Ischemic preconditioning: fact or fantasy?

Viability testing and transplantation of marginal livers (VITTAL) using normothermic machine perfusion: study protocol for an open-label, non-randomised, prospective, single-arm trial

INTRODUCTION

The use of marginal or extended criteria donor livers is increasing. These organs carry a greater risk of initial dysfunction and early failure, as well as inferior long-term outcomes. As such, many are rejected due to a perceived risk of use and use varies widely between centres. Ex situ normothermic machine perfusion of the liver (NMP-L) may enable the safe transplantation of organs that meet defined objective criteria denoting their high-risk status and are currently being declined for use by all the UK transplant centres.

METHODS AND ANALYSIS

Viability testing and transplantation of marginal livers is an open-label, non-randomised, prospective, single-arm trial designed to determine whether currently unused donor livers can be salvaged and safely transplanted with equivalent outcomes in terms of patient survival. The procured rejected livers must meet predefined criteria that objectively denote their marginal condition. The liver is subjected to NMP-L following a period of static cold storage. Organs metabolising lactate to ≤2.5 mmol/L within 4 hours of the perfusion commencing in combination with two or more of the following parameters-bile production, metabolism of glucose, a hepatic arterial flow rate ≥150 mL/min and a portal venous flow rate ≥500 mL/min, a pH ≥7.30 and/or maintain a homogeneous perfusion-will be considered viable and transplanted into a suitable consented recipient. The coprimary outcome measures are the success rate of NMP-L to produce a transplantable organ and 90-day patient post-transplant survival.

ETHICS AND DISSEMINATION

The protocol was approved by the National Research Ethics Service (London-Dulwich Research Ethics Committee, 16/LO/1056), the Medicines and Healthcare Products Regulatory Agency and is endorsed by the National Health Service Blood and Transplant Research, Innovation and Novel Technologies Advisory Group. The findings of this trial will be disseminated through national and international presentations and peer-reviewed publications.

TRIAL REGISTRATION NUMBER

NCT02740608; Pre-results.

Mechanisms of the beneficial actions of ischemic preconditioning on subcellular remodeling in ischemic-reperfused heart

Cardiac function is compromised by oxidative stress which occurs upon exposing the heart to ischemia reperfusion (I/R) for a prolonged period. The reactive oxygen species (ROS) that are generated during I/R incur extensive damage to the myocardium and result in subcellular organelle remodeling. The cardiac nucleus, glycocalyx, myofilaments, sarcoplasmic reticulum, sarcolemma, and mitochondria are affected by ROS during I/R injury. On the other hand, brief periods of ischemia followed by reperfusion, or ischemic preconditioning (IPC), have been shown to be cardioprotective against oxidative stress by attenuating the cellular damage and alterations of subcellular organelles caused by subsequent I/R injury. Endogenous defense mechanisms, such as antioxidant enzymes and heat shock proteins, are activated by IPC and thus prevent damage caused by oxidative stress. Although these cardioprotective effects of IPC against I/R injury are considered to be a consequence of changes in the redox state of cardiomyocytes, IPC is considered to promote the production of NO which may protect subcellular organelles from the deleterious actions of oxidative stress. The article is intended to focus on the I/R-induced oxidative damage to subcellular organelles and to highlight the cardioprotective effects of IPC. In addition, the actions of various endogenous cardioprotective interventions are discussed to illustrate that changes in the redox state due to IPC are cardioprotective against I/R injury to the heart.

Organ Preservation: Current Concepts and New Strategies for the Next Decade

SUMMARY: Organ transplantation has developed over the past 50 years to reach the sophisticated and integrated clinical service of today through several advances in science. One of the most important of these has been the ability to apply organ preservation protocols to deliver donor organs of high quality, via a network of organ exchange to match the most suitable recipient patient to the best available organ, capable of rapid resumption of life-sustaining function in the recipient patient. This has only been possible by amassing a good understanding of the potential effects of hypoxic injury on donated organs, and how to prevent these by applying organ preservation. This review sets out the history of organ preservation, how applications of hypothermia have become central to the process, and what the current status is for the range of solid organs commonly transplanted. The science of organ preservation is constantly being updated with new knowledge and ideas, and the review also discusses what innovations are coming close to clinical reality to meet the growing demands for high quality organs in transplantation over the next few years.

Diazoxide increases liver and kidney HSP25 and HSP70 after shock and stroke

BACKGROUND

The compound, diazoxide (DZ), is known to induce preconditioning through its effect as a mitochondrial K(ATP) channel opener and succinate dehydrogenase inhibitor. Our team tested the hypothesis that pharmacological induction of ischemic preconditioning with DZ can offer cytoprotection and preserve vital tissues after hemorrhagic shock and stroke.

MATERIALS AND METHODS

Sprague-Dawley male rats received an intraperitoneal injection of sterile saline or 5 mg/kg DZ in saline 24 h prior to 1 h of hemorrhagic shock, by approximately 40% total blood loss volume (Shock Study), or a permanent unilateral common carotid ligation just before shock (Stroke + Shock Study). While remaining under isoflurane anesthesia, animals then received 81 mL/kg intravenous sterile saline over the next 45 min for recovery and survived for another 24 h.

RESULTS

When DZ was administered 24 h prior to shock, it significantly reduced hyperglycemia, which in vehicle-treated animals persisted after resuscitation. DZ also attenuated hyperlactatemia during the 1-h shock period. With more severe trauma from combined stroke and shock, DZ also decreased hyperlactatemia and hyperglycemia levels but the reduction was only significant for hyperglycemia. The expression levels of heat shock proteins 25 (HSP25) and 70 (HSP70) were used as biomarkers for response of the kidney and liver to DZ and combined stroke and shock. Compared to vehicle-treated animals, DZ-treated rats subjected to shock and stroke exhibited increased HSP25 and HSP70 in kidney and liver tissue.

CONCLUSIONS

DZ-attenuated physiological indicators of metabolic stress following shock or combined shock and stroke and enhanced the up-regulation of cytoprotective heat shock protein expression.

Usage of the T1 effect of an iron oxide contrast agent in an animal model to quantify myocardial blood flow by MRI

BACKGROUND

To present a new method for fully quantitative analysis of myocardial blood flow (MBF) using magnetic resonance imaging. The first pass of an intravascular iron oxide contrast medium can be used to quantify myocardial perfusion. The technique was validated in an animal model using colored microspheres.

MATERIALS AND METHODS

In six pigs, a tracking catheter was positioned in the left anterior descending artery (LAD). Dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) was performed on a 1.5-T scanner using a hybrid gradient-echo/echoplanar imaging (GRE-EPI) sequence. Regional myocardial blood flow (rMBF) was altered by either inducing vasodilatation with adenosine or creating coronary artery obstruction. The T(1) effect of a superparamagnetic iron oxide-based contrast medium (Resovist) administered at a dose of 8 micromol/kg was used. Upslope, time-to-peak and peak intensity were calculated from the signal intensity-time curves and absolute rMBF using the Kety-Schmidt equation; results were compared to those obtained using colored microspheres.

RESULTS

The mean rMBF calculated by MRI was 1.49 (+/-6.91, quartile width) ml/min/g versus 3.21 (+/-1.61) ml/min/g measured by means of microspheres under resting conditions. rMBF increased to a mean of 6.21 (+/-2.83) ml/min/g versus 4.22 (+/-1.70) ml/min/g under adenosine and was reduced to zero flow in total occlusion. Linear regression showed the best correlation for upslope (R=0.714), time-to-peak (R=0.626) and the Kety-Schmidt equation (R=0.584).

CONCLUSIONS

The T(1) effect of an iron oxide-based contrast medium allows determination of rMBF when using the Kety-Schmidt equation. The results are similar to those obtained with the standard of reference, colored micropheres, but not better than the results of the semiquantitative approach.

Cardioprotective properties of humoral factors released from rat hearts subject to ischemic preconditioning

Myocardial protection can be achieved by transfer of coronary effluent from ischemically preconditioned to non-preconditioned hearts. This study was designed to test the hypothesis that preconditioned effluent from rat hearts purified by Sep-Pak C-18 cartridges could induce remote cardioprotection against ischemia/reperfusion (I/R) injury through the activation of protein kinase C signaling pathway. Buffer-perfused rat hearts were subject to 30 min ischemia and 60 min reperfusion. The myocardial I/R injury was assessed by postischemic contractile function recovery and infarct size. The protective effect of coronary effluent collected during ischemic preconditioning (IPC) was tested in non-preconditioned hearts in presence or absence of a PKC inhibitor, chelerythrine. Infarct size was 17 +/- 2% in preconditioned versus 37 +/- 1% in control hearts (P < 0.001). Hearts perfused with fresh preconditioned effluent had infarct sizes of 16 +/- 3% versus 36 +/- 1% in hearts treated with non-preconditioned effluent. The cardioprotective effect was lost when the effluent was left at room temperature during 24 h (infarct size, 40 +/- 3%) or heated to 70 degrees C (26 +/- 4%, P < 0.05) or 100 degrees C (39 +/- 1%, P < 0.001). The lyophilized effluent was stable for 30 days, and its purification in a Sep-Pak C-18 column resulted in a hydrophobic fraction that reduced the infarct size to 17 +/- 2% versus 38 +/- 2% for the hydrophilic fraction. Chelerythrine (100 microM) inhibited the reduction of infarct size induced by IPC (35 +/- 4%) or hydrophobic fraction (37 +/- 3%). Recovery of the contractile function at reperfusion was higher in preconditioned group (74 +/- 6% versus 17 +/- 7% in control, P < 0.001) and hydrophobic fraction (66 +/- 7% versus 8 +/- 4% in hydrophilic fraction, P < 0.001). Similarly, chelerythrine was able to abrogate the contractile function recovery (12 +/- 6%, P < 0.001 versus preconditioned group and 19 +/- 7%, P < 0.001 versus hydrophobic fraction). In conclusion, the cardioprotective factors released in the coronary effluent by IPC are thermolabile hydrophobic substances with molecular weights higher than 3.5 kDa and acting through PKC activation.

Induction of Thioredoxin and Mitochondrial Survival Proteins Mediates Preconditioning-Induced Cardioprotection and Neuroprotection

Delayed cardio- and neuroprotection are observed following a preconditioning procedure evoked by a brief and nontoxic oxidative stress due to deprivation of oxygen, glucose, serum, trophic factors, and/or antioxidative enzymes. Preconditioning protection can be observed in vivo and is under clinical trials for preservation of cell viability following organ transplants of liver. Previous studies indicated that ischemic preconditioning increases the expression of heat-shock proteins (HSPs) and nitric oxide synthase (NOS). Our pilot studies indicate that the treatment of neuronal NOS inhibitor (7-nitroindazole) and 6Br-cGMP blocks and mimics, respectively, preconditioning protection in human neuroblastoma SH-SY5Y cells. This minireview focuses on nitric oxide-mediated cellular adaptation and the related cGMP/PKG signaling pathway in a compensatory mechanism underlying preconditioning-induced hormesis. Both preconditioning and 6Br-cGMP increase the induction of human thioredoxin (Trx) mRNA and protein for cytoprotection, which is largely prevented by transfection of cells with Trx antisense but not sense oligonucleotides. Cytosolic Trx1 and mitochondrial Trx2 suppress free radical formation, lipid peroxidation, oxidative stress, and mitochondria-dependent apoptosis; knock out/down of either Trx1 or Trx2 is detrimental to cell survival. Other recent findings indicate that a transgenic increase of Trx in mice increases tolerance against oxidative nigral injury caused by 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP). Trx1 can be translocated into nucleus and phosphoactivated CREB for a delayed induction of mitochondrial anti-apoptotic Bcl-2 and antioxidative MnSOD that is known to increase vitality and survival of cells in the brain and the heart. In conclusion, preconditioning adaptation or a brief oxidative stress induces a delayed nitric oxide-mediated compensatory mechanism for cell survival and vitality in the central nervous system and the cardiovascular system. Preconditioning-induced adaptive tolerance may be signaling through a cGMP-dependent induction of cytosolic redox protein Trx1 and subsequently mitochondrial proteins such as Bcl-2, MnSOD, and perhaps Trx2 or HSP70.

Laparoscopic warm renal ischemia in the solitary porcine kidney model

OBJECTIVES

To determine the effect of a laparoscopic approach on warm renal ischemia in the pig with a solitary kidney. Although the maximal safe duration for warm ischemia during open partial nephrectomy is commonly accepted to be 30 minutes, the maximal safe ischemic time during laparoscopic partial nephrectomy has not been previously determined.

METHODS

Sixteen farm pigs underwent unilateral laparoscopic right nephrectomy. Two weeks later, the pigs underwent complete laparoscopic mobilization of the remaining left kidney and were randomized to complete hilar clamp times of 0, 30, 60, or 90 minutes. Serum creatinine was evaluated before right nephrectomy and at days 0, 2, 4, 7, 14, and 30 after renal ischemia during laparoscopy. All renal specimens were evaluated by an experienced nephropathologist in a blinded fashion.

RESULTS

The serum creatinine remained stable at all points in the control and 30-minute ischemia groups. The serum creatinine level rose initially on days 2 and 4 in the 60-minute and 90-minute ischemia groups but returned to baseline by day 7. At harvest, no statistically significant difference was found among the groups in serum creatinine or histologic features.

CONCLUSIONS

Renal ischemic times up to 90 minutes during laparoscopy were well tolerated by the solitary porcine kidney. Possible explanations for this finding include the protective effect of a solitary kidney and the potential protective effect of relative ischemic preconditioning provided by the pneumoperitoneum.

The role of C-reactive protein in ischemia/reperfusion injury and preconditioning in a rat model of myocardial infarction

For the first time the involvement of C-Reactive protein (CRP) in early (acute) and delayed ischemic (IPC) and pharmacological (chemical) preconditioning (CPC) in an in vivo model of rat myocardial infarction was presented. Acute IPC was produced by three 5 minute occlusion (ischemia) periods interspersed with 5 minute reperfusion, followed by 30 minute occlusion of the left coronary artery and 2 hour reperfusion injury. Acute CPC was produced by a k-opioid receptor agonist U50488H (5 mg/kg) applied i.v. 15 minutes before 30 minute ischemia/ 2 hour reperfusion. Delayed preconditioning was produced by 30 minute ischemia/ 2 hour reperfusion, induced 24 hour after either ischemic or pharmacological preconditioning. The myocardial ischemia/reperfusion injury was evaluated on the basis of total and cardiac creatine kinase isoenzyme activity, functional recovery of the heart (ECG), infarct size (% IS/RA) and mortality at the end of the experiments. The results obtained showed that: k-opioid receptor agonist U50488H mimics both the acute and delayed IPC in the above experimental protocol; Both acute IPC and most probably CPC act by opening of K(ATP) channels (the effects were blocked by nonspecific ATP-sensitive K channel blocker glybenclamide), and via activation of protein kinase C (a selective protein kinase C inhibitor chelerythrine blocked the efects); C-reactive protein (CRP) was significantly elevated by 54% in non-preconditioned acute ischemia/reperfusion injury. The elevation was more pronounced (82% increase) 24 hour after non-preconditioned ischemia/reperfusion injury. It reflected very well the increase in cardiac isoenzymes, infarct size and mortality of the rats, and can be used as a marker of the severity of myocardial injury in this model; The increase of CRP was prevented by both IPC and CPC in early, and especially in late preconditioning. This confirms the involvement of CRP as a marker in cardiac ischemic/reperfusion injury. It was concluded that in addition to the established involvement of adenosine, bradykinin, opioid and other receptors, a suppression of myocardial CRP/complement production might be involved in the biological mechanism of preconditioning. This could be a promising perspective in clinical interventions against ischemia/reperfusion injuries of the heart.

Cecilie Greig memorial lecture 2002. Myocardial protection: an expanding or contracting discipline?

For the past thirty years cardiac surgeons have had a unique opportunity to study the consequences of myocardial ischemia and reperfusion. With the advent of an ability to intervene in acute myocardial syndromes, cardiologists have vigorously joined that effort as have fundamental scientists. Exogenous myocardial protective strategies have emerged as have novel strategies that take advantage of endogenous mechanisms of myocardial protection. As a consequence of improved myocardial protection, operative mortality and morbidity, in particular the low output syndrome, have diminished. However, despite important increases in the knowledge base referable to myocardial ischemia and reperfusion, major advances in myocardial protection have slowed in the past several years. This article explores potential untapped options for augmenting myocardial protection and focuses on the potential adverse interactions between cardiopulmonary bypass and myocardial protection as a prime target for future investigations leading to improved myocardial management during heart operations.