conducted a differences-in-differences analysis using linear regression to estimate the impact of MP adoption on the transplant centers' donor utilization. We found a significant increase in cold ischemia time and organs with donor warm ischemia time over 30 minutes (P < .05). After removing one outlier center, the analysis showed that these centers through MP accepted overall more donation after circulatory death donors, donation after circulatory death donors over 50 years old, donors with macrovesicular steatosis greater than 30% on liver biopsy, and donor warm ischemia time over 30 minutes (P < .05). MP has allowed centers to expand their use of extended-criteria donors beyond traditional cutoffs and to increase patient access to liver transplantation.
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Affiliation(s)
- Stalin Canizares
- Division of Transplant Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Adriana Montalvan
- Division of Transplant Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Ritah Chumdermpadetsuk
- Division of Transplant Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Anna Modest
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA; Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Boston, Massachusetts, USA
| | - Devin Eckhoff
- Division of Transplant Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - David D Lee
- Division of Transplant Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.
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2
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Patrono D, De Stefano N, Vissio E, Apostu AL, Petronio N, Vitelli G, Catalano G, Rizza G, Catalano S, Colli F, Chiusa L, Romagnoli R. How to Preserve Steatotic Liver Grafts for Transplantation. J Clin Med 2023; 12:3982. [PMID: 37373676 DOI: 10.3390/jcm12123982] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 06/05/2023] [Accepted: 06/08/2023] [Indexed: 06/29/2023] Open
Abstract
Liver allograft steatosis is a significant risk factor for postoperative graft dysfunction and has been associated with inferior patient and graft survival, particularly in the case of moderate or severe macrovesicular steatosis. In recent years, the increasing incidence of obesity and fatty liver disease in the population has led to a higher proportion of steatotic liver grafts being used for transplantation, making the optimization of their preservation an urgent necessity. This review discusses the mechanisms behind the increased susceptibility of fatty livers to ischemia-reperfusion injury and provides an overview of the available strategies to improve their utilization for transplantation, with a focus on preclinical and clinical evidence supporting donor interventions, novel preservation solutions, and machine perfusion techniques.
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Affiliation(s)
- Damiano Patrono
- General Surgery 2U-Liver Transplant Unit, Department of Surgical Sciences, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Università di Torino, Corso Bramante 88-90, 10126 Turin, Italy
| | - Nicola De Stefano
- General Surgery 2U-Liver Transplant Unit, Department of Surgical Sciences, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Università di Torino, Corso Bramante 88-90, 10126 Turin, Italy
| | - Elena Vissio
- Department of Pathology, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Università di Torino, Corso Bramante 88-90, 10126 Turin, Italy
| | - Ana Lavinia Apostu
- General Surgery 2U-Liver Transplant Unit, Department of Surgical Sciences, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Università di Torino, Corso Bramante 88-90, 10126 Turin, Italy
| | - Nicoletta Petronio
- General Surgery 2U-Liver Transplant Unit, Department of Surgical Sciences, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Università di Torino, Corso Bramante 88-90, 10126 Turin, Italy
| | - Giovanni Vitelli
- General Surgery 2U-Liver Transplant Unit, Department of Surgical Sciences, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Università di Torino, Corso Bramante 88-90, 10126 Turin, Italy
| | - Giorgia Catalano
- General Surgery 2U-Liver Transplant Unit, Department of Surgical Sciences, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Università di Torino, Corso Bramante 88-90, 10126 Turin, Italy
| | - Giorgia Rizza
- General Surgery 2U-Liver Transplant Unit, Department of Surgical Sciences, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Università di Torino, Corso Bramante 88-90, 10126 Turin, Italy
| | - Silvia Catalano
- General Surgery 2U-Liver Transplant Unit, Department of Surgical Sciences, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Università di Torino, Corso Bramante 88-90, 10126 Turin, Italy
| | - Fabio Colli
- General Surgery 2U-Liver Transplant Unit, Department of Surgical Sciences, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Università di Torino, Corso Bramante 88-90, 10126 Turin, Italy
| | - Luigi Chiusa
- Department of Pathology, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Università di Torino, Corso Bramante 88-90, 10126 Turin, Italy
| | - Renato Romagnoli
- General Surgery 2U-Liver Transplant Unit, Department of Surgical Sciences, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Università di Torino, Corso Bramante 88-90, 10126 Turin, Italy
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3
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Staubli SM, Ceresa CDL, Pollok JM. The Current Role and Future Applications of Machine Perfusion in Liver Transplantation. Bioengineering (Basel) 2023; 10:bioengineering10050593. [PMID: 37237663 DOI: 10.3390/bioengineering10050593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 04/07/2023] [Accepted: 04/25/2023] [Indexed: 05/28/2023] Open
Abstract
The relative paucity of donor livers suitable for transplantation has sparked innovations to preserve and recondition organs to expand the pool of transplantable organs. Currently, machine perfusion techniques have led to the improvement of the quality of marginal livers and to prolonged cold ischemia time and have allowed for the prediction of graft function through the analysis of the organ during perfusion, improving the rate of organ use. In the future, the implementation of organ modulation might expand the scope of machine perfusion beyond its current usage. The aim of this review was to provide an overview of the current clinical use of machine perfusion devices in liver transplantation and to provide a perspective for future clinical use, including therapeutic interventions in perfused donor liver grafts.
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Affiliation(s)
- Sebastian M Staubli
- HPB and Liver Transplantation Service, Royal Free London NHS Foundation Trust, Pond Street, London NW3 QG, UK
| | - Carlo D L Ceresa
- HPB and Liver Transplantation Service, Royal Free London NHS Foundation Trust, Pond Street, London NW3 QG, UK
- Oxford University Hospitals NHS Foundation Trust, University of Oxford, Oxfordshire OX3 9DU, UK
| | - Joerg M Pollok
- HPB and Liver Transplantation Service, Royal Free London NHS Foundation Trust, Pond Street, London NW3 QG, UK
- Division of Surgery & Interventional Science, University College London, London WC1E 6BT, UK
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Croome KP. Introducing Machine Perfusion into Routine Clinical Practice for Liver Transplantation in the United States: The Moment Has Finally Come. J Clin Med 2023; 12:jcm12030909. [PMID: 36769557 PMCID: PMC9918031 DOI: 10.3390/jcm12030909] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 01/06/2023] [Accepted: 01/17/2023] [Indexed: 01/25/2023] Open
Abstract
While adoption of machine perfusion technologies into clinical practice in the United States has been much slower than in Europe, recent changes in the transplant landscape as well as device availability following FDA approval have paved the way for rapid growth. Machine perfusion may provide one mechanism to maximize the utilization of potential donor liver grafts. Indeed, multiple studies have shown increased organ utilization with the implementation of technologies such as ex-situ normothermic machine perfusion (NMP), ex-situ hypothermic machine perfusion (HMP) and in-situ normothermic regional perfusion (NRP). The current review describes the history and development of machine perfusion utilization in the Unites States along with future directions. It also describes the differences in landscape between Europe and the United States and how this has shaped clinical application of these technologies.
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Zeng J, Li Q, Wu Q, Li L, Ye X, Liu J, Cao B. A Novel Online Calculator Predicting Acute Kidney Injury After Liver Transplantation: A Retrospective Study. Transpl Int 2023; 36:10887. [PMID: 36744052 PMCID: PMC9892055 DOI: 10.3389/ti.2023.10887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 01/11/2023] [Indexed: 01/20/2023]
Abstract
Acute kidney injury (AKI) after liver transplantation (LT) is a common complication, and its development is thought to be multifactorial. We aimed to investigate potential risk factors and build a model to identify high-risk patients. A total of 199 LT patients were enrolled and each patient data was collected from the electronic medical records. Our primary outcome was postoperative AKI as diagnosed and classified by the KDIGO criteria. A least absolute shrinkage and selection operating algorithm and multivariate logistic regression were utilized to select factors and construct the model. Discrimination and calibration were used to estimate the model performance. Decision curve analysis (DCA) was applied to assess the clinical application value. Five variables were identified as independent predictors for post-LT AKI, including whole blood serum lymphocyte count, RBC count, serum sodium, insulin dosage and anhepatic phase urine volume. The nomogram model showed excellent discrimination with an AUC of 0.817 (95% CI: 0.758-0.876) in the training set. The DCA showed that at a threshold probability between 1% and 70%, using this model clinically may add more benefit. In conclusion, we developed an easy-to-use tool to calculate the risk of post-LT AKI. This model may help clinicians identify high-risk patients.
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Affiliation(s)
- Jianfeng Zeng
- Department of Anesthesiology, The Sun Yat-sen Memorial Hospital of Sun Yat-sen University, Guangzhou, China
| | - Qiaoyun Li
- Department of Physiology, The Zhongshan Medical School of Sun Yat-sen University, Guangzhou, China
| | - Qixing Wu
- Department of Anesthesiology, The First Affiliated Hospital University of Science and Technology of China, Hefei, China
| | - Li Li
- Department of Anesthesiology, The Sun Yat-sen Memorial Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xijiu Ye
- Department of Anesthesiology, The Sun Yat-sen Memorial Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jing Liu
- Department of Anesthesiology, The Eighth Affiliated Hospital of Sun Yat-sen University, Shenzhen, China,*Correspondence: Jing Liu, ; Bingbing Cao,
| | - Bingbing Cao
- Department of Anesthesiology, The Sun Yat-sen Memorial Hospital of Sun Yat-sen University, Guangzhou, China,*Correspondence: Jing Liu, ; Bingbing Cao,
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6
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Riveros S, Marino C, Ochoa G, Soto D, Alegría L, Zenteno MJ, San Martín S, Brañes A, Achurra P, Rebolledo R. Customized normothermic machine perfusion decreases ischemia-reperfusion injury compared with static cold storage in a porcine model of liver transplantation. Artif Organs 2023; 47:148-159. [PMID: 36007920 DOI: 10.1111/aor.14390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 07/20/2022] [Accepted: 08/09/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND Liver transplantation has been demonstrated to be the best treatment for several liver diseases, while grafts are limited. This has caused an increase in waiting lists, making it necessary to find ways to expand the number of organs available for transplantation. Normothermic perfusion (NMP) of liver grafts has been established as an alternative to static cold storage (SCS), but only a small number of perfusion machines are commercially available. METHODS Using a customized ex situ machine perfusion, we compared the results between ex situ NMP and SCS preservation in a porcine liver transplant model. RESULTS During NMP, lactate concentrations were 80% lower after the 3-h perfusion period, compared with SCS. Bile production had a 2.5-fold increase during the NMP period. After transplantation, aspartate transaminase (AST) and alanine transaminase (ALT) levels were 35% less in the NMP group, compared to the SCS group. In pathologic analyses of grafts after transplant, tissue oxidation did not change between groups, but the ischemia-reperfusion injury score was lower in the NMP group. CONCLUSION NMP reduced hepatocellular damage and ischemia-reperfusion injury when compared to SCS using a customized perfusion machine. This could be an alternative for low-income countries to include machine perfusion in their therapeutic options.
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Affiliation(s)
- Sergio Riveros
- Department of Digestive Surgery, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Carlo Marino
- Department of Digestive Surgery, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Gabriela Ochoa
- Department of Digestive Surgery, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Dagoberto Soto
- Department of Intensive Care Unit, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Leyla Alegría
- Department of Intensive Care Unit, Pontificia Universidad Católica de Chile, Santiago, Chile
| | | | - Sebastián San Martín
- Biomedical Research Center, School of Medicine, Universidad de Valparaíso, Valparaíso, Chile
| | - Alejandro Brañes
- Hepato-Pancreato-Biliary Surgery Unit, Surgery Service, Complejo Asistencial Dr. Sótero Del Río, Santiago, Chile
| | - Pablo Achurra
- Department of Digestive Surgery, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Rolando Rebolledo
- Hepato-Pancreato-Biliary Surgery Unit, Surgery Service, Complejo Asistencial Dr. Sótero Del Río, Santiago, Chile.,Institute for Biological and Medical Engineering, Schools of Engineering, Medicine and Biological Sciences, Pontificia Universidad Católica de Chile, Santiago, Chile
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7
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Li B, Zhang J, Shen C, Zong T, Zhao C, Zhao Y, Lu Y, Sun S, Zhu H. Application of polymerized porcine hemoglobin in the ex vivo normothermic machine perfusion of rat livers. Front Bioeng Biotechnol 2022; 10:1072950. [PMID: 36686244 PMCID: PMC9854803 DOI: 10.3389/fbioe.2022.1072950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 11/22/2022] [Indexed: 12/04/2022] Open
Abstract
Background: In contrast to traditional static cold preservation of donor livers, normothermic machine perfusion (NMP) may reduce preservation injury, improve graft viability and potentially allows ex vivo assessment of graft viability before transplantation. The polymerized porcine hemoglobin is a kind of hemoglobin oxygen carrier prepared by crosslinking porcine hemoglobin by glutaraldehyde to form a polymer. The pPolyHb has been proved to have the ability of transporting oxygen which could repair the organ ischemia-reperfusion injury in rats. Objective: In order to evaluate the effectiveness of rat liver perfusion in vitro based on pPolyHb, we established the NMP system, optimized the perfusate basic formula and explored the optimal proportion of pPolyHb and basal perfusate. Methods: The liver was removed and perfused for 6 h at 37°C. We compared the efficacy of liver perfusion with different ratios of pPolyHb. Subsequently, compared the perfusion effect using Krebs Henseleit solution and pPolyHb perfusate of the optimal proportion, and compared with the liver preserved with UW solution. At 0 h, 1 h, 3 h and 6 h after perfusion, appropriate samples were collected for blood gas analysis and liver injury indexes detection. Some tissue samples were collected for H&E staining and TUNEL staining to observe the morphology and detect the apoptosis rate of liver cells. And we used Western Blot test to detect the expression of Bcl-2 and Bax in the tissues. Results: According to the final results, the optimal addition ratio of pPolyHb was 24%. By comparing the values of Bcl-2/Bax, the apoptosis rate of pPolyHb group was significantly reduced. Under this ratio, the results of H&E staining and TUNEL staining showed that the liver morphology was well preserved without additional signs of hepatocyte ischemia, biliary tract injury, or hepatic sinusoid injury, and hepatocyte apoptosis was relatively mild. Conclusion: Through the above-mentioned study we show that within 6 h of perfusion based on pPolyHb, liver physiological and biochemical activities may essentially be maintained in vitro. This study demonstrates that a pPolyHb-based perfusate is feasible for NMP of rat livers. This opens up a prospect for further research on NMP.
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Affiliation(s)
- Bin Li
- The College of Life Sciences, Northwest University, Xi’an, Shaanxi, China,National Engineering Research Center for Miniaturized Detection Systems, Northwest University, Xi’an, China,Key Laboratory of Resource Biology and Biotechnology in Western China, Ministry of Education, School of Medicine, Northwest University, Xi’an, China
| | - Jie Zhang
- The College of Life Sciences, Northwest University, Xi’an, Shaanxi, China
| | - Chuanyan Shen
- The College of Life Sciences, Northwest University, Xi’an, Shaanxi, China
| | - Tingting Zong
- The College of Life Sciences, Northwest University, Xi’an, Shaanxi, China
| | - Cong Zhao
- The College of Life Sciences, Northwest University, Xi’an, Shaanxi, China
| | - Yumin Zhao
- The College of Life Sciences, Northwest University, Xi’an, Shaanxi, China
| | - Yunhua Lu
- The College of Life Sciences, Northwest University, Xi’an, Shaanxi, China
| | - Siyue Sun
- The College of Life Sciences, Northwest University, Xi’an, Shaanxi, China
| | - Hongli Zhu
- The College of Life Sciences, Northwest University, Xi’an, Shaanxi, China,National Engineering Research Center for Miniaturized Detection Systems, Northwest University, Xi’an, China,Key Laboratory of Resource Biology and Biotechnology in Western China, Ministry of Education, School of Medicine, Northwest University, Xi’an, China,*Correspondence: Hongli Zhu,
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Moein M, Ahmed M, Arafa F, Saidi RF. Hemoglobin-based oxygen carriers: Clinical application of HBOC-201 as an alternative to red blood cells for machine perfusion in liver transplantation. SURGERY IN PRACTICE AND SCIENCE 2022. [DOI: 10.1016/j.sipas.2022.100120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Bone marrow mesenchymal stem cells modified with heme oxygenase-1 alleviate rejection of donation after circulatory death liver transplantation by inhibiting dendritic cell maturation in rats. Int Immunopharmacol 2022; 107:108643. [DOI: 10.1016/j.intimp.2022.108643] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 02/10/2022] [Accepted: 02/18/2022] [Indexed: 12/21/2022]
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Quantitative Metabolomics of Tissue, Perfusate, and Bile from Rat Livers Subjected to Normothermic Machine Perfusion. Biomedicines 2022; 10:biomedicines10030538. [PMID: 35327340 PMCID: PMC8945564 DOI: 10.3390/biomedicines10030538] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 02/16/2022] [Accepted: 02/21/2022] [Indexed: 12/13/2022] Open
Abstract
Machine perfusion (MP) allows the maintenance of liver cells in a metabolically active state ex vivo and can potentially revert metabolic perturbations caused by donor warm ischemia, procurement, and static cold storage (SCS). The present preclinical research investigated the metabolic outcome of the MP procedure by analyzing rat liver tissue, bile, and perfusate samples by means of high-field (600 MHz) nuclear magnetic resonance (NMR) spectroscopy. An established rat model of normothermic MP (NMP) was used. Experiments were carried out with the addition of an oxygen carrier (OxC) to the perfusion fluid (OxC-NMP, n = 5) or without (h-NMP, n = 5). Bile and perfusate samples were collected throughout the procedure, while biopsies were only taken at the end of NMP. Two additional groups were: (1) Native, in which tissue or bile specimens were collected from rats in resting conditions; and (2) SCS, in which biopsies were taken from cold-stored livers. Generally, NMP groups showed a distinctive metabolomic signature in all the analyzed biological matrices. In particular, many of the differentially expressed metabolites were involved in mitochondrial biochemical pathways. Succinate, acetate, 3-hydroxybutyrate, creatine, and O-phosphocholine were deeply modulated in ex vivo perfused livers compared to both the Native and SCS groups. These novel results demonstrate a broad modulation of mitochondrial metabolism during NMP that exceeds energy production and redox balance maintenance.
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12
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Dual Lactate Clearance in the Viability Assessment of Livers Donated After Circulatory Death With Ex Situ Normothermic Machine Perfusion. Transplant Direct 2021; 7:e789. [PMID: 34805491 PMCID: PMC8601326 DOI: 10.1097/txd.0000000000001243] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 08/26/2021] [Accepted: 09/11/2021] [Indexed: 12/16/2022] Open
Abstract
Supplemental Digital Content is available in the text. Perfusate lactate clearance (LC) is considered one of the useful indicators of liver viability assessment during normothermic machine perfusion (NMP); however, the applicable scope and potential mechanisms of LC remain poorly defined in the setting of liver donation after circulatory death.
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13
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Jakubauskas M, Jakubauskiene L, Leber B, Strupas K, Stiegler P, Schemmer P. Machine Perfusion in Liver Transplantation: A Systematic Review and Meta-Analysis. Visc Med 2021; 38:243-254. [PMID: 36160822 PMCID: PMC9421699 DOI: 10.1159/000519788] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 09/12/2021] [Indexed: 11/27/2022] Open
Abstract
Background Liver transplantation (LTx) is the only treatment option for patients with end-stage liver disease. Novel organ preservation techniques such as hypothermic machine perfusion (HMP) or normothermic machine perfusion (NMP) are under investigation in order to improve organ quality from extended criteria donors and donors after circulatory death. The aim of this study was to systematically review the literature reporting LTx outcomes using NMP or HMP compared to static cold storage (SCS). Methods The following data were retrieved: graft primary nonfunction rate, early allograft dysfunction (EAD) rate, biliary complication rate, and 12-month graft and patient survival. A total of 15 studies were included (6 NMP and 9 HMP studies), and meta-analysis was performed only for HMP studies because NMP had considerable differences. Results The systematic review showed the potential of NMP to reduce graft injury and lower the liver graft discard rate. The performed quantitative analyses showed that the use of HMP reduces the rate of EAD (odds ratio [OR] 0.51; 95% confidence interval [CI] 0.34–0.76; p = 0.001; I2 = 0%) and non-anastomotic biliary strictures (OR 0.34; 95% CI 0.17–0.67; p = 0.002; I2 = 0%) compared to SCS. Conclusion Our systematic review and meta-analysis revealed that the use of HMP reduces the rate of EAD and non-anastomotic biliary strictures compared to SCS.
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Affiliation(s)
- Matas Jakubauskas
- General, Visceral and Transplant Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
- Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Lina Jakubauskiene
- General, Visceral and Transplant Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
- Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Bettina Leber
- General, Visceral and Transplant Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | | | - Philipp Stiegler
- General, Visceral and Transplant Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
- *Philipp Stiegler,
| | - Peter Schemmer
- General, Visceral and Transplant Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
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Huang H, He X, Yarmush ML. Advanced technologies for the preservation of mammalian biospecimens. Nat Biomed Eng 2021; 5:793-804. [PMID: 34426675 PMCID: PMC8765766 DOI: 10.1038/s41551-021-00784-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 06/23/2021] [Indexed: 02/07/2023]
Abstract
The three classical core technologies for the preservation of live mammalian biospecimens-slow freezing, vitrification and hypothermic storage-limit the biomedical applications of biospecimens. In this Review, we summarize the principles and procedures of these three technologies, highlight how their limitations are being addressed via the combination of microfabrication and nanofabrication, materials science and thermal-fluid engineering and discuss the remaining challenges.
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Affiliation(s)
- Haishui Huang
- Center for Engineering in Medicine, Massachusetts General Hospital, Harvard Medical School and Shriners Hospitals for Children, Boston, MA, USA.
- Bioinspired Engineering and Biomechanics Center, The Key Laboratory of Biomedical Information Engineering of Ministry of Education, School of Life Science and Technology, Xi'an Jiaotong University, Xi'an, China.
| | - Xiaoming He
- Fischell Department of Bioengineering, University of Maryland, College Park, MD, USA.
- Robert E. Fischell Institute for Biomedical Devices, University of Maryland, College Park, MD, USA.
- Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland, Baltimore, MD, United States.
| | - Martin L Yarmush
- Center for Engineering in Medicine, Massachusetts General Hospital, Harvard Medical School and Shriners Hospitals for Children, Boston, MA, USA.
- Department of Biomedical Engineering, Rutgers University, Piscataway, NJ, USA.
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15
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Rohde E, Goudarzi M, Madajka M, Said SAD, Ordenana C, Rezaei M, Fahradyan V, Pozza ED, Willard B, Brunengraber H, Dasarathy S, Rampazzo A, Gharb BB. Metabolic Profiling of Skeletal Muscle During Ex-Vivo Normothermic Limb Perfusion. Mil Med 2021; 186:358-363. [PMID: 33499445 DOI: 10.1093/milmed/usaa268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 07/29/2020] [Accepted: 08/18/2020] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Ex vivo normothermic limb perfusion (EVNLP) provides several advantages for the preservation of limbs following amputation: the ability to maintain oxygenation and temperature of the limb close to physiological values, a perfusion solution providing all necessary nutrients at optimal concentrations, and the ability to maintain physiological pH and electrolytes. However, EVNLP cannot preserve the organ viability infinitely. We identified evidence of mitochondrial injury (swelling, elongation, and membrane disruption) after 24 hours of EVNLP of human upper extremities. The goal of this study was to identify metabolic derangements in the skeletal muscle during EVNLP. MATERIALS AND METHODS Fourteen human upper extremities were procured from organ donors after family consent. Seven limbs underwent EVNLP for an average of 41.6 ± 9.4 hours, and seven contralateral limbs were preserved at 4°C for the same amount of time. Muscle biopsies were performed at 24 hours of perfusion, both from the EVNLP and control limbs. Perturbations in the metabolic profiles of the muscle during EVNLP were determined via untargeted liquid chromatography-mass spectrometry (MS) operated in positive and negative electrospray ionization modes, over a mass range of 50 to 750 Da. The data were deconvoluted using the XCMS software and further statistically analyzed using the in-house statistical package, MetaboLyzer. Putative identification of metabolites using exact mass within ±7 ppm mass error and MS/MS spectral matching to the mzCloud spectral library were performed via Compound Discoverer v.2.1 (Thermo Scientific, Fremont, CA, USA). We further validated the identity of candidate metabolites by matching the fragmentation pattern of these metabolites to those of their reference pure chemicals. A nonparametric Mann-Whitney U-test was used to compare EVNLP and control group spectral features. Differences were considered significantly different when P-value < 0.05. RESULTS We detected over 13,000 spectral features of which 58 met the significance criteria with biologically relevant putative identifications. Furthermore we were able to confirm the identities of the ions taurine (P-value: 0.002) and tryptophan (P-value: 0.002), which were among the most significantly perturbed ions at 24 hours between the experimental and control groups. Metabolites belonging to the following pathways were the most perturbed at 24 hours: neuroactive ligand-receptor interaction (P-values: 0.031 and 0.036) and amino acid metabolism, including tyrosine and tryptophan metabolism (P-values: 0.015, 0.002, and 0.017). Taurine abundance decreased and tryptophan abundance increased at 24 hours. Other metabolites also identified at 24 hours included phenylalanine, xanthosine, and citric acid (P-values: 0.002, 0.002, and 0.0152). DISCUSSION This study showed presence of active metabolism during EVNLP and metabolic derangement toward the end of perfusion, which correlated with detection of altered mitochondrial structure, swelling, and elongation.
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Affiliation(s)
- Elizabeth Rohde
- Cleveland Clinic Department of Plastic Surgery, Cleveland, OH 44195, USA
| | - Maryam Goudarzi
- Cleveland Clinic Lerner Research Institute Proteomics and Metabolomics Core, Cleveland, OH 44195, USA
| | - Maria Madajka
- Cleveland Clinic Department of Plastic Surgery, Cleveland, OH 44195, USA
| | - Sayf Al-Deen Said
- Cleveland Clinic Department of Plastic Surgery, Cleveland, OH 44195, USA
| | - Carlos Ordenana
- Cleveland Clinic Department of Plastic Surgery, Cleveland, OH 44195, USA
| | - Majid Rezaei
- Cleveland Clinic Department of Plastic Surgery, Cleveland, OH 44195, USA
| | - Vahe Fahradyan
- Cleveland Clinic Department of Plastic Surgery, Cleveland, OH 44195, USA
| | - Edoardo Dall Pozza
- Cleveland Clinic Department of Plastic Surgery, Cleveland, OH 44195, USA
| | - Belinda Willard
- Cleveland Clinic Lerner Research Institute Proteomics and Metabolomics Core, Cleveland, OH 44195, USA
| | - Henri Brunengraber
- Case Western Reserve University School of Medicine Department of Nutrition and Biochemistry, Cleveland, OH 44106, USA
| | - Srinivasan Dasarathy
- Cleveland Clinic Lerner Research Institute Department of Pathobiology, Cleveland, OH 44195, USA
| | - Antonio Rampazzo
- Cleveland Clinic Department of Plastic Surgery, Cleveland, OH 44195, USA
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Bertile F, Habold C, Le Maho Y, Giroud S. Body Protein Sparing in Hibernators: A Source for Biomedical Innovation. Front Physiol 2021; 12:634953. [PMID: 33679446 PMCID: PMC7930392 DOI: 10.3389/fphys.2021.634953] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 01/12/2021] [Indexed: 12/11/2022] Open
Abstract
Proteins are not only the major structural components of living cells but also ensure essential physiological functions within the organism. Any change in protein abundance and/or structure is at risk for the proper body functioning and/or survival of organisms. Death following starvation is attributed to a loss of about half of total body proteins, and body protein loss induced by muscle disuse is responsible for major metabolic disorders in immobilized patients, and sedentary or elderly people. Basic knowledge of the molecular and cellular mechanisms that control proteostasis is continuously growing. Yet, finding and developing efficient treatments to limit body/muscle protein loss in humans remain a medical challenge, physical exercise and nutritional programs managing to only partially compensate for it. This is notably a major challenge for the treatment of obesity, where therapies should promote fat loss while preserving body proteins. In this context, hibernating species preserve their lean body mass, including muscles, despite total physical inactivity and low energy consumption during torpor, a state of drastic reduction in metabolic rate associated with a more or less pronounced hypothermia. The present review introduces metabolic, physiological, and behavioral adaptations, e.g., energetics, body temperature, and nutrition, of the torpor or hibernation phenotype from small to large mammals. Hibernating strategies could be linked to allometry aspects, the need for periodic rewarming from torpor, and/or the ability of animals to fast for more or less time, thus determining the capacity of individuals to save proteins. Both fat- and food-storing hibernators rely mostly on their body fat reserves during the torpid state, while minimizing body protein utilization. A number of them may also replenish lost proteins during arousals by consuming food. The review takes stock of the physiological, molecular, and cellular mechanisms that promote body protein and muscle sparing during the inactive state of hibernation. Finally, the review outlines how the detailed understanding of these mechanisms at play in various hibernators is expected to provide innovative solutions to fight human muscle atrophy, to better help the management of obese patients, or to improve the ex vivo preservation of organs.
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Affiliation(s)
- Fabrice Bertile
- University of Strasbourg, CNRS, IPHC UMR 7178, Laboratoire de Spectrométrie de Masse Bio-Organique, Strasbourg, France
| | - Caroline Habold
- University of Strasbourg, CNRS, IPHC UMR 7178, Ecology, Physiology & Ethology Department, Strasbourg, France
| | - Yvon Le Maho
- University of Strasbourg, CNRS, IPHC UMR 7178, Ecology, Physiology & Ethology Department, Strasbourg, France.,Centre Scientifique de Monaco, Monaco, Monaco
| | - Sylvain Giroud
- Research Institute of Wildlife Ecology, Department of Interdisciplinary Life Sciences, University of Veterinary Medicine Vienna, Vienna, Austria
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17
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Gao J, He K, Xia Q, Zhang J. Research progress on hepatic machine perfusion. Int J Med Sci 2021; 18:1953-1959. [PMID: 33850464 PMCID: PMC8040389 DOI: 10.7150/ijms.56139] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 02/12/2021] [Indexed: 01/08/2023] Open
Abstract
Nowadays, liver transplantation is the most effective treatment for end-stage liver disease. However, the increasing imbalance between growing demand for liver transplantation and the shortage of donor pool restricts the development of liver transplantation. How to expand the donor pool is a significant problem to be solved clinically. Many doctors have devoted themselves to marginal grafting, which introduces livers with barely passable quality but a high risk of transplant failure into the donor pool. However, existing common methods of preserving marginal grafts lead to both high risk of postoperative complications and high mortality. The application of machine perfusion allows surgeons to make marginal livers meet the standard criteria for transplant, which shows promising prospect in preserving and repairing donor livers and improving ischemia reperfusion injury. This review summarizes the progress of recent researches on hepatic machine perfusion.
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Affiliation(s)
- Junda Gao
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Kang He
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Qiang Xia
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jianjun Zhang
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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18
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Fahradyan V, Said SAD, Ordenana C, Dalla Pozza E, Frautschi R, Duraes EFR, Madajka-Niemeyer M, Papay FA, Rampazzo A, Bassiri Gharb B. Extended ex vivo normothermic perfusion for preservation of vascularized composite allografts. Artif Organs 2020; 44:846-855. [PMID: 32133657 DOI: 10.1111/aor.13678] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 02/02/2020] [Accepted: 02/27/2020] [Indexed: 12/15/2022]
Abstract
Ischemia and reperfusion injury remains a significant limiting factor for the successful revascularization of amputated extremities. Ex vivo normothermic perfusion is a novel approach to prolong the viability of the amputated limbs by maintaining physiologic cellular metabolism. This study aimed to evaluate the outcomes of extended ex vivo normothermic limb perfusion (EVNLP) in preserving the viability of amputated limbs for over 24 hours. A total of 10 porcine forelimbs underwent EVNLP. Limbs were perfused using an oxygenated colloid solution at 38°C containing washed RBCs. Five forelimbs (Group A) were perfused for 12 hours and the following 5 (Group B) until the vascular resistance increased. Contralateral forelimbs in each group were preserved at 4°C as a cold storage control group. Limb viability was compared between the 2 groups through assessment of muscle contractility, compartment pressure, tissue oxygen saturation, indocyanine green (ICG) angiography and thermography. EVNLP was performed for 12 hours in group A and up to 44 hours (24-44 hours) in group B. The final weight increase (-1.28 ± 8.59% vs. 7.28 ± 15.05%, P = .548) and compartment pressure (16.50 ± 8.60 vs. 24.00 ± 9.10) (P = .151) were not significantly different between the two groups. Final myoglobin and CK mean values in group A and B were: 875.0 ± 325.8 ng/mL (A) versus 1133.8 ± 537.7 ng/mL (B) (P = .056) and 53 344.0 ± 16 603.0 U/L versus 64 333.3 ± 32 481.8 U/L (P = .286). Tissue oxygen saturation was stable until the end in both groups. Infra-red thermography and ICG-angiography detected variations of peripheral limb perfusion. Our results suggest that extended normothermic preservation of amputated limbs is feasible and that the outcomes of prolonged EVNLP (>24 hours) are not significantly different from short EVNLP (12 hours).
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Affiliation(s)
- Vahe Fahradyan
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | | | - Carlos Ordenana
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | | | | | | | | | - Frank A Papay
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Antonio Rampazzo
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, OH, USA
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19
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Czigany Z, Lurje I, Schmelzle M, Schöning W, Öllinger R, Raschzok N, Sauer IM, Tacke F, Strnad P, Trautwein C, Neumann UP, Fronek J, Mehrabi A, Pratschke J, Schlegel A, Lurje G. Ischemia-Reperfusion Injury in Marginal Liver Grafts and the Role of Hypothermic Machine Perfusion: Molecular Mechanisms and Clinical Implications. J Clin Med 2020; 9:E846. [PMID: 32244972 PMCID: PMC7141496 DOI: 10.3390/jcm9030846] [Citation(s) in RCA: 66] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 03/09/2020] [Accepted: 03/11/2020] [Indexed: 12/19/2022] Open
Abstract
Ischemia-reperfusion injury (IRI) constitutes a significant source of morbidity and mortality after orthotopic liver transplantation (OLT). The allograft is metabolically impaired during warm and cold ischemia and is further damaged by a paradox reperfusion injury after revascularization and reoxygenation. Short-term and long-term complications including post-reperfusion syndrome, delayed graft function, and immune activation have been associated with IRI. Due to the current critical organ shortage, extended criteria grafts are increasingly considered for transplantation, however, with an elevated risk to develop significant features of IRI. In recent years, ex vivo machine perfusion (MP) of the donor liver has witnessed significant advancements. Here, we describe the concept of hypothermic (oxygenated) machine perfusion (HMP/HOPE) approaches and highlight which allografts may benefit from this technology. This review also summarizes clinical applications and the main aspects of ongoing randomized controlled trials on hypothermic perfusion. The mechanistic aspects of IRI and hypothermic MP-which include tissue energy replenishment, optimization of mitochondrial function, and the reduction of oxidative and inflammatory damage following reperfusion-will be comprehensively discussed within the context of current preclinical and clinical evidence. Finally, we highlight novel trends and future perspectives in the field of hypothermic MP in the context of recent findings of basic and translational research.
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Affiliation(s)
- Zoltan Czigany
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, 52074 Aachen, Germany; (Z.C.); (U.P.N.)
| | - Isabella Lurje
- Department of Surgery, Campus Charité Mitte | Campus Virchow-Klinikum—Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany; (I.L.); (M.S.); (W.S.); (R.Ö.); (N.R.); (I.M.S.); (J.P.)
| | - Moritz Schmelzle
- Department of Surgery, Campus Charité Mitte | Campus Virchow-Klinikum—Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany; (I.L.); (M.S.); (W.S.); (R.Ö.); (N.R.); (I.M.S.); (J.P.)
| | - Wenzel Schöning
- Department of Surgery, Campus Charité Mitte | Campus Virchow-Klinikum—Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany; (I.L.); (M.S.); (W.S.); (R.Ö.); (N.R.); (I.M.S.); (J.P.)
| | - Robert Öllinger
- Department of Surgery, Campus Charité Mitte | Campus Virchow-Klinikum—Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany; (I.L.); (M.S.); (W.S.); (R.Ö.); (N.R.); (I.M.S.); (J.P.)
| | - Nathanael Raschzok
- Department of Surgery, Campus Charité Mitte | Campus Virchow-Klinikum—Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany; (I.L.); (M.S.); (W.S.); (R.Ö.); (N.R.); (I.M.S.); (J.P.)
| | - Igor M. Sauer
- Department of Surgery, Campus Charité Mitte | Campus Virchow-Klinikum—Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany; (I.L.); (M.S.); (W.S.); (R.Ö.); (N.R.); (I.M.S.); (J.P.)
| | - Frank Tacke
- Department of Hepatology and Gastroenterology, Campus Charité Mitte | Campus Virchow-Klinikum—Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany;
| | - Pavel Strnad
- Department of Gastroenterology, Metabolic Disorders and Intensive Care, University Hospital RWTH Aachen, 52074 Aachen, Germany; (P.S.); (C.T.)
| | - Christian Trautwein
- Department of Gastroenterology, Metabolic Disorders and Intensive Care, University Hospital RWTH Aachen, 52074 Aachen, Germany; (P.S.); (C.T.)
| | - Ulf Peter Neumann
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, 52074 Aachen, Germany; (Z.C.); (U.P.N.)
| | - Jiri Fronek
- Department of Transplant Surgery, Institute for Clinical and Experimental Medicine, 140 21 Prague, Czech Republic;
| | - Arianeb Mehrabi
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, 69120 Heidelberg, Germany;
| | - Johann Pratschke
- Department of Surgery, Campus Charité Mitte | Campus Virchow-Klinikum—Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany; (I.L.); (M.S.); (W.S.); (R.Ö.); (N.R.); (I.M.S.); (J.P.)
| | - Andrea Schlegel
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham B15 2TH, UK;
| | - Georg Lurje
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, 52074 Aachen, Germany; (Z.C.); (U.P.N.)
- Department of Surgery, Campus Charité Mitte | Campus Virchow-Klinikum—Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany; (I.L.); (M.S.); (W.S.); (R.Ö.); (N.R.); (I.M.S.); (J.P.)
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New Strategies to Expand and Optimize Heart Donor Pool: Ex Vivo Heart Perfusion and Donation After Circulatory Death: A Review of Current Research and Future Trends. Anesth Analg 2019; 128:406-413. [PMID: 30531220 DOI: 10.1213/ane.0000000000003919] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Heart transplantation remains the definitive management for end-stage heart failure refractory to medical therapy. While heart transplantation cases are increasing annually worldwide, there remains a deficiency in organ availability with significant patient mortality while on the waiting list. Attempts have therefore been made to expand the donor pool and improve access to available organs by recruiting donors who may not satisfy the standard criteria for organ donation because of donor pathology, anticipated organ ischemic time, or donation after circulatory death. "Ex vivo" heart perfusion (EVHP) is an emerging technique for the procurement of heart allografts. This technique provides mechanically supported warm circulation to a beating heart once removed from the donor and before implantation into the recipient. EVHP can be sustained for several hours, facilitate extended travel time, and enable administration of pharmacological agents to optimize cardiac recovery and function, as well as allow assessment of allograft function before implantation. In this article, we review recent advances in expanding the donor pool for cardiac transplantation. Current limitations of conventional donor criteria are outlined, including the determinants of organ suitability and assessment, involving transplantation of donation after circulatory death hearts, extended criteria donors, and EVHP-associated assessment, optimization, and transportation. Finally, ongoing research relating to organ optimization and functional ex vivo allograft assessment are reviewed.
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Abstract
In this paper we will describe anaesthetic management of solid organ and reconstructive transplantation (RT) patients. We will focus on similar underlying principles of reperfusion, ischaemic-reperfusion injury, preconditioning and extracorporeal donor organ preservation. Special concerns for anaesthetic management of these patients need to focus on pre-assessment, pre-operative optimisation, vascular access, fluid management, blood and products replacement, cardiovascular monitoring, use of inotropes and vasoconstrictors, maintaining electrolyte balance and regional anaesthesia. Despite the complexity and long duration of transplant procedures, fast-tracking to the surgical ward after transplantation is becoming more popular and its benefits are well recognised.
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Affiliation(s)
- Zoka Milan
- Anaesthetic Department, King's College Hospital, Denmark Hill, SE5 9RS London, UK.
| | - Miriam Cortes
- Surgical Department, King's College Hospital, London, UK
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Thuillier R, Delpy E, Matillon X, Kaminski J, Kasil A, Soussi D, Danion J, Sauvageon Y, Rod X, Donatini G, Barrou B, Badet L, Zal F, Hauet T. Preventing acute kidney injury during transplantation: the application of novel oxygen carriers. Expert Opin Investig Drugs 2019; 28:643-657. [PMID: 31165652 DOI: 10.1080/13543784.2019.1628217] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Delayed graft function (DGF) has a significant impact on kidney transplantation outcome. One of the underlying pivotal mechanisms is organ preservation and associated hypothermia and biochemical alteration. AREAS COVERED This paper focuses on organ preservation and its clinical consequences and describes 1. A comprehensive presentation of the pathophysiological mechanism involved in delayed graft function development; 2. The impact on endothelial cells and microvasculature integrity and the consequences on transplanted organ outcome; 3. The reassessment of dynamic organ preservation motivated by the growing use of extended criteria donors and the interest in the potential of normothermia; 4. The role of oxygenation during dynamic preservation; and 5. Novel oxygen carriers and their proof of concept in transplantation, among which M101 (HEMO2life®) is currently the most extensively investigated. EXPERT OPINION Metabolic disturbances and imbalance of oxygen supply during preservation highlight the importance of providing oxygen. Normothermia, permitted by recent advances in machine perfusion technology, appears to be the leading edge of preservation technology. Several oxygen transporters are compatible with normothermia; however, only M101 also demonstrates compatibility with standard hypothermic preservation.
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Affiliation(s)
- Raphael Thuillier
- a Inserm U1082 , Inserm, Poitiers , France.,b Fédération Hospitalo-Universitaire SUPORT , CHU Poitiers, Poitiers , France.,c Faculté de Médecine et de Pharmacie , Université de Poitiers , Poitiers , France.,d Service de Biochimie , CHU Poitiers , Poitiers , France
| | - Eric Delpy
- e HEMARINA S.A., Aéropole centre, Biotechnopôle , Morlaix , France
| | - Xavier Matillon
- a Inserm U1082 , Inserm, Poitiers , France.,f Modélisations Précliniques Innovation Chirurgicale et Technologique , Infrastructures en Biologie et Santé Animale, Génétique, Expérimentations et Systèmes Innovants, Département Génétique Animale , INRA Le Magneraud,Surgères , France.,g Service d'urologie et de chirurgie de la transplantation , Hospices Civiles de Lyon , Lyon , France.,h Faculté de Médecine Lyon Est , Université Claude Bernard Lyon 1 , Villeurbanne , France
| | - Jacques Kaminski
- a Inserm U1082 , Inserm, Poitiers , France.,c Faculté de Médecine et de Pharmacie , Université de Poitiers , Poitiers , France
| | - Abdelsalam Kasil
- a Inserm U1082 , Inserm, Poitiers , France.,c Faculté de Médecine et de Pharmacie , Université de Poitiers , Poitiers , France
| | - David Soussi
- a Inserm U1082 , Inserm, Poitiers , France.,c Faculté de Médecine et de Pharmacie , Université de Poitiers , Poitiers , France.,d Service de Biochimie , CHU Poitiers , Poitiers , France
| | - Jerome Danion
- a Inserm U1082 , Inserm, Poitiers , France.,c Faculté de Médecine et de Pharmacie , Université de Poitiers , Poitiers , France.,i Service de Chirurgie viscérale et endocrinienne , CHU Poitiers , Poitiers , France
| | - Yse Sauvageon
- a Inserm U1082 , Inserm, Poitiers , France.,c Faculté de Médecine et de Pharmacie , Université de Poitiers , Poitiers , France.,d Service de Biochimie , CHU Poitiers , Poitiers , France
| | - Xavier Rod
- a Inserm U1082 , Inserm, Poitiers , France
| | - Gianluca Donatini
- a Inserm U1082 , Inserm, Poitiers , France.,i Service de Chirurgie viscérale et endocrinienne , CHU Poitiers , Poitiers , France
| | - Benoit Barrou
- a Inserm U1082 , Inserm, Poitiers , France.,j Service de Transplantation Rénale, Département d'Urologie et de Transplantation , Groupe Hospitalier Pitié Salpétrière , Paris , France
| | - Lionel Badet
- a Inserm U1082 , Inserm, Poitiers , France.,f Modélisations Précliniques Innovation Chirurgicale et Technologique , Infrastructures en Biologie et Santé Animale, Génétique, Expérimentations et Systèmes Innovants, Département Génétique Animale , INRA Le Magneraud,Surgères , France.,g Service d'urologie et de chirurgie de la transplantation , Hospices Civiles de Lyon , Lyon , France.,h Faculté de Médecine Lyon Est , Université Claude Bernard Lyon 1 , Villeurbanne , France
| | - Franck Zal
- e HEMARINA S.A., Aéropole centre, Biotechnopôle , Morlaix , France
| | - Thierry Hauet
- a Inserm U1082 , Inserm, Poitiers , France.,b Fédération Hospitalo-Universitaire SUPORT , CHU Poitiers, Poitiers , France.,c Faculté de Médecine et de Pharmacie , Université de Poitiers , Poitiers , France.,d Service de Biochimie , CHU Poitiers , Poitiers , France.,f Modélisations Précliniques Innovation Chirurgicale et Technologique , Infrastructures en Biologie et Santé Animale, Génétique, Expérimentations et Systèmes Innovants, Département Génétique Animale , INRA Le Magneraud,Surgères , France.,k Consortium for Organ Preservation in Europe, Nuffield Department of Surgical Sciences , Oxford Transplant Centre, Churchill Hospital , Oxford , United Kingdom
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Liu J, Tian L, Wang S, Luo Z. Study of Hepatic Vascular Dynamics Based on Symmetrical Pulsating Perfusion. Ann Transplant 2019; 24:214-222. [PMID: 31000689 PMCID: PMC6486798 DOI: 10.12659/aot.913008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Background The traditionally used perfusion method is constant flow. This study proposes a novel method called Symmetric Pulsating Flow (SPF) and verified that this method is applicable. Material/Methods The fluid dynamic behavior of perfusate in the vessel, the shear stress, and the vascular deformation were simulated based on the bi-directional fluid-structure interaction. The differences of the fluid dynamic behaviors and the mechanical characteristics of vascular wall were studied and compared between the 2 methods during the process of hepatic perfusion. The simulations and comparisons were carried out on 3 different vascular models. Results Utilizing the constant flow perfusion, a double vortex clearly appeared at the rear end of the foreign matter and reflux retention can be caused by the double vortex. The reflux retention caused lower shear stress against the vascular wall and thus brought new accumulation of foreign matter. The SPF perfusion, however, prevented the double vortex, and avoided such reflux retention during the vascular perfusion. In addition, the SPF can clean the vascular wall better with a slower speed, which causes less injury to the vessel, and the pulsating effect can reduce the accumulation of new foreign matter. Conclusions The SPF perfusion can clean the vascular wall more thoroughly with less injury.
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Affiliation(s)
- Jun Liu
- Tianjin Key Laboratory for Advanced Mechatronic System Design and Intelligent Control, National Demonstration Center for Experimental Mechanical and Electrical Engineering Education, Tianjin University of Technology, Tianjin, China (mainland)
| | - Lanlan Tian
- Tianjin Key Laboratory for Advanced Mechatronic System Design and Intelligent Control, National Demonstration Center for Experimental Mechanical and Electrical Engineering Education, Tianjin University of Technology, Tianjin, China (mainland)
| | - Songli Wang
- Tianjin Key Laboratory for Advanced Mechatronic System Design and Intelligent Control, National Demonstration Center for Experimental Mechanical and Electrical Engineering Education, Tianjin University of Technology, Tianjin, China (mainland)
| | - Zhiwei Luo
- Organization of Advanced Science and Technology, Kobe University, Kobe, Hyogo, Japan
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Pavel MC, Reyner E, Molina V, Garcia R, Ruiz A, Roque R, Diaz A, Fuster J, Garcia-Valdecasas JC. Evolution Under Normothermic Machine Perfusion of Type 2 Donation After Cardiac Death Livers Discarded as Nontransplantable. J Surg Res 2019; 235:383-394. [DOI: 10.1016/j.jss.2018.09.066] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Revised: 09/05/2018] [Accepted: 09/20/2018] [Indexed: 02/06/2023]
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25
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The Effects of Short-term Subnormothermic Perfusion After Cold Preservation on Liver Grafts From Donors After Circulatory Death: An Ex Vivo Rat Model. Transplantation 2018; 102:e147-e154. [PMID: 29309377 DOI: 10.1097/tp.0000000000002080] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND We previously reported that short oxygenated warm perfusion before cold storage (CS) had improved the graft viability of rat livers from donors after circulatory death (DCD). In this study, we investigated the effectiveness of short-term oxygenated subnormothermic perfusion for different durations after CS in a rat DCD model. METHODS We used an isolated perfused rat liver system. In study 1: the grafts were retrieved from Wistar rats 30 minutes after cardiac arrest (thoracotomy), preserved in CS for 6 hours, and perfused with oxygenated subnormothermic (20-25°C) Krebs-Henseleit buffer for different durations (0, 15, 30, 60, and 90 minutes groups; n = 5 in each). In study 2: in addition to subnormothermic ex vivo liver perfusion (SELP), after 15-minute incubation at room temperature, the grafts were reperfused under normothermic condition for 60 minutes as a model of liver transplantation (0, 30, 60, and 90 minutes groups; n = 5 in each). RESULTS In study 1, portal flow, bile production and tissue adenosine triphosphate increased with perfusion duration. In study 2, SELP significantly improved portal flow volume (P <0.05), and bile production (P <0.05), decreased liver enzymes (P <0.05) and cytokines (P <0.0001), and increased tissue adenosine triphosphate (P <0.01). Histological examinations showed that additional SELP ameliorated tissue deterioration, preserved the parenchymal structure, and decreased apoptosis (P <0.01). Furthermore, scanning electron microscopy revealed that additional SELP alleviated sinusoidal endothelial cells and hepatic microvasculature. CONCLUSIONS Even 30 minutes of SELP after CS rescued DCD livers from ischemia-reperfusion injury, which may help the viability of the grafts.
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Branchereau J, Renaudin K, Kervella D, Bernadet S, Karam G, Blancho G, Cantarovich D. Hypothermic pulsatile perfusion of human pancreas: Preliminary technical feasibility study based on histology. Cryobiology 2018; 85:56-62. [PMID: 30292812 DOI: 10.1016/j.cryobiol.2018.10.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 09/21/2018] [Accepted: 10/01/2018] [Indexed: 01/21/2023]
Abstract
BACKGROUND There are currently two approaches to hypothermic preservation for most solid organs: static or dynamic. Cold storage is the main method used for static storage (SS), while hypothermic pulsatile perfusion (HPP) and other machine perfusion-based methods, such as normothermic machine perfusion and oxygen persufflation, are the methods used for dynamic preservation. HPP is currently approved for kidney transplantation. METHODS We evaluated, for the first time, the feasibility of HPP on 11 human pancreases contraindicated for clinical transplantation because of advanced age and/or history of severe alcoholism and/or abnormal laboratory tests. Two pancreases were used as SS controls, pancreas splitting was performed on 2 other pancreases for SS and HPP and 7 pancreases were tested for HPP. HPP preservation lasted 24 h at 25 mmHg. Resistance index was continuously monitored and pancreas and duodenum histology was evaluated every 6 h. RESULTS The main finding was the complete absence of edema of the pancreas and duodenum at all time-points during HPP. Insulin, glucagon and somatostatin staining was normal. Resistance index decreased during the first 12 h and remained stable thereafter. CONCLUSION 24 h hypothermic pulsatile perfusion of marginal human pancreas-duodenum organs was feasible with no deleterious parenchymal effect. These observations encourage us to further develop this technique and evaluate the safety of HPP after clinical transplantation.
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Affiliation(s)
- J Branchereau
- Centre de Recherche en Transplantation et Immunologie UMR 1064, INSERM, Université de Nantes, Nantes, France; Institut de Transplantation Urologie Néphrologie (ITUN), CHU Nantes, Nantes, France.
| | - K Renaudin
- Department of Pathology, CHU Nantes, Nantes, France
| | - Delphine Kervella
- Centre de Recherche en Transplantation et Immunologie UMR 1064, INSERM, Université de Nantes, Nantes, France
| | - S Bernadet
- Centre de Recherche en Transplantation et Immunologie UMR 1064, INSERM, Université de Nantes, Nantes, France
| | - Georges Karam
- Institut de Transplantation Urologie Néphrologie (ITUN), CHU Nantes, Nantes, France
| | - Gilles Blancho
- Centre de Recherche en Transplantation et Immunologie UMR 1064, INSERM, Université de Nantes, Nantes, France; Institut de Transplantation Urologie Néphrologie (ITUN), CHU Nantes, Nantes, France
| | - D Cantarovich
- Institut de Transplantation Urologie Néphrologie (ITUN), CHU Nantes, Nantes, France
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Lonati C, Bassani GA, Brambilla D, Leonardi P, Carlin A, Faversani A, Gatti S, Valenza F. Influence of
ex vivo
perfusion on the biomolecular profile of rat lungs. FASEB J 2018; 32:5532-5549. [DOI: 10.1096/fj.201701255r] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Caterina Lonati
- Center for Surgical ResearchFondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca′ Granda‐Ospedale Maggiore Policlinico Milan Italy
- Center for Preclinical Investigation, Dipartimento di Anestesia, Rianimazione ed Emergenza UrgenzaFondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca′ Granda‐Ospedale Maggiore Policlinico Milan Italy
| | - Giulia A. Bassani
- Center for Surgical ResearchFondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca′ Granda‐Ospedale Maggiore Policlinico Milan Italy
- Center for Preclinical Investigation, Dipartimento di Anestesia, Rianimazione ed Emergenza UrgenzaFondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca′ Granda‐Ospedale Maggiore Policlinico Milan Italy
| | - Daniela Brambilla
- Center for Surgical ResearchFondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca′ Granda‐Ospedale Maggiore Policlinico Milan Italy
| | - Patrizia Leonardi
- Center for Preclinical Investigation, Dipartimento di Anestesia, Rianimazione ed Emergenza UrgenzaFondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca′ Granda‐Ospedale Maggiore Policlinico Milan Italy
- Department of Pathophysiology and Transplantation and Dental SciencesUniversity of Milan Milan Italy
| | - Andrea Carlin
- Center for Preclinical Investigation, Dipartimento di Anestesia, Rianimazione ed Emergenza UrgenzaFondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca′ Granda‐Ospedale Maggiore Policlinico Milan Italy
- Department of Pathophysiology and Transplantation and Dental SciencesUniversity of Milan Milan Italy
| | - Alice Faversani
- Division of PathologyFondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca′ Granda‐Ospedale Maggiore Policlinico Milan Italy
- Department of BiomedicalSurgical, and Dental Sciences, University of Milan Milan Italy
| | - Stefano Gatti
- Center for Surgical ResearchFondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca′ Granda‐Ospedale Maggiore Policlinico Milan Italy
| | - Franco Valenza
- Center for Preclinical Investigation, Dipartimento di Anestesia, Rianimazione ed Emergenza UrgenzaFondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca′ Granda‐Ospedale Maggiore Policlinico Milan Italy
- Department of Pathophysiology and Transplantation and Dental SciencesUniversity of Milan Milan Italy
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Gallinat A, Amrillaeva V, Hoyer DP, Kocabayoglu P, Benko T, Treckmann JW, van Meel M, Samuel U, Minor T, Paul A. Reconditioning by end-ischemic hypothermic in-house machine perfusion: A promising strategy to improve outcome in expanded criteria donors kidney transplantation. Clin Transplant 2018; 31. [PMID: 28035688 DOI: 10.1111/ctr.12904] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/22/2016] [Indexed: 12/01/2022]
Abstract
This clinical study evaluates end-ischemic hypothermic machine perfusion (eHMP) in expanded criteria donors (ECD) kidneys. eHMP was initiated upon arrival of the kidney in our center and continued until transplantation. Between 11/2011 and 8/2014 eHMP was performed in 66 ECD kidneys for 369 (98-912) minutes after 863 (364-1567) minutes of cold storage (CS). In 49 of 66 cases, the contralateral kidney from the same donor was preserved by static CS only and accepted by another Eurotransplant (ET) center. Five (10.2%) of these kidneys were ultimately judged as "not transplantable" by the accepting center and discarded. After exclusion of early unrelated graft losses, 43 kidney pairs from the same donor were eligible for direct comparison of eHMP vs CS only: primary non-function and delayed graft function (DGF) were 0% vs 9.3% (P=.04) and 11.6% vs 20.9% (P=.24). There was no statistically significant difference in 1-year graft survival (eHMP vs CS only: 97.7% vs 88.4%, P=.089). In a multivariate analysis, eHMP was an independent factor for prevention of DGF (OR: 0.28, P=.041). Development of DGF was the strongest risk factor for 1-year graft failure (Renal resistance: 38.2, P<.001). In summary, eHMP is a promising reconditioning technique to improve the quality and acceptance rate of suboptimal grafts.
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Affiliation(s)
- Anja Gallinat
- Department of General, Visceral and Transplantation Surgery, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Vera Amrillaeva
- Department of General, Visceral and Transplantation Surgery, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Dieter P Hoyer
- Department of General, Visceral and Transplantation Surgery, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Peri Kocabayoglu
- Department of General, Visceral and Transplantation Surgery, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Tamas Benko
- Department of General, Visceral and Transplantation Surgery, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Jürgen W Treckmann
- Department of General, Visceral and Transplantation Surgery, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Marieke van Meel
- Eurotransplant International Foundation, Leiden, The Netherlands
| | - Undine Samuel
- Eurotransplant International Foundation, Leiden, The Netherlands
| | - Thomas Minor
- Department of General, Visceral and Transplantation Surgery, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Andreas Paul
- Department of General, Visceral and Transplantation Surgery, University Hospital Essen, University Duisburg-Essen, Essen, Germany
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Laing RW, Mergental H, Yap C, Kirkham A, Whilku M, Barton D, Curbishley S, Boteon YL, Neil DA, Hübscher SG, Perera MTPR, Muiesan P, Isaac J, Roberts KJ, Cilliers H, Afford SC, Mirza DF. Viability testing and transplantation of marginal livers (VITTAL) using normothermic machine perfusion: study protocol for an open-label, non-randomised, prospective, single-arm trial. BMJ Open 2017; 7:e017733. [PMID: 29183928 PMCID: PMC5719273 DOI: 10.1136/bmjopen-2017-017733] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION The use of marginal or extended criteria donor livers is increasing. These organs carry a greater risk of initial dysfunction and early failure, as well as inferior long-term outcomes. As such, many are rejected due to a perceived risk of use and use varies widely between centres. Ex situ normothermic machine perfusion of the liver (NMP-L) may enable the safe transplantation of organs that meet defined objective criteria denoting their high-risk status and are currently being declined for use by all the UK transplant centres. METHODS AND ANALYSIS Viability testing and transplantation of marginal livers is an open-label, non-randomised, prospective, single-arm trial designed to determine whether currently unused donor livers can be salvaged and safely transplanted with equivalent outcomes in terms of patient survival. The procured rejected livers must meet predefined criteria that objectively denote their marginal condition. The liver is subjected to NMP-L following a period of static cold storage. Organs metabolising lactate to ≤2.5 mmol/L within 4 hours of the perfusion commencing in combination with two or more of the following parameters-bile production, metabolism of glucose, a hepatic arterial flow rate ≥150 mL/min and a portal venous flow rate ≥500 mL/min, a pH ≥7.30 and/or maintain a homogeneous perfusion-will be considered viable and transplanted into a suitable consented recipient. The coprimary outcome measures are the success rate of NMP-L to produce a transplantable organ and 90-day patient post-transplant survival. ETHICS AND DISSEMINATION The protocol was approved by the National Research Ethics Service (London-Dulwich Research Ethics Committee, 16/LO/1056), the Medicines and Healthcare Products Regulatory Agency and is endorsed by the National Health Service Blood and Transplant Research, Innovation and Novel Technologies Advisory Group. The findings of this trial will be disseminated through national and international presentations and peer-reviewed publications. TRIAL REGISTRATION NUMBER NCT02740608; Pre-results.
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Affiliation(s)
- Richard W Laing
- Department of Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Department of Liver Biomedical Research Unit, National Institute for Health Research (NIHR), Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Hynek Mergental
- Department of Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Department of Liver Biomedical Research Unit, National Institute for Health Research (NIHR), Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Christina Yap
- Department of Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Amanda Kirkham
- Department of Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Manpreet Whilku
- Department of Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Darren Barton
- Department of Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Stuart Curbishley
- Department of Liver Biomedical Research Unit, National Institute for Health Research (NIHR), Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Yuri L Boteon
- Department of Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Department of Liver Biomedical Research Unit, National Institute for Health Research (NIHR), Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Desley A Neil
- Department of Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Stefan G Hübscher
- Department of Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Department of Liver Biomedical Research Unit, National Institute for Health Research (NIHR), Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - M Thamara P R Perera
- Department of Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Department of Liver Biomedical Research Unit, National Institute for Health Research (NIHR), Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Paolo Muiesan
- Department of Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Department of Liver Biomedical Research Unit, National Institute for Health Research (NIHR), Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - John Isaac
- Department of Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Keith J Roberts
- Department of Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Hentie Cilliers
- Department of Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Simon C Afford
- Department of Liver Biomedical Research Unit, National Institute for Health Research (NIHR), Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Darius F Mirza
- Department of Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Department of Liver Biomedical Research Unit, National Institute for Health Research (NIHR), Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
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Duraes EFR, Madajka M, Frautschi R, Soliman B, Cakmakoglu C, Barnett A, Tadisina K, Liu Q, Grady P, Quintini C, Okamoto T, Papay F, Rampazzo A, Bassiri Gharb B. Developing a protocol for normothermic ex-situ limb perfusion. Microsurgery 2017; 38:185-194. [DOI: 10.1002/micr.30252] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Revised: 07/24/2017] [Accepted: 09/18/2017] [Indexed: 11/07/2022]
Affiliation(s)
| | - Maria Madajka
- Plastic Surgery Department; Cleveland Clinic; Cleveland Ohio
| | | | - Basem Soliman
- General Surgery Department; Cleveland Clinic; Cleveland Ohio
| | | | - Addison Barnett
- Plastic Surgery Department; Cleveland Clinic; Cleveland Ohio
| | | | - Qiang Liu
- General Surgery Department; Cleveland Clinic; Cleveland Ohio
| | - Patrick Grady
- Heart and Vascular Institute, Cleveland Clinic; Cleveland Ohio
| | | | | | - Francis Papay
- Plastic Surgery Department; Cleveland Clinic; Cleveland Ohio
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31
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Jager NM, Poppelaars F, Daha MR, Seelen MA. Complement in renal transplantation: The road to translation. Mol Immunol 2017; 89:22-35. [PMID: 28558950 DOI: 10.1016/j.molimm.2017.05.014] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 05/17/2017] [Accepted: 05/19/2017] [Indexed: 02/08/2023]
Abstract
Renal transplantation is the treatment of choice for patients with end-stage renal disease. The vital role of the complement system in renal transplantation is widely recognized. This review discusses the role of complement in the different phases of renal transplantation: in the donor, during preservation, in reperfusion and at the time of rejection. Here we examine the current literature to determine the importance of both local and systemic complement production and how complement activation contributes to the pathogenesis of renal transplant injury. In addition, we dissect the complement pathways involved in the different phases of renal transplantation. We also review the therapeutic strategies that have been tested to inhibit complement during the kidney transplantation. Several clinical trials are currently underway to evaluate the therapeutic potential of complement inhibition for the treatment of brain death-induced renal injury, renal ischemia-reperfusion injury and acute rejection. We conclude that it is expected that in the near future, complement-targeted therapeutics will be used clinically in renal transplantation. This will hopefully result in improved renal graft function and increased graft survival.
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Affiliation(s)
- Neeltina M Jager
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
| | - Felix Poppelaars
- Department of Internal Medicine, Division of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Mohamed R Daha
- Department of Internal Medicine, Division of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands; Department of Nephrology, Leiden University Medical Center, University of Leiden, Leiden, The Netherlands
| | - Marc A Seelen
- Department of Internal Medicine, Division of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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32
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Okamura Y, Hata K, Tanaka H, Hirao H, Kubota T, Inamoto O, Kageyama S, Tamaki I, Yermek N, Yoshikawa J, Uemoto S. Impact of Subnormothermic Machine Perfusion Preservation in Severely Steatotic Rat Livers: A Detailed Assessment in an Isolated Setting. Am J Transplant 2017; 17:1204-1215. [PMID: 27860296 DOI: 10.1111/ajt.14110] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Revised: 10/09/2016] [Accepted: 10/30/2016] [Indexed: 01/25/2023]
Abstract
The current drastic shortage of donor organs has led to acceptance of extended-criteria donors for transplantation, despite higher risk of primary nonfunction. Here, we report the impact of subnormothermic machine perfusion (SMP) preservation on the protection of >50% macrosteatotic livers. Dietary hepatic steatosis was induced in Wistar rats via 2-day fasting and subsequent 3-day re-feeding with a fat-free, carbohydrate-rich diet. This protocol induces 50-60% macrovesicular steatosis, which should be discarded when preserved via cold storage (CS). The fatty livers were retrieved and preserved for 4 h using either CS in histidine-tryptophan-ketoglutarate or SMP in polysol solution. Graft functional integrity was evaluated via oxygenated ex vivo reperfusion for 2 h at 37°C. SMP resulted in significant reductions in not only parenchymal alanine aminotransferase (p < 0.001), but also mitochondrial glutamate dehydrogenase (p < 0.001) enzyme release. Moreover, portal venous pressure (p = 0.047), tissue adenosine triphosphate (p = 0.001), bile production (p < 0.001), high-mobility group box protein-1 (p < 0.001), lipid peroxidation, and tissue glutathione were all significantly improved by SMP. Electron microscopy revealed that SMP alleviated deleterious alterations of sinusoidal microvasculature and hepatocellular mitochondria, both of which are characteristic disadvantages associated with steatosis. SMP could protect 50-60% macrosteatotic livers from preservation/reperfusion injury, and may thus represent a new means for expanding available donor pools.
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Affiliation(s)
- Y Okamura
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - K Hata
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - H Tanaka
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - H Hirao
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - T Kubota
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - O Inamoto
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - S Kageyama
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - I Tamaki
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - N Yermek
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - J Yoshikawa
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - S Uemoto
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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Bral M, Gala-Lopez B, Bigam D, Kneteman N, Malcolm A, Livingstone S, Andres A, Emamaullee J, Russell L, Coussios C, West LJ, Friend PJ, Shapiro AMJ. Preliminary Single-Center Canadian Experience of Human Normothermic Ex Vivo Liver Perfusion: Results of a Clinical Trial. Am J Transplant 2017; 17:1071-1080. [PMID: 27639262 DOI: 10.1111/ajt.14049] [Citation(s) in RCA: 145] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2016] [Revised: 08/28/2016] [Accepted: 08/30/2016] [Indexed: 01/25/2023]
Abstract
After extensive experimentation, outcomes of a first clinical normothermic machine perfusion (NMP) liver trial in the United Kingdom demonstrated feasibility and clear safety, with improved liver function compared with standard static cold storage (SCS). We present a preliminary single-center North American experience using identical NMP technology. Ten donor liver grafts were procured, four (40%) from donation after circulatory death (DCD), of which nine were transplanted. One liver did not proceed because of a technical failure with portal cannulation and was discarded. Transplanted NMP grafts were matched 1:3 with transplanted SCS livers. Median NMP was 11.5 h (range 3.3-22.5 h) with one DCD liver perfused for 22.5 h. All transplanted livers functioned, and serum transaminases, bilirubin, international normalized ratio, and lactate levels corrected in NMP recipients similarly to controls. Graft survival at 30 days (primary outcome) was not statistically different between groups on an intent-to-treat basis (p = 0.25). Intensive care and hospital stays were significantly more prolonged in the NMP group. This preliminary experience demonstrates feasibility as well as potential technical risks of NMP in a North American setting and highlights a need for larger, randomized studies.
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Affiliation(s)
- M Bral
- Department of Surgery, University of Alberta, Edmonton, Canada.,Members of the Canadian National Transplant Research Project (CNTRP), Edmonton, Canada
| | - B Gala-Lopez
- Department of Surgery, University of Alberta, Edmonton, Canada.,Members of the Canadian National Transplant Research Project (CNTRP), Edmonton, Canada
| | - D Bigam
- Department of Surgery, University of Alberta, Edmonton, Canada
| | - N Kneteman
- Department of Surgery, University of Alberta, Edmonton, Canada.,Members of the Canadian National Transplant Research Project (CNTRP), Edmonton, Canada
| | - A Malcolm
- Department of Surgery, University of Alberta, Edmonton, Canada.,Members of the Canadian National Transplant Research Project (CNTRP), Edmonton, Canada
| | - S Livingstone
- Department of Surgery, University of Alberta, Edmonton, Canada
| | - A Andres
- Department of Surgery, University of Alberta, Edmonton, Canada
| | - J Emamaullee
- Department of Surgery, University of Alberta, Edmonton, Canada
| | | | - C Coussios
- Institute of Biomedical Engineering, University of Oxford, Oxford, UK
| | - L J West
- Department of Surgery, University of Alberta, Edmonton, Canada.,Members of the Canadian National Transplant Research Project (CNTRP), Edmonton, Canada
| | - P J Friend
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - A M J Shapiro
- Department of Surgery, University of Alberta, Edmonton, Canada.,Members of the Canadian National Transplant Research Project (CNTRP), Edmonton, Canada
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34
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Goldaracena N, Spetzler VN, Echeverri J, Kaths JM, Cherepanov V, Persson R, Hodges MR, Janssen HLA, Selzner N, Grant DR, Feld JJ, Selzner M. Inducing Hepatitis C Virus Resistance After Pig Liver Transplantation-A Proof of Concept of Liver Graft Modification Using Warm Ex Vivo Perfusion. Am J Transplant 2017; 17:970-978. [PMID: 27805315 DOI: 10.1111/ajt.14100] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Revised: 10/12/2016] [Accepted: 10/16/2016] [Indexed: 01/25/2023]
Abstract
Normothermic ex vivo liver perfusion (NEVLP) offers the potential to optimize graft function prior to liver transplantation (LT). Hepatitis C virus (HCV) is dependent on the presence of miRNA(microRNA)-122. Miravirsen, a locked-nucleic acid oligonucleotide, sequesters miR-122 and inhibits HCV replication. The aim of this study was to assess the efficacy of delivering miravirsen during NEVLP to inhibit miR-122 function in a pig LT model. Pig livers were treated with miravirsen during NEVLP or cold storage (CS). Miravirsen absorption, miR-122 sequestration, and miR-122 target gene derepression were determined before and after LT. The effect of miravirsen treatment on HCV infection of hepatoma cells was also assessed. NEVLP improved miravirsen uptake versus CS. Significant miR-122 sequestration and miR-122 target gene derepression were seen with NEVLP but not with CS. In vitro data confirmed miravirsen suppression of HCV replication after established infection and prevented HCV infection with pretreatment of cells, analogous to the pretreatment of grafts in the transplant setting. In conclusion, miravirsen delivery during NEVLP is a potential strategy to prevent HCV reinfection after LT. This is the first large-animal study to provide "proof of concept" for using NEVLP to modify and optimize liver grafts for transplantation.
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Affiliation(s)
- N Goldaracena
- Multi Organ Transplant Program-Department of Surgery, Toronto General Hospital, Toronto, ON, Canada
| | - V N Spetzler
- Multi Organ Transplant Program-Department of Surgery, Toronto General Hospital, Toronto, ON, Canada
| | - J Echeverri
- Multi Organ Transplant Program-Department of Surgery, Toronto General Hospital, Toronto, ON, Canada
| | - J M Kaths
- Multi Organ Transplant Program-Department of Surgery, Toronto General Hospital, Toronto, ON, Canada
| | - V Cherepanov
- Toronto Centre for Liver Disease, Sandra Rotman Centre for Global Research, Toronto General Hospital, Toronto, ON, Canada
| | - R Persson
- Roche Innovation Center, Copenhagen, Denmark
| | | | - H L A Janssen
- Toronto Centre for Liver Disease, Sandra Rotman Centre for Global Research, Toronto General Hospital, Toronto, ON, Canada
| | - N Selzner
- Multi Organ Transplant Program-Department of Medicine, Toronto General Hospital, Toronto, ON, Canada
| | - D R Grant
- Multi Organ Transplant Program-Department of Surgery, Toronto General Hospital, Toronto, ON, Canada
| | - J J Feld
- Toronto Centre for Liver Disease, Sandra Rotman Centre for Global Research, Toronto General Hospital, Toronto, ON, Canada
| | - M Selzner
- Multi Organ Transplant Program-Department of Surgery, Toronto General Hospital, Toronto, ON, Canada
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de Haan JE, Hoorn EJ, de Geus HRH. Acute kidney injury after liver transplantation: Recent insights and future perspectives. Best Pract Res Clin Gastroenterol 2017. [PMID: 28624104 DOI: 10.1016/j.bpg.2017.03.004] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Acute kidney injury (AKI) is a common postoperative complication after liver transplantation (LT). The occurrence of postoperative AKI after LT (Post-LT AKI) is associated with inferior patient and graft outcomes. Post-LT AKI is multifactorial in origin and has been related to the severity of liver disease, pre-LT renal dysfunction, graft quality, perioperative events and toxicity of immunosuppressive therapy. Furthermore it is thought that hepatic ischaemia reperfusion injury might be a driving force in the aetiology of post-LT AKI. Novel biomarkers for AKI are emerging and can be useful for early identification and characterization of AKI. There is a clear need for strategies aimed at preventing or treating post-LT AKI. Several pharmacological and non-pharmacological interventions have been studied, but so far failed to show any benefit in the prevention of post-LT AKI. Further studies are needed to develop and evaluate new interventions aimed at preventing post-LT AKI and improve patient outcomes.
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Affiliation(s)
- Jubi E de Haan
- Department of Adult Intensive Care, Erasmus MC University Medical Centre, Rotterdam, The Netherlands.
| | - Ewout J Hoorn
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Hilde R H de Geus
- Department of Adult Intensive Care, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
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36
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Kumar R, Chung WY, Dennison AR, Garcea G. Ex Vivo Porcine Organ Perfusion Models as a Suitable Platform for Translational Transplant Research. Artif Organs 2017; 41:E69-E79. [PMID: 28266040 DOI: 10.1111/aor.12865] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Revised: 08/03/2016] [Accepted: 08/24/2016] [Indexed: 12/24/2022]
Abstract
In transplantation surgery, extending the criteria for organ donation to include organs that may have otherwise been previously discarded has provided the impetus to improve organ preservation. The traditional method of cold static storage (CS) has been tried and tested and is suitable for organs meeting standard criteria donation. Ex vivo machine perfusion is, however, associated with evidence suggesting that it may be better than CS alone and may allow for organ donation criteria to be extended. Much of our knowledge of organ preservation is derived from animal studies. We review ex vivo porcine organ perfusion models and discuss the relevance to the field of transplantation surgery. Following a systematic literature search, only articles that reported on experimental studies with focus on any aspect(s) of ex vivo and porcine perfusion of organs yet limited to the context of organ transplantation surgery were included. The database search and inclusion/exclusion criteria identified 22 journal articles. All 22 articles discussed ex vivo porcine organ perfusion within the context of transplant preservation surgery: 8 liver, 3 kidney, 3 lung, 2 pancreas/islet, 4 discussed a combined liver-kidney multiorgan model, 1 small bowel, and 1 cardiac perfusion model systems. The ex vivo porcine perfusion model is a suitable, reliable, and safe translational research model. It has advantages to investigate organ preservation techniques in a reproducible fashion in order to improve our understanding and has implications to extend the criteria for organ donation.
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Affiliation(s)
- Rohan Kumar
- Department of Hepato-Pancreato-Biliary Surgery, University Hospitals of Leicester, Leicester, UK
| | - Wen Yuan Chung
- Department of Hepato-Pancreato-Biliary Surgery, University Hospitals of Leicester, Leicester, UK
| | | | - Giuseppe Garcea
- Department of Hepato-Pancreato-Biliary Surgery, University Hospitals of Leicester, Leicester, UK
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37
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38
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Taeger CD, Friedrich O, Drechsler C, Weigand A, Hobe F, Geppert CI, Münch F, Birkholz T, Buchholz R, Horch RE, Präbst K. Hydroxyethyl starch solution for extracorporeal tissue perfusion. Clin Hemorheol Microcirc 2016; 64:91-103. [DOI: 10.3233/ch-162049] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Christian D. Taeger
- Department of Plastic and Hand Surgery, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (FAU), Erlangen, Germany
| | - Oliver Friedrich
- Institute of Medical Biotechnology, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Caroline Drechsler
- Department of Plastic and Hand Surgery, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (FAU), Erlangen, Germany
| | - Annika Weigand
- Department of Plastic and Hand Surgery, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (FAU), Erlangen, Germany
| | - Frieder Hobe
- Institute of Bioprocess Engineering, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Carol I. Geppert
- Chair of Pathology and Anatomy, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Frank Münch
- Department of Paediatric Cardiac Surgery, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Torsten Birkholz
- Department of Anesthesiology, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Rainer Buchholz
- Institute of Bioprocess Engineering, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Raymund E. Horch
- Department of Plastic and Hand Surgery, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (FAU), Erlangen, Germany
| | - Konstantin Präbst
- Institute of Bioprocess Engineering, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
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39
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Gilbo N, Catalano G, Salizzoni M, Romagnoli R. Liver graft preconditioning, preservation and reconditioning. Dig Liver Dis 2016; 48:1265-1274. [PMID: 27448845 DOI: 10.1016/j.dld.2016.06.031] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Revised: 05/02/2016] [Accepted: 06/27/2016] [Indexed: 12/11/2022]
Abstract
Liver transplantation is the successful treatment of end-stage liver disease; however, the ischaemia-reperfusion injury still jeopardizes early and long-term post-transplant outcomes. In fact, ischaemia-reperfusion is associated with increased morbidity and graft dysfunction, especially when suboptimal donors are utilized. Strategies to reduce the severity of ischaemia-reperfusion can be applied at different steps of the transplantation process: organ procurement, preservation phase or before revascularization. During the donor procedure, preconditioning consists of pre-treating the graft prior to a sustained ischaemia either by a transient period of ischaemia-reperfusion or administration of anti-ischaemic medication, although a multi-pharmacological approach seems more promising. Different preservation solutions were developed to maintain graft viability during static cold storage, achieving substantial results in terms of liver function and survival in good quality organs but not in suboptimal ones. Indeed, preservation solutions do not prevent dysfunction of poor quality organs and are burdened with inadequate preservation of the biliary epithelium. Advantages derived from either hypo- or normothermic machine perfusion are currently investigated in experimental and clinical settings, suggesting a reconditioning effect possibly improving hepatocyte and biliary preservation and resuscitating graft function prior to transplantation. In this review, we highlight acquired knowledge and recent advances in liver graft preconditioning, preservation and reconditioning.
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Affiliation(s)
- Nicholas Gilbo
- Liver Transplantation Center, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Giorgia Catalano
- Liver Transplantation Center, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Mauro Salizzoni
- Liver Transplantation Center, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Renato Romagnoli
- Liver Transplantation Center, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy.
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40
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Selzner M, Goldaracena N, Echeverri J, Kaths JM, Linares I, Selzner N, Serrick C, Marquez M, Sapisochin G, Renner EL, Bhat M, McGilvray ID, Lilly L, Greig PD, Tsien C, Cattral MS, Ghanekar A, Grant DR. Normothermic ex vivo liver perfusion using steen solution as perfusate for human liver transplantation: First North American results. Liver Transpl 2016; 22:1501-1508. [PMID: 27339754 DOI: 10.1002/lt.24499] [Citation(s) in RCA: 140] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2016] [Revised: 05/08/2016] [Accepted: 05/23/2016] [Indexed: 12/12/2022]
Abstract
The European trial investigating normothermic ex vivo liver perfusion (NEVLP) as a preservation technique for liver transplantation (LT) uses gelofusine, a non-US Food and Drug Administration-approved, bovine-derived, gelatin-based perfusion solution. We report a safety and feasibility clinical NEVLP trial with human albumin-based Steen solution. Transplant outcomes of 10 human liver grafts that were perfused on the Metra device at 37 °C with Steen solution, plus 3 units of erythrocytes were compared with a matched historical control group of 30 grafts using cold storage (CS) as the preservation technique. Ten liver grafts were perfused for 480 minutes (340-580 minutes). All livers cleared lactate (final lactate 1.46 mmol/L; 0.56-1.74 mmol/L) and produced bile (61 mL; 14-146 mL) during perfusion. No technical problems occurred during perfusion, and all NEVLP-preserved grafts functioned well after LT. NEVLP versus CS had lower aspartate aminotransferase and alanine aminotransferase values on postoperative days 1-3 without reaching significance. No difference in postoperative graft function between NEVLP and CS grafts was detected as measured by day 7 international normalized ratio (1.1 [1-1.56] versus 1.1 [1-1.3]; P = 0.5) and bilirubin (1.5; 1-7.7 mg/dL versus 2.78; 0.4-15 mg/dL; P = 0.5). No difference was found in the duration of intensive care unit stay (median, 1 versus 2 days; range, 0-8 versus 0-23 days; P = 0.5) and posttransplant hospital stay (median, 11 versus 13 days; range, 8-17 versus 7-89 days; P = 0.23). Major complications (Dindo-Clavien ≥ 3b) occurred in 1 patient in the NEVLP group (10%) compared with 7 (23%) patients in the CS group (P = 0.5). No graft loss or patient death was observed in either group. Liver preservation with normothermic ex vivo perfusion with the Metra device using Steen solution is safe and results in comparable outcomes to CS after LT. Using US Food and Drug Administration-approved Steen solution will avoid a potential regulatory barrier in North America. Liver Transplantation 22 1501-1508 2016 AASLD.
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Affiliation(s)
- Markus Selzner
- Departments of Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | | | - Juan Echeverri
- Departments of Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Johan M Kaths
- Departments of Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Ivan Linares
- Departments of Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Nazia Selzner
- Departments of Medicine, Toronto General Hospital, Toronto, Ontario, Canada
| | - Cyril Serrick
- Perfusion Services, Multi-Organ Transplant Program, Toronto General Hospital, Toronto, Ontario, Canada
| | - Max Marquez
- Departments of Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Gonzalo Sapisochin
- Departments of Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Eberhard L Renner
- Departments of Medicine, Toronto General Hospital, Toronto, Ontario, Canada
| | - Mamatha Bhat
- Departments of Medicine, Toronto General Hospital, Toronto, Ontario, Canada
| | - Ian D McGilvray
- Departments of Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Leslie Lilly
- Departments of Medicine, Toronto General Hospital, Toronto, Ontario, Canada
| | - Paul D Greig
- Departments of Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Cynthia Tsien
- Departments of Medicine, Toronto General Hospital, Toronto, Ontario, Canada
| | - Mark S Cattral
- Departments of Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Anand Ghanekar
- Departments of Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - David R Grant
- Departments of Surgery, Toronto General Hospital, Toronto, Ontario, Canada.
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41
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Lee DD, Croome KP, Shalev JA, Musto KR, Sharma M, Keaveny AP, Taner CB. Early allograft dysfunction after liver transplantation: an intermediate outcome measure for targeted improvements. Ann Hepatol 2016; 15:53-60. [PMID: 26626641 DOI: 10.5604/16652681.1184212] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The term early allograft dysfunction (EAD) identifies liver transplant (LT) allografts with initial poor function and portends poor allograft and patient survival. Aims of this study are to use EAD as an intermediate outcome measure in a large single center cohort and identify donor, recipient and peri-operative risk factors. MATERIAL AND METHODS In 1950 consecutive primary LT, donor, recipient and peri-operative data were collected. EAD was defined by the presence of one or more of the following: total bilirubin ≥ 10 mg/dL (171 μmol/L) or, INR ≥ 1.6 on day 7, and ALT/AST > 2,000 IU/L within the first 7 days. RESULTS The incidence of EAD was 26.5%. 1-, 3-, and 5-year allograft and patient survival for patients who developed EAD were significantly inferior to those who did not (P < 0.01 at all time points). Multivariate analysis demonstrated associations in the development of EAD with recipient pre-operative ventilator status, donation after cardiac death allografts, donor age, allograft size, degree of steatosis, operative time and intra-operative transfusion requirements (all P < 0.01). Patients with EAD had a significantly longer hospitalization at 20.9 ± 38.9 days (median: 9; range: 4-446) compared with 10.7 ± 13.5 days (median: 7; range: 3-231) in patients with no EAD (P < 0.01). CONCLUSIONS This is the largest single center experience demonstrating incidence of EAD and identifying factors associated with development of EAD. EAD is a useful intermediate outcome measure for allograft and patient survival. Balancing recipient pretransplant conditions, donor risk factors and intra-operative conditions are necessary for avoiding EAD.
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Affiliation(s)
- David D Lee
- Mayo Clinic Collaborative in Transplant Research and Outcomes, Department of Transplant. Mayo Clinic Florida. USA
| | - Kristopher P Croome
- Mayo Clinic Collaborative in Transplant Research and Outcomes, Department of Transplant. Mayo Clinic Florida. USA
| | - Jefree A Shalev
- Mayo Clinic Collaborative in Transplant Research and Outcomes, Department of Transplant. Mayo Clinic Florida. USA
| | - Kaitlyn R Musto
- Mayo Clinic Collaborative in Transplant Research and Outcomes, Department of Transplant. Mayo Clinic Florida. USA
| | - Meenu Sharma
- Mayo Clinic Collaborative in Transplant Research and Outcomes, Department of Transplant. Mayo Clinic Florida. USA
| | - Andrew P Keaveny
- Mayo Clinic Collaborative in Transplant Research and Outcomes, Department of Transplant. Mayo Clinic Florida. USA
| | - C Burcin Taner
- Mayo Clinic Collaborative in Transplant Research and Outcomes, Department of Transplant. Mayo Clinic Florida. USA
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42
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Normothermic Machine Perfusion of Deceased Donor Liver Grafts Is Associated With Improved Postreperfusion Hemodynamics. Transplant Direct 2016; 2:e97. [PMID: 27795989 PMCID: PMC5068202 DOI: 10.1097/txd.0000000000000611] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 06/16/2016] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Graft reperfusion poses a critical challenge during liver transplantation and can be associated with hemodynamic instability/postreperfusion syndrome. This is sequel to ischemia-reperfusion injury and normothermic machine preservation (NMP) may affect hemodynamic changes. Herein, we characterize postreperfusion hemodynamics in liver grafts after NMP and traditional cold preservation. MATERIALS AND METHODS Intraoperative records of patients receiving grafts after NMP (n = 6; NMP group) and cold storage (CS) (n = 12; CS group) were compared. The mean arterial pressure (MAP) was defined as the average pressure in the radial artery during 1 cardiac cycle by invasive monitoring. Postreperfusion syndrome was defined as MAP drop greater than 30% of baseline, lasting for 1 minute or longer within the first 5 minutes from graft reperfusion. RESULTS Donor, recipient, demographics, and surgical parameters were evenly matched. Normothermic machine preservation grafts were perfused for 525 minutes (395-605 minutes) after initial cold ischemic time of 91 minutes (73-117 minutes), whereas in CS group cold ischemic time was 456 minutes (347-685 minutes) (P = 0.001). None developed postreperfusion syndrome in the NMP group against n = 2 (16.7%) in CS group (P = 0.529). Normothermic machine preservation group had better intraoperative MAP at 90 minutes postreperfusion (P = 0.029), achieved with a significantly less vasopressor requirement (P = <0.05) and less transfusion of blood products (P = 0.030) compared with CS group. CONCLUSIONS Normothermic machine perfusion is associated with a stable intraoperative hemodynamic profile postreperfusion, requiring significantly less vasopressor infusions and blood product transfusion after graft reperfusion and may have benefit to alleviate ischemia-reperfusion injury in liver transplantation.
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43
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Banan B, Watson R, Xu M, Lin Y, Chapman W. Development of a normothermic extracorporeal liver perfusion system toward improving viability and function of human extended criteria donor livers. Liver Transpl 2016; 22:979-93. [PMID: 27027254 DOI: 10.1002/lt.24451] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Revised: 03/08/2016] [Accepted: 03/21/2016] [Indexed: 12/23/2022]
Abstract
Donor organ shortages have led to an increased interest in finding new approaches to recover organs from extended criteria donors (ECD). Normothermic extracorporeal liver perfusion (NELP) has been proposed as a superior preservation method to reduce ischemia/reperfusion injury (IRI), precondition suboptimal grafts, and treat ECD livers so that they can be successfully used for transplantation. The aim of this study was to investigate the beneficial effects of a modified NELP circuit on discarded human livers. Seven human livers that were rejected for transplantation were placed on a modified NELP circuit for 8 hours. Perfusate samples and needle core biopsies were obtained at hourly intervals. A defatting solution that contained exendin-4 (50 nM) and L-carnitine (10 mM) was added to the perfusate for 2 steatotic livers. NELP provided normal temperature, electrolytes, and pH and glucose levels in the perfusate along with physiological vascular flows and pressures. Functional, biochemical, and microscopic evaluation revealed no additional injuries to the grafts during NELP with an improved oxygen extraction ratio (>0.5) and stabilized markers of hepatic injury. All livers synthesized adequate amounts of bile and coagulation factors. We also demonstrated a mild reduction (10%) of macroglobular steatosis with the use of the defatting solution. Histology demonstrated normal parenchymal architecture and a minimal to complete lack of IRI at the end of NELP. In conclusion, a modified NELP circuit preserved hepatocyte architecture, recovered synthetic functions, and hepatobiliary parameters of ECD livers without additional injuries to the grafts. This approach has the potential to increase the donor pool for clinical transplantation. Liver Transplantation 22 979-993 2016 AASLD.
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Affiliation(s)
- Babak Banan
- Departments of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Rao Watson
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO.,Department of Pathology and Laboratory Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Min Xu
- Departments of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Yiing Lin
- Departments of Surgery, Washington University School of Medicine, St. Louis, MO
| | - William Chapman
- Departments of Surgery, Washington University School of Medicine, St. Louis, MO
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44
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Laing RW, Scalera I, Isaac J, Mergental H, Mirza DF, Hodson J, Wilkin RJW, Perera MTPR, Muiesan P. Liver Transplantation Using Grafts From Donors After Circulatory Death: A Propensity Score-Matched Study From a Single Center. Am J Transplant 2016; 16:1795-804. [PMID: 26725645 DOI: 10.1111/ajt.13699] [Citation(s) in RCA: 102] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Revised: 11/29/2015] [Accepted: 12/15/2015] [Indexed: 01/25/2023]
Abstract
The use of livers from donation after circulatory death (DCD) is increasing, but concerns exist regarding outcomes following use of grafts from "marginal" donors. To compare outcomes in transplants using DCD and donation after brain death (DBD), propensity score matching was performed for 973 patients with chronic liver disease and/or malignancy who underwent primary whole-liver transplant between 2004 and 2014 at University Hospitals Birmingham NHS Foundation Trust. Primary end points were overall graft and patient survival. Secondary end points included postoperative, biliary and vascular complications. Over 10 years, 234 transplants were carried out using DCD grafts. Of the 187 matched DCDs, 82.9% were classified as marginal per British Transplantation Society guidelines. Kaplan-Meier analysis of graft and patient survival found no significant differences for either outcome between the paired DCD and DBD patients (p = 0.162 and p = 0.519, respectively). Aspartate aminotransferase was significantly higher in DCD recipients until 48 h after transplant (p < 0.001). The incidences of acute kidney injury and ischemic cholangiopathy were greater in DCD recipients (32.6% vs. 15% [p < 0.001] and 9.1% vs. 1.1% [p < 0.001], respectively). With appropriate recipient selection, the use of DCDs, including those deemed marginal, can be safe and can produce outcomes comparable to those seen using DBD grafts in similar recipients.
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Affiliation(s)
- R W Laing
- Department of Liver Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,NIHR Liver Biomedical Research Unit, University Hospitals Birmingham, Birmingham, UK
| | - I Scalera
- Department of Liver Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - J Isaac
- Department of Liver Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Department of Liver Surgery, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - H Mergental
- Department of Liver Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - D F Mirza
- Department of Liver Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Department of Liver Surgery, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - J Hodson
- Department of Liver Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - R J W Wilkin
- Department of Liver Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,NIHR Liver Biomedical Research Unit, University Hospitals Birmingham, Birmingham, UK
| | - M T P R Perera
- Department of Liver Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Department of Liver Surgery, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - P Muiesan
- Department of Liver Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Department of Liver Surgery, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, UK
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45
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Montero RM, Sacks SH, Smith RA. Complement-here, there and everywhere, but what about the transplanted organ? Semin Immunol 2016; 28:250-9. [PMID: 27179705 DOI: 10.1016/j.smim.2016.04.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Revised: 04/20/2016] [Accepted: 04/26/2016] [Indexed: 12/15/2022]
Abstract
The part of the innate immune system that communicates and effectively primes the adaptive immune system was termed "complement" by Ehrlich to reflect its complementarity to antibodies having previously been described as "alexine" (i.e protective component of serum) by Buchner and Bordet. It has been established that complement is not solely produced systemically but may have origin in different tissues where it can influence organ specific functions that may affect the outcome of transplanted organs. This review looks at the role of complement in particular to kidney transplantation. We look at current literature to determine whether blockade of the peripheral or central compartments of complement production may prevent ischaemic reperfusion injury or rejection in the transplanted organ. We also review new therapeutics that have been developed to inhibit components of the complement cascade with varying degrees of success leading to an increase in our understanding of the multiple triggers of this complex system. In addition, we consider whether biomarkers in this field are effective markers of disease or treatment.
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Affiliation(s)
- R M Montero
- MRC Centre for Transplantation, Division of Transplant Immunology and Mucosal Biology, NIHR Comprehensive Biomedical Research Centre, King's College London, Guy's & St Thomas' NHS Foundation Trust, United Kingdom
| | - S H Sacks
- MRC Centre for Transplantation, Division of Transplant Immunology and Mucosal Biology, NIHR Comprehensive Biomedical Research Centre, King's College London, Guy's & St Thomas' NHS Foundation Trust, United Kingdom.
| | - R A Smith
- MRC Centre for Transplantation, Division of Transplant Immunology and Mucosal Biology, NIHR Comprehensive Biomedical Research Centre, King's College London, Guy's & St Thomas' NHS Foundation Trust, United Kingdom
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46
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Abstract
BACKGROUND Limb transplantation is emerging as a promising area of surgery and is an indispensable alternative for prosthetic rehabilitation of amputees, the severity of which is increasing because of combat-related injuries. Successful unilateral and bilateral limb transplantations have already been performed before this operation. METHODS We performed the first ever quadruple limb transplantation in February 2012. The limbs procured from a 40-year-old man heart-beating donor were transplanted to a 27-year-old male patient who was a quadruple amputee for the last 14 years because of an electrical injury. RESULTS To shorten the ischemic period to a minimum, 3 separate microsurgery teams worked simultaneously. All extremities were reperfused within 8 hours of procurement, and the operation lasted for 12 hours. Metabolic load was managed by hemodialysis. One hour after the completion of the operation, cardiac arrest developed, resuscitation of which necessitated median sternotomy and temporary partial cardiopulmonary support. Despite the removal of the transplanted limbs and all efforts including continuous hemodialysis, plasmapheresis, and extracorporeal membrane oxygenation, the patient died on the fourth day after transplantation in a clinical condition of severe systemic inflammation. CONCLUSIONS The problems we faced were difficulty of vascular access for invasive monitoring and fluid replacement, and the severe systemic inflammation effects of which could not be dealt with, despite aggressive supportive treatment. We hope that our experience will enlighten the surgeons who are willing to extend the limits of limb transplantation and serve the success of future operations.
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47
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Banan B, Xiao Z, Watson R, Xu M, Jia J, Upadhya GA, Mohanakumar T, Lin Y, Chapman W. Novel strategy to decrease reperfusion injuries and improve function of cold-preserved livers using normothermic ex vivo liver perfusion machine. Liver Transpl 2016; 22:333-43. [PMID: 26439190 DOI: 10.1002/lt.24352] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Revised: 09/15/2015] [Accepted: 09/30/2015] [Indexed: 12/15/2022]
Abstract
Normothermic extracorporeal liver perfusion (NELP) can decrease ischemia/reperfusion injury to the greatest degree when cold ischemia time is minimized. Warm perfusion of cold-stored livers results in hepatocellular damage, sinusoidal endothelial cell (SEC) dysfunction, and Kupffer cell activation. However, the logistics of organ procurement mandates a period of cold preservation before NELP. The aim of this study was to determine the beneficial effects of gradual rewarming of cold-stored livers by placement on NELP. Three female porcine livers were used for each group. In the immediate NELP group, procured livers were immediately placed on NELP for 8 hours. In the cold NELP group, livers were cold-stored for 4 hours followed by NELP for 4 hours. In rewarming groups, livers were cold-stored for 4 hours, then gradually rewarmed in different durations to 38°C and kept on NELP for an additional 4 hours. For comparison purposes, the last 4 hours of NELP runs were considered to be the evaluation phase. Immediate NELP livers had significantly lower concentrations of liver transaminases, hyaluronic acid, and β-galactosidase and had higher bile production compared to the other groups. Rewarming livers had significantly lower concentrations of hyaluronic acid and β-galactosidase compared to the cold NELP livers. In addition, there was a significant decline in international normalized ratio values, improved bile production, reduced biliary epithelial cell damage, and improved cholangiocyte function. Thus, if a NELP machine is not available at the procurement site and livers will need to undergo a period of cold preservation, a gradual rewarming protocol before NELP may greatly reduce damages that are associated with reperfusion. In conclusion, gradual rewarming of cold-preserved livers upon NELP can minimize the hepatocellular damage, Kupffer cell activation, and SEC dysfunction.
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Affiliation(s)
- Babak Banan
- Departments of Surgery School of Medicine, Washington University, St. Louis, MO
| | - Zhenyu Xiao
- Departments of Surgery School of Medicine, Washington University, St. Louis, MO
| | - Rao Watson
- Departments of Pathology and Immunology, School of Medicine, Washington University, St. Louis, MO.,Department of Pathology and Laboratory Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, WI
| | - Min Xu
- Departments of Surgery School of Medicine, Washington University, St. Louis, MO
| | - Jianluo Jia
- Departments of Surgery School of Medicine, Washington University, St. Louis, MO
| | - Gundumi A Upadhya
- Departments of Surgery School of Medicine, Washington University, St. Louis, MO
| | - Thalachallour Mohanakumar
- Departments of Surgery School of Medicine, Washington University, St. Louis, MO.,Departments of Pathology and Immunology, School of Medicine, Washington University, St. Louis, MO
| | - Yiing Lin
- Departments of Surgery School of Medicine, Washington University, St. Louis, MO
| | - William Chapman
- Departments of Surgery School of Medicine, Washington University, St. Louis, MO
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Metabolic Flux Distribution during Defatting of Steatotic Human Hepatoma (HepG2) Cells. Metabolites 2016; 6:metabo6010001. [PMID: 26742084 PMCID: PMC4812330 DOI: 10.3390/metabo6010001] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Revised: 12/23/2015] [Accepted: 12/29/2015] [Indexed: 12/19/2022] Open
Abstract
Methods that rapidly decrease fat in steatotic hepatocytes may be helpful to recover severely fatty livers for transplantation. Defatting kinetics are highly dependent upon the extracellular medium composition; however, the pathways involved are poorly understood. Steatosis was induced in human hepatoma cells (HepG2) by exposure to high levels of free fatty acids, followed by defatting using plain medium containing no fatty acids, or medium supplemented with a cocktail of defatting agents previously described before. We measured the levels of 28 extracellular metabolites and intracellular triglyceride, and fed the data into a steady-state mass balance model to estimate strictly intracellular fluxes. We found that during defatting, triglyceride content decreased, while beta-oxidation, the tricarboxylic acid cycle, and the urea cycle increased. These fluxes were augmented by defatting agents, and even more so by hyperoxic conditions. In all defatting conditions, the rate of extracellular glucose uptake/release was very small compared to the internal supply from glycogenolysis, and glycolysis remained highly active. Thus, in steatotic HepG2 cells, glycolysis and fatty acid oxidation may co-exist. Together, these pathways generate reducing equivalents that are supplied to mitochondrial oxidative phosphorylation.
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49
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Spetzler VN, Goldaracena N, Echiverri J, Kaths JM, Louis KS, Adeyi OA, Yip PM, Grant DR, Selzner N, Selzner M. Subnormothermic ex vivo liver perfusion is a safe alternative to cold static storage for preserving standard criteria grafts. Liver Transpl 2016; 22:111-9. [PMID: 26390093 DOI: 10.1002/lt.24340] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2015] [Revised: 08/01/2015] [Accepted: 09/01/2015] [Indexed: 02/07/2023]
Abstract
We developed a novel technique of subnormothermic ex vivo liver perfusion (SNEVLP) for the storage of liver grafts before transplantation. To test the safety of SNEVLP for the nonextended criteria grafts (standard grafts), we compared it to a control group with minimal cold static storage (CS) time. Heart-beating pig liver retrieval was performed. Grafts were either stored in cold unmodified University of Wisconsin solution (CS-1), in cold University of Wisconsin solution with ex vivo perfusion additives (CS-2), or preserved with a sequence of 3 hours CS and 3 hours SNEVLP (33°C), followed by orthotopic liver transplantation. Liver function tests and histology were investigated. Aspartate aminotransferase (AST) levels during SNEVLP remained stable (54.3 ± 12.6 U/L at 1 hour to 47.0 ± 31.9 U/L at 3 hours). Posttransplantation, SNEVLP versus CS-1 livers had decreased AST levels (peak at day 1, 1081.9 ± 788.5 versus 1546.7 ± 509.3 U/L; P = 0.14; at day 2, 316.7 ± 188.1 versus 948.2 ± 740.9 U/L; P = 0.04) and alkaline phosphatase levels (peak at day 1, 150.4 ± 19.3 versus 203.7 ± 33.6 U/L; P = 0.003). Bilirubin levels were constantly within the physiological range in the SNEVLP group, whereas the CS-1 group presented a large standard deviation, including pathologically increased values. Hyaluronic acid as a marker of endothelial cell (EC) function was markedly improved by SNEVLP during the early posttransplant phase (5 hours posttransplant, 1172.75 ± 598.5 versus 5540.5 ± 2755.4 ng/mL). Peak international normalized ratio was similar between SNEVLP and CS-1 groups after transplantation. Immunohistochemistry for cleaved caspase 3 demonstrated more apoptotic sinusoidal cells in the CS-1 group when compared to SNEVLP grafts 2 hours after reperfusion (19.4 ± 19.5 versus 133.2 ± 48.8 cells/high-power field; P = 0.002). Adding normothermic CS-2 had no impact on liver injury or function after transplantation when compared to CS-1. In conclusion, SNEVLP is safe to use for standard donor grafts and is associated with improved EC and bile duct injury even in grafts with minimal CS time.
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Affiliation(s)
- Vinzent N Spetzler
- Multi-Organ Transplant Program, Department of Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Nicolas Goldaracena
- Multi-Organ Transplant Program, Department of Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Juan Echiverri
- Multi-Organ Transplant Program, Department of Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - J Moritz Kaths
- Multi-Organ Transplant Program, Department of Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Kristine S Louis
- Multi-Organ Transplant Program, Department of Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Oyedele A Adeyi
- Departments of Pathology, University of Toronto, Toronto, Ontario, Canada
| | - Paul M Yip
- Departments of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - David R Grant
- Multi-Organ Transplant Program, Department of Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Nazia Selzner
- Departments of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Markus Selzner
- Multi-Organ Transplant Program, Department of Surgery, Toronto General Hospital, Toronto, Ontario, Canada
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50
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Kuan KG, Wee MN, Chung WY, Kumar R, Mees ST, Dennison A, Maddern G, Trochsler M. Extracorporeal machine perfusion of the pancreas: technical aspects and its clinical implications – a systematic review of experimental models. Transplant Rev (Orlando) 2016; 30:31-47. [DOI: 10.1016/j.trre.2015.06.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Revised: 06/11/2015] [Accepted: 06/14/2015] [Indexed: 12/25/2022]
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