1
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Tawa P, Goutard M, Andrews AR, de Vries RJ, Rosales IA, Yeh H, Uygun B, Randolph MA, Lellouch AG, Uygun K, Cetrulo CL. Response Regarding: Continuous Versus Pulsatile Flow in 24-h Vascularized Composite Allograft Machine Perfusion in Swine: A Pilot Study. J Surg Res 2023; 291:751-753. [PMID: 37517972 DOI: 10.1016/j.jss.2023.05.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 05/27/2023] [Indexed: 08/01/2023]
Affiliation(s)
- Pierre Tawa
- Division of Plastic Surgery, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Shriners Hospital for Children, Boston, Massachusetts
| | - Marion Goutard
- Division of Plastic Surgery, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Shriners Hospital for Children, Boston, Massachusetts
| | - Alec R Andrews
- Division of Plastic Surgery, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Shriners Hospital for Children, Boston, Massachusetts
| | - Reinier J de Vries
- Harvard Medical School, Boston, Massachusetts; Shriners Hospital for Children, Boston, Massachusetts; Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, Boston, Massachusetts; Department of Surgery, Amsterdam University Medical Centers-location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Ivy A Rosales
- Harvard Medical School, Boston, Massachusetts; Immunopathology Research Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Boston, Massachusetts
| | - Heidi Yeh
- Harvard Medical School, Boston, Massachusetts; Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Basak Uygun
- Division of Plastic Surgery, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Shriners Hospital for Children, Boston, Massachusetts; Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Mark A Randolph
- Division of Plastic Surgery, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Shriners Hospital for Children, Boston, Massachusetts
| | - Alexandre G Lellouch
- Division of Plastic Surgery, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Shriners Hospital for Children, Boston, Massachusetts; Service de Chirurgie Plastique, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris (APHP), Université Paris Descartes, Paris, France
| | - Korkut Uygun
- Division of Plastic Surgery, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Shriners Hospital for Children, Boston, Massachusetts; Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, Boston, Massachusetts.
| | - Curtis L Cetrulo
- Division of Plastic Surgery, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Shriners Hospital for Children, Boston, Massachusetts.
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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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Tawa P, Goutard M, Andrews AR, de Vries RJ, Rosales IA, Yeh H, Uygun B, Randolph MA, Lellouch AG, Uygun K, Cetrulo CL. Continuous versus Pulsatile Flow in 24-Hour Vascularized Composite Allograft Machine Perfusion in Swine: A Pilot Study. J Surg Res 2023; 283:1145-1153. [PMID: 36915006 PMCID: PMC10867902 DOI: 10.1016/j.jss.2022.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 10/12/2022] [Accepted: 11/02/2022] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Multiple perfusion systems have been investigated on vascularized composite allografts, with various temperatures and different preservation solutions, most using continuous flow (CF). However, physiological flow is pulsatile and provides better outcomes in kidney and lung ex vivo perfusions. The objective of this pilot study is to compare pulsatile flow (PF) with CF in our 24-h subnormothermic machine perfusion protocol for swine hindlimbs. METHODS Partial hindlimbs were harvested from Yorkshire pigs and perfused with a modified Steen solution at 21°C for 24 h either with CF (n = 3) or with pulsatile flow (PF) at 60 beats/min (n = 3). Perfusion parameters, endothelial markers, and muscle biopsies were assessed at different timepoints. RESULTS Overall, lactate levels were significantly lower in the PF group (P = 0.001). Glucose uptake and potassium concentration were similar in both groups throughout perfusion. Total nitric oxide levels were significantly higher in the PF group throughout perfusion (P = 0.032). Nitric oxide/endothelin-1 ratio also tends to be higher in the PF group, reflecting a potentially better vasoconductivity with PF, although not reaching statistical significance (P = 0.095). Arterial resistances were higher in the PF group (P < 0.001). Histological assessment did not show significant difference in muscular injury between the two groups. Weight increased quicker in the CF group but reached similar values with the PF after 24 h. CONCLUSIONS This pilot study suggests that PF may provide superior preservation of vascularized composite allografts when perfused for 24 h at subnormothermic temperatures, with potential improvement in endothelial function and decreased ischemic injury.
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Affiliation(s)
- Pierre Tawa
- Division of Plastic Surgery, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Shriners Hospital for Children, Boston, Massachusetts; Service de Chirurgie Plastique, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris (APHP), Université Paris Descartes, Paris, France
| | - Marion Goutard
- Division of Plastic Surgery, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Shriners Hospital for Children, Boston, Massachusetts; Service de Chirurgie Plastique, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris (APHP), Université Paris Descartes, Paris, France
| | - Alec R Andrews
- Division of Plastic Surgery, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Shriners Hospital for Children, Boston, Massachusetts
| | - Reinier J de Vries
- Harvard Medical School, Boston, Massachusetts; Shriners Hospital for Children, Boston, Massachusetts; Department of Surgery, Amsterdam University Medical Centers - Location AMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Ivy A Rosales
- Harvard Medical School, Boston, Massachusetts; Immunopathology Research Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Boston, Massachusetts
| | - Heidi Yeh
- Harvard Medical School, Boston, Massachusetts; Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Basak Uygun
- Harvard Medical School, Boston, Massachusetts; Shriners Hospital for Children, Boston, Massachusetts; Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Mark A Randolph
- Division of Plastic Surgery, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Shriners Hospital for Children, Boston, Massachusetts
| | - Alexandre G Lellouch
- Division of Plastic Surgery, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Shriners Hospital for Children, Boston, Massachusetts; Service de Chirurgie Plastique, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris (APHP), Université Paris Descartes, Paris, France
| | - Korkut Uygun
- Division of Plastic Surgery, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Shriners Hospital for Children, Boston, Massachusetts; Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, Boston, Massachusetts.
| | - Curtis L Cetrulo
- Division of Plastic Surgery, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Shriners Hospital for Children, Boston, Massachusetts.
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Hemodynamic Effect of Pulsatile on Blood Flow Distribution with VA ECMO: A Numerical Study. Bioengineering (Basel) 2022; 9:bioengineering9100487. [PMID: 36290455 PMCID: PMC9598990 DOI: 10.3390/bioengineering9100487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 08/20/2022] [Accepted: 09/09/2022] [Indexed: 11/20/2022] Open
Abstract
The pulsatile properties of arterial flow and pressure have been thought to be important. Nevertheless, a gap still exists in the hemodynamic effect of pulsatile flow in improving blood flow distribution of veno-arterial extracorporeal membrane oxygenation (VA ECMO) supported by the circulatory system. The finite-element models, consisting of the aorta, VA ECMO, and intra-aortic balloon pump (IABP) are proposed for fluid-structure interaction calculation of the mechanical response. Group A is cardiogenic shock with 1.5 L/min of cardiac output. Group B is cardiogenic shock with VA ECMO. Group C is added to IABP based on Group B. The sum of the blood flow of cardiac output and VA ECMO remains constant at 4.5 L/min in Group B and Group C. With the recovery of the left ventricular, the flow of VA ECMO declines, and the effective blood of IABP increases. IABP plays the function of balancing blood flow between left arteria femoralis and right arteria femoralis compared with VA ECMO only. The difference of the equivalent energy pressure (dEEP) is crossed at 2.0 L/min to 1.5 L/min of VA ECMO. PPI’ (the revised pulse pressure index) with IABP is twice as much as without IABP. The intersection with two opposing blood generates the region of the aortic arch for the VA ECMO (Group B). In contrast to the VA ECMO, the blood intersection appears from the descending aorta to the renal artery with VA ECMO and IABP. The maximum time-averaged wall shear stress (TAWSS) of the renal artery is a significant difference with or not IABP (VA ECMO: 2.02 vs. 1.98 vs. 2.37 vs. 2.61 vs. 2.86 Pa; VA ECMO and IABP: 8.02 vs. 6.99 vs. 6.62 vs. 6.30 vs. 5.83 Pa). In conclusion, with the recovery of the left ventricle, the flow of VA ECMO declines and the effective blood of IABP increases. The difference between the equivalent energy pressure (EEP) and the surplus hemodynamic energy (SHE) indicates the loss of pulsation from the left ventricular to VA ECMO. 2.0 L/min to 1.5 L/min of VA ECMO showing a similar hemodynamic energy loss with the weak influence of IABP.
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Lodhi S, Stone JP, Entwistle TR, Fildes JE. The Use of Hemoglobin-Based Oxygen Carriers in Ex Vivo Machine Perfusion of Donor Organs for Transplantation. ASAIO J 2022; 68:461-470. [PMID: 35220355 DOI: 10.1097/mat.0000000000001597] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
There has been significant progress in the development of ex vivo machine perfusion for the nonischemic preservation of donor organs. However, several complications remain, including the logistics of using human blood for graft oxygenation and hemolysis occurring as a result of mechanical technology. Recently, hemoglobin-based oxygen carriers, originally developed for use as blood substitutes, have been studied as an alternative to red blood cell-based perfusates. Although research in this field is somewhat limited, the findings are promising. We offer a brief review of the use of hemoglobin-based oxygen carriers in ex vivo machine perfusion and discuss future directions that will likely have a major impact in progressing oxygen carrier use in clinical practice.
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Affiliation(s)
- Sirat Lodhi
- From the The Ex-Vivo Research Centre, 3F66, Block 3, Alderley Park, Nether Alderley, Cheshire, United Kingdom
- The Ex-Vivo Lab, Division of Cell Matrix Biology and Regenerative Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - John P Stone
- From the The Ex-Vivo Research Centre, 3F66, Block 3, Alderley Park, Nether Alderley, Cheshire, United Kingdom
- The Ex-Vivo Lab, Division of Cell Matrix Biology and Regenerative Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
- The Transplant Centre, Manchester Foundation Trust, Manchester, United Kingdom
- Lydia Becker Institute of Immunology and Inflammation, School of Biological Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
| | - Timothy R Entwistle
- From the The Ex-Vivo Research Centre, 3F66, Block 3, Alderley Park, Nether Alderley, Cheshire, United Kingdom
- The Ex-Vivo Lab, Division of Cell Matrix Biology and Regenerative Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
- The Transplant Centre, Manchester Foundation Trust, Manchester, United Kingdom
- Lydia Becker Institute of Immunology and Inflammation, School of Biological Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
| | - James E Fildes
- From the The Ex-Vivo Research Centre, 3F66, Block 3, Alderley Park, Nether Alderley, Cheshire, United Kingdom
- The Ex-Vivo Lab, Division of Cell Matrix Biology and Regenerative Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
- The Transplant Centre, Manchester Foundation Trust, Manchester, United Kingdom
- Lydia Becker Institute of Immunology and Inflammation, School of Biological Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
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Hamelink TL, Ogurlu B, De Beule J, Lantinga VA, Pool MBF, Venema LH, Leuvenink HGD, Jochmans I, Moers C. Renal Normothermic Machine Perfusion: The Road Toward Clinical Implementation of a Promising Pretransplant Organ Assessment Tool. Transplantation 2022; 106:268-279. [PMID: 33979315 DOI: 10.1097/tp.0000000000003817] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The increased utilization of high-risk renal grafts for transplantation requires optimization of pretransplant organ assessment strategies. Current decision-making methods to accept an organ for transplantation lack overall predictive power and always contain an element of subjectivity. Normothermic machine perfusion (NMP) creates near-physiological conditions, which might facilitate a more objective assessment of organ quality before transplantation. NMP is rapidly gaining popularity, with various transplant centers developing their own NMP protocols and renal viability criteria. However, to date, no validated sets of on-pump viability markers exist nor are there unified NMP protocols. This review provides a critical overview of the fundamentals of current renal NMP protocols and proposes a framework to approach further development of ex vivo organ evaluation. We also comment on the potential logistical implications of routine clinical use of NMP, which is a more complex procedure compared with static cold storage or even hypothermic machine perfusion.
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Affiliation(s)
- Tim L Hamelink
- Department of Surgery-Organ Donation and Transplantation, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Baran Ogurlu
- Department of Surgery-Organ Donation and Transplantation, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Julie De Beule
- Laboratory of Abdominal Transplantation, Transplantation Research Group, Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium
| | - Veerle A Lantinga
- Department of Surgery-Organ Donation and Transplantation, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Merel B F Pool
- Department of Surgery-Organ Donation and Transplantation, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Leonie H Venema
- Department of Surgery-Organ Donation and Transplantation, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Henri G D Leuvenink
- Department of Surgery-Organ Donation and Transplantation, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Ina Jochmans
- Laboratory of Abdominal Transplantation, Transplantation Research Group, Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium
- Department of Abdominal Transplant Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Cyril Moers
- Department of Surgery-Organ Donation and Transplantation, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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Lascaris B, Thorne AM, Lisman T, Nijsten MWN, Porte RJ, de Meijer VE. Long-term normothermic machine preservation of human livers: what is needed to succeed? Am J Physiol Gastrointest Liver Physiol 2022; 322:G183-G200. [PMID: 34756122 DOI: 10.1152/ajpgi.00257.2021] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Although short-term machine perfusion (≤24 h) allows for resuscitation and viability assessment of high-risk donor livers, the donor organ shortage might be further remedied by long-term perfusion machines. Extended preservation of injured donor livers may allow reconditioning, repairing, and regeneration. This review summarizes the necessary requirements and challenges for long-term liver machine preservation, which requires integrating multiple core physiological functions to mimic the physiological environment inside the body. A pump simulates the heart in the perfusion system, including automatically controlled adjustment of flow and pressure settings. Oxygenation and ventilation are required to account for the absence of the lungs combined with continuous blood gas analysis. To avoid pressure necrosis and achieve heterogenic tissue perfusion during preservation, diaphragm movement should be simulated. An artificial kidney is required to remove waste products and control the perfusion solution's composition. The perfusate requires an oxygen carrier, but will also be challenged by coagulation and activation of the immune system. The role of the pancreas can be mimicked through closed-loop control of glucose concentrations by automatic injection of insulin or glucagon. Nutrients and bile salts, generally transported from the intestine to the liver, have to be supplemented when preserving livers long term. Especially for long-term perfusion, the container should allow maintenance of sterility. In summary, the main challenge to develop a long-term perfusion machine is to maintain the liver's homeostasis in a sterile, carefully controlled environment. Long-term machine preservation of human livers may allow organ regeneration and repair, thereby ultimately solving the shortage of donor livers.
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Affiliation(s)
- Bianca Lascaris
- Section of Hepatopancreatobiliary Surgery & Liver Transplantation, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Adam M Thorne
- Section of Hepatopancreatobiliary Surgery & Liver Transplantation, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Ton Lisman
- Surgical Research Laboratory, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Maarten W N Nijsten
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Robert J Porte
- Section of Hepatopancreatobiliary Surgery & Liver Transplantation, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Vincent E de Meijer
- Section of Hepatopancreatobiliary Surgery & Liver Transplantation, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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8
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Walther CP, Civitello AB, Liao KK, Navaneethan SD. Nephrology Considerations in the Management of Durable and Temporary Mechanical Circulatory Support. KIDNEY360 2022; 3:569-579. [PMID: 35582171 PMCID: PMC9034823 DOI: 10.34067/kid.0003382021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 01/04/2022] [Indexed: 01/10/2023]
Abstract
Durable and temporary mechanical circulatory support (MCS) use is growing for a range of cardiovascular indications. Kidney dysfunction is common in people evaluated for or receiving durable or temporary MCS and portends worse outcomes. This kidney dysfunction can be due to preexisting kidney chronic kidney disease (CKD), acute kidney injury (AKI) related to acute cardiovascular disease necessitating MCS, AKI due to cardiac procedures, and acute and chronic MCS effects and complications. Durable MCS, with implantable continuous flow pumps, is used for long-term support in advanced heart failure refractory to guideline-directed medical and device therapy, either permanently or as a bridge to heart transplantation. Temporary MCS-encompassing in this review intra-aortic balloon pumps (IABP), axial flow pumps, centrifugal flow pumps, and venoarterial ECMO-is used for diverse situations: high-risk percutaneous coronary interventions (PCI), acute decompensated heart failure, cardiogenic shock, and resuscitation after cardiac arrest. The wide adoption of MCS makes it imperative to improve understanding of the effects of MCS on kidney health/function and of kidney health/function on MCS outcomes. The complex structure and functions of the kidney, and the complex health states of individuals receiving MCS, makes investigations in this area challenging, and current knowledge is limited. Fortunately, the increasing nephrology toolbox of noninvasive kidney health/function assessments may enable development and testing of individualized management strategies and therapeutics in the future. We review technology, epidemiology, pathophysiology, clinical considerations, and future directions in MCS and nephrology.
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Affiliation(s)
- Carl P. Walther
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Andrew B. Civitello
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas,Advanced Heart Failure Center of Excellence, Baylor College of Medicine, Houston, Texas
| | - Kenneth K. Liao
- Division of Cardiothoracic Transplantation and Circulatory Support, Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Sankar D. Navaneethan
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas,Section of Nephrology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas,Institute of Clinical and Translational Research, Baylor College of Medicine, Houston, Texas
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9
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Preservation of Mitochondrial Coupling and Renal Function by Controlled Oxygenated Rewarming of Porcine Kidney Grafts. Biomolecules 2021; 11:biom11121880. [PMID: 34944524 PMCID: PMC8699534 DOI: 10.3390/biom11121880] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 12/07/2021] [Accepted: 12/09/2021] [Indexed: 12/21/2022] Open
Abstract
Background: Warm reperfusion after previous cold storage has been shown to have a negative impact on mitochondrial function of organ grafts. Here, we wanted to investigate whether a more controlled warming up of the cold graft by ex vivo machine perfusion with gradually elevated temperature from cold to normothermia (including comparison of two warming up protocols) prior to implantation would be effective in preventing mitochondrial dysfunction upon reperfusion. Methods: All experiments were conducted on porcine kidneys retrieved 15 min after cardiac arrest. After 18 h of cold storage in HTK solution (CS, n = 6), kidneys (n = 6) were subjected to 2 h of reconditioning machine perfusion starting with a hypothermic period followed by a gradual increase in perfusion temperature up to 35 °C (controlled oxygenated rewarming—COR). For a second group (n = 6), the slow warming up was begun instantly after connecting the graft onto the machine (iCOR). Functional recovery of all grafts was then observed upon normothermic reperfusion in vitro. At the conclusion of the experiments, tissue specimens were taken for immediate isolation and analysis of renal mitochondria. Results: COR resulted in a significantly and more than 3-fold increased glomerular filtration rate upon reperfusion, along with a significant higher tubular sodium reabsorption and lesser loss of glucose in comparison to the controls. Enzyme release (AST) was also massively reduced during the reperfusion period. Specific analysis at the mitochondrial level revealed significantly better coupling efficiency and spare respiratory capacity in the COR group compared to the cold storage group. Interestingly, additional experiments revealed that the omission of a hypothermic perfusion period did not deteriorate any of the results after COR, provided that the instant temperature increase from 10 to 35 °C was effectuated in the same controlled manner. Conclusion: Controlled rewarming after extended cold preservation effectively improves mitochondrial recovery upon reperfusion and early functional outcome of kidney grafts.
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10
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von Horn C, Wilde B, Rauen U, Paul A, Minor T. Use of the new preservation solution Custodiol-MP for ex vivo reconditioning of kidney grafts. Artif Organs 2021; 45:1117-1123. [PMID: 33683761 DOI: 10.1111/aor.13951] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 11/12/2020] [Accepted: 03/02/2021] [Indexed: 01/02/2023]
Abstract
Organ shortage and the increasing use of extended criteria donor grafts for transplantation drives efforts for more efficient organ preservation strategies from simple cold storage toward dynamic organ reconditioning. The choice of a suitable preservation solution is of high relevance in different organ preservation or reconditioning situations. Custodiol-MP is a new machine perfusion solution giving the opportunity to add colloids according to organ requirements. The present study aimed to compare new Custodiol-MP with clinically established Belzer MPS solution. Porcine kidneys were ischemically predamaged and cold stored for 20 hours. Ex vivo machine reconditioning was performed either with Custodiol-MP (n = 6) or with Belzer MPS solution (n = 6) for 90 minutes with controlled oxygenated rewarming up to 20°C. Kidney function was evaluated using an established ex vivo reperfusion model. In this experimental setting, differences between both types of perfusion solutions could not be observed. Machine perfusion with Custodiol-MP resulted in higher creatinine clearance (7.4 ± 8.6 mL/min vs. 2.8 ± 2.5 mL/min) and less TNC perfusate levels (0.22 ± 0.25 ng/mL vs. 0.09 ± 0.08 ng/mL), although differences did not reach significance. For short-term kidney perfusion Custodiol-MP is safe and applicable. Particularly, the unique feature of flexible colloid supplementation makes the solution attractive in specific experimental and clinical settings.
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Affiliation(s)
- Charlotte von Horn
- Department of Surgical Research, Clinic for General, Visceral and Transplantation Surgery, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Benjamin Wilde
- Department of Nephrology, University Hospital Essen, University of Duisburg-Essen, University Duisburg-Essen, Essen, Germany
| | - Ursula Rauen
- Institut für Physiologische Chemie, Universitätsklinikum Essen, University Duisburg-Essen, Essen, Germany
| | - Andreas Paul
- Clinic for General, Visceral and Transplantation Surgery, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Thomas Minor
- Department of Surgical Research, Clinic for General, Visceral and Transplantation Surgery, University Hospital Essen, University Duisburg-Essen, Essen, Germany
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Rajaram A, Milej D, Suwalski M, Yip LCM, Guo LR, Chu MWA, Chui J, Diop M, Murkin JM, St. Lawrence K. Optical monitoring of cerebral perfusion and metabolism in adults during cardiac surgery with cardiopulmonary bypass. BIOMEDICAL OPTICS EXPRESS 2020; 11:5967-5981. [PMID: 33149999 PMCID: PMC7587277 DOI: 10.1364/boe.404101] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 09/03/2020] [Accepted: 09/03/2020] [Indexed: 05/23/2023]
Abstract
During cardiac surgery with cardiopulmonary bypass (CPB), adequate maintenance of cerebral blood flow (CBF) is vital in preventing postoperative neurological injury - i.e. stroke, delirium, cognitive impairment. Reductions in CBF large enough to impact cerebral energy metabolism can lead to tissue damage and subsequent brain injury. Current methods for neuromonitoring during surgery are limited. This study presents the clinical translation of a hybrid optical neuromonitor for continuous intraoperative monitoring of cerebral perfusion and metabolism in ten patients undergoing non-emergent cardiac surgery with non-pulsatile CPB. The optical system combines broadband near-infrared spectroscopy (B-NIRS) to measure changes in the oxidation state of cytochrome c oxidase (oxCCO) - a direct marker of cellular energy metabolism - and diffuse correlation spectroscopy (DCS) to provide an index of cerebral blood flow (CBFi). As the heart was arrested and the CPB-pump started, increases in CBFi (88.5 ± 125.7%) and significant decreases in oxCCO (-0.5 ± 0.2 µM) were observed; no changes were noted during transitions off CPB. Fifteen hypoperfusion events, defined as large and sustained reductions in CPB-pump flow rate, were identified across all patients and resulted in significant decreases in perfusion and metabolism when mean arterial pressure dropped to 30 mmHg or below. The maximum reduction in cerebral blood flow preceded the corresponding metabolic reduction by 18.2 ± 15.0 s. Optical neuromonitoring provides a safe and non-invasive approach for assessing intraoperative perfusion and metabolism and has potential in guiding patient management to prevent adverse clinical outcomes.
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Affiliation(s)
- Ajay Rajaram
- Imaging Program, Lawson Health Research Institute, 268 Grosvenor St., London, ON, N6A 4V2, Canada
- Department of Medical Biophysics, Western University, 1151 Richmond St., London, ON, N6A 3K7, Canada
| | - Daniel Milej
- Imaging Program, Lawson Health Research Institute, 268 Grosvenor St., London, ON, N6A 4V2, Canada
| | - Marianne Suwalski
- Imaging Program, Lawson Health Research Institute, 268 Grosvenor St., London, ON, N6A 4V2, Canada
- Department of Medical Biophysics, Western University, 1151 Richmond St., London, ON, N6A 3K7, Canada
| | - Lawrence C. M. Yip
- Imaging Program, Lawson Health Research Institute, 268 Grosvenor St., London, ON, N6A 4V2, Canada
- Department of Medical Biophysics, Western University, 1151 Richmond St., London, ON, N6A 3K7, Canada
| | - Linrui R. Guo
- Division of Cardiac Surgery, London Health Science Centre, 339 Windermere Rd, London, ON, N6A 5A5, Canada
| | - Michael W. A. Chu
- Division of Cardiac Surgery, London Health Science Centre, 339 Windermere Rd, London, ON, N6A 5A5, Canada
| | - Jason Chui
- Department of Anesthesiology and Perioperative Medicine, London Health Science Centre, 339 Windermere Rd, London, ON, N6A 5A5, Canada
| | - Mamadou Diop
- Imaging Program, Lawson Health Research Institute, 268 Grosvenor St., London, ON, N6A 4V2, Canada
- Department of Medical Biophysics, Western University, 1151 Richmond St., London, ON, N6A 3K7, Canada
| | - John M. Murkin
- Department of Anesthesiology and Perioperative Medicine, London Health Science Centre, 339 Windermere Rd, London, ON, N6A 5A5, Canada
| | - Keith St. Lawrence
- Imaging Program, Lawson Health Research Institute, 268 Grosvenor St., London, ON, N6A 4V2, Canada
- Department of Medical Biophysics, Western University, 1151 Richmond St., London, ON, N6A 3K7, Canada
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12
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Uehara M, Bahmani B, Jiang L, Jung S, Banouni N, Kasinath V, Solhjou Z, Jing Z, Ordikhani F, Bae M, Clardy J, Annabi N, McGrath MM, Abdi R. Nanodelivery of Mycophenolate Mofetil to the Organ Improves Transplant Vasculopathy. ACS NANO 2019; 13:12393-12407. [PMID: 31518498 PMCID: PMC7247279 DOI: 10.1021/acsnano.9b05115] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
Inflammation occurring within the transplanted organ from the time of harvest is an important stimulus of early alloimmune reactivity and promotes chronic allograft rejection. Chronic immune-mediated injury remains the primary obstacle to the long-term success of organ transplantation. However, organ transplantation represents a rare clinical setting in which the organ is accessible ex vivo, providing an opportunity to use nanotechnology to deliver therapeutics directly to the graft. This approach facilitates the directed delivery of immunosuppressive agents (ISA) to target local pathogenic immune responses prior to the transplantation. Here, we have developed a system of direct delivery and sustained release of mycophenolate mofetil (MMF) to treat the donor organ prior to transplantation. Perfusion of a donor mouse heart with MMF-loaded PEG-PLGA nanoparticles (MMF-NPs) prior to transplantation abrogated cardiac transplant vasculopathy by suppressing intragraft pro-inflammatory cytokines and chemokines. Our findings demonstrate that ex vivo delivery of an ISA to donor organs using a nanocarrier can serve as a clinically feasible approach to reduce transplant immunity.
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Affiliation(s)
- Mayuko Uehara
- Transplantation Research Center, Renal Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Baharak Bahmani
- Transplantation Research Center, Renal Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Liwei Jiang
- Transplantation Research Center, Renal Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Sungwook Jung
- Transplantation Research Center, Renal Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Naima Banouni
- Transplantation Research Center, Renal Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Vivek Kasinath
- Transplantation Research Center, Renal Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Zhabiz Solhjou
- Transplantation Research Center, Renal Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Zhao Jing
- Transplantation Research Center, Renal Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Farideh Ordikhani
- Transplantation Research Center, Renal Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Munhyung Bae
- Department of Biological Chemistry and Molecular Pharmacology, Harvard Medical School, Boston, MA, USA
| | - Jon Clardy
- Department of Biological Chemistry and Molecular Pharmacology, Harvard Medical School, Boston, MA, USA
| | - Nasim Annabi
- Department of Chemical and Biomolecular Engineering, University of California Los Angeles, Los Angeles, CA, USA
| | - Martina M. McGrath
- Transplantation Research Center, Renal Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- Address correspondence to: Reza Abdi, MD, Transplantation Research Center, Brigham and Women’s Hospital, 221 Longwood Ave, Boston MA 02115, USA, Tel: 617-732-5259, Fax: 617-732-5254, ; Martina M. McGrath, Transplantation Research Center, Brigham and Women’s Hospital, 221 Longwood Ave, Boston MA 02115, USA, Tel: 617-732-5259, Fax: 617-732-5254,
| | - Reza Abdi
- Transplantation Research Center, Renal Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- Address correspondence to: Reza Abdi, MD, Transplantation Research Center, Brigham and Women’s Hospital, 221 Longwood Ave, Boston MA 02115, USA, Tel: 617-732-5259, Fax: 617-732-5254, ; Martina M. McGrath, Transplantation Research Center, Brigham and Women’s Hospital, 221 Longwood Ave, Boston MA 02115, USA, Tel: 617-732-5259, Fax: 617-732-5254,
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Intermittent application of external positive pressure helps to preserve organ viability during ex vivo perfusion and culture. J Artif Organs 2019; 23:36-45. [PMID: 31617028 PMCID: PMC7046602 DOI: 10.1007/s10047-019-01141-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 10/05/2019] [Indexed: 12/03/2022]
Abstract
The perfusion of medium through blood vessels allows the preservation of donor organs and culture of bioengineered organs. However, tissue damage due to inadequate perfusion remains a problem. We evaluated whether intermittent external pressurization would improve the perfusion and viability of organs in culture. A bioreactor system was used to perfuse and culture rat small intestine and femoral muscle preparations. Intermittent positive external pressure (10 mmHg) was applied for 20 s at intervals of 20 s. Intermittent pressurization resulted in uniform perfusion of small intestine preparations and minimal tissue damage after 20 h of perfusion, whereas non-pressurized (control) preparations exhibited significantly worse perfusion of the upper surface than the lower surface and histologic evidence of tissue damage. Longer term studies were undertaken in luciferase-expressing rat femoral muscle preparations. Compared with non-pressurized controls, intermittent pressurization led to better perfusion throughout the 14-day experimental period, improved organ viability as indicated by a higher bioluminescence intensity after perfusion with luciferin, and reduced levels of tissue necrosis with better preservation of vascular structures and skeletal muscle nuclei (histologic analyses). Therefore, intermittent application of external positive pressure improved the perfusion of small intestine and skeletal muscle preparations and enhanced tissue viability when compared with controls. We anticipate that this innovative perfusion technique could be used to improve the preservation of donor organs and culture of bioengineered organs.
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Mahboub P, Aburawi M, Karimian N, Lin F, Karabacak M, Fontan F, Tessier SN, Markmann J, Yeh H, Uygun K. The efficacy of HBOC-201 in ex situ gradual rewarming kidney perfusion in a rat model. Artif Organs 2019; 44:81-90. [PMID: 31368159 PMCID: PMC6916591 DOI: 10.1111/aor.13534] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 06/03/2019] [Accepted: 07/03/2019] [Indexed: 02/06/2023]
Abstract
Gradual rewarming from hypothermic to normothermic is a novel perfusion modality with superior outcome to sudden rewarming to normothermic. However, the identification of an oxygen carrier that could function at a temperature range from 4 to 7°C or whether it is necessary to use oxygen carrier during kidney rewarming, remains unresolved. This study was designed to test the use of a hemoglobin‐based oxygen carrier (HBOC) during gradual kidney rewarming as an alternative to simple dissolved oxygen. In this study, 10 rat kidneys were randomly divided into the control and the HBOC group. In the control group, no oxygen carrier was used during rewarming perfusion and the perfusion solution was oxygenated only by applying diffused carbogen flow. The protocol mimicked a donor after circulatory death (DCD) kidney transplantation, where after 30 minutes warm ischemia and 120 minutes cold storage in University of Wisconsin solution, the DCD kidneys underwent gradual rewarming from 10 to 37°C during 90 minutes with or without HBOC. This was followed by 30 minutes of warm ischemia in room temperature to mimic the anastomosis time and 120 minutes of reperfusion at 37°C to mimic the early post‐transplant state of the graft. The HBOC group demonstrated superior kidney function which was highlighted by higher ultrafiltrate production, better glomerular filtration rate and improved sodium reabsorption. There was no significant difference between the 2 groups regarding the hemodynamics, tissue injury, and adenosine triphosphate levels. In conclusion, this study suggests better renal function recovery in DCD kidneys after rewarming with HBOC compared to rewarming without an oxygen carrier.
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Affiliation(s)
- Paria Mahboub
- University Medical Center Groningen, Groningen, Netherlands.,Center for Engineering in Medicine, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mohamed Aburawi
- Transplant Center, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Negin Karimian
- Center for Engineering in Medicine, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Florence Lin
- Center for Engineering in Medicine, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Murat Karabacak
- Center for Engineering in Medicine, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Fermin Fontan
- Transplant Center, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Shannon N Tessier
- Center for Engineering in Medicine, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - James Markmann
- Transplant Center, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Heidi Yeh
- Center for Engineering in Medicine, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.,Transplant Center, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Korkut Uygun
- Center for Engineering in Medicine, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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15
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16
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Padma AM, Truong M, Jar-Allah T, Song MJ, Oltean M, Brännström M, Hellström M. The development of an extended normothermic ex vivo reperfusion model of the sheep uterus to evaluate organ quality after cold ischemia in relation to uterus transplantation. Acta Obstet Gynecol Scand 2019; 98:1127-1138. [PMID: 30932168 DOI: 10.1111/aogs.13617] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 03/01/2019] [Accepted: 03/27/2019] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Uterus transplantation has recently proved that infertility in women with uterine factor infertility can be cured. It is still an experimental procedure with numerous critical details remaining to be established, including tolerance to warm and cold ischemic insults. In preparation for human uterus transplantation trials, most teams use the sheep as a model system for research and team training, since the vasculature and the uterus is of similar size as in the human. We, therefore, aimed to develop an ex vivo sheep uterus reperfusion platform that mimics the reperfusion situation so that initial assessments and comparisons can be performed without the need for costly and labor-intensive in vivo transplantation experiments. MATERIAL AND METHODS Isolated sheep uteri were perfused with the preservation solution IGL-1 and were then exposed to cold ischemia for either 4 (n = 6) or 48 hours (n = 7). Uteri were then reperfused for 48 hours under normothermic conditions with an oxygenated recirculating perfusate containing growth factors and synthetic oxygen carriers. Histological and biochemical analysis of the perfusate was conducted to assess reperfusion injury. RESULTS Quantification of cell density indicated no significant edema in the myometrium or in the endometrium of uteri exposed to 4 hours cold ischemia and then a normothermic ex vivo reperfusion for 48 hours. Only the outer serosa layer and the inner columnar luminal epithelial cells were affected by the reperfusion. However, a much faster and severe reperfusion damage of all uterine layers were evident during the reperfusion experiment following 48 hours of cold ischemia. This was indicated by major accumulation of extracellular fluid, presence of apoptotic-labeled glandular epithelial layer and vascular endothelium. A significant accumulation of lactate was measured in the perfusate with a subsequent decrease in pH. CONCLUSIONS We developed a novel ex vivo sheep uterus model for prolonged perfusion. This model proved to be able to distinguish reperfusion injury-related differences associated to organ preservation. The experimental setup is a platform that can be used to conduct further studies on uterine ischemia- and reperfusion injury that may lead to improved human uterus transplantation protocols.
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Affiliation(s)
- Arvind M Padma
- Laboratory for Transplantation and Regenerative Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Obstetrics and Gynecology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - MyLan Truong
- Laboratory for Transplantation and Regenerative Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Obstetrics and Gynecology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Tagrid Jar-Allah
- Laboratory for Transplantation and Regenerative Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Obstetrics and Gynecology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Min J Song
- Laboratory for Transplantation and Regenerative Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Obstetrics and Gynecology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Daejeon St. Mary's Hospital, The Catholic University of Korea, Daejeon, South Korea
| | - Mihai Oltean
- Laboratory for Transplantation and Regenerative Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Surgery, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Mats Brännström
- Laboratory for Transplantation and Regenerative Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Obstetrics and Gynecology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Stockholm IVF-EUGIN, Stockholm, Sweden
| | - Mats Hellström
- Laboratory for Transplantation and Regenerative Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Obstetrics and Gynecology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Miyamoto T, Karimov JH, Fukamachi K. Acute and chronic effects of continuous‐flow support and pulsatile‐flow support. Artif Organs 2019; 43:618-623. [DOI: 10.1111/aor.13446] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 02/21/2019] [Indexed: 01/03/2023]
Affiliation(s)
- Takuma Miyamoto
- Department of Biomedical Engineering Lerner Research Institute, Cleveland Clinic Cleveland Ohio
| | - Jamshid H. Karimov
- Department of Biomedical Engineering Lerner Research Institute, Cleveland Clinic Cleveland Ohio
| | - Kiyotaka Fukamachi
- Department of Biomedical Engineering Lerner Research Institute, Cleveland Clinic Cleveland Ohio
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Cold Pulsatile Machine Perfusion versus Static Cold Storage in Kidney Transplantation: A Single Centre Experience. BIOMED RESEARCH INTERNATIONAL 2019; 2019:7435248. [PMID: 30792996 PMCID: PMC6354149 DOI: 10.1155/2019/7435248] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 12/26/2018] [Accepted: 01/08/2019] [Indexed: 12/23/2022]
Abstract
Introduction We present our experience with hypothermic machine perfusion (HMP) versus cold storage (CS) in relation to kidney transplant outcomes. Methods Retrospective analysis of 33 consecutive HMP kidney transplant outcomes matched with those of 33 cold stored: delayed graft function (DGF), length of hospital stay (LOS), estimated glomerular filtration rate (eGFR), and patient and graft survival were compared. Renal Resistive Indexes (RIs) during HMP in relation to DGF were also analysed. Results In the HMP group, mean HMP time was 5.7 ± 3.9 hours with a mean cold ischaemic time (CIT) of 15 ± 5.6 versus 15.1 ± 5.3 hours in the CS group. DGF was lower in the HMP group (p=0.041), and donation after Circulatory Death (DCD) was a predictor for DGF (p<0.01). HMP decreased DGF in DCD grafts (p=0.036). Patient and graft survival were similar, but eGFR at 365 days was higher in the HMP cohort (p<0.001). RIs decreased during HMP (p<0.01); 2-hours RI ≥ 0.45 mmHg/mL/min predicted DGF in DCD kidneys (75% sensitivity, 80% specificity; area under the curve 0.78); 2-hours RI ≥ 0.2 mmHg/ml/min predicted DGF in DBD grafts (sensitivity 100%, specificity 91%; area under the curve 0.87). Conclusion HMP decreased DGF compared to CS, offering viability assessment pretransplant and improving one-year renal function of the grafts.
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Minor T, von Horn C, Paul A. Role of erythrocytes in short-term rewarming kidney perfusion after cold storage. Artif Organs 2019; 43:584-592. [PMID: 30511774 DOI: 10.1111/aor.13403] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 11/27/2018] [Accepted: 11/29/2018] [Indexed: 12/23/2022]
Abstract
Short term normothermic reconditioning by machine perfusion after cold storage has shown beneficial effects in renal transplantation models. Systematic investigations concerning the inclusion of washed erythrocytes as oxygen carriers are lacking in this context. Porcine kidneys were subjected to 20 h of static cold storage. Prior to reperfusion, grafts were put on a machine for 2 h of oxygenated (95% O2 ; 5% CO2 ) rewarming perfusion. In one group (n = 6) washed erythrocytes were added to the perfusate after temperature has reached 20°C; the other group (n = 6) was run without additives. Control kidneys (n = 6) were immediately reperfused without treatment. Upon reperfusion in vitro, a more than twofold improvement of renal clearance of creatinine, urinary protein loss, fractional excretion of sodium, efficiency of oxygen utilization (TNa/VO2 ) and a significant reduction of innate immune activation (HMGB1, tenascin C, expression of TLR4) was seen after machine perfusion, compared with the controls. However, no advantage could be obtained by the addition of erythrocytes and inner cortical tissue pO2 always remained above normal values during cell-free machine perfusion. Our data strongly argue in favor of a rewarming perfusion of cold stored donor kidneys but do not substantiate an indication for adding oxygen carriers in this particular setting.
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Affiliation(s)
- Thomas Minor
- Department of Surgical Research, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Charlotte von Horn
- Department of Surgical Research, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Andreas Paul
- Clinic for General, Visceral and Transplantation Surgery, University Hospital Essen, University Duisburg-Essen, Essen, Germany
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Barriers and Advances in Kidney Preservation. BIOMED RESEARCH INTERNATIONAL 2018; 2018:9206257. [PMID: 30643824 PMCID: PMC6311271 DOI: 10.1155/2018/9206257] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 10/15/2018] [Accepted: 11/14/2018] [Indexed: 12/16/2022]
Abstract
Despite the fact that a significant fraction of kidney graft dysfunctions observed after transplantation is due to ischemia-reperfusion injuries, there is still no clear consensus regarding optimal kidney preservation strategy. This stems directly from the fact that as of yet, the mechanisms underlying ischemia-reperfusion injury are poorly defined, and the role of each preservation parameter is not clearly outlined. In the meantime, as donor demography changes, organ quality is decreasing which directly increases the rate of poor outcome. This situation has an impact on clinical guidelines and impedes their possible harmonization in the transplant community, which has to move towards changing organ preservation paradigms: new concepts must emerge and the definition of a new range of adapted preservation method is of paramount importance. This review presents existing barriers in transplantation (e.g., temperature adjustment and adequate protocol, interest for oxygen addition during preservation, and clear procedure for organ perfusion during machine preservation), discusses the development of novel strategies to overcome them, and exposes the importance of identifying reliable biomarkers to monitor graft quality and predict short and long-term outcomes. Finally, perspectives in therapeutic strategies will also be presented, such as those based on stem cells and their derivatives and innovative models on which they would need to be properly tested.
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A Comparative Study of Single and Dual Perfusion During End-ischemic Subnormothermic Liver Machine Preservation. Transplant Direct 2018; 4:e400. [PMID: 30534591 PMCID: PMC6233661 DOI: 10.1097/txd.0000000000000840] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 09/11/2018] [Indexed: 12/19/2022] Open
Abstract
Background It remains controversial if arterial perfusion in addition to portal vein perfusion during machine preservation improves liver graft quality. Comparative studies using both techniques are lacking. We studied the impact of using single or dual machine perfusion of donation after circulatory death rat livers. In addition, we analyzed the effect of pulsatile versus continuous arterial flow. Methods Donation after circulatory death rat livers (n = 18) were preserved by 6 hours cold storage, followed by 1 hour subnormothermic machine perfusion (20°C, pressure of 40/5 mm Hg) and 2 hours ex vivo warm reperfusion (37°C, pressure of 80/11 mm Hg, 9% whole blood). Machine preservation was either through single portal vein perfusion (SP), dual pulsatile (DPP), or dual continuous perfusion (DCP) of the portal vein and hepatic artery. Hydrodynamics, liver function tests, histopathology, and expression of endothelial specific genes were assessed during 2 hours warm reperfusion. Results At the end of reperfusion, arterial flow in DPP livers tended to be higher compared to DCP and SP grafts. However, this difference was not significant nor was better flow associated with better outcome. No differences in bile production or alanine aminotransferase levels were observed. SP livers had significantly lower lactate compared to DCP, but not DPP livers. Levels of Caspase-3 and tumor necrosis factor-α were similar between the groups. Expression of endothelial genes Krüppel-like-factor 2 and endothelial nitric oxide synthase tended to be higher in dual perfused livers, but no histological evidence of better preservation of the biliary endothelium or vasculature of the hepatic artery was observed. Conclusions This study shows comparable outcomes after using a dual or single perfusion approach during end-ischemic subnormothermic liver machine preservation.
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