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Forgie K, Watkins A, Du K, Ribano A, Fialka N, Himmat S, Hatami S, Khan M, Wang X, Edgar R, Buswell-Zuk KM, Freed DH, Nagendran J. Perfusate Exchange Does Not Improve Outcomes in 24-hour Ex Situ Lung Perfusion. Transplant Proc 2024; 56:1811-1819. [PMID: 39242310 DOI: 10.1016/j.transproceed.2024.08.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2024] [Accepted: 08/23/2024] [Indexed: 09/09/2024]
Abstract
BACKGROUND Reliable 24-hour preservation is required to optimize the rehabilitation potential of Ex Situ Lung Perfusion (ESLP). Other ESLP protocols include fresh perfusate replacement to counteract an accumulation of deleterious by-products. We describe the results of our reliable 24-hour negative pressure ventilation (NPV)-ESLP protocol with satisfactory acute post-transplant outcomes and investigate perfusate exchange (PE) as a modification to enhance prolonged ESLP. METHODS Twelve pig lungs underwent 24 hours of NPV-ESLP using 1.5L of cellular perfusate (500 mL packed red blood cells and 1 L buffered perfusate). The Control (n = 6) had no PE; the PE (n = 6) had 500 mL replaced after 12 hours of NPV-ESLP with 1000 mL fresh perfusate. Three left lungs per group were transplanted. RESULTS Results are reported as Control vs PE (mean ± SEM). Both groups demonstrated stable and acceptable oxygenation during 24 hours of ESLP with final PF ratios of 527.5 ± 42.19 and 488.4 ± 35.38 (P = .25). Final compliance measurements were 20.52 ± 3.59 and 18.55 ± 2.91 (P = .34). There were no significant differences in pulmonary artery pressure after 24 hours of ESLP (10.02 ± 2.69 vs 14.34 ± 1.64, P = .10), and pulmonary vascular resistance only differed significantly at T12 (417.6 ± 53.06 vs 685.4 ± 81.19, P = .02). Percentage weight gain between groups was similar (24.32 ± 8.4 and 45.33 ± 7.76, P = .07). Post-transplant left lung oxygenation was excellent (327.3 ± 14.62 and 313.3 ± 15.38, P = .28). There was no significant difference in % weight gain of lungs post-transplant (22.20 ± 7.22 vs 14.36 ± 9.96, P = .28). CONCLUSION Acceptable lung function was maintained during 24-hour NPV-ESLP and post-transplant regardless of PE.
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Affiliation(s)
- Keir Forgie
- Department of Surgery, Division of Cardiac Surgery, Faculty of Medicine, University of Alberta, Edmonton, AB, Canada; Mazankowski Alberta Heart Institute, Edmonton, AB, Canada
| | - Abeline Watkins
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Katie Du
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Alynne Ribano
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Nicholas Fialka
- Department of Surgery, Division of Cardiac Surgery, Faculty of Medicine, University of Alberta, Edmonton, AB, Canada; Mazankowski Alberta Heart Institute, Edmonton, AB, Canada
| | - Sayed Himmat
- Department of Surgery, Faculty of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Sanaz Hatami
- Department of Surgery, Faculty of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Mubashir Khan
- Department of Surgery, Faculty of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Xiuhua Wang
- Department of Surgery, Faculty of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Ryan Edgar
- Ray Rajotte Surgical Medical Research Institute (SMRI), Edmonton, AB, Canada
| | | | - Darren H Freed
- Department of Surgery, Division of Cardiac Surgery, Faculty of Medicine, University of Alberta, Edmonton, AB, Canada; Mazankowski Alberta Heart Institute, Edmonton, AB, Canada; Alberta Transplant Institute, Edmonton, AB, Canada; Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
| | - Jayan Nagendran
- Department of Surgery, Division of Cardiac Surgery, Faculty of Medicine, University of Alberta, Edmonton, AB, Canada; Mazankowski Alberta Heart Institute, Edmonton, AB, Canada; Alberta Transplant Institute, Edmonton, AB, Canada; Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada.
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Forgie K, Fialka N, Watkins A, Du K, Himmat S, Hatami S, Khan M, Wang X, Edgar R, Buswell-Zuk KM, Freed D, Nagendran J. Moderate-Flow Perfusion is Superior to Low-Flow Perfusion in Ex Situ Lung Perfusion. Transplant Proc 2024; 56:1820-1827. [PMID: 39242316 DOI: 10.1016/j.transproceed.2024.08.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2024] [Accepted: 08/24/2024] [Indexed: 09/09/2024]
Abstract
BACKGROUND Full-flow perfusion during prolonged ex situ lung perfusion (ESLP) results in unacceptable pulmonary edema formation. Clinical ESLP at 30% to 50% predicted cardiac output (CO) supports acceptable physiologic outcomes; however, progressive pulmonary edema still develops. Lower flow rates may provide equivalent physiologic preservation with less edema formation due to reduced hydrostatic pressures. We report our results of moderate-flow (MF; 30% CO) vs low-flow (LF; 10% CO) negative pressure ventilation (NPV)-ESLP with transplantation. METHODS Twelve pig lungs underwent 12-hours of NPV-ESLP with 30% or 10% CO (n = 6/group). Three left lungs per group were transplanted post-ESLP and assessed in vivo over 4 hours. Lung function was assessed by physiologic parameters, weight-gain, and pro-inflammatory cytokine profiles. RESULTS Results are MF vs LF (mean ± SEM). All lungs demonstrated acceptable oxygenation post-ESLP (454.2 ± 40.85 vs 422.7 ± 31.68, P = .28); however, after transplantation, the MF lungs demonstrated significantly better oxygenation (300.7 ± 52.26 vs 141.9 ± 36.75, P = .03). There was no significant difference in compliance after ESLP (21.38 ± 2.28 vs 16.48 ± 2.34, P = .08); however, pulmonary artery pressure (PAP; 10.89 ± 2.28 vs 21.11 ± 0.93, P = .06) and pulmonary vascular resistance (PVR; 438.60 ± 97.97 vs 782.20 ± 162.20, P = .05) were significantly higher in the LF group. Weight gain (%) post-ESLP and post-transplant was similar between groups (29.42 ± 5.72 vs 24.17 ± 4.42, P = .24; and 29.63 ± 7.23 vs 57.04 ± 15.78, P = .09). TNF-α and IL-6 were significantly greater throughout LF ESLP. CONCLUSIONS The MF NPV-ESLP results in superior lung function with less inflammation compared to LF NPV-ESLP.
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Affiliation(s)
- Keir Forgie
- Division of Cardiac Surgery, Department of Surgery, Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada; Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Nicholas Fialka
- Division of Cardiac Surgery, Department of Surgery, Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada; Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Abeline Watkins
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Katie Du
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Sayed Himmat
- Department of Surgery, Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Sanaz Hatami
- Department of Surgery, Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Mubashir Khan
- Department of Surgery, Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Xiuhua Wang
- Department of Surgery, Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Ryan Edgar
- Ray Rajotte Surgical Medical Research Institute (SMRI) , Edmonton, AB, Canada
| | | | - Darren Freed
- Division of Cardiac Surgery, Department of Surgery, Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada; Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada; Alberta Transplant Institute, Edmonton, AB, Canada; Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
| | - Jayan Nagendran
- Division of Cardiac Surgery, Department of Surgery, Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada; Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada; Alberta Transplant Institute, Edmonton, AB, Canada; Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada.
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Aburahma K, de Manna ND, Kuehn C, Salman J, Greer M, Ius F. Pushing the Survival Bar Higher: Two Decades of Innovation in Lung Transplantation. J Clin Med 2024; 13:5516. [PMID: 39337005 PMCID: PMC11432129 DOI: 10.3390/jcm13185516] [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: 08/23/2024] [Revised: 09/13/2024] [Accepted: 09/16/2024] [Indexed: 09/30/2024] Open
Abstract
Survival after lung transplantation has significantly improved during the last two decades. The refinement of the already existing extracorporeal life support (ECLS) systems, such as extracorporeal membrane oxygenation (ECMO), and the introduction of new techniques for donor lung optimization, such as ex vivo lung perfusion (EVLP), have allowed the extension of transplant indication to patients with end-stage lung failure after acute respiratory distress syndrome (ARDS) and the expansion of the donor organ pool, due to the better evaluation and optimization of extended-criteria donor (ECD) lungs and of donors after circulatory death (DCD). The close monitoring of anti-HLA donor-specific antibodies (DSAs) has allowed the early recognition of pulmonary antibody-mediated rejection (AMR), which requires a completely different treatment and has a worse prognosis than acute cellular rejection (ACR). As such, the standardization of patient selection and post-transplant management has significantly contributed to this positive trend, especially at high-volume centers. This review focuses on lung transplantation after ARDS, on the role of EVLP in lung donor expansion, on ECMO as a principal cardiopulmonary support system in lung transplantation, and on the diagnosis and therapy of pulmonary AMR.
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Affiliation(s)
- Khalil Aburahma
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, 30625 Hannover, Germany
| | - Nunzio Davide de Manna
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, 30625 Hannover, Germany
| | - Christian Kuehn
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, 30625 Hannover, Germany
- German Centre for Lung Research (DZL/BREATH), 35392 Hannover, Germany
| | - Jawad Salman
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, 30625 Hannover, Germany
- German Centre for Lung Research (DZL/BREATH), 35392 Hannover, Germany
| | - Mark Greer
- German Centre for Lung Research (DZL/BREATH), 35392 Hannover, Germany
- Department of Respiratory Medicine and Infectious Diseases, Hannover Medical School, 30625 Hannover, Germany
| | - Fabio Ius
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, 30625 Hannover, Germany
- German Centre for Lung Research (DZL/BREATH), 35392 Hannover, Germany
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Katsirntaki K, Hagner S, Werlein C, Braubach P, Jonigk D, Adam D, Hidaji H, Kühn C, Falk CS, Ruhparwar A, Wiegmann B. Low-Volume Ex Situ Lung Perfusion System for Single Lung Application in a Small Animal Model Enables Optimal Compliance With " Reduction" in 3R Principles of Animal Research. Transpl Int 2024; 37:13189. [PMID: 39314923 PMCID: PMC11418019 DOI: 10.3389/ti.2024.13189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Accepted: 08/27/2024] [Indexed: 09/25/2024]
Abstract
Ex situ lung perfusion (ESLP) is used for organ reconditioning, repair, and re-evaluation prior to transplantation. Since valid preclinical animal models are required for translationally relevant studies, we developed a 17 mL low-volume ESLP for double- and single-lung application that enables cost-effective optimal compliance "reduction" of the 3R principles of animal research. In single-lung mode, ten Fischer344 and Lewis rat lungs were subjected to ESLP and static cold storage using STEEN or PerfadexPlus. Key perfusion parameters, thermal lung imaging, blood gas analysis (BGA), colloid oncotic pressure (COP), lung weight gain, histological work-up, and cytokine analysis were performed. Significant differences between perfusion solutions but not between the rat strains were detected. Most relevant perfusion parameters confirmed valid ESLP with homogeneous lung perfusion, evidenced by uniform lung surface temperature. BGA showed temperature-dependent metabolic activities with differences depending on perfusion solution composition. COP is not decisive for pulmonary oedema and associated weight gain, but possibly rather observed chemokine profile and dextran sensitivity of rats. Histological examination confirmed intact lung architecture without infarcts or hemorrhages due to optimal organ procurement and single-lung application protocol using our in-house-designed ESLP system.
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Affiliation(s)
- K. Katsirntaki
- Department for Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
- Lower Saxony Center for Biomedical Engineering, Implant Research and Development (NIFE), Hannover, Germany
| | - S. Hagner
- Department for Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
- Lower Saxony Center for Biomedical Engineering, Implant Research and Development (NIFE), Hannover, Germany
| | - C. Werlein
- Institute of Pathology, Hannover Medical School, Hannover, Germany
| | - P. Braubach
- Institute of Pathology, Hannover Medical School, Hannover, Germany
| | - D. Jonigk
- Member of the German Center for Lung Research (DZL), Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Hannover, Germany
- Institute of Pathology, RWTH Aachen Medical University, Aachen, Germany
| | - D. Adam
- Department for Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
- Lower Saxony Center for Biomedical Engineering, Implant Research and Development (NIFE), Hannover, Germany
| | - H. Hidaji
- Department for Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
- Lower Saxony Center for Biomedical Engineering, Implant Research and Development (NIFE), Hannover, Germany
| | - C. Kühn
- Department for Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
- Lower Saxony Center for Biomedical Engineering, Implant Research and Development (NIFE), Hannover, Germany
| | - C. S. Falk
- Member of the German Center for Lung Research (DZL), Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Hannover, Germany
- Institute of Transplant Immunology, Hannover Medical School, Hannover, Germany
| | - A. Ruhparwar
- Department for Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
- Lower Saxony Center for Biomedical Engineering, Implant Research and Development (NIFE), Hannover, Germany
- Member of the German Center for Lung Research (DZL), Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Hannover, Germany
| | - B. Wiegmann
- Department for Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
- Lower Saxony Center for Biomedical Engineering, Implant Research and Development (NIFE), Hannover, Germany
- Member of the German Center for Lung Research (DZL), Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Hannover, Germany
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5
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Bakhtiyar SS, Maksimuk TE, Cain MT, Hoffman JRH. Comment on: Characteristics and outcomes of lung transplants performed with ex-situ lung perfusion. J Heart Lung Transplant 2024; 43:1525-1526. [PMID: 38735422 DOI: 10.1016/j.healun.2024.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Accepted: 05/06/2024] [Indexed: 05/14/2024] Open
Affiliation(s)
- Syed Shahyan Bakhtiyar
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado, Aurora, Colorado.
| | - Tiffany E Maksimuk
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado, Aurora, Colorado
| | - Michael T Cain
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado, Aurora, Colorado; University of Colorado Hospital Transplant Center, Aurora, Colorado
| | - Jordan R H Hoffman
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado, Aurora, Colorado; University of Colorado Hospital Transplant Center, Aurora, Colorado
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Niroomand A, Nita GE, Lindstedt S. Machine Perfusion and Bioengineering Strategies in Transplantation-Beyond the Emerging Concepts. Transpl Int 2024; 37:13215. [PMID: 39267617 PMCID: PMC11390383 DOI: 10.3389/ti.2024.13215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2024] [Accepted: 08/19/2024] [Indexed: 09/15/2024]
Abstract
Solid organ transplantation has progressed rapidly over the decades from the first experimental procedures to its role in the modern era as an established treatment for end-stage organ disease. Solid organ transplantation including liver, kidney, pancreas, heart, and lung transplantation, is the definitive option for many patients, but despite the advances that have been made, there are still significant challenges in meeting the demand for viable donor grafts. Furthermore, post-operatively, the recipient faces several hurdles, including poor early outcomes like primary graft dysfunction and acute and chronic forms of graft rejection. In an effort to address these issues, innovations in organ engineering and treatment have been developed. This review covers efforts made to expand the donor pool including bioengineering techniques and the use of ex vivo graft perfusion. It also covers modifications and treatments that have been trialed, in addition to research efforts in both abdominal organs and thoracic organs. Overall, this article discusses recent innovations in machine perfusion and organ bioengineering with the aim of improving and increasing the quality of donor organs.
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Affiliation(s)
- Anna Niroomand
- Department of Clinical Sciences, Lund University, Lund, Sweden
- Lund Stem Cell Center, Lund University, Lund, Sweden
- Department of Cardiothoracic Surgery and Transplantation, Skåne University Hospital, Lund, Sweden
| | - George Emilian Nita
- Department of Transplantation Surgery, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
- Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, United Kingdom
- Division of Transplantation Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Sandra Lindstedt
- Department of Clinical Sciences, Lund University, Lund, Sweden
- Lund Stem Cell Center, Lund University, Lund, Sweden
- Department of Cardiothoracic Surgery and Transplantation, Skåne University Hospital, Lund, Sweden
- Wallenberg Center for Molecular Medicine, Lund University, Lund, Sweden
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Hoetzenecker K, Demarest C, Lemaitre P, Chang SH, Cypel M, Bacchetta M. Expert opinion-Avaricious bundled services of third-party lung procurement organizations. J Heart Lung Transplant 2024:S1053-2498(24)01797-2. [PMID: 39147003 DOI: 10.1016/j.healun.2024.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2024] [Accepted: 08/08/2024] [Indexed: 08/17/2024] Open
Affiliation(s)
- Konrad Hoetzenecker
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria.
| | - Caitlin Demarest
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Philippe Lemaitre
- Department of Surgery, Columbia University Irving Medical Center, New York, New York
| | - Stephanie H Chang
- Department of Cardiothoracic Surgery, New York University Langone Health, New York, New York
| | - Marcelo Cypel
- Division of Thoracic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Matthew Bacchetta
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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Zhou AL, Ruck JM, Casillan AJ, Larson EL, Shou BL, Ha JS, Shah PD, Merlo CA, Bush EL. National utilization, trends, and lung transplant outcomes of static versus portable ex vivo lung perfusion platforms. J Thorac Cardiovasc Surg 2024; 168:431-439. [PMID: 38141853 PMCID: PMC11192856 DOI: 10.1016/j.jtcvs.2023.12.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 11/20/2023] [Accepted: 12/16/2023] [Indexed: 12/25/2023]
Abstract
BACKGROUND This study compared utilization and outcomes of the 2 widely utilized ex vivo lung perfusion (EVLP) platforms in the United States: a static platform and a portable platform. METHODS Adult (age 18 years or older) bilateral lung-only transplants utilizing EVLP between February 28, 2018, and December 31, 2022, in the United Network for Organ Sharing database were included. Predischarge acute rejection, intubation at 72 hours posttransplant, extracorporeal membrane oxygenation at 72 hours posttransplant, primary graft dysfunction grade 3 at 72 hours posttransplant, 30-day mortality, and 1-year mortality were evaluated using multivariable regressions. RESULTS Overall, 607 (6.3%) lung transplants during the study period used EVLP (51.2% static, 48.8% portable). Static EVLP was primarily utilized in the eastern United States, whereas portable EVLP was primarily utilized in the western United States. Static EVLP donors were more likely to be donation after circulatory death (33.4% vs 26.0%; P = .005), have a >20 pack-year smoking history (13.5% vs 6.5%; P = .005), and be extended criteria donors (92.3% vs 85.0%; P = .013), whereas portable EVLP donors were more likely to be older than age 55 years (14.2% vs 8.0%; P = .02). Transplants utilizing the static and portable platforms had similar risk of acute rejection, intubation at 72 hours, extracorporeal membrane oxygenation at 72 hours, primary graft dysfunction grade 3 at 72 hours, and posttransplant mortality at 30 days and 1 year (all P values > .05). CONCLUSIONS The static and portable platforms had significant differences in donor characteristics and geographic distributions of utilization. Despite this, posttransplant survival was similar between the 2 EVLP platforms.
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Affiliation(s)
- Alice L Zhou
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Md
| | - Jessica M Ruck
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Md
| | - Alfred J Casillan
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Md
| | - Emily L Larson
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Md
| | - Benjamin L Shou
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Md
| | - Jinny S Ha
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Md
| | - Pali D Shah
- Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins Hospital, Baltimore, Md
| | - Christian A Merlo
- Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins Hospital, Baltimore, Md
| | - Errol L Bush
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Md.
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Purssell A, Kumar D. Impact of machine perfusion on transplant infectious diseases: New challenges and opportunities. Transpl Infect Dis 2024:e14348. [PMID: 39078339 DOI: 10.1111/tid.14348] [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: 04/01/2024] [Revised: 06/30/2024] [Accepted: 07/09/2024] [Indexed: 07/31/2024]
Abstract
Preservation techniques that maintain the viability of an organ graft between retrieval from the donor and implantation into the recipient remain a critical aspect of solid organ transplantation. While traditionally preservation is accomplished with static cold storage, advances in ex vivo dynamic machine perfusion, both hypothermic and normothermic, have allowed for prolongation of organ viability and recovery of marginal organs effectively increasing the usable donor pool. However, the use of these novel machine perfusion technologies likely exposes the recipient to additional infectious risk either through clonal expansion of pathogens derived during organ recovery or de novo exogenous acquisition of pathogens while the organ remains on the machine perfusion circuit. There is a paucity of high-quality studies that have attempted to quantify infection risk, although it appears that prolonging the time on the machine perfusion circuit and normothermic parameters increases the risk of infection. Conversely, the use of ex vivo machine perfusion unlocks new opportunities to detect and treat donor-derived infections before implantation into the recipient. This review seeks to reveal how the use of ex vivo machine perfusion strategies may augment the risk of infection in the organ recipient as well as outline ways that this technology could be leveraged to enhance our ability to manage donor-derived infections.
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Affiliation(s)
- Andrew Purssell
- Ajmera Transplant Centre, University Health Network, Toronto, Canada
| | - Deepali Kumar
- Ajmera Transplant Centre, University Health Network, Toronto, Canada
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Gouchoe DA, Cui EY, Satija D, Henn MC, Choi K, Rosenheck JP, Nunley DR, Mokadam NA, Ganapathi AM, Whitson BA. Ex Vivo Lung Perfusion and Primary Graft Dysfunction Following Lung Transplantation: A Contemporary United Network for Organ Sharing Database Analysis. J Clin Med 2024; 13:4440. [PMID: 39124711 PMCID: PMC11313603 DOI: 10.3390/jcm13154440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2024] [Revised: 07/14/2024] [Accepted: 07/25/2024] [Indexed: 08/12/2024] Open
Abstract
Background: Primary graft dysfunction (PGD) has detrimental effects on recipients following lung transplantation. Here, we determined the contemporary trends of PGD in a national database, factors associated with the development of PGD grade 3 (PGD3) and ex vivo lung perfusion's (EVLP) effect on this harmful postoperative complication. Methods: The United Network for Organ Sharing database was queried from 2015 to 2023, and recipients were stratified into No-PGD, PGD1/2, or PGD3. The groups were analyzed with comparative statistics, and survival was determined with Kaplan-Meier methods. Multivariable Cox regression was used to determine factors associated with increased mortality. PGD3 recipients were then stratified based on EVLP use prior to transplantation, and a 3:1 propensity match was performed to determine outcomes following transplantation. Finally, logistic regression models based on select criteria were used to determine risk factors associated with the development of PGD3 and mortality within 1 year. Results: A total of 21.4% of patients were identified as having PGD3 following lung transplant. Those with PGD3 suffered significantly worse perioperative morbidity, mortality, and had worse long-term survival. PGD3 was also independently associated with increased mortality. Matched EVLP PGD3 recipients had significantly higher use of ECMO postoperatively; however, they did not suffer other significant morbidity or mortality as compared to PGD3 recipients without EVLP use. Importantly, EVLP use prior to transplantation was significantly associated with decreased likelihood of PGD3 development, while having no significant association with early mortality. Conclusions: EVLP is associated with decreased PGD3 development, and further optimization of this technology is necessary to expand the donor pool.
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Affiliation(s)
- Doug A. Gouchoe
- Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA; (D.A.G.)
- COPPER Laboratory, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Ervin Y. Cui
- Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA; (D.A.G.)
- COPPER Laboratory, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Divyaam Satija
- College of Medicine, The Ohio State University, Columbus, OH 43210, USA
| | - Matthew C. Henn
- Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA; (D.A.G.)
| | - Kukbin Choi
- Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA; (D.A.G.)
| | - Justin P. Rosenheck
- Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - David R. Nunley
- Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Nahush A. Mokadam
- Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA; (D.A.G.)
| | - Asvin M. Ganapathi
- Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA; (D.A.G.)
| | - Bryan A. Whitson
- Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA; (D.A.G.)
- COPPER Laboratory, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
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Kent J, Nordgren R, Ahn D, Lysandrou M, Diaz A, Fenton D, Wignakumar T, McMeekin N, Salerno C, Donington J, Madariaga MLL. Cost effectiveness of commercial portable ex vivo lung perfusion at a low-volume US lung transplant center. Artif Organs 2024. [PMID: 38924545 DOI: 10.1111/aor.14816] [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: 03/13/2024] [Revised: 05/20/2024] [Accepted: 06/11/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND Portable ex vivo lung perfusion during lung transplantation is a resource-intensive technology. In light of its increasing use, we evaluated the cost-effectiveness of ex vivo lung perfusion at a low-volume lung transplant center in the USA. METHODS Patients listed for lung transplantation (2015-2021) in the United Network for Organ Sharing database were included. Quality-of-life was approximated by Karnofsky Performance Status scores 1-year post-transplant. Total transplantation encounter and 1-year follow-up costs accrued by our academic center for patients listed from 2018 to 2021 were obtained. Cost-effectiveness was calculated by evaluating the number of patients attaining various Karnofsky scores relative to cost. RESULTS Of the 13 930 adult patients who underwent lung transplant in the United Network for Organ Sharing database, 13 477 (96.7%) used static cold storage and 453 (3.3%) used ex vivo lung perfusion, compared to 30/58 (51.7%) and 28/58 (48.3%), respectively, at our center. Compared to static cold storage, median total costs at 1 year were higher for ex vivo lung perfusion ($918 000 vs. $516 000; p = 0.007) along with the cost of living 1 year with a Karnofsky functional status of 100 after transplant ($1 290 000 vs. $841 000). In simulated scenarios, each Karnofsky-adjusted life year gained by ex vivo lung perfusion was 1.00-1.72 times more expensive. CONCLUSIONS Portable ex vivo lung perfusion is not currently cost-effective at a low-volume transplant centers in the USA, being 1.53 times more expensive per Karnofsky-adjusted life year. Improving donor lung and/or recipient biology during ex vivo lung perfusion may improve its utility for routine transplantation.
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Affiliation(s)
- Johnathan Kent
- Department of Surgery, University of Chicago Medicine, Chicago, Illinois, USA
| | - Rachel Nordgren
- Department of Public Health Sciences, University of Chicago, Chicago, Illinois, USA
| | - Daniel Ahn
- Pritzker School of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Maria Lysandrou
- Pritzker School of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Ashley Diaz
- Pritzker School of Medicine, University of Chicago, Chicago, Illinois, USA
| | - David Fenton
- Pritzker School of Medicine, University of Chicago, Chicago, Illinois, USA
| | | | - Nicola McMeekin
- Glasgow Institute of Health & Wellbeing, University of Glasgow, Glasgow, UK
| | - Christopher Salerno
- Department of Surgery, University of Chicago Medicine, Chicago, Illinois, USA
| | - Jessica Donington
- Department of Surgery, University of Chicago Medicine, Chicago, Illinois, USA
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12
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Sonnenberg EM, Abu-Gazala S, Bittermann T, Abt PL. Following the Flow: Changes in Organ Preservation Methods Require Changes in Our Data Collection. Transplantation 2024; 108:1265-1268. [PMID: 38291568 DOI: 10.1097/tp.0000000000004920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
Affiliation(s)
| | - Samir Abu-Gazala
- Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Therese Bittermann
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, PA
| | - Peter L Abt
- Department of Surgery, University of Pennsylvania, Philadelphia, PA
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13
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Iskender I. Technical Advances Targeting Multiday Preservation of Isolated Ex Vivo Lung Perfusion. Transplantation 2024; 108:1319-1332. [PMID: 38499501 DOI: 10.1097/tp.0000000000004992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/20/2024]
Abstract
Indications for ex vivo lung perfusion (EVLP) have evolved from assessment of questionable donor lungs to treatment of some pathologies and the logistics. Yet up to 3 quarters of donor lungs remain discarded across the globe. Multiday preservation of discarded human lungs on EVLP platforms would improve donor lung utilization rates via application of sophisticated treatment modalities, which could eventually result in zero waitlist mortality. The purpose of this article is to summarize advances made on the technical aspects of the protocols in achieving a stable multiday preservation of isolated EVLP. Based on the evidence derived from large animal and/or human studies, the following advances have been considered important in achieving this goal: ability to reposition donor lungs during EVLP; perfusate adsorption/filtration modalities; perfusate enrichment with plasma and/or donor whole blood, nutrients, vitamins, and amino acids; low-flow, pulsatile, and subnormothermic perfusion; positive outflow pressure; injury specific personalized ventilation strategies; and negative pressure ventilation. Combination of some of these advances in an automatized EVLP device capable of managing perfusate biochemistry and ventilation would likely speed up the processes of achieving multiday preservation of isolated EVLP.
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Affiliation(s)
- Ilker Iskender
- Department of Cardiac Surgery, East Limburg Hospital, Genk, Belgium
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14
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M M, Attawar S, BN M, Tisekar O, Mohandas A. Ex vivo lung perfusion and the Organ Care System: a review. CLINICAL TRANSPLANTATION AND RESEARCH 2024; 38:23-36. [PMID: 38725180 PMCID: PMC11075812 DOI: 10.4285/ctr.23.0057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 01/29/2024] [Accepted: 03/08/2024] [Indexed: 05/14/2024]
Abstract
With the increasing prevalence of heart failure and end-stage lung disease, there is a sustained interest in expanding the donor pool to alleviate the thoracic organ shortage crisis. Efforts to extend the standard donor criteria and to include donation after circulatory death have been made to increase the availability of suitable organs. Studies have demonstrated that outcomes with extended-criteria donors are comparable to those with standard-criteria donors. Another promising approach to augment the donor pool is the improvement of organ preservation techniques. Both ex vivo lung perfusion (EVLP) for the lungs and the Organ Care System (OCS, TransMedics) for the heart have shown encouraging results in preserving organs and extending ischemia time through the application of normothermic regional perfusion. EVLP has been effective in improving marginal or borderline lungs by preserving and reconditioning them. The use of OCS is associated with excellent short-term outcomes for cardiac allografts and has improved utilization rates of hearts from extended-criteria donors. While both EVLP and OCS have successfully transitioned from research to clinical practice, the costs associated with commercially available systems and consumables must be considered. The ex vivo perfusion platform, which includes both EVLP and OCS, holds the potential for diverse and innovative therapies, thereby transforming the landscape of thoracic organ transplantation.
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Affiliation(s)
- Menander M
- Institute of Heart and Lung Transplant, Krishna Institute of Medical Sciences (KIMS) Hospital, Secunderabad, India
| | - Sandeep Attawar
- Institute of Heart and Lung Transplant, Krishna Institute of Medical Sciences (KIMS) Hospital, Secunderabad, India
| | - Mahesh BN
- Institute of Heart and Lung Transplant, Krishna Institute of Medical Sciences (KIMS) Hospital, Secunderabad, India
| | - Owais Tisekar
- Institute of Heart and Lung Transplant, Krishna Institute of Medical Sciences (KIMS) Hospital, Secunderabad, India
| | - Anoop Mohandas
- Institute of Heart and Lung Transplant, Krishna Institute of Medical Sciences (KIMS) Hospital, Secunderabad, India
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15
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Buttar SN, Schultz HHL, Møller-Sørensen H, Perch M, Petersen RH, Møller CH. Long-term outcomes of lung transplantation with ex vivo lung perfusion technique. FRONTIERS IN TRANSPLANTATION 2024; 3:1324851. [PMID: 38993789 PMCID: PMC11235351 DOI: 10.3389/frtra.2024.1324851] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 01/18/2024] [Indexed: 07/13/2024]
Abstract
Ex vivo lung perfusion (EVLP) has demonstrated encouraging short- and medium-term outcomes with limited data available on its long-term outcomes. This study assesses (1) EVLP long-term outcomes and (2) EVLP era-based sub-analysis in addition to secondary outcomes of recipients with EVLP-treated donor lungs compared with recipients of conventionally preserved donor lungs in unmatched and propensity score-matched cohorts. Double lung transplants performed between 1st January 2012 and 31st December 2021 were included. A total of 57 recipients received EVLP-treated lungs compared to 202 unmatched and 57 matched recipients who were subjected to non-EVLP-treated lungs. The EVLP group had a significantly lower mean PaO2/FiO2 ratio and significantly higher mean BMI than the non-EVLP group in the unmatched and matched cohorts. The proportion of smoking history in the unmatched cohort was significantly higher in the EVLP group, while a similar smoking history was demonstrated in the matched cohorts. No difference was demonstrated in overall freedom from death and retransplantation between the groups in the unmatched and matched cohorts (unmatched: hazard ratio (HR) 1.28, 95% confidence interval (CI) 0.79-2.07, P = 0.32; matched: HR 1.06, 95% CI 0.59-1.89). P = 0.89). In the unmatched cohort, overall freedom from chronic allograft dysfunction (CLAD) was significantly different between the groups (HR 1.64, 95% CI 1.07-2.52, P = 0.02); however, the cumulative CLAD incidence was similar (HR 0.72, 95% CI 0.48-1.1, P = 0.13). In the matched cohort, the overall freedom from CLAD (HR 1.69, 95% CI 0.97-2.95, P = 0.06) and cumulative CLAD incidence (HR 0.91, 95% CI 0.37-2.215, P = 0.83) were similar between the groups. The EVLP era sub-analysis of the unmatched cohort in 2012-2014 had a significantly higher cumulative CLAD incidence in the EVLP group; however, this was not demonstrated in the matched cohort. All secondary outcomes were similar between the groups in the unmatched and matched cohorts. In conclusion, transplantation of marginal donor lungs after EVLP evaluation is non-detrimental compared to conventionally preserved donor lungs in terms of mortality, retransplantation, cumulative CLAD incidence, and secondary outcomes. Although the unmatched EVLP era of 2012-2014 had a significantly higher cumulative CLAD incidence, no such finding was demonstrated in the matched cohort of the same era.
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Affiliation(s)
- Sana N Buttar
- Department of Cardiothoracic Surgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Hans Henrik L Schultz
- Department of Cardiology, Section for Lung Transplantation, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Hasse Møller-Sørensen
- Department of Cardiothoracic Anaesthesiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Michael Perch
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Cardiology, Section for Lung Transplantation, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Rene Horsleben Petersen
- Department of Cardiothoracic Surgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Christian H Møller
- Department of Cardiothoracic Surgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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16
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Jenkins JA, Verdiner R, Omar A, Farina JM, Wilson R, D’Cunha J, Reck Dos Santos PA. Donor and recipient risk factors for the development of primary graft dysfunction following lung transplantation. Front Immunol 2024; 15:1341675. [PMID: 38380332 PMCID: PMC10876853 DOI: 10.3389/fimmu.2024.1341675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 01/22/2024] [Indexed: 02/22/2024] Open
Abstract
Primary Graft Dysfunction (PGD) is a major cause of both short-term and long-term morbidity and mortality following lung transplantation. Various donor, recipient, and technical risk factors have been previously identified as being associated with the development of PGD. Here, we present a comprehensive review of the current literature as it pertains to PGD following lung transplantation, as well as discussing current strategies to mitigate PGD and future directions. We will pay special attention to recent advances in lung transplantation such as ex-vivo lung perfusion, thoracoabdominal normothermic regional perfusion, and up-to-date literature published in the interim since the 2016 ISHLT consensus statement on PGD and the COVID-19 pandemic.
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Affiliation(s)
- J. Asher Jenkins
- Department of Cardiothoracic Surgery, Mayo Clinic Arizona, Phoenix, AZ, United States
| | - Ricardo Verdiner
- Department of Anesthesia and Perioperative Medicine, Mayo Clinic Arizona, Phoenix, AZ, United States
| | - Ashraf Omar
- Division of Pulmonology and Critical Care Medicine, Mayo Clinic Arizona, Phoenix, AZ, United States
| | - Juan Maria Farina
- Department of Cardiothoracic Surgery, Mayo Clinic Arizona, Phoenix, AZ, United States
| | - Renita Wilson
- Department of Cardiothoracic Surgery, Mayo Clinic Arizona, Phoenix, AZ, United States
| | - Jonathan D’Cunha
- Department of Cardiothoracic Surgery, Mayo Clinic Arizona, Phoenix, AZ, United States
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17
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Xia Y, Kim ST, Dacey M, Sayah D, Biniwale R, Ardehali A. Characteristics and outcomes of lung transplants performed with ex-situ lung perfusion. J Heart Lung Transplant 2024; 43:217-225. [PMID: 37643655 DOI: 10.1016/j.healun.2023.08.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 07/22/2023] [Accepted: 08/23/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND Ex-situ lung perfusion (ESLP) can be used to assess and rehabilitate donor lungs, potentially expanding the donor pool. We examined the characteristics and outcomes of lung transplants performed with ESLP in the United States. METHODS Retrospective review of the United Network for Organ Sharing registry of primary adult lung transplant recipients from February 28, 2018, to June 30, 2021, was performed, comparing baseline characteristics, in-hospital outcomes, and 1-year survival of ESLP vs no ESLP lung transplants. RESULTS Of 8204 lung transplants, 426 (5.2%) were performed with ESLP. ESLP donors were older, more donation after circulatory death (DCD), and had lower PaO2:FiO2 (P:F) ratios. Recipients had lower lung allocation scores. ESLP lungs traveled further, had longer preservation times, and were more likely double lung transplants. Reintubation rates, extracorporeal membrane oxygenation at 72 hours, and hospital length of stay were greater in the ESLP group. On multivariable analysis, ESLP was not an independent predictor of 1-year survival. However, further analysis showed that DCD lungs managed on ESLP had worse 1-year survival compared to DCD lungs preserved with standard cold storage or with donation after brain death donor lungs. CONCLUSIONS ESLP is used in a small percentage of lung transplants in the US and is not independently associated with 1-year survival. ESLP combined with DCD lungs, however, is associated with worse 1-year survival and warrants further investigation.
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Affiliation(s)
- Yu Xia
- Department of Surgery, Division of Cardiothoracic Surgery, University of Wisconsin, Madison, Wisconsin.
| | - Samuel T Kim
- Department of Surgery, Division of Cardiac Surgery, University of California, Los Angeles, California
| | - Michael Dacey
- Department of Surgery, Division of Cardiac Surgery, University of California, Los Angeles, California
| | - David Sayah
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of California, Los Angeles, California
| | - Reshma Biniwale
- Department of Surgery, Division of Cardiac Surgery, University of California, Los Angeles, California
| | - Abbas Ardehali
- Department of Surgery, Division of Cardiac Surgery, University of California, Los Angeles, California
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18
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Alderete IS, Hartwig MG. Commentary: Who should be using ex vivo lung perfusion? J Thorac Cardiovasc Surg 2024; 167:382-383. [PMID: 37160218 DOI: 10.1016/j.jtcvs.2023.04.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 04/27/2023] [Indexed: 05/11/2023]
Affiliation(s)
| | - Matthew G Hartwig
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University, Medical Center, Durham, NC.
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19
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López-Martínez S, Simón C, Santamaria X. Normothermic Machine Perfusion Systems: Where Do We Go From Here? Transplantation 2024; 108:22-44. [PMID: 37026713 DOI: 10.1097/tp.0000000000004573] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023]
Abstract
Normothermic machine perfusion (NMP) aims to preserve organs ex vivo by simulating physiological conditions such as body temperature. Recent advancements in NMP system design have prompted the development of clinically effective devices for liver, heart, lung, and kidney transplantation that preserve organs for several hours/up to 1 d. In preclinical studies, adjustments to circuit structure, perfusate composition, and automatic supervision have extended perfusion times up to 1 wk of preservation. Emerging NMP platforms for ex vivo preservation of the pancreas, intestine, uterus, ovary, and vascularized composite allografts represent exciting prospects. Thus, NMP may become a valuable tool in transplantation and provide significant advantages to biomedical research. This review recaps recent NMP research, including discussions of devices in clinical trials, innovative preclinical systems for extended preservation, and platforms developed for other organs. We will also discuss NMP strategies using a global approach while focusing on technical specifications and preservation times.
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Affiliation(s)
- Sara López-Martínez
- Carlos Simon Foundation, Centro de Investigación Príncipe Felipe, Valencia, Spain
| | - Carlos Simón
- Carlos Simon Foundation, Centro de Investigación Príncipe Felipe, Valencia, Spain
- Department of Obstetrics and Gynecology, Universidad de Valencia, Valencia, Spain
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Harvard University, Boston, MA
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX
| | - Xavier Santamaria
- Carlos Simon Foundation, Centro de Investigación Príncipe Felipe, Valencia, Spain
- INCLIVA Biomedical Research Institute, Valencia, Spain
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20
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Yang S, Hou W, Liu L. Progress in preservation of intestinal grafts by oxygenated hypothermic machine perfusion. Transplant Rev (Orlando) 2024; 38:100802. [PMID: 37891046 DOI: 10.1016/j.trre.2023.100802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 07/03/2023] [Accepted: 10/07/2023] [Indexed: 10/29/2023]
Abstract
Intestine transplantation (IT) is a critical treatment strategy for irreversible intestinal failure. Among all abdominal solid organ transplants, the intestine was the most vulnerable to ischemia and reperfusion injury (IRI). The static cold storage (SCS) technique is currently the most commonly used graft preservation method, but its hypoxia condition causes metabolic disorders, resulting in the occurrence of IRI, limiting its application in marginal organs. It is especially important to improve preservation techniques in order to minimize damage to marginal donor organs, which draws more attention to machine perfusion (MP). There has been much debate about whether it is necessary to increase oxygen in these conditions to support low levels of metabolism since the use of machine perfusion to preserve organs. There is evidence that oxygenation helps to restore intracellular ATP levels in the intestine after thermal or cold ischemia damage. The goal of this review is to provide an overview of the role of oxygen in maintaining environmental stability in the gut under hypoxic conditions, as well as to investigate the possibilities and mechanisms of oxygen delivery during preservation in intestine transplantation studies and clinical models.
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Affiliation(s)
- Shuang Yang
- National Health Commission's Key Laboratory for Critical Care Medicine, Tianjin First Central Hospital, Nankai University, Tianjin, China
| | - Wen Hou
- Research Institute of Transplant Medicine, Tianjin First Central Hospital, Nankai University, Tianjin, China.
| | - Lei Liu
- Research Institute of Transplant Medicine, Tianjin First Central Hospital, Nankai University, Tianjin, China; Tianjin Key Laboratory for Organ Transplantation, Tianjin First Central Hospital, Nankai University, Tianjin, China; Organ Transplant Department, Tianjin First Central Hospital, Nankai University, Tianjin, China.
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21
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Siddique A, Parekh KR, Huddleston SJ, Shults A, Locke JE, Keshavamurthy S, Schwartz G, Hartwig MG, Whitson BA. A call to action in thoracic transplant surgical training. J Heart Lung Transplant 2023; 42:1627-1631. [PMID: 37268052 DOI: 10.1016/j.healun.2023.05.017] [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: 12/12/2022] [Revised: 05/19/2023] [Accepted: 05/30/2023] [Indexed: 06/04/2023] Open
Abstract
Thoracic organ recovery and implantation is increasing in complexity. Simultaneously the logistic burden and associated cost is rising. An electronic survey distributed to the surgical directors of thoracic transplant programs in the United States indicated dissatisfaction amongst 72% of respondents with current procurement training and 85% of respondents favored a process for certification in thoracic organ transplantation. These responses highlight concerns for the current paradigm of training in thoracic transplantation. We discuss the implications of advancements in organ retrieval and implant for surgical training and propose that the thoracic transplant community might address the need through formalized training in procurement and certification in thoracic transplantation.
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Affiliation(s)
- A Siddique
- University of Nebraska Medical Center, Department of Surgery, Division of Cardiothoracic Surgery, Omaha, Nebraska.
| | - K R Parekh
- University of Iowa Hospitals and Clinics, Department of Cardiothoracic Surgery, Carver College of Medicine, Iowa City, Iowa
| | - S J Huddleston
- University of Minnesota, Department of Surgery, Division of Cardiothoracic Surgery
| | - A Shults
- American Society of Thoracic Surgeons, Arlington, Virginia
| | - J E Locke
- University of Alabama at Birmingham, Department of Surgery, Division of Transplantation, Birmingham, Alabama
| | - S Keshavamurthy
- University of Kentucky College of Medicine, Department of Surgery, Division of Cardiothoracic Surgery, Lexington, Kentucky
| | - G Schwartz
- Baylor University Medical Center, Department of Thoracic Surgery, Dallas, Texas
| | - M G Hartwig
- Duke University Health System, Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Durham, North Carolina
| | - B A Whitson
- The Ohio State University Wexner Medical Center, Department of Surgery, Division of Cardiac Surgery, Columbus, Ohio
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22
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Iske J, Schroeter A, Knoedler S, Nazari-Shafti TZ, Wert L, Roesel MJ, Hennig F, Niehaus A, Kuehn C, Ius F, Falk V, Schmelzle M, Ruhparwar A, Haverich A, Knosalla C, Tullius SG, Vondran FWR, Wiegmann B. Pushing the boundaries of innovation: the potential of ex vivo organ perfusion from an interdisciplinary point of view. Front Cardiovasc Med 2023; 10:1272945. [PMID: 37900569 PMCID: PMC10602690 DOI: 10.3389/fcvm.2023.1272945] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 09/22/2023] [Indexed: 10/31/2023] Open
Abstract
Ex vivo machine perfusion (EVMP) is an emerging technique for preserving explanted solid organs with primary application in allogeneic organ transplantation. EVMP has been established as an alternative to the standard of care static-cold preservation, allowing for prolonged preservation and real-time monitoring of organ quality while reducing/preventing ischemia-reperfusion injury. Moreover, it has paved the way to involve expanded criteria donors, e.g., after circulatory death, thus expanding the donor organ pool. Ongoing improvements in EVMP protocols, especially expanding the duration of preservation, paved the way for its broader application, in particular for reconditioning and modification of diseased organs and tumor and infection therapies and regenerative approaches. Moreover, implementing EVMP for in vivo-like preclinical studies improving disease modeling raises significant interest, while providing an ideal interface for bioengineering and genetic manipulation. These approaches can be applied not only in an allogeneic and xenogeneic transplant setting but also in an autologous setting, where patients can be on temporary organ support while the diseased organs are treated ex vivo, followed by reimplantation of the cured organ. This review provides a comprehensive overview of the differences and similarities in abdominal (kidney and liver) and thoracic (lung and heart) EVMP, focusing on the organ-specific components and preservation techniques, specifically on the composition of perfusion solutions and their supplements and perfusion temperatures and flow conditions. Novel treatment opportunities beyond organ transplantation and limitations of abdominal and thoracic EVMP are delineated to identify complementary interdisciplinary approaches for the application and development of this technique.
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Affiliation(s)
- Jasper Iske
- Department of Cardiothoracic Surgery, Deutsches Herzzentrum der Charité, Berlin, Germany
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Andreas Schroeter
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
- Division of Transplant Surgery, Department of Surgery, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, United States
| | - Samuel Knoedler
- Division of Plastic Surgery, Department of Surgery, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, United States
- Department of Plastic Surgery and Hand Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Timo Z. Nazari-Shafti
- Department of Cardiothoracic Surgery, Deutsches Herzzentrum der Charité, Berlin, Germany
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Leonard Wert
- Department of Cardiothoracic Surgery, Deutsches Herzzentrum der Charité, Berlin, Germany
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Maximilian J. Roesel
- Department of Cardiothoracic Surgery, Deutsches Herzzentrum der Charité, Berlin, Germany
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Division of Transplant Surgery, Department of Surgery, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, United States
| | - Felix Hennig
- Department of Cardiothoracic Surgery, Deutsches Herzzentrum der Charité, Berlin, Germany
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Adelheid Niehaus
- Department for Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Christian Kuehn
- Department for Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
- German Center for Lung Research (DZL), Hannover, Germany
- Lower Saxony Center for Biomedical Engineering, Implant Research and Development (NIFE), Hannover, Germany
| | - Fabio Ius
- Department for Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
- German Center for Lung Research (DZL), Hannover, Germany
| | - Volkmar Falk
- Department of Cardiothoracic Surgery, Deutsches Herzzentrum der Charité, Berlin, Germany
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site, Berlin, Germany
- Department of Health Science and Technology, Translational Cardiovascular Technology, ETH Zurich, Zürich, Switzerland
| | - Moritz Schmelzle
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Arjang Ruhparwar
- Department for Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
- German Center for Lung Research (DZL), Hannover, Germany
- Lower Saxony Center for Biomedical Engineering, Implant Research and Development (NIFE), Hannover, Germany
| | - Axel Haverich
- Department for Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
- German Center for Lung Research (DZL), Hannover, Germany
- Lower Saxony Center for Biomedical Engineering, Implant Research and Development (NIFE), Hannover, Germany
| | - Christoph Knosalla
- Department of Cardiothoracic Surgery, Deutsches Herzzentrum der Charité, Berlin, Germany
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site, Berlin, Germany
| | - Stefan G. Tullius
- Division of Transplant Surgery, Department of Surgery, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, United States
| | - Florian W. R. Vondran
- Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Bettina Wiegmann
- Department for Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
- German Center for Lung Research (DZL), Hannover, Germany
- Lower Saxony Center for Biomedical Engineering, Implant Research and Development (NIFE), Hannover, Germany
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23
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Mesaki K, Juvet S, Yeung J, Guan Z, Wilson GW, Hu J, Davidson AR, Kleinstiver BP, Cypel M, Liu M, Keshavjee S. Immunomodulation of the donor lung with CRISPR-mediated activation of IL-10 expression. J Heart Lung Transplant 2023; 42:1363-1377. [PMID: 37315746 PMCID: PMC10538378 DOI: 10.1016/j.healun.2023.06.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 05/22/2023] [Accepted: 06/04/2023] [Indexed: 06/16/2023] Open
Abstract
BACKGROUND Inflammatory injury in the donor lung remains a persistent challenge in lung transplantation that limits donor organ usage and post-transplant outcomes. Inducing immunomodulatory capacity in donor organs could address this unsolved clinical problem. We sought to apply clustered regularly interspaced short palindromic repeats (CRISPR)-associated (Cas) technologies to the donor lung to fine-tune immunomodulatory gene expression, exploring for the first time the therapeutic use of CRISPR-mediated transcriptional activation in the whole donor lung. METHODS We explored the feasibility of CRISPR-mediated transcriptional upregulation of interleukin 10 (IL-10), a key immunomodulatory cytokine, in vitro and in vivo. We first evaluated the potency, titratability, and multiplexibility of the gene activation in rat and human cell lines. Next, in vivo CRISPR-mediated IL-10 activation was characterized in rat lungs. Finally, the IL-10-activated donor lungs were transplanted into recipient rats to assess the feasibility in a transplant setting. RESULTS The targeted transcriptional activation induced robust and titrable IL-10 upregulation in vitro. The combination of guide RNAs also facilitated multiplex gene modulation, that is, simultaneous activation of IL-10 and IL1 receptor antagonist. In vivo profiling demonstrated that adenoviral delivery of Cas9-based activators to the lung was feasible with the use of immunosuppression, which is routinely applied to organ transplant recipients. The transcriptionally modulated donor lungs retained IL-10 upregulation in isogeneic and allogeneic recipients. CONCLUSIONS Our findings highlight the potential of CRISPR epigenome editing to improve lung transplant outcomes by creating a more favorable immunomodulatory environment in the donor organ, a paradigm that may be extendable to other organ transplants.
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Affiliation(s)
- Kumi Mesaki
- From the Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada; Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Stephen Juvet
- From the Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada; Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Division of Respirology, Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jonathan Yeung
- From the Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada; Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Division of Thoracic Surgery, Department of Surgery, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Zehong Guan
- From the Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Gavin W Wilson
- From the Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada; Department of Surgery, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jim Hu
- Department of Laboratory Medicine and Pathobiology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Translation Medicine Program, the Hospital for Sick Children, Toronto, Ontario, Canada
| | - Alan R Davidson
- Department of Biochemistry, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Molecular Genetics, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Benjamin P Kleinstiver
- Center for Genomic Medicine, Massachusetts General Hospital & Harvard Medical School, Boston, Massachusetts, USA; Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts, USA; Department of Pathology, Harvard Medical School, Boston, Massachusetts, USA
| | - Marcelo Cypel
- From the Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada; Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Mingyao Liu
- From the Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada; Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Division of Thoracic Surgery, Department of Surgery, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Shaf Keshavjee
- From the Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada; Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Division of Thoracic Surgery, Department of Surgery, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
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24
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Pither T, Wang L, Bates L, Morrison M, Charlton C, Griffiths C, Macdonald J, Bigley V, Mavridou M, Barsby J, Borthwick L, Dark J, Scott W, Ali S, Fisher AJ. Modeling the Effects of IL-1β-mediated Inflammation During Ex Vivo Lung Perfusion Using a Split Human Donor Model. Transplantation 2023; 107:2179-2189. [PMID: 37143202 PMCID: PMC10519297 DOI: 10.1097/tp.0000000000004613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 02/08/2023] [Accepted: 02/23/2023] [Indexed: 05/06/2023]
Abstract
BACKGROUND The association between interleukin-1β (IL-1β) concentrations during ex vivo lung perfusion (EVLP) with donor organ quality and post-lung transplant outcome has been demonstrated in several studies. The mechanism underlying IL-1β-mediated donor lung injury was investigated using a paired single-lung EVLP model. METHODS Human lung pairs were dissected into individual lungs and perfused on identical separate EVLP circuits, with one lung from each pair receiving a bolus of IL-1β. Fluorescently labeled human neutrophils isolated from a healthy volunteer were infused into both circuits and quantified in perfusate at regular timepoints. Perfusates and tissues were subsequently analyzed, with perfusates also used in functional assays. RESULTS Neutrophil numbers were significantly lower in perfusate samples collected from the IL-1β-stimulated lungs consistent with increased neutrophil adhesion ( P = 0.042). Stimulated lungs gained significantly more weight than controls ( P = 0.046), which correlated with soluble intercellular adhesion molecule-1 (R 2 = 0.71, P = 0.0043) and von-Willebrand factor (R 2 = 0.39, P = 0.040) in perfusate. RNA expression patterns for inflammatory genes were differentially regulated via IL-1β. Blockade of IL-1β significantly reduced neutrophil adhesion in vitro ( P = 0.025). CONCLUSION These data illustrate the proinflammatory functions of IL-1β in the context of EVLP, suggesting this pathway may be susceptible to therapeutic modulation before transplantation.
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Affiliation(s)
- Thomas Pither
- Regenerative Medicine, Stem Cells and Transplantation Research Group, Faculty of Medical Sciences, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Lu Wang
- Regenerative Medicine, Stem Cells and Transplantation Research Group, Faculty of Medical Sciences, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Lucy Bates
- Regenerative Medicine, Stem Cells and Transplantation Research Group, Faculty of Medical Sciences, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Morvern Morrison
- Regenerative Medicine, Stem Cells and Transplantation Research Group, Faculty of Medical Sciences, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Catriona Charlton
- Regenerative Medicine, Stem Cells and Transplantation Research Group, Faculty of Medical Sciences, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Chelsea Griffiths
- Regenerative Medicine, Stem Cells and Transplantation Research Group, Faculty of Medical Sciences, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Jamie Macdonald
- Regenerative Medicine, Stem Cells and Transplantation Research Group, Faculty of Medical Sciences, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Venetia Bigley
- Regenerative Medicine, Stem Cells and Transplantation Research Group, Faculty of Medical Sciences, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Maria Mavridou
- Regenerative Medicine, Stem Cells and Transplantation Research Group, Faculty of Medical Sciences, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Joseph Barsby
- Regenerative Medicine, Stem Cells and Transplantation Research Group, Faculty of Medical Sciences, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Lee Borthwick
- Regenerative Medicine, Stem Cells and Transplantation Research Group, Faculty of Medical Sciences, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - John Dark
- Regenerative Medicine, Stem Cells and Transplantation Research Group, Faculty of Medical Sciences, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - William Scott
- Regenerative Medicine, Stem Cells and Transplantation Research Group, Faculty of Medical Sciences, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Simi Ali
- Regenerative Medicine, Stem Cells and Transplantation Research Group, Faculty of Medical Sciences, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Andrew J Fisher
- Regenerative Medicine, Stem Cells and Transplantation Research Group, Faculty of Medical Sciences, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
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25
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Bromberger B, Brzezinski M, Kukreja J. Lung preservation: from perfusion to temperature. Curr Opin Organ Transplant 2023; 28:168-173. [PMID: 37053078 DOI: 10.1097/mot.0000000000001067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2023]
Abstract
PURPOSE OF REVIEW This article will review the evidence behind elements of the lung preservation process that have remained relatively stable over the past decade as well as summarize recent developments in ex-vivo lung perfusion and new research challenging the standard temperature for static cold storage. RECENT FINDINGS Ex-vivo lung perfusion is becoming an increasingly well established means to facilitate greater travel distance and allow for continued reassessment of marginal donor lungs. Preliminary reports of the use of normothermic regional perfusion to allow utilization of lungs after DCD recovery exist, but further research is needed to determine its ability to improve upon the current method of DCD lung recovery. Also, research from the University of Toronto is re-assessing the optimal temperature for static cold storage; pilot studies suggest it is a feasible means to allow for storage of lungs overnight to allow for daytime transplantation, but ongoing research is awaited to determine if outcomes are superior to traditional static cold storage. SUMMARY It is crucial to understand the fundamental principles of organ preservation to ensure optimal lung function posttransplant. Recent advances in the past several years have the potential to challenge standards of the past decade and reshape how lung transplantation is performed.
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Affiliation(s)
| | | | - Jasleen Kukreja
- Division of Cardiothoracic Surgery, University of California San Francisco, San Francisco, California, USA
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26
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Wong W, Johnson B, Cheng PC, Josephson MB, Maeda K, Berg RA, Kawut SM, Harhay MO, Goldfarb SB, Yehya N, Himebauch AS. Primary graft dysfunction grade 3 following pediatric lung transplantation is associated with chronic lung allograft dysfunction. J Heart Lung Transplant 2023; 42:669-678. [PMID: 36639317 PMCID: PMC10811698 DOI: 10.1016/j.healun.2022.12.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 12/01/2022] [Accepted: 12/15/2022] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Severe primary graft dysfunction (PGD) is associated with the development of bronchiolitis obliterans syndrome (BOS), the most common form of chronic lung allograft dysfunction (CLAD), in adults. However, PGD associations with long-term outcomes following pediatric lung transplantation are unknown. We hypothesized that PGD grade 3 (PGD 3) at 48- or 72-hours would be associated with shorter CLAD-free survival following pediatric lung transplantation. METHODS This was a single center retrospective cohort study of patients ≤ 21 years of age who underwent bilateral lung transplantation between 2005 and 2019 with ≥ 1 year of follow-up. PGD and CLAD were defined by published criteria. We evaluated the association of PGD 3 at 48- or 72-hours with CLAD-free survival by using time-to-event analyses. RESULTS Fifty-one patients were included (median age 12.7 years; 51% female). The most common transplant indications were cystic fibrosis (29%) and pulmonary hypertension (20%). Seventeen patients (33%) had PGD 3 at either 48- or 72-hours. In unadjusted analysis, PGD 3 was associated with an increased risk of CLAD or mortality (HR 2.10, 95% CI 1.01-4.37, p=0.047). This association remained when adjusting individually for multiple potential confounders. There was evidence of effect modification by sex (interaction p = 0.055) with the association of PGD 3 and shorter CLAD-free survival driven predominantly by males (HR 4.73, 95% CI 1.44-15.6) rather than females (HR 1.23, 95% CI 0.47-3.20). CONCLUSIONS PGD 3 at 48- or 72-hours following pediatric lung transplantation was associated with shorter CLAD-free survival. Sex may be a modifier of this association.
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Affiliation(s)
- Wai Wong
- Department of Pediatrics, Division of Pulmonary Medicine and Respiratory Diseases, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Division of Pulmonary and Sleep Medicine, Perelman School of Medicine at the University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
| | - Brandy Johnson
- Department of Pediatrics, Division of Pulmonary and Sleep Medicine, Perelman School of Medicine at the University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Pi Chun Cheng
- Department of Pediatrics, Division of Pulmonary and Sleep Medicine, Perelman School of Medicine at the University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Pediatrics, Division of Pediatric Pulmonology, Allergy, and Sleep Medicine, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, Indiana
| | - Maureen B Josephson
- Department of Pediatrics, Division of Pulmonary and Sleep Medicine, Perelman School of Medicine at the University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Katsuhide Maeda
- Department of Surgery, Division of Cardiothoracic Surgery, Perelman School of Medicine at the University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Steven M Kawut
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael O Harhay
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Samuel B Goldfarb
- Department of Pediatrics, Division of Pulmonary and Sleep Medicine, University of Minnesota, Masonic Children's Hospital, Minneapolis, Minnesota
| | - Nadir Yehya
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Adam S Himebauch
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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27
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Avtaar Singh SS, Das De S, Al-Adhami A, Singh R, Hopkins PMA, Curry PA. Primary graft dysfunction following lung transplantation: From pathogenesis to future frontiers. World J Transplant 2023; 13:58-85. [PMID: 36968136 PMCID: PMC10037231 DOI: 10.5500/wjt.v13.i3.58] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 11/11/2022] [Accepted: 02/17/2023] [Indexed: 03/16/2023] Open
Abstract
Lung transplantation is the treatment of choice for patients with end-stage lung disease. Currently, just under 5000 lung transplants are performed worldwide annually. However, a major scourge leading to 90-d and 1-year mortality remains primary graft dysfunction. It is a spectrum of lung injury ranging from mild to severe depending on the level of hypoxaemia and lung injury post-transplant. This review aims to provide an in-depth analysis of the epidemiology, pathophysiology, risk factors, outcomes, and future frontiers involved in mitigating primary graft dysfunction. The current diagnostic criteria are examined alongside changes from the previous definition. We also highlight the issues surrounding chronic lung allograft dysfunction and identify the novel therapies available for ex-vivo lung perfusion. Although primary graft dysfunction remains a significant contributor to 90-d and 1-year mortality, ongoing research and development abreast with current technological advancements have shed some light on the issue in pursuit of future diagnostic and therapeutic tools.
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Affiliation(s)
- Sanjeet Singh Avtaar Singh
- Department of Cardiothoracic Surgery, Royal Infirmary of Edinburgh, Edinburgh EH16 4SA, United Kingdom
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow G12 8QQ, United Kingdom
| | - Sudeep Das De
- Heart and Lung Transplant Unit, Wythenshawe Hospital, Manchester M23 9NJ, United Kingdom
| | - Ahmed Al-Adhami
- Department of Cardiothoracic Surgery, Royal Infirmary of Edinburgh, Edinburgh EH16 4SA, United Kingdom
- Department of Heart and Lung Transplant, Royal Papworth Hospital, Cambridge CB2 0AY, United Kingdom
| | - Ramesh Singh
- Mechanical Circulatory Support, Inova Health System, Falls Church, VA 22042, United States
| | - Peter MA Hopkins
- Queensland Lung Transplant Service, Prince Charles Hospital, Brisbane, QLD 4032, Australia
| | - Philip Alan Curry
- Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Glasgow G81 4DY, United Kingdom
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28
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Van Raemdonck D, Ceulemans LJ, Van Beersel D, Neyrinck A. Current achievements and future applications of ex vivo lung perfusion; where do we go from here? J Thorac Cardiovasc Surg 2023; 165:920-924. [PMID: 35931582 DOI: 10.1016/j.jtcvs.2022.06.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Revised: 06/07/2022] [Accepted: 06/09/2022] [Indexed: 11/25/2022]
Affiliation(s)
- Dirk Van Raemdonck
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium; Department of Chronic Diseases and Metabolism, Catholic University Leuven, Leuven, Belgium.
| | - Laurens J Ceulemans
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium; Department of Chronic Diseases and Metabolism, Catholic University Leuven, Leuven, Belgium
| | - Dieter Van Beersel
- Department of Anesthesiology, University Hospitals Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, Catholic University Leuven, Leuven, Belgium
| | - Arne Neyrinck
- Department of Anesthesiology, University Hospitals Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, Catholic University Leuven, Leuven, Belgium
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Abstract
OBJECTIVE To define textbook outcome (TO) for lung transplantation (LTx) using a contemporary cohort from a high-volume institution. SUMMARY BACKGROUND DATA TO is a standardized, composite quality measure based on multiple postoperative endpoints representing the ideal "textbook" hospitalization. METHODS Adult patients who underwent LTx at our institution between 2016 and 2019 were included. TO was defined as freedom from intraoperative complication, postoperative reintervention, 30-day intensive care unit or hospital readmission, length of stay >75th percentile of LTx patients, 90 day mortality, 30-day acute rejection, grade 3 primary graft dysfunction at 48 or 72 hours, postoperative extracorporeal membrane oxygenation, tracheostomy within 7 days, inpatient dialysis, reintubation, and extubation >48 hours post-transplant. Recipient, operative, financial characteristics, and post-transplant outcomes were recorded from institutional data and compared between TO and non-TO groups. RESULTS Of 401 LTx recipients, 97 (24.2%) achieved TO. The most common reason for TO failure was extubation >48 hours post-transplant (N = 119, 39.1%); the least common was mortality (N = 15, 4.9%). Patient and graft survival were improved among patients who achieved versus failed TO (patient survival: log-rank P < 0.01; graft survival: log-rank P < 0.01). Rejection-free and chronic lung allograft dysfunction-free survival were similar between TO and non-TO groups (rejection-free survival: log-rank P = 0.07; chronic lung allograft dysfunction-free survival: log-rank P = 0.3). On average, patients who achieved TO incurred approximately $638,000 less in total inpatient charges compared to those who failed TO. CONCLUSIONS TO in LTx was associated with favorable post-transplant outcomes and significant cost-savings. TO may offer providers and patients new insight into transplant center quality of care and highlight areas for improvement.
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30
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Noda K, Chan EG, Furukawa M, Ryan JP, Clifford S, Luketich JD, Sanchez PG. Single-center experience of ex vivo lung perfusion and subsequent lung transplantation. Clin Transplant 2023; 37:e14901. [PMID: 36588340 DOI: 10.1111/ctr.14901] [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: 09/30/2022] [Revised: 12/21/2022] [Accepted: 12/28/2022] [Indexed: 01/03/2023]
Abstract
BACKGROUND The safety of lung transplantation using ex vivo lung perfusion (EVLP) has been confirmed in multiple clinical studies; however, limited evidence is currently available regarding the potential effects of EVLP on posttransplant graft complications and survival with mid- to long-term follow-up. In this study, we reviewed our institutional data to better understand the impact of EVLP. METHODS Lungs placed on EVLP from 2014 through 2020 and transplant outcomes were retrospectively analyzed. Data were compared between lungs transplanted and declined after EVLP, between patients with severe primary graft dysfunction (PGD3) and no PGD3 after EVLP, and between matched patients with lungs transplanted with and without EVLP. RESULTS In total, 98 EVLP cases were performed. Changes in metabolic indicators during EVLP were correlated with graft quality and transplantability, but not changes in physiological parameters. Among 58 transplanted lungs after EVLP, PGD3 at 72 h occurred in 36.9% and was associated with preservation time, mechanical support prior to transplant, and intraoperative transfusion volume. Compared with patients without EVLP, patients who received lungs screened with EVLP had a higher incidence of PGD3 and longer ICU and hospital stays. Lung grafts placed on EVLP exhibited a significantly higher chance of developing airway anastomotic ischemic injury by 30 days posttransplant. Acute and chronic graft rejection, pulmonary function, and posttransplant survival were not different between patients with lungs screened on EVLP versus lungs with no EVLP. CONCLUSION EVLP use is associated with an increase of early posttransplant adverse events, but graft functional outcomes and patient survival are preserved.
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Affiliation(s)
- Kentaro Noda
- Division of Lung Transplant and Lung Failure, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ernest G Chan
- Division of Lung Transplant and Lung Failure, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Masashi Furukawa
- Division of Lung Transplant and Lung Failure, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - John P Ryan
- Division of Lung Transplant and Lung Failure, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Sarah Clifford
- Division of Lung Transplant and Lung Failure, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - James D Luketich
- Division of Lung Transplant and Lung Failure, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Pablo G Sanchez
- Division of Lung Transplant and Lung Failure, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Attawar S, Manoly I, Shah U. Lung Transplantation in India: a Brief Review, Landmarks, Indian Scenario, and our Experience. Indian J Surg 2023; 85:1-12. [PMID: 36686557 PMCID: PMC9841148 DOI: 10.1007/s12262-023-03663-w] [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: 04/10/2022] [Accepted: 01/03/2023] [Indexed: 01/18/2023] Open
Abstract
Lung transplantation is gaining widespread acceptance as the preferred therapeutic option for selected cases of end-stage lung disease in India. The indications of lung transplantation are increasing, with better post-operative survival, including the COVID affected lung, if we choose our patients well. The national acceptance of expanded criteria in lung donation, streamlining of the process of lung transplantation by governmental, and non-governmental organizations and significant increase in the number of organ donations in India have strengthened the lung transplantation program within the country. Through this article, we describe a brief history, the process, and our experience of lung transplantation since we started our program in 2017 until date.
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Affiliation(s)
- Sandeep Attawar
- Institute of Heart and Lung Transplant, Krishna Institute of Medical Sciences, Hyderabad, Telangana India
| | - Imthiaz Manoly
- Cardiothoracic Surgery , Burjeel Hospitals, Abu Dhabi, United Arab Emirates
- Department of Surgery, UAE University, Al Ain, United Arab Emirates
| | - Unmil Shah
- Institute of Heart and Lung Transplant, Krishna Institute of Medical Sciences, Hyderabad, Telangana India
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32
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Diagnostic and Therapeutic Implications of Ex Vivo Lung Perfusion in Lung Transplantation: Potential Benefits and Inherent Limitations. Transplantation 2023; 107:105-116. [PMID: 36508647 DOI: 10.1097/tp.0000000000004414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Ex vivo lung perfusion (EVLP), a technique in which isolated lungs are continually ventilated and perfused at normothermic temperature, is emerging as a promising platform to optimize donor lung quality and increase the lung graft pool. Over the past few decades, the EVLP technique has become recognized as a significant achievement and gained much attention in the field of lung transplantation. EVLP has been demonstrated to be an effective platform for various targeted therapies to optimize donor lung function before transplantation. Additionally, some physical parameters during EVLP and biological markers in the EVLP perfusate can be used to evaluate graft function before transplantation and predict posttransplant outcomes. However, despite its advantages, the clinical practice of EVLP continuously encounters multiple challenges associated with both intrinsic and extrinsic limitations. It is of utmost importance to address the advantages and disadvantages of EVLP for its broader clinical usage. Here, the pros and cons of EVLP are comprehensively discussed, with a focus on its benefits and potential approaches for overcoming the remaining limitations. Directions for future research to fully explore the clinical potential of EVLP in lung transplantation are also discussed.
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33
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Johnson B, Bucio J, Salerno C, Jeevanandam V, Song T, Wool G. Decreasing blood wastage during ex vivo lung perfusion recovery through utilization of thermal control technology. J Card Surg 2022; 37:5011-5018. [PMID: 36349705 PMCID: PMC10099649 DOI: 10.1111/jocs.17147] [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: 09/30/2022] [Accepted: 10/29/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND The Organ Care System (OCS) is a revolutionary ex vivo organ perfusion technology that can potentially expand the organ retrieval range. The OCS Lung device uses packed red blood cells (pRBC) with a proprietary solution. We report the ability to reduce blood waste during this procedure by using a thermal packaging solution in conjunction with the OCS platform. METHODS We retrospectively reviewed all OCS Lung recoveries performed by our recovery team, using pRBCfrom May 2019 to January 2021. Initially, units were stored using passive refrigeration with the Performance cooler at a temperature range of 1-6°C for 4 h. Subsequently, thermal control technology with the ProMed cooler was utilized to maintain the same temperature range for 72 h. RESULTS Twenty-three recoveries were initiated with 63 pRBC. The Performance cooler was used for 8, while the ProMed cooler for 13. 37.5% of pRBC transported with the Performance cooler was used within the validated time range, while 25.0% were used beyond the validated time range based on clinical judgment. In addition, 37.5% of pRBC transported with the Performance cooler were returned to the institution after canceled recoveries with an estimated loss of $1800; the ProMed cooler had no wastage. CONCLUSIONS This study showed that using an advanced thermal packaging solution facilitates proper storage of pRBC and represents an advancement for extended donor lung preservation. The elimination of blood wastage in this initial study portends ongoing benefits for the limited blood supply and reduced cost.
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Affiliation(s)
- Blaine Johnson
- Perfusion Services, UChicago Medicine, Chicago, Illinois, USA
| | - Jamie Bucio
- Department of Surgery, Section of Cardiac Surgery, University of Chicago, Chicago, Illinois, USA
| | - Christopher Salerno
- Department of Surgery, Section of Cardiac Surgery, University of Chicago, Chicago, Illinois, USA
| | - Valluvan Jeevanandam
- Department of Surgery, Section of Cardiac Surgery, University of Chicago, Chicago, Illinois, USA
| | - Tae Song
- Department of Surgery, Section of Cardiac Surgery, University of Chicago, Chicago, Illinois, USA
| | - Geoffrey Wool
- Department of Pathology, University of Chicago, Chicago, Illinois, USA
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Lepoittevin M, Giraud S, Kerforne T, Allain G, Thuillier R, Hauet T. How to improve results after DCD (donation after circulation death). Presse Med 2022; 51:104143. [PMID: 36216034 DOI: 10.1016/j.lpm.2022.104143] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Accepted: 09/29/2022] [Indexed: 11/09/2022] Open
Abstract
The shortage of organs for transplantation has led health professionals to look for alternative sources of donors. One of the avenues concerns donors who have died after circulatory arrest. This is a special situation because the organs from these donors are exposed to warm ischaemia-reperfusion lesions that are unavoidable during the journey of the organs from the donor to the moment of transplantation in the recipient. We will address and discuss the key issues from the perspective of team organization, legislation and its evolution, and the ethical framework. In a second part, the avenues to improve the quality of organs will be presented following the itinerary of the organs between the donor and the recipient. The important moments from the point of view of therapeutic strategy will be put into perspective. New connections between key players involved in pathophysiological mechanisms and implications for innate immunity and injury processes are among the avenues to explore. Technological developments to improve the quality of organs from these recipients will be analyzed, such as perfusion techniques with new modalities of temperatures and oxygenation. New molecules are being investigated for their potential role in protecting these organs and an analysis of potential prospects will be proposed. Finally, the important perspectives that seem to be favored will be discussed in order to reposition the use of deceased donors after circulatory arrest. The use of these organs has become a routine procedure and improving their quality and providing the means for their evaluation is absolutely inevitable.
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Affiliation(s)
- Maryne Lepoittevin
- Unité UMR U1082, F-86000 Poitiers, France; Faculté de Médecine et de Pharmacie, Université de Poitiers, F-86000 Poitiers, France
| | - Sébastien Giraud
- Unité UMR U1082, F-86000 Poitiers, France; Service de Biochimie, Pôle Biospharm, Centre Hospitalier Universitaire, 2 rue de la Milétrie, CS 90577, 86021 Poitiers Cedex, France
| | - Thomas Kerforne
- Unité UMR U1082, F-86000 Poitiers, France; Faculté de Médecine et de Pharmacie, Université de Poitiers, F-86000 Poitiers, France; CHU Poitiers, Service de Réanimation Chirurgie Cardio-Thoracique et Vasculaire, Coordination des P.M.O., F-86021 Poitiers, France
| | - Géraldine Allain
- Unité UMR U1082, F-86000 Poitiers, France; Faculté de Médecine et de Pharmacie, Université de Poitiers, F-86000 Poitiers, France; CHU Poitiers, Service de Chirurgie Cardiothoracique et Vasculaire, F-86021 Poitiers, France
| | - Raphaël Thuillier
- Unité UMR U1082, F-86000 Poitiers, France; Faculté de Médecine et de Pharmacie, Université de Poitiers, F-86000 Poitiers, France; Service de Biochimie, Pôle Biospharm, Centre Hospitalier Universitaire, 2 rue de la Milétrie, CS 90577, 86021 Poitiers Cedex, France
| | - Thierry Hauet
- Unité UMR U1082, F-86000 Poitiers, France; Faculté de Médecine et de Pharmacie, Université de Poitiers, F-86000 Poitiers, France; Fédération Hospitalo-Universitaire « Survival Optimization in Organ Transplantation », CHU de Poitiers, 2 rue de la Milétrie - CS 90577, 86021 Poitiers Cedex, France.
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Remote ex vivo lung perfusion at a centralized evaluation facility. J Heart Lung Transplant 2022; 41:1700-1711. [PMID: 36229329 DOI: 10.1016/j.healun.2022.09.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 08/24/2022] [Accepted: 09/08/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND In the US, only 23% of lungs offered for transplantation are transplanted. Ex vivo lung perfusion (EVLP) allows for evaluation of additional donor lungs; its adoption has been limited by resources and expertise. Dedicated facilities with a centralized lung evaluation system (CLES) could expand access to EVLP. METHODS In this unblinded, nonrandomized, traditional feasibility study, 7 US transplant centers referred lungs declined for standard transplantation to a dedicated EVLP facility, which utilized a CLES. EVLP was remotely monitored by the transplant teams. CLES lungs were matched with contemporaneous conventional static cold-preserved controls at each center. RESULTS A total of 115 recipients were enrolled, and 66 received allografts from 63 donors after EVLP at the dedicated CLES facility. Forty-nine contemporaneous patients served as controls. Primary graft dysfunction grade 3 at 72 hours (PGD3-72 hours) was higher in the CLES group with 16 (24%) vs 2 (4%) in the control (common RD 95% CI, 0.07-0.32; p = 0.0009). All recipients survived to 30 days and 1-year survival was similar for both groups (92% controls vs 89% CLES; common RD 95% CI, -0.14-0.08; p = 0.58). Total preservation time, hospital and ICU lengths of stay, and time to first extubation were longer in the CLES group. CONCLUSIONS Remote ex vivo perfusion of lung allografts declined for conventional transplantation at a dedicated CLES facility is feasible and resulted in additional transplants. Recipients of allografts assessed with a CLES had a higher rate of PGD3-72 hours, but similar 30-day and 1-year outcomes compared to conventional lung recipients. (NCT02234128).
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Li JH, Xu X, Wang YF, Xie HY, Chen JY, Dong NG, Badiwala M, Xin LM, Ribeiro RVP, Yin H, Zhang H, Zhang JZ, Huo F, Yang JY, Yang HJ, Pan H, Li SG, Qiao YB, Luo J, Li HY, Jia JJ, Yu H, Liang H, Yang SJ, Wang H, Liu ZY, Zhang LC, Hu XY, Wu H, Hu YQ, Tang PF, Ye QF, Zheng SS. Chinese expert consensus on organ protection of transplantation (2022 edition). Hepatobiliary Pancreat Dis Int 2022; 21:516-526. [PMID: 36376226 DOI: 10.1016/j.hbpd.2022.10.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 10/24/2022] [Indexed: 11/07/2022]
Affiliation(s)
- Jian-Hui Li
- Department of Hepatobiliary and Pancreatic Surgery, Department of Liver Transplantation, Shulan (Hangzhou) Hospital, Zhejiang Shuren University School of Medicine, Hangzhou 310022, China
| | - Xiao Xu
- Department of Hepatobiliary and Pancreatic Surgery, Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou 310000, China
| | - Yan-Feng Wang
- Zhongnan Hospital of Wuhan University, Institute of Hepatobiliary Diseases of Wuhan University, Transplant Center of Wuhan University, Hubei Key Laboratory of Medical Technology on Transplantation, Wuhan 430062, China
| | - Hai-Yang Xie
- NHC Key Laboratory of Combined Multi-organ Transplantation, Hangzhou 310003, China
| | - Jing-Yu Chen
- Wuxi Lung Transplantation Center, Wuxi People's Hospital Affiliated with Nanjing Medical University, Wuxi 214023, China
| | - Nian-Guo Dong
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Mitesh Badiwala
- Peter Munk Cardiac Centre, Toronto General Hospital-University Health Network, Toronto, Canada
| | - Li-Ming Xin
- School of Computer Engineering and Science, Shanghai University, Shanghai 200444, China
| | | | - Hao Yin
- Organ Transplant Center, Shanghai Changzheng Hospital, Shanghai 200003, China
| | - Hao Zhang
- Department of Orthopedics, Chinese PLA General Hospital, Beijing 100039, China; National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing 100039, China
| | - Jian-Zheng Zhang
- Department of Orthopedics, Chinese PLA General Hospital, Beijing 100039, China; National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing 100039, China
| | - Feng Huo
- Department of Surgery, General Hospital of Guangzhou Military Command of PLA, Guangzhou 510040, China
| | - Jia-Yin Yang
- Department of Liver Surgery, Liver Transplantation Center, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Hong-Ji Yang
- Organ Transplantation Center, Sichuan Provincial People's Hospital and School of Medicine, University of Electronic Science and Technology of China, Chengdu 610072, China
| | - Hui Pan
- Department of Lung Transplantation, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Shao-Guang Li
- Department of Orthopedics, Chinese PLA General Hospital, Beijing 100039, China; National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing 100039, China
| | - Yin-Biao Qiao
- NHC Key Laboratory of Combined Multi-organ Transplantation, Hangzhou 310003, China
| | - Jia Luo
- NHC Key Laboratory of Combined Multi-organ Transplantation, Hangzhou 310003, China
| | - Hao-Yu Li
- NHC Key Laboratory of Combined Multi-organ Transplantation, Hangzhou 310003, China
| | - Jun-Jun Jia
- Division of Hepatobiliary Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Hao Yu
- Division of Hepatobiliary Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Han Liang
- Zhongnan Hospital of Wuhan University, Institute of Hepatobiliary Diseases of Wuhan University, Transplant Center of Wuhan University, Hubei Key Laboratory of Medical Technology on Transplantation, Wuhan 430062, China
| | - Si-Jia Yang
- Department of Lung Transplantation, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Hao Wang
- Department of Orthopedics, Chinese PLA General Hospital, Beijing 100039, China; National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing 100039, China
| | - Zhong-Yang Liu
- Department of Orthopedics, Chinese PLA General Hospital, Beijing 100039, China; National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing 100039, China
| | - Li-Cheng Zhang
- Department of Orthopedics, Chinese PLA General Hospital, Beijing 100039, China; National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing 100039, China
| | - Xiao-Yi Hu
- Division of Hepatobiliary Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Hao Wu
- Division of Hepatobiliary Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Yi-Qing Hu
- Division of Hepatobiliary Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Pei-Fu Tang
- Department of Orthopedics, Chinese PLA General Hospital, Beijing 100039, China; National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing 100039, China
| | - Qi-Fa Ye
- Zhongnan Hospital of Wuhan University, Institute of Hepatobiliary Diseases of Wuhan University, Transplant Center of Wuhan University, Hubei Key Laboratory of Medical Technology on Transplantation, Wuhan 430062, China
| | - Shu-Sen Zheng
- Department of Hepatobiliary and Pancreatic Surgery, Department of Liver Transplantation, Shulan (Hangzhou) Hospital, Zhejiang Shuren University School of Medicine, Hangzhou 310022, China; NHC Key Laboratory of Combined Multi-organ Transplantation, Hangzhou 310003, China; Division of Hepatobiliary Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China.
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Lung transplantation following donation after circulatory death. TRANSPLANTATION REPORTS 2022. [DOI: 10.1016/j.tpr.2022.100110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Roesel MJ, Wiegmann B, Ius F, Knosalla C, Iske J. The role of ex-situ perfusion for thoracic organs. Curr Opin Organ Transplant 2022; 27:466-473. [PMID: 35950888 DOI: 10.1097/mot.0000000000001008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
PURPOSE OF REVIEW Ex-situ machine perfusion for both heart (HTx) and lung transplantation (LuTx) reduces ischemia-reperfusion injury (IRI), allows for greater flexibility in geographical donor management, continuous monitoring, organ assessment for extended evaluation, and potential reconditioning of marginal organs. In this review, we will delineate the impact of machine perfusion, characterize novel opportunities, and outline potential challenges lying ahead to improve further implementation. RECENT FINDINGS Due to the success of several randomized controlled trials (RCT), comparing cold storage to machine perfusion in HTx and LuTx, implementation and innovation continues. Indeed, it represents a promising interface for organ-specific therapies targeting IRI, allo-immune responses, and graft reconditioning. These mostly experimental efforts range from genetic approaches and nanotechnology to cellular therapies, involving mesenchymal stem cell application. Despite tremendous potential, prior to clinical transition, more data is needed. SUMMARY Collectively, machine perfusion constitutes the vanguard in thoracic organ transplantation research with extensive potential for expanding the donor pool, enhancing transplant outcomes as well as developing novel therapy approaches.
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Affiliation(s)
- Maximilian J Roesel
- Department of Cardiothoracic Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany
- Institute of Medical Immunology, Charite Universitaetsmedizin Berlin, Berlin, Germany
| | - Bettina Wiegmann
- Department for Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
- German Center for Lung Research (DZL), Hannover, Germany
- DFG Priority Program SPP 2014, German Research Foundation, Bonn, Germany
| | - Fabio Ius
- Department for Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Christoph Knosalla
- Department of Cardiothoracic Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Jasper Iske
- Department of Cardiothoracic Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany
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Miller CL, O JM, Allan JS, Madsen JC. Novel approaches for long-term lung transplant survival. Front Immunol 2022; 13:931251. [PMID: 35967365 PMCID: PMC9363671 DOI: 10.3389/fimmu.2022.931251] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 07/04/2022] [Indexed: 11/16/2022] Open
Abstract
Allograft failure remains a major barrier in the field of lung transplantation and results primarily from acute and chronic rejection. To date, standard-of-care immunosuppressive regimens have proven unsuccessful in achieving acceptable long-term graft and patient survival. Recent insights into the unique immunologic properties of lung allografts provide an opportunity to develop more effective immunosuppressive strategies. Here we describe advances in our understanding of the mechanisms driving lung allograft rejection and highlight recent progress in the development of novel, lung-specific strategies aimed at promoting long-term allograft survival, including tolerance.
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Affiliation(s)
- Cynthia L. Miller
- Center for Transplantation Sciences, Massachusetts General Hospital, Boston, MA, United States
| | - Jane M. O
- Center for Transplantation Sciences, Massachusetts General Hospital, Boston, MA, United States
| | - James S. Allan
- Center for Transplantation Sciences, Massachusetts General Hospital, Boston, MA, United States
- Division of Thoracic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA, United States
| | - Joren C. Madsen
- Center for Transplantation Sciences, Massachusetts General Hospital, Boston, MA, United States
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA, United States
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40
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Gao Q, DeLaura IF, Anwar IJ, Kesseli SJ, Kahan R, Abraham N, Asokan A, Barbas AS, Hartwig MG. Gene Therapy: Will the Promise of Optimizing Lung Allografts Become Reality? Front Immunol 2022; 13:931524. [PMID: 35844566 PMCID: PMC9283701 DOI: 10.3389/fimmu.2022.931524] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 06/09/2022] [Indexed: 01/21/2023] Open
Abstract
Lung transplantation is the definitive therapy for patients living with end-stage lung disease. Despite significant progress made in the field, graft survival remains the lowest of all solid organ transplants. Additionally, the lung has among the lowest of organ utilization rates-among eligible donors, only 22% of lungs from multi-organ donors were transplanted in 2019. Novel strategies are needed to rehabilitate marginal organs and improve graft survival. Gene therapy is one promising strategy in optimizing donor allografts. Over-expression or inhibition of specific genes can be achieved to target various pathways of graft injury, including ischemic-reperfusion injuries, humoral or cellular rejection, and chronic lung allograft dysfunction. Experiments in animal models have historically utilized adenovirus-based vectors and the majority of literature in lung transplantation has focused on overexpression of IL-10. Although several strategies were shown to prevent rejection and prolong graft survival in preclinical models, none have led to clinical translation. The past decade has seen a renaissance in the field of gene therapy and two AAV-based in vivo gene therapies are now FDA-approved for clinical use. Concurrently, normothermic ex vivo machine perfusion technology has emerged as an alternative to traditional static cold storage. This preservation method keeps organs physiologically active during storage and thus potentially offers a platform for gene therapy. This review will explore the advantages and disadvantages of various gene therapy modalities, review various candidate genes implicated in various stages of allograft injury and summarize the recent efforts in optimizing donor lungs using gene therapy.
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Affiliation(s)
- Qimeng Gao
- Department of Surgery, Duke University Medical Center, Durham, NC, United States
| | - Isabel F. DeLaura
- Department of Surgery, Duke University Medical Center, Durham, NC, United States
| | - Imran J. Anwar
- Department of Surgery, Duke University Medical Center, Durham, NC, United States
| | - Samuel J. Kesseli
- Department of Surgery, Duke University Medical Center, Durham, NC, United States
| | - Riley Kahan
- Department of Surgery, Duke University Medical Center, Durham, NC, United States
| | - Nader Abraham
- Department of Surgery, Duke University Medical Center, Durham, NC, United States
| | - Aravind Asokan
- Department of Surgery, Duke University Medical Center, Durham, NC, United States
- Department of Molecular Genetics & Microbiology, Duke University School of Medicine, Durham, NC, United States
- Department of Biomedical Engineering, Duke University, Durham, NC, United States
| | - Andrew S. Barbas
- Department of Surgery, Duke University Medical Center, Durham, NC, United States
| | - Matthew G. Hartwig
- Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC, United States
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41
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Hirdman G, Niroomand A, Olm F, Lindstedt S. Taking a Deep Breath: an Examination of Current Controversies in Surgical Procedures in Lung Transplantation. CURRENT TRANSPLANTATION REPORTS 2022; 9:160-172. [PMID: 35601346 PMCID: PMC9108015 DOI: 10.1007/s40472-022-00367-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/2022] [Indexed: 11/30/2022]
Abstract
Purpose of Review This article reviews controversial questions within the field of lung transplantation, with a focus on data generated within the last 3 years. We aim to summarize differing opinions on a selection of topics, including bridge-to-transplantation, intraoperative machine circulatory support, bronchial anastomosis, size mismatch, delayed chest closure, and ex vivo lung perfusion. Recent Findings With the growing rate of lung transplantations worldwide and increasing numbers of patients placed on waiting lists, the importance of determining best practices has only increased in recent years. Factors which promote successful outcomes have been identified across all the topics, with certain approaches promoted, such as ambulation in bridge-to-transplant and widespread intraoperative ECMO as machine support. Summary While great strides have been made in the operative procedures involved in lung transplantation, there are still key questions to be answered. The consensus which can be reached will be instrumental in further improving outcomes in recipients.
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Affiliation(s)
- Gabriel Hirdman
- Department of Cardiothoracic Surgery and Transplantation, Skåne University Hospital, Lund University, Lund, Sweden
- Wallenberg Center for Molecular Medicine, Lund University, Lund, Sweden
- Department of Clinical Sciences, Lund University, Lund, Sweden
- Lund Stem Cell Center, Lund University, Lund, Sweden
| | - Anna Niroomand
- Wallenberg Center for Molecular Medicine, Lund University, Lund, Sweden
- Department of Clinical Sciences, Lund University, Lund, Sweden
- Lund Stem Cell Center, Lund University, Lund, Sweden
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ USA
| | - Franziska Olm
- Department of Cardiothoracic Surgery and Transplantation, Skåne University Hospital, Lund University, Lund, Sweden
- Wallenberg Center for Molecular Medicine, Lund University, Lund, Sweden
- Department of Clinical Sciences, Lund University, Lund, Sweden
- Lund Stem Cell Center, Lund University, Lund, Sweden
| | - Sandra Lindstedt
- Department of Cardiothoracic Surgery and Transplantation, Skåne University Hospital, Lund University, Lund, Sweden
- Wallenberg Center for Molecular Medicine, Lund University, Lund, Sweden
- Department of Clinical Sciences, Lund University, Lund, Sweden
- Lund Stem Cell Center, Lund University, Lund, Sweden
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Abdoul N, Legeai C, Cantrelle C, Mercier O, Olland A, Mordant P, Thomas PA, Jougon J, Tissot A, Maury JM, Sage E, Dorent R. Impact of ex vivo lung perfusion on brain-dead donor lung utilization: The French experience. Am J Transplant 2022; 22:1409-1417. [PMID: 35000283 DOI: 10.1111/ajt.16953] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 12/17/2021] [Accepted: 01/04/2022] [Indexed: 01/25/2023]
Abstract
Ex vivo lung perfusion (EVLP) is a valuable method for expanding the lung donor pool. Its indications currently differ across centers. This national retrospective cohort study aimed to describe the profile of donors with lungs transplanted after EVLP and determine the effectiveness of EVLP on lung utilization. We included brain-dead donors with at least one lung offered between 2012 and 2019 in France. Lungs transplanted without or after EVLP were compared with those that were rejected. Donor group phenotypes were determined with multiple correspondence analysis (MCA). The association between donor factors and lung transplantation was assessed with a multivariable multinomial logistic regression. MCA revealed that donors whose lungs were transplanted after EVLP had profiles similar to the donors whose lungs were declined and quite different from those of donors with lungs transplanted without EVLP. Donor predictors of graft nonuse included age ≥50 years, smoking history, PaO2 /FiO2 ratio ≤300 mmHg, abnormal chest imaging, and purulent secretions. EVLP increased utilization of lungs from donors with a smoking history, PaO2 /FiO2 ratio ≤300 mmHg, and abnormal chest imaging.
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Affiliation(s)
| | | | | | - Olaf Mercier
- Department of Thoracic Surgery and Lung Transplantation, Marie Lannelongue Hospital, Le Plessis Robinson, France
| | - Anne Olland
- Department of Thoracic Surgery, University Hospital Strasbourg, Strasbourg, France
| | - Pierre Mordant
- Division of Thoracic and Vascular Surgery, Bichat Hospital, Assistance Publique-Hôpitaux de Paris, Paris University, Paris, France
| | | | - Jacques Jougon
- Department of Thoracic Surgery, Haut-Leveque Hospital, Bordeaux University, Bordeaux, France
| | - Adrien Tissot
- Department of Pneumology, Thorax Institute, Nantes University Hospital, Nantes, France
| | - Jean-Michel Maury
- Department of Thoracic Surgery, Lung and Lung Transplantation, Louis Pradel Hospital, Lyon, France
| | - Edouard Sage
- Department of Thoracic Surgery and Lung Transplantation, Foch Hospital, Suresnes, France
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Lepoittevin M, Giraud S, Kerforne T, Barrou B, Badet L, Bucur P, Salamé E, Goumard C, Savier E, Branchereau J, Battistella P, Mercier O, Mussot S, Hauet T, Thuillier R. Preservation of Organs to Be Transplanted: An Essential Step in the Transplant Process. Int J Mol Sci 2022; 23:ijms23094989. [PMID: 35563381 PMCID: PMC9104613 DOI: 10.3390/ijms23094989] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 04/25/2022] [Accepted: 04/27/2022] [Indexed: 12/23/2022] Open
Abstract
Organ transplantation remains the treatment of last resort in case of failure of a vital organ (lung, liver, heart, intestine) or non-vital organ (essentially the kidney and pancreas) for which supplementary treatments exist. It remains the best alternative both in terms of quality-of-life and life expectancy for patients and of public health expenditure. Unfortunately, organ shortage remains a widespread issue, as on average only about 25% of patients waiting for an organ are transplanted each year. This situation has led to the consideration of recent donor populations (deceased by brain death with extended criteria or deceased after circulatory arrest). These organs are sensitive to the conditions of conservation during the ischemia phase, which have an impact on the graft’s short- and long-term fate. This evolution necessitates a more adapted management of organ donation and the optimization of preservation conditions. In this general review, the different aspects of preservation will be considered. Initially done by hypothermia with the help of specific solutions, preservation is evolving with oxygenated perfusion, in hypothermia or normothermia, aiming at maintaining tissue metabolism. Preservation time is also becoming a unique evaluation window to predict organ quality, allowing repair and/or optimization of recipient choice.
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Affiliation(s)
- Maryne Lepoittevin
- Biochemistry Department, CHU Poitiers, 86021 Poitiers, France; (M.L.); (S.G.); (R.T.)
- Faculty of Medicine and Pharmacy, University of Poitiers, 86073 Poitiers, France;
- INSERM U1313, IRMETIST, 86021 Poitiers, France; (B.B.); (L.B.)
| | - Sébastien Giraud
- Biochemistry Department, CHU Poitiers, 86021 Poitiers, France; (M.L.); (S.G.); (R.T.)
- Faculty of Medicine and Pharmacy, University of Poitiers, 86073 Poitiers, France;
- INSERM U1313, IRMETIST, 86021 Poitiers, France; (B.B.); (L.B.)
| | - Thomas Kerforne
- Faculty of Medicine and Pharmacy, University of Poitiers, 86073 Poitiers, France;
- INSERM U1313, IRMETIST, 86021 Poitiers, France; (B.B.); (L.B.)
- Cardio-Thoracic and Vascular Surgery Intensive Care Unit, Coordination of P.M.O., CHU Poitiers, 86021 Poitiers, France
| | - Benoit Barrou
- INSERM U1313, IRMETIST, 86021 Poitiers, France; (B.B.); (L.B.)
- Sorbonne Université Campus Pierre et Marie Curie, Faculté de Médecine, 75005 Paris, France
- Service Médico-Chirurgical de Transplantation Rénale, APHP, Hôpital Pitié-Salpêtrière, 75013 Paris, France
- Société Francophone de Transplantation et de l’Ecole Francophone pour le Prélèvement Multi-Organes, 75013 Paris, France; (P.B.); (E.S.); (C.G.); (E.S.); (J.B.); (P.B.); (O.M.); (S.M.)
| | - Lionel Badet
- INSERM U1313, IRMETIST, 86021 Poitiers, France; (B.B.); (L.B.)
- Société Francophone de Transplantation et de l’Ecole Francophone pour le Prélèvement Multi-Organes, 75013 Paris, France; (P.B.); (E.S.); (C.G.); (E.S.); (J.B.); (P.B.); (O.M.); (S.M.)
- Faculté de Médecine, Campus Lyon Santé Est, Université Claude Bernard, 69622 Lyon, France
- Service d’Urologie et Transplantation, Hospices Civils de Lyon, Hôpital Edouard-Herriot, 69003 Lyon, France
| | - Petru Bucur
- Société Francophone de Transplantation et de l’Ecole Francophone pour le Prélèvement Multi-Organes, 75013 Paris, France; (P.B.); (E.S.); (C.G.); (E.S.); (J.B.); (P.B.); (O.M.); (S.M.)
- Service de Chirurgie Digestive et Endocrinienne, Transplantation Hépatique, CHU de Tours, 37170 Chambray les Tours, France
- Groupement d’Imagerie Médicale, CHU de Tours, 37000 Tours, France
- University Hospital Federation SUPORT Tours Poitiers Limoges, 86021 Poitiers, France
| | - Ephrem Salamé
- Société Francophone de Transplantation et de l’Ecole Francophone pour le Prélèvement Multi-Organes, 75013 Paris, France; (P.B.); (E.S.); (C.G.); (E.S.); (J.B.); (P.B.); (O.M.); (S.M.)
- Service de Chirurgie Digestive et Endocrinienne, Transplantation Hépatique, CHU de Tours, 37170 Chambray les Tours, France
- Groupement d’Imagerie Médicale, CHU de Tours, 37000 Tours, France
- University Hospital Federation SUPORT Tours Poitiers Limoges, 86021 Poitiers, France
| | - Claire Goumard
- Société Francophone de Transplantation et de l’Ecole Francophone pour le Prélèvement Multi-Organes, 75013 Paris, France; (P.B.); (E.S.); (C.G.); (E.S.); (J.B.); (P.B.); (O.M.); (S.M.)
- Service de Chirurgie Digestive, Hépato-Bilio-Pancréatique et Transplantation Hépatique, APHP, Hôpital Pitié-Salpêtrière, 75013 Paris, France
| | - Eric Savier
- Société Francophone de Transplantation et de l’Ecole Francophone pour le Prélèvement Multi-Organes, 75013 Paris, France; (P.B.); (E.S.); (C.G.); (E.S.); (J.B.); (P.B.); (O.M.); (S.M.)
- Service de Chirurgie Digestive, Hépato-Bilio-Pancréatique et Transplantation Hépatique, APHP, Hôpital Pitié-Salpêtrière, 75013 Paris, France
| | - Julien Branchereau
- Société Francophone de Transplantation et de l’Ecole Francophone pour le Prélèvement Multi-Organes, 75013 Paris, France; (P.B.); (E.S.); (C.G.); (E.S.); (J.B.); (P.B.); (O.M.); (S.M.)
- Service d’Urologie et de Transplantation, CHU de Nantes, 44000 Nantes, France
| | - Pascal Battistella
- Société Francophone de Transplantation et de l’Ecole Francophone pour le Prélèvement Multi-Organes, 75013 Paris, France; (P.B.); (E.S.); (C.G.); (E.S.); (J.B.); (P.B.); (O.M.); (S.M.)
- Service de Cardiologie et Maladies Vasculaires, CHU de Montpellier, CEDEX 5, 34295 Montpellier, France
| | - Olaf Mercier
- Société Francophone de Transplantation et de l’Ecole Francophone pour le Prélèvement Multi-Organes, 75013 Paris, France; (P.B.); (E.S.); (C.G.); (E.S.); (J.B.); (P.B.); (O.M.); (S.M.)
- Service de Chirurgie Thoracique et Cardio-Vasculaire, Centre Chirurgical Marie LANNELONGUE, 92350 Le Plessis Robinson, France
| | - Sacha Mussot
- Société Francophone de Transplantation et de l’Ecole Francophone pour le Prélèvement Multi-Organes, 75013 Paris, France; (P.B.); (E.S.); (C.G.); (E.S.); (J.B.); (P.B.); (O.M.); (S.M.)
- Service de Chirurgie Thoracique et Cardio-Vasculaire, Centre Chirurgical Marie LANNELONGUE, 92350 Le Plessis Robinson, France
| | - Thierry Hauet
- Biochemistry Department, CHU Poitiers, 86021 Poitiers, France; (M.L.); (S.G.); (R.T.)
- Faculty of Medicine and Pharmacy, University of Poitiers, 86073 Poitiers, France;
- INSERM U1313, IRMETIST, 86021 Poitiers, France; (B.B.); (L.B.)
- Société Francophone de Transplantation et de l’Ecole Francophone pour le Prélèvement Multi-Organes, 75013 Paris, France; (P.B.); (E.S.); (C.G.); (E.S.); (J.B.); (P.B.); (O.M.); (S.M.)
- University Hospital Federation SUPORT Tours Poitiers Limoges, 86021 Poitiers, France
- Correspondence:
| | - Raphael Thuillier
- Biochemistry Department, CHU Poitiers, 86021 Poitiers, France; (M.L.); (S.G.); (R.T.)
- Faculty of Medicine and Pharmacy, University of Poitiers, 86073 Poitiers, France;
- INSERM U1313, IRMETIST, 86021 Poitiers, France; (B.B.); (L.B.)
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Lee ACH, Edobor A, Wigakumar T, Lysandrou M, Johnston LK, McMullen P, Mirle V, Diaz A, Piech R, Rose R, Jendrisak M, di Sabato D, Shanmugarajah K, Fung J, Donington J, Madariaga ML. Donor leukocyte trafficking during human ex vivo lung perfusion. Clin Transplant 2022; 36:e14670. [PMID: 35396887 PMCID: PMC9540615 DOI: 10.1111/ctr.14670] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 03/09/2022] [Accepted: 04/04/2022] [Indexed: 11/30/2022]
Abstract
Background Ex vivo lung perfusion (EVLP) is used to assess and preserve lungs prior to transplantation. However, its inherent immunomodulatory effects are not completely understood. We examine perfusate and tissue compartments to determine the change in immune cell composition in human lungs maintained on EVLP. Methods Six human lungs unsuitable for transplantation underwent EVLP. Tissue and perfusate samples were obtained during cold storage and at 1‐, 3‐ and 6‐h during perfusion. Flow cytometry, immunohistochemistry, and bead‐based immunoassays were used to measure leukocyte composition and cytokines. Mean values between baseline and time points were compared by Student's t test. Results During the 1st hour of perfusion, perfusate neutrophils increased (+22.2 ± 13.5%, p < 0.05), monocytes decreased (−77.5 ± 8.6%, p < 0.01) and NK cells decreased (−61.5 ± 22.6%, p < 0.01) compared to cold storage. In contrast, tissue neutrophils decreased (−22.1 ± 12.2%, p < 0.05) with no change in monocytes and NK cells. By 6 h, perfusate neutrophils, NK cells, and tissue neutrophils were similar to baseline. Perfusate monocytes remained decreased, while tissue monocytes remained unchanged. There was no significant change in B cells or T cell subsets. Pro‐inflammatory cytokines (IL‐1b, G‐CSF, IFN‐gamma, CXCL2, CXCL1 granzyme A, and granzyme B) and lymphocyte activating cytokines (IL‐2, IL‐4, IL‐6, IL‐8) increased during perfusion. Conclusions Early mobilization of innate immune cells occurs in both perfusate and tissue compartments during EVLP, with neutrophils and NK cells returning to baseline and monocytes remaining depleted after 6 h. The immunomodulatory effect of EVLP may provide a therapeutic window to decrease the immunogenicity of lungs prior to transplantation.
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Affiliation(s)
| | - Arianna Edobor
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | | | - Maria Lysandrou
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - Laura K Johnston
- Office of Shared Research Facilities, University of Chicago, Chicago, Illinois, USA
| | - Phillip McMullen
- Department of Pathology, University of Chicago, Chicago, Illinois, USA
| | - Vikranth Mirle
- Pritzker School of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Ashley Diaz
- Pritzker School of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Ryan Piech
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - Rebecca Rose
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | | | - Diego di Sabato
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | | | - John Fung
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - Jessica Donington
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
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Kirste G. Cold but not too cold: advances in hypothermic and normothermic organ perfusion. KOREAN JOURNAL OF TRANSPLANTATION 2022; 36:2-14. [PMID: 35769433 PMCID: PMC9235527 DOI: 10.4285/kjt.22.0008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 02/21/2022] [Indexed: 11/24/2022] Open
Abstract
Transplantation is the method of choice and, in many cases, the only method of treatment for patients with end-stage organ disease. Excellent results have been achieved, and the main focus today is to extend the number of available donors. The use of extended-criteria donors or donors after circulatory death is standard, but is accompanied by an increased risk of ischemia reperfusion injury. This review presents newly developed machine perfusion techniques using hypothermic, subnormothermic, or normothermic conditions, with or without oxygenation. Possibilities for treatment and quality assessment in decision-making about organ acceptability are also discussed.
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Affiliation(s)
- Guenter Kirste
- Department of Surgery, University Hospital of Freiburg, Albert Ludwig University of Freiburg, Freiburg im Breisgau, Germany
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Ex Vivo Lung Perfusion: A Review of Current and Future Application in Lung Transplantation. Pulm Ther 2022; 8:149-165. [PMID: 35316525 PMCID: PMC9098710 DOI: 10.1007/s41030-022-00185-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 01/25/2022] [Indexed: 12/23/2022] Open
Abstract
The number of waitlisted lung transplant candidates exceeds the availability of donor organs. Barriers to utilization of donor lungs include suboptimal lung allograft function, long ischemic times due to geographical distance between donor and recipient, and a wide array of other logistical and medical challenges. Ex vivo lung perfusion (EVLP) is a modality that allows donor lungs to be evaluated in a closed circuit outside of the body and extends lung donor assessment prior to final acceptance for transplantation. EVLP was first utilized successfully in 2001 in Lund, Sweden. Since its initial use, EVLP has facilitated hundreds of lung transplants that would not have otherwise happened. EVLP technology continues to evolve and improve, and currently there are multiple commercially available systems, and more under investigation worldwide. Although barriers to universal utilization of EVLP exist, the possibility for more widespread adaptation of this technology abounds. Not only does EVLP have diagnostic capabilities as an organ monitoring device but also the therapeutic potential to improve lung allograft quality when specific issues are encountered. Expanded treatment potential includes the use of immunomodulatory treatment to reduce primary graft dysfunction, as well as targeted antimicrobial therapy to treat infection. In this review, we will highlight the historical development, the current state of utilization/capability, and the future promise of this technology.
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HOLM AM, COURTWRIGHT A, OLLAND A, ZUCKERMANN A, RAEMDONCK DVAN. ISHLT Position Paper on Thoracic Organ Transplantation in Controlled Donation after Circulatory Determination of Death (cDCD). J Heart Lung Transplant 2022; 41:671-677. [DOI: 10.1016/j.healun.2022.03.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 02/28/2022] [Accepted: 03/08/2022] [Indexed: 01/12/2023] Open
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Ex-Vivo Preservation with the Organ Care System in High Risk Heart Transplantation. Life (Basel) 2022; 12:life12020247. [PMID: 35207534 PMCID: PMC8877453 DOI: 10.3390/life12020247] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 01/25/2022] [Accepted: 01/25/2022] [Indexed: 11/17/2022] Open
Abstract
Objective: Ex vivo organ perfusion is an advanced preservation technique that allows graft assessment and extended ex situ intervals. We hypothesized that its properties might be especially beneficial for high-risk recipients and/or donors with extended criteria. Methods: We reviewed the outcomes of 119 consecutive heart transplant patients, which were divided into two groups: A (OCS) vs. B (conventional). Ex vivo organ perfusion was performed using the Organ Care System (OCS). Indications for OCS-usage were expected ischemic time of >4 h or >2 h plus given extended donor criteria. Results: Both groups included mostly redo cases (A: 89.7% vs. B: 78.4%; p = 0.121). Incidences of donors with previous cardiac arrest (%) (A: 32.4 vs. B: 22.2; p < 0.05) or LV-hypertrophy (%) (A: 19.1 vs. B: 8.3; p = 0.119) were also increased in Group A. Ex situ time (min) was significantly longer in Group A (A: 381 (74) vs. B: 228 (43); p < 0.05). Ventilation time (days) (A: 10.0 (19.9) vs. B: 24.3 (43.2); p = 0.057), postoperative need for ECLS (%) (A: 25.0 vs. B: 39.2; p = 0.112) and postoperative dialysis (chronic) (%) (A: 4.4 vs. B: 27.5; p < 0.001) were numerically better in the OCS group, without any difference in the occurrence of early graft rejection. The 30-d-survival (A: 92.4% vs. B: 90.2%; p = 0.745) and mid-term survival were statistically not different between both groups. Conclusions: OCS heart allowed safe transplantation of surgically complex recipients with excellent one-year outcomes, despite long preservation times and unfavourable donor characteristics. Furthermore, we observed trends towards decreased ventilation times and fewer ECLS treatments. In times of reduced organ availability and increasing recipient complexity, OCS heart is a valuable instrument that enables otherwise infeasible allocations and contributes to increase surgical safety.
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Halpern SE, Kesseli SJ, Au S, Krischak MK, Olaso DG, Smith H, Tipton G, Jamieson IR, Barbas AS, Haney JC, Klapper JA, Hartwig MG. Lung transplantation after ex vivo lung perfusion versus static cold storage: An institutional cost analysis. Am J Transplant 2022; 22:552-564. [PMID: 34379885 PMCID: PMC8813879 DOI: 10.1111/ajt.16794] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 08/04/2021] [Accepted: 08/04/2021] [Indexed: 02/03/2023]
Abstract
Ex vivo lung perfusion (EVLP) is a novel lung preservation strategy that facilitates the use of marginal allografts; however, it is more expensive than static cold storage (SCS). To understand how preservation method might affect postoperative costs, we compared outcomes and index hospitalization costs among matched EVLP and SCS preserved lung transplant (LTx) recipients at a single, high-volume institution. A total of 22 EVLP and 66 matched SCS LTx recipients were included; SCS grafts were further stratified as either standard-criteria (SCD) or extended-criteria donors (ECD). Median total preservation time was 857, 409, and 438 min for EVLP, SCD, and ECD lungs, respectively (p < .0001). EVLP patients had similar perioperative outcomes and posttransplant survival compared to SCS SCD and ECD recipients. Excluding device-specific costs, total direct variable costs were similar among EVLP, SCD, and ECD recipients (median $200,404, vs. $154,709 vs. $168,334, p = .11). The median direct contribution margin was positive for EVLP recipients, and similar to that for SCD and ECD graft recipients (all p > .99). These findings demonstrate that the use of EVLP was profitable at an institutional level; however, further investigation is needed to better understand the financial implications of EVLP in facilitating donor pool expansion in an era of broader lung sharing.
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Affiliation(s)
| | - Samuel J. Kesseli
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Sandra Au
- School of Medicine, Duke University, Durham, NC, USA
| | | | | | - Haley Smith
- Office of Finance, Duke Transplant Center, Durham, NC, USA
| | - Greg Tipton
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | | | - Andrew S. Barbas
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - John C. Haney
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Jacob A. Klapper
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
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Lung Transplant Outcome following Donation after Euthanasia. J Heart Lung Transplant 2022; 41:745-754. [DOI: 10.1016/j.healun.2022.01.1375] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 01/13/2022] [Accepted: 01/24/2022] [Indexed: 11/20/2022] Open
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