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Gouchoe DA, Sanchez PG, D'Cunha J, Bermudez CA, Daneshmand MA, Davis RD, Hartwig MG, Wozniak TC, Kon ZN, Griffith BP, Lynch WR, Machuca TN, Weyant MJ, Jessen ME, Mulligan MS, D'Ovidio F, Camp PC, Cantu E, Whitson BA. Ex vivo lung perfusion in donation after circulatory death: A post hoc analysis of the Normothermic Ex Vivo Lung Perfusion as an Assessment of Extended/Marginal Donors Lungs trial. J Thorac Cardiovasc Surg 2024; 168:724-734.e7. [PMID: 38508486 DOI: 10.1016/j.jtcvs.2024.03.011] [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: 01/19/2024] [Revised: 03/06/2024] [Accepted: 03/06/2024] [Indexed: 03/22/2024]
Abstract
OBJECTIVE Donation after circulatory death (DCD) donors offer the ability to expand the lung donor pool and ex vivo lung perfusion (EVLP) further contributes to this ability by allowing for additional evaluation and resuscitation of these extended criteria donors. We sought to determine the outcomes of recipients receiving organs from DCD EVLP donors in a multicenter setting. METHODS This was an unplanned post hoc analysis of a multicenter, prospective, nonrandomized trial that took place during 2011 to 2017 with 3 years of follow-up. Patients were placed into 3 groups based off procurement strategy: brain-dead donor (control), brain-dead donor evaluated by EVLP, and DCD donors evaluated by EVLP. The primary outcomes were severe primary graft dysfunction at 72 hours and survival. Secondary outcomes included select perioperative outcomes, and 1-year and 3-years allograft function and quality of life measures. RESULTS The DCD EVLP group had significantly higher incidence of severe primary graft dysfunction at 72 hours (P = .03), longer days on mechanical ventilation (P < .001) and in-hospital length of stay (P = .045). Survival at 3 years was 76.5% (95% CI, 69.2%-84.7%) for the control group, 68.3% (95% CI, 58.9%-79.1%) for the brain-dead donor group, and 60.7% (95% CI, 45.1%-81.8%) for the DCD group (P = .36). At 3-year follow-up, presence observed bronchiolitis obliterans syndrome or quality of life metrics did not differ among the groups. CONCLUSIONS Although DCD EVLP allografts might not be appropriate to transplant in every candidate recipient, the expansion of their use might afford recipients stagnant on the waitlist a viable therapy.
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Affiliation(s)
- Doug A Gouchoe
- Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Center, College of Medicine, Columbus, Ohio; 88th Surgical Operations Squadron, Wright-Patterson Medical Center, Wright-Patterson Air Force Base, Ohio
| | - Pablo G Sanchez
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Jonathan D'Cunha
- Department of Cardiothoracic Surgery, Mayo Clinic Arizona, Phoenix, Ariz
| | | | - Mani A Daneshmand
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Robert D Davis
- Department of Cardiovascular and Thoracic Surgery, Florida Hospital Transplant Center, Orlando, Fla
| | - Matthew G Hartwig
- Division of Cardiovascular and Thoracic Surgery, Duke University School of Medicine, Durham, NC
| | - Thomas C Wozniak
- Division of Cardiothoracic Surgery, ProHealth Care, Waukesha, Wis
| | - Zachary N Kon
- Division of Cardiothoracic Surgery, Department of Surgery, Northwell Health, Manhasset, NY
| | - Bartley P Griffith
- Department of Cardiac Surgery, University of Maryland Medical Center, Baltimore, Md
| | - William R Lynch
- Section of Thoracic Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich
| | - Tiago N Machuca
- Division of Lung Transplantation, Department of Surgery, University of Miami Miller School of Medicine, Miami, Fla
| | | | - Michael E Jessen
- Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern, Dallas, Tex
| | - Michael S Mulligan
- Division of Cardiothoracic Surgery, Department of Surgery, University of Washington, Seattle, Wash
| | - Frank D'Ovidio
- Section of General Thoracic Surgery, Lung Transplant Program, Columbia University Medical Center, New York, NY
| | - Phillip C Camp
- Department of Cardiothoracic Surgery, Corewell Health-East, Dearborn, Mich
| | - Edward Cantu
- Division of Cardiac Surgery, University of Pennsylvania, Philadelphia, Pa
| | - Bryan A Whitson
- Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Center, College of Medicine, Columbus, Ohio; Collaboration for Organ Perfusion, Protection, Engineering, and Regeneration Laboratory, The Ohio State University, Columbus, Ohio; The Davis Heart and Lung Research Institute, The Ohio State University Wexner Center, College of Medicine, Columbus, Ohio.
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2
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Boffini M, Costamagna A, Marro M, Simonato E, Cassoni P, Bertero L, Fanelli V, Barbero C, Brazzi L, Rinaldi M. Orthostatic Ex-Vivo Lung Perfusion (EVLP): A Proof of Concept. Transpl Int 2024; 37:13178. [PMID: 39144835 PMCID: PMC11321966 DOI: 10.3389/ti.2024.13178] [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: 04/24/2024] [Accepted: 07/11/2024] [Indexed: 08/16/2024]
Abstract
The key goal in lung donation remains the improvement of graft preservation with the ultimate objective of increasing the number and quality of lung transplants (LTx). Therefore, in recent years the field of graft preservation focused on improving outcomes related to solid organ regeneration and restoration. In this contest Ex-Vivo Lung Perfusion (EVLP) plays a crucial role with the purpose to increase the donor pool availability transforming marginal and/or declined donor lungs suitable for transplantation. Aim of this proof of concept is to test the safety, suitability and feasibility of a new tilting dome for EVLP designed considering the dorsal lung areas as the "Achilles' heel" of the EVLP due to a more fluid accumulation than in the supine standard position.
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Affiliation(s)
- Massimo Boffini
- Cardiac Surgery Division, Surgical Sciences Department, Citta della Salute e della Scienza, University of Torino, Turin, Italy
| | - Andrea Costamagna
- Anesthesiology and Intensive Care Division, Surgical Sciences Department, Citta della Salute e della Scienza, University of Torino, Turin, Italy
| | - Matteo Marro
- Cardiac Surgery Division, Surgical Sciences Department, Citta della Salute e della Scienza, University of Torino, Turin, Italy
| | - Erika Simonato
- Cardiac Surgery Division, Surgical Sciences Department, Citta della Salute e della Scienza, University of Torino, Turin, Italy
| | - Paola Cassoni
- Pathology Unit, Medical Sciences Department, Citta della Salute e della Scienza, University of Torino, Turin, Italy
| | - Luca Bertero
- Pathology Unit, Medical Sciences Department, Citta della Salute e della Scienza, University of Torino, Turin, Italy
| | - Vito Fanelli
- Anesthesiology and Intensive Care Division, Surgical Sciences Department, Citta della Salute e della Scienza, University of Torino, Turin, Italy
| | - Cristina Barbero
- Cardiac Surgery Division, Surgical Sciences Department, Citta della Salute e della Scienza, University of Torino, Turin, Italy
| | - Luca Brazzi
- Anesthesiology and Intensive Care Division, Surgical Sciences Department, Citta della Salute e della Scienza, University of Torino, Turin, Italy
| | - Mauro Rinaldi
- Cardiac Surgery Division, Surgical Sciences Department, Citta della Salute e della Scienza, University of Torino, Turin, Italy
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3
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Ponholzer F, Dumfarth J, Krapf C, Pircher A, Hautz T, Wolf D, Augustin F, Schneeberger S. The impact and relevance of techniques and fluids on lung injury in machine perfusion of lungs. Front Immunol 2024; 15:1358153. [PMID: 38510260 PMCID: PMC10950925 DOI: 10.3389/fimmu.2024.1358153] [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: 12/19/2023] [Accepted: 02/26/2024] [Indexed: 03/22/2024] Open
Abstract
Primary graft dysfunction (PGD) is a common complication after lung transplantation. A plethora of contributing factors are known and assessment of donor lung function prior to organ retrieval is mandatory for determination of lung quality. Specialized centers increasingly perform ex vivo lung perfusion (EVLP) to further assess lung functionality and improve and extend lung preservation with the aim to increase lung utilization. EVLP can be performed following different protocols. The impact of the individual EVLP parameters on PGD development, organ function and postoperative outcome remains to be fully investigated. The variables relate to the engineering and function of the respective perfusion devices, such as the type of pump used, functional, like ventilation modes or physiological (e.g. perfusion solutions). This review reflects on the individual technical and fluid components relevant to EVLP and their respective impact on inflammatory response and outcome. We discuss key components of EVLP protocols and options for further improvement of EVLP in regard to PGD. This review offers an overview of available options for centers establishing an EVLP program and for researchers looking for ways to adapt existing protocols.
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Affiliation(s)
- Florian Ponholzer
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Julia Dumfarth
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Christoph Krapf
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Andreas Pircher
- Department of Haematology and Oncology, Internal Medicine V, Medical University of Innsbruck, Innsbruck, Austria
| | - Theresa Hautz
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Dominik Wolf
- Department of Haematology and Oncology, Internal Medicine V, Medical University of Innsbruck, Innsbruck, Austria
| | - Florian Augustin
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Stefan Schneeberger
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
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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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5
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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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6
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Boffini M, Marro M, Simonato E, Scalini F, Costamagna A, Fanelli V, Barbero C, Solidoro P, Brazzi L, Rinaldi M. Cytokines Removal During Ex-Vivo Lung Perfusion: Initial Clinical Experience. Transpl Int 2023; 36:10777. [PMID: 37645241 PMCID: PMC10460908 DOI: 10.3389/ti.2023.10777] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 07/31/2023] [Indexed: 08/31/2023]
Abstract
Ex Vivo Lung Perfusion (EVLP) can be potentially used to manipulate organs and to achieve a proper reconditioning process. During EVLP pro-inflammatory cytokines have been shown to accumulate in perfusate over time and their production is correlated with poor outcomes of the graft. Aim of the present study is to investigate the feasibility and safety of cytokine adsorption during EVLP. From July 2011 to March 2020, 54 EVLP procedures have been carried out, 21 grafts treated with an adsorption system and 33 without. Comparing the grafts perfused during EVLP with or without cytokine adsorption, the use of a filter significantly decreased the levels of IL10 and GCSFat the end of the procedure. Among the 38 transplanted patients, the adsorption group experienced a significant decreased IL6, IL10, MCP1 and GCSF concentrations and deltas compared to the no-adsorption group, with a lower in-hospital mortality (p = 0.03) and 1-year death rate (p = 0.01). This interventional study is the first human experience suggesting the safety and efficacy of a porous polymer beads adsorption device in reducing the level of inflammatory mediators during EVLP. Clinical impact of cytokines reduction during EVLP must be evaluated in further studies.
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Affiliation(s)
- Massimo Boffini
- Cardiac Surgery Division, Surgical Sciences Department, Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Matteo Marro
- Cardiac Surgery Division, Surgical Sciences Department, Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Erika Simonato
- Cardiac Surgery Division, Surgical Sciences Department, Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Fabrizio Scalini
- Cardiac Surgery Division, Surgical Sciences Department, Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Andrea Costamagna
- Anesthesiology and Intensive Care Division, Surgical Sciences Department, Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Vito Fanelli
- Anesthesiology and Intensive Care Division, Surgical Sciences Department, Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Cristina Barbero
- Cardiac Surgery Division, Surgical Sciences Department, Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Paolo Solidoro
- Pulmonology Division, Medical Sciences Department, Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Luca Brazzi
- Anesthesiology and Intensive Care Division, Surgical Sciences Department, Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Mauro Rinaldi
- Cardiac Surgery Division, Surgical Sciences Department, Città della Salute e della Scienza, University of Turin, Turin, Italy
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Józsa L, Nemes D, Pető Á, Kósa D, Révész R, Bácskay I, Haimhoffer Á, Vasvári G. Recent Options and Techniques to Assess Improved Bioavailability: In Vitro and Ex Vivo Methods. Pharmaceutics 2023; 15:pharmaceutics15041146. [PMID: 37111632 PMCID: PMC10144798 DOI: 10.3390/pharmaceutics15041146] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 03/28/2023] [Accepted: 03/31/2023] [Indexed: 04/08/2023] Open
Abstract
Bioavailability assessment in the development phase of a drug product is vital to reveal the disadvantageous properties of the substance and the possible technological interventions. However, in vivo pharmacokinetic studies provide strong evidence for drug approval applications. Human and animal studies must be designed on the basis of preliminary biorelevant experiments in vitro and ex vivo. In this article, the authors have reviewed the recent methods and techniques from the last decade that are in use for assessing the bioavailability of drug molecules and the effects of technological modifications and drug delivery systems. Four main administration routes were selected: oral, transdermal, ocular, and nasal or inhalation. Three levels of methodologies were screened for each category: in vitro techniques with artificial membranes; cell culture, including monocultures and co-cultures; and finally, experiments where tissue or organ samples were used. Reproducibility, predictability, and level of acceptance by the regulatory organizations are summarized for the readers.
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Affiliation(s)
- Liza Józsa
- Department of Pharmaceutical Technology, Faculty of Pharmacy, University of Debrecen, Nagyerdei St. 98, H-4032 Debrecen, Hungary
| | - Dániel Nemes
- Department of Pharmaceutical Technology, Faculty of Pharmacy, University of Debrecen, Nagyerdei St. 98, H-4032 Debrecen, Hungary
| | - Ágota Pető
- Department of Pharmaceutical Technology, Faculty of Pharmacy, University of Debrecen, Nagyerdei St. 98, H-4032 Debrecen, Hungary
| | - Dóra Kósa
- Department of Pharmaceutical Technology, Faculty of Pharmacy, University of Debrecen, Nagyerdei St. 98, H-4032 Debrecen, Hungary
| | - Réka Révész
- Department of Pharmaceutical Technology, Faculty of Pharmacy, University of Debrecen, Nagyerdei St. 98, H-4032 Debrecen, Hungary
| | - Ildikó Bácskay
- Department of Pharmaceutical Technology, Faculty of Pharmacy, University of Debrecen, Nagyerdei St. 98, H-4032 Debrecen, Hungary
- Institute of Healthcare Industry, University of Debrecen, Nagyerdei St. 98, H-4032 Debrecen, Hungary
| | - Ádám Haimhoffer
- Department of Pharmaceutical Technology, Faculty of Pharmacy, University of Debrecen, Nagyerdei St. 98, H-4032 Debrecen, Hungary
| | - Gábor Vasvári
- Department of Pharmaceutical Technology, Faculty of Pharmacy, University of Debrecen, Nagyerdei St. 98, H-4032 Debrecen, Hungary
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8
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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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Brevini T, Maes M, Webb GJ, John BV, Fuchs CD, Buescher G, Wang L, Griffiths C, Brown ML, Scott WE, Pereyra-Gerber P, Gelson WTH, Brown S, Dillon S, Muraro D, Sharp J, Neary M, Box H, Tatham L, Stewart J, Curley P, Pertinez H, Forrest S, Mlcochova P, Varankar SS, Darvish-Damavandi M, Mulcahy VL, Kuc RE, Williams TL, Heslop JA, Rossetti D, Tysoe OC, Galanakis V, Vila-Gonzalez M, Crozier TWM, Bargehr J, Sinha S, Upponi SS, Fear C, Swift L, Saeb-Parsy K, Davies SE, Wester A, Hagström H, Melum E, Clements D, Humphreys P, Herriott J, Kijak E, Cox H, Bramwell C, Valentijn A, Illingworth CJR, Dahman B, Bastaich DR, Ferreira RD, Marjot T, Barnes E, Moon AM, Barritt AS, Gupta RK, Baker S, Davenport AP, Corbett G, Gorgoulis VG, Buczacki SJA, Lee JH, Matheson NJ, Trauner M, Fisher AJ, Gibbs P, Butler AJ, Watson CJE, Mells GF, Dougan G, Owen A, Lohse AW, Vallier L, Sampaziotis F. FXR inhibition may protect from SARS-CoV-2 infection by reducing ACE2. Nature 2023; 615:134-142. [PMID: 36470304 PMCID: PMC9977684 DOI: 10.1038/s41586-022-05594-0] [Citation(s) in RCA: 134] [Impact Index Per Article: 134.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 11/23/2022] [Indexed: 12/12/2022]
Abstract
Preventing SARS-CoV-2 infection by modulating viral host receptors, such as angiotensin-converting enzyme 2 (ACE2)1, could represent a new chemoprophylactic approach for COVID-19 that complements vaccination2,3. However, the mechanisms that control the expression of ACE2 remain unclear. Here we show that the farnesoid X receptor (FXR) is a direct regulator of ACE2 transcription in several tissues affected by COVID-19, including the gastrointestinal and respiratory systems. We then use the over-the-counter compound z-guggulsterone and the off-patent drug ursodeoxycholic acid (UDCA) to reduce FXR signalling and downregulate ACE2 in human lung, cholangiocyte and intestinal organoids and in the corresponding tissues in mice and hamsters. We show that the UDCA-mediated downregulation of ACE2 reduces susceptibility to SARS-CoV-2 infection in vitro, in vivo and in human lungs and livers perfused ex situ. Furthermore, we reveal that UDCA reduces the expression of ACE2 in the nasal epithelium in humans. Finally, we identify a correlation between UDCA treatment and positive clinical outcomes after SARS-CoV-2 infection using retrospective registry data, and confirm these findings in an independent validation cohort of recipients of liver transplants. In conclusion, we show that FXR has a role in controlling ACE2 expression and provide evidence that modulation of this pathway could be beneficial for reducing SARS-CoV-2 infection, paving the way for future clinical trials.
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Affiliation(s)
- Teresa Brevini
- Wellcome-MRC Cambridge Stem Cell Institute, Cambridge, UK.
| | - Mailis Maes
- Cambridge Institute of Therapeutic Immunology & Infectious Disease (CITIID), Department of Medicine, University of Cambridge, Cambridge, UK
| | - Gwilym J Webb
- Cambridge Liver Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Binu V John
- Division of Gastroenterology and Hepatology, University of Miami and Miami VA Health System, Miami, FL, USA
| | - Claudia D Fuchs
- Hans Popper Laboratory of Molecular Hepatology, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Gustav Buescher
- Department of Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Lu Wang
- Transplant and Regenerative Medicine Laboratory, Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Chelsea Griffiths
- Transplant and Regenerative Medicine Laboratory, Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Marnie L Brown
- Transplant and Regenerative Medicine Laboratory, Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - William E Scott
- Transplant and Regenerative Medicine Laboratory, Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Pehuén Pereyra-Gerber
- Cambridge Institute of Therapeutic Immunology & Infectious Disease (CITIID), Department of Medicine, University of Cambridge, Cambridge, UK
| | - William T H Gelson
- Cambridge Liver Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Department of Medicine, University of Cambridge, Cambridge, UK
| | | | - Scott Dillon
- Wellcome-MRC Cambridge Stem Cell Institute, Cambridge, UK
| | | | - Jo Sharp
- Centre of Excellence in Long-acting Therapeutics (CELT), Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Megan Neary
- Centre of Excellence in Long-acting Therapeutics (CELT), Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Helen Box
- Centre of Excellence in Long-acting Therapeutics (CELT), Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Lee Tatham
- Centre of Excellence in Long-acting Therapeutics (CELT), Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - James Stewart
- Department of Infection Biology and Microbiomes, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK
| | - Paul Curley
- Centre of Excellence in Long-acting Therapeutics (CELT), Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Henry Pertinez
- Centre of Excellence in Long-acting Therapeutics (CELT), Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Sally Forrest
- Cambridge Institute of Therapeutic Immunology & Infectious Disease (CITIID), Department of Medicine, University of Cambridge, Cambridge, UK
| | - Petra Mlcochova
- Cambridge Institute of Therapeutic Immunology & Infectious Disease (CITIID), Department of Medicine, University of Cambridge, Cambridge, UK
- Division of Gastroenterology and Hepatology, University of Miami and Miami VA Health System, Miami, FL, USA
| | | | - Mahnaz Darvish-Damavandi
- Wellcome-MRC Cambridge Stem Cell Institute, Cambridge, UK
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Victoria L Mulcahy
- Academic Department of Medical Genetics, University of Cambridge, Cambridge, UK
| | - Rhoda E Kuc
- Experimental Medicine and Immunotherapeutics, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Thomas L Williams
- Experimental Medicine and Immunotherapeutics, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - James A Heslop
- Wellcome-MRC Cambridge Stem Cell Institute, Cambridge, UK
| | | | - Olivia C Tysoe
- Wellcome-MRC Cambridge Stem Cell Institute, Cambridge, UK
- Department of Surgery, University of Cambridge and NIHR Cambridge Biomedical Research Centre, Cambridge, UK
| | | | | | - Thomas W M Crozier
- Cambridge Institute of Therapeutic Immunology & Infectious Disease (CITIID), Department of Medicine, University of Cambridge, Cambridge, UK
| | - Johannes Bargehr
- Wellcome-MRC Cambridge Stem Cell Institute, Cambridge, UK
- Department of Medicine, University of Cambridge, Cambridge, UK
- Division of Cardiovascular Medicine, University of Cambridge, Cambridge, UK
| | - Sanjay Sinha
- Wellcome-MRC Cambridge Stem Cell Institute, Cambridge, UK
- Division of Cardiovascular Medicine, University of Cambridge, Cambridge, UK
| | - Sara S Upponi
- Department of Radiology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Corrina Fear
- Department of Surgery, University of Cambridge and NIHR Cambridge Biomedical Research Centre, Cambridge, UK
| | - Lisa Swift
- Department of Surgery, University of Cambridge and NIHR Cambridge Biomedical Research Centre, Cambridge, UK
| | - Kourosh Saeb-Parsy
- Department of Surgery, University of Cambridge and NIHR Cambridge Biomedical Research Centre, Cambridge, UK
- Roy Calne Transplant Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Susan E Davies
- Department of Histopathology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Axel Wester
- Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Hannes Hagström
- Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Espen Melum
- Norwegian PSC Research Center, Department of Transplantation Medicine, Division of Surgery, Inflammatory Diseases and Transplantation, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- Research Institute of Internal Medicine, Division of Surgery, Inflammatory Diseases and Transplantation, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Section of Gastroenterology, Department of Transplantation Medicine, Division of Surgery, Inflammatory Diseases and Transplantation, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- Hybrid Technology Hub Centre of Excellence, Institute of Basic Medical Sciences, Faculty of Medicine, University of Oslo, Oslo, Norway
| | | | | | - Jo Herriott
- Centre of Excellence in Long-acting Therapeutics (CELT), Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Edyta Kijak
- Centre of Excellence in Long-acting Therapeutics (CELT), Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Helen Cox
- Centre of Excellence in Long-acting Therapeutics (CELT), Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Chloe Bramwell
- Centre of Excellence in Long-acting Therapeutics (CELT), Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Anthony Valentijn
- Centre of Excellence in Long-acting Therapeutics (CELT), Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Christopher J R Illingworth
- MRC-University of Glasgow Centre for Virus Research, Glasgow, UK
- Department of Applied Mathematics and Theoretical Physics, University of Cambridge, Cambridge, UK
| | - Bassam Dahman
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, VA, USA
| | - Dustin R Bastaich
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, VA, USA
| | - Raphaella D Ferreira
- Division of Gastroenterology and Hepatology, University of Miami and Miami VA Health System, Miami, FL, USA
| | - Thomas Marjot
- Oxford Liver Unit, Translational Gastroenterology Unit, Oxford University Hospitals NHS Foundation Trust, University of Oxford, Oxford, UK
| | - Eleanor Barnes
- Oxford Liver Unit, Translational Gastroenterology Unit, Oxford University Hospitals NHS Foundation Trust, University of Oxford, Oxford, UK
| | - Andrew M Moon
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, NC, USA
| | - Alfred S Barritt
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, NC, USA
| | - Ravindra K Gupta
- Cambridge Institute of Therapeutic Immunology & Infectious Disease (CITIID), Department of Medicine, University of Cambridge, Cambridge, UK
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Stephen Baker
- Cambridge Institute of Therapeutic Immunology & Infectious Disease (CITIID), Department of Medicine, University of Cambridge, Cambridge, UK
| | - Anthony P Davenport
- Experimental Medicine and Immunotherapeutics, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Gareth Corbett
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Vassilis G Gorgoulis
- Department of Histology and Embryology, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
- Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
- Biomedical Research Foundation, Academy of Athens, Athens, Greece
| | - Simon J A Buczacki
- Wellcome-MRC Cambridge Stem Cell Institute, Cambridge, UK
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Joo-Hyeon Lee
- Wellcome-MRC Cambridge Stem Cell Institute, Cambridge, UK
- Department of Physiology, Development and Neuroscience, University of Cambridge, Cambridge, UK
| | - Nicholas J Matheson
- Cambridge Institute of Therapeutic Immunology & Infectious Disease (CITIID), Department of Medicine, University of Cambridge, Cambridge, UK
- Department of Medicine, University of Cambridge, Cambridge, UK
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, NC, USA
- NHS Blood and Transplant, Cambridge, UK
| | - Michael Trauner
- Hans Popper Laboratory of Molecular Hepatology, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Andrew J Fisher
- Transplant and Regenerative Medicine Laboratory, Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Paul Gibbs
- Department of Surgery, University of Cambridge and NIHR Cambridge Biomedical Research Centre, Cambridge, UK
- Roy Calne Transplant Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Andrew J Butler
- Department of Surgery, University of Cambridge and NIHR Cambridge Biomedical Research Centre, Cambridge, UK
- Roy Calne Transplant Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Christopher J E Watson
- Department of Surgery, University of Cambridge and NIHR Cambridge Biomedical Research Centre, Cambridge, UK
- Roy Calne Transplant Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- National Institute of Health Research (NIHR) Cambridge Biomedical Research Centre, and the NIHR Blood and Transplant Research Unit (BTRU) at the University of Cambridge in collaboration with Newcastle University and in partnership with NHS Blood and Transplant (NHSBT), Cambridge, UK
| | - George F Mells
- Cambridge Liver Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Academic Department of Medical Genetics, University of Cambridge, Cambridge, UK
| | - Gordon Dougan
- Cambridge Institute of Therapeutic Immunology & Infectious Disease (CITIID), Department of Medicine, University of Cambridge, Cambridge, UK
| | - Andrew Owen
- Centre of Excellence in Long-acting Therapeutics (CELT), Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Ansgar W Lohse
- Department of Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Ludovic Vallier
- Wellcome-MRC Cambridge Stem Cell Institute, Cambridge, UK.
- Wellcome Sanger Institute, Hinxton, UK.
- Berlin Institute of Health (BIH), BIH Centre for Regenerative Therapies (BCRT), Charité-Universitätsmedizin Berlin, Berlin, Germany.
- Max Planck Institute for Molecular Genetics, Berlin, Germany.
| | - Fotios Sampaziotis
- Wellcome-MRC Cambridge Stem Cell Institute, Cambridge, UK.
- Cambridge Liver Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.
- Department of Medicine, University of Cambridge, Cambridge, UK.
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Peel JK, Keshavjee S, Naimark D, Liu M, Del Sorbo L, Cypel M, Barrett K, Pullenayegum EM, Sander B. Determining the impact of ex-vivo lung perfusion on hospital costs for lung transplantation: A retrospective cohort study. J Heart Lung Transplant 2023; 42:356-367. [PMID: 36411188 DOI: 10.1016/j.healun.2022.10.016] [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: 06/03/2022] [Revised: 10/04/2022] [Accepted: 10/20/2022] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Ex-vivo lung perfusion (EVLP) has improved organ utilization for lung transplantation, but it is not yet known whether the benefits of this technology offset its additional costs. We compared the institutional costs of lung transplantation before vs after EVLP was available to identify predictors of costs and determine the health-economic impact of EVLP. METHODS We performed a retrospective, before-after, propensity-score weighted cohort study of patients wait-listed for lung transplant at University Health Network (UHN) in Ontario, Canada, between January 2005 and December 2019 using institutional administrative data. We compared costs, in 2019 Canadian Dollars ($), between patients referred for transplant before EVLP was available (Pre-EVLP) to after (Modern EVLP). Cumulative costs were estimated using a novel application of multistate survival models. Predictors of costs were identified using weighted log-gamma generalized linear regression. RESULTS A total of 1,199 patients met inclusion criteria (352 Pre-EVLP; 847 Modern EVLP). Mean total costs for the transplant hospitalization were $111,878 ($94,123-$130,767) in the Pre-EVLP era and $110,969 ($87,714-$136,000) in the Modern EVLP era. Cumulative five-year costs since referral were $278,777 ($82,575-$298,135) in the Pre-EVLP era and $293,680 ($252,832-$317,599) in the Modern EVLP era. We observed faster progression to transplantation when EVLP was available. EVLP availability was not a predictor of waitlist (cost ratio [CR] 1.04 [0.81-1.37]; p = 0.354) or transplant costs (CR 1.02 [0.80-1.29]; p = 0.425) but was associated with lower costs during posttransplant years 1&2 (CR 0.75 [0.58-1.06]; p = 0.05) and posttransplant years 3+ (CR 0.43 [0.26-0.74]; p = 0.001). CONCLUSIONS At our center, EVLP availability was associated with faster progression to transplantation at no significant marginal cost.
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Affiliation(s)
- John Kenneth Peel
- Department of Anesthesiology, University Health Network, Toronto, Ontario, Canada; Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, Dalla Lana School for Public Health, University of Toronto, Toronto, Ontario, Canada.
| | - Shaf Keshavjee
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada; Division of Thoracic Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada; Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | - David Naimark
- Institute of Health Policy, Management and Evaluation, Dalla Lana School for Public Health, University of Toronto, Toronto, Ontario, Canada; Division of Nephrology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Mingyao Liu
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada; Division of Thoracic Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada; Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Lorenzo Del Sorbo
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada; Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Marcelo Cypel
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada; Division of Thoracic Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada; Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Kali Barrett
- Institute of Health Policy, Management and Evaluation, Dalla Lana School for Public Health, University of Toronto, Toronto, Ontario, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Eleanor M Pullenayegum
- Institute of Health Policy, Management and Evaluation, Dalla Lana School for Public Health, University of Toronto, Toronto, Ontario, Canada; The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Beate Sander
- Institute of Health Policy, Management and Evaluation, Dalla Lana School for Public Health, University of Toronto, Toronto, Ontario, Canada; Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada; ICES, Ontario, Canada; Public Health Ontario, Ontario, Canada.
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11
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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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A Randomized, Multicenter, Blinded Pilot Study Assessing the Effects of Gaseous Nitric Oxide in an Ex Vivo System of Human Lungs. Pulm Ther 2022; 9:151-163. [PMID: 36510099 PMCID: PMC9744669 DOI: 10.1007/s41030-022-00209-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 11/14/2022] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Normothermic ex vivo lung perfusion (EVLP) is used to evaluate and condition donor lungs for transplantation. The objective of this study was to determine whether administration of exogenous nitric oxide during EVLP contributes to improvement of lung health. METHODS A multicenter, blinded, two-arm, randomized pilot study evaluated the effect of gaseous nitric oxide (gNO) administered during EVLP on donor lungs rejected for transplantation. gNO introduced into the perfusate at 80 parts per million (ppm) was compared with perfusate alone (P). An open-label substudy assessed inhaled nitric oxide gas (iNO) delivered into the lungs at 20 ppm via a ventilator. Primary endpoints were an aggregate score of lung physiology indicators and total duration of stable EVLP time. Secondary endpoints included assessments of lung weight and left atrium partial pressure of oxygen (LAPO2). RESULTS Twenty bilateral donor lungs (blinded study, n = 16; open-label substudy, n = 4) from three centers were enrolled. Median (min, max) total EVLP times for the gNO, P, and iNO groups were 12.4 (8.6, 12.6), 10.6 (6.0, 12.4), and 12.4 (8.7, 13.0) hours, respectively. In the blinded study, median aggregate scores were higher in the gNO group compared to the P group at most time points, suggesting better lung health with gNO (median score range [min, max], 0-3.5 [0, 7]) vs. P (0-2.0 [0, 5] at end of study). In the substudy, median aggregate scores did not improve for lungs in the iNO group. However, both the gNO and iNO groups showed improvements in lung weight and LAPO2 compared to the P group. CONCLUSIONS The data suggest that inclusion of gNO during EVLP may potentially prolong duration of organ stability and improve donor lung health, which warrants further investigation.
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Bisbee CR, Sherard C, Kwon J, Hashmi ZA, Gibney BC, Rajab T. Devices for donor lung preservation. Expert Rev Med Devices 2022; 19:959-964. [PMID: 36444725 DOI: 10.1080/17434440.2022.2151359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Lung transplantation is the gold standard for the treatment of end stage lung disease but is limited by donor availability. Recently, the donor pool has seen significant expansion with liberalization of donor criteria. However, extended criteria donors can require additional time to prepare for implantation, necessitating additional preservation time of donor lungs. AREAS COVERED We present a review of current lung transplant storage strategies including new methodologies and technological advancements. The current standard, static cold storage, is a simple and cost-effective method of preserving grafts, but offers little flexibility with limited ability to mitigate ischemic-reperfusion injury, inflammation, and hypothermic tissue damage. Novel ex vivo lung perfusion (EVLP) devices, TransMedics OCS and XVIVO perfusion systems, extend preservation time by perfusing, and ventilating donor lungs while simultaneously allowing for evaluation of lung viability. Perfusate, preservation solutions, additives, temperature regulation, and assessment of organ damage are all critical components when evaluating the success and outcomes of these devices. EXPERT OPINION EVLP devices are more costly and often require additional resources and personnel support compared to static cold storage, but may provide the opportunity to extend preservation time, perform functional assessment, mitigate ischemic injury, and optimize extended criteria donors.
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Affiliation(s)
- Cora R Bisbee
- College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | | | - Jennie Kwon
- College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Zubair A Hashmi
- Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Barry C Gibney
- Cardiothoracic Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Taufiek Rajab
- Surgery, Medical University of South Carolina, Charleston, SC, USA
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14
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Haam S. Ex Vivo Lung Perfusion in Lung Transplantation. J Chest Surg 2022; 55:288-292. [PMID: 35924535 PMCID: PMC9358162 DOI: 10.5090/jcs.22.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 07/21/2022] [Indexed: 11/16/2022] Open
Abstract
Ex vivo lung perfusion (EVLP) is a technique that enables active metabolism of the lung by creating an environment similar to that inside the body, even though the explanted lungs are outside the body. The EVLP system enables the use of lung grafts that do not satisfy the acceptance criteria for lung transplantation (LTx) by making it possible to evaluate the function of the lung grafts and repair lungs in poor condition, thereby reducing the waiting time of patients requiring LTx and consequently mortality.
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Affiliation(s)
- Seokjin Haam
- Department of Thoracic and Cardiovascular Surgery, Ajou University School of Medicine, Suwon, Korea
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15
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Bos S, Ricciardi S, Caruana EJ, Öztürk NAA, Magouliotis D, Pompili C, Migliore M, Vos R, Meloni F, Elia S, Hellemons M. ERS International Congress 2021: highlights from Assembly 8 Thoracic Surgery and Lung Transplantation. ERJ Open Res 2022; 8:00649-2021. [PMID: 35615414 PMCID: PMC9125043 DOI: 10.1183/23120541.00649-2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 02/22/2022] [Indexed: 11/05/2022] Open
Abstract
The thoracic surgery and lung transplantation assembly of the European Respiratory Society (ERS) is delighted to present the highlights from the 2021 International ERS Congress. We have selected four sessions that discussed recent advances across a wide range of topics: including digital health surveillance in thoracic surgery, emerging concepts in pulmonary metastasectomy, advances in mesothelioma care, and novel developments in lung graft allocation and monitoring. The sessions are summarised by early career members in close collaboration with the assembly faculty. We aim to give the reader an update on the highlights of the conference in the fields of thoracic surgery and lung transplantation.
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Ferdinand JR, Morrison MI, Andreasson A, Charlton C, Chhatwal AK, Scott WE, Borthwick LA, Clatworthy MR, Fisher AJ. Transcriptional analysis identifies potential novel biomarkers associated with successful ex-vivo perfusion of human donor lungs. Clin Transplant 2021; 36:e14570. [PMID: 34954872 PMCID: PMC9285052 DOI: 10.1111/ctr.14570] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Revised: 12/14/2021] [Accepted: 12/20/2021] [Indexed: 11/30/2022]
Abstract
Background Transplantation is an effective treatment for end‐stage lung disease, but the donor organ shortage is a major problem. Ex‐vivo lung perfusion (EVLP) of extended criteria organs enables functional assessment to facilitate clinical decision‐making around utilization, but the molecular processes occurring during EVLP, and how they differ between more or less viable lungs, remain to be determined. Methods We used RNA sequencing of lung tissue to delineate changes in gene expression occurring in 10 donor lungs undergoing EVLP and compare lungs that were deemed non‐transplantable (n = 4) to those deemed transplantable (n = 6) following perfusion. Results We found that lungs deemed unsuitable for transplantation had increased induction of innate immune pathways and lower expression of oxidative phosphorylation related genes. Furthermore, the expression of SCGB1A1, a gene encoding an anti‐inflammatory secretoglobin CC10, and other club cell genes was significantly decreased in non‐transplantable lungs, while CHIT‐1 was increased. Using a larger validation cohort (n = 17), we confirmed that the ratio of CHIT1 and SCGB1A1 protein levels in lung perfusate have potential utility to distinguish transplantable from non‐transplantable lungs (AUC .81). Conclusions Together, our data identify novel biomarkers that may assist with pre‐transplant lung assessment, as well as pathways that may be amenable to therapeutic intervention during EVLPAQ6.
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Affiliation(s)
- John Robert Ferdinand
- Molecular Immunity Unit, University of Cambridge Department of Medicine, Cambridge, UK
| | | | - Anders Andreasson
- Institute of Transplantation, Freeman Hospital, Newcastle Upon Tyne, UK
| | - Catriona Charlton
- Newcastle University Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, UK
| | - Alisha Kaur Chhatwal
- Newcastle University Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, UK
| | - William Earl Scott
- Newcastle University Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, UK
| | - Lee Anthony Borthwick
- Newcastle University Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, UK
| | - Menna Ruth Clatworthy
- Molecular Immunity Unit, University of Cambridge Department of Medicine, Cambridge, UK.,Cellular Genetics, Wellcome Sanger Institute, Hinxton, UK
| | - Andrew J Fisher
- Newcastle University Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, UK.,Institute of Transplantation, Freeman Hospital, Newcastle Upon Tyne, UK
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17
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Murala JS, Whited WM, Banga A, Castillo R, Peltz M, Huffman LC, Hackmann AE, Jessen ME, Torres F, Wait MA. Ex vivo lung perfusion: how we do it. Indian J Thorac Cardiovasc Surg 2021; 37:433-444. [PMID: 34483507 PMCID: PMC8408366 DOI: 10.1007/s12055-021-01215-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 05/10/2021] [Accepted: 05/12/2021] [Indexed: 11/26/2022] Open
Abstract
Lung transplantation is an established treatment for patients with end-stage lung disease. However, a shortage of donors, low lung utilization among potential donors, and waitlist mortality continue to be challenges. In the last decade, ex vivo lung perfusion (EVLP) has expanded the donor pool by allowing prolonged evaluation of marginal donor lungs and allowing reparative therapies for lungs, which are otherwise considered not transplantable. In this review, we describe in detail our experience with EVLP including our workflow, setup, operative technique, and protocols. Our multidisciplinary EVLP program functions with the collaboration of surgeons, pulmonologists, and EVLP nurses who run the pump. EVLP program has been a valuable addition to our program. Since Food and Drug Administration (FDA) approval in 2019, we experienced incremental increased lung transplant volume of 12% annually.
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Affiliation(s)
- John Santosh Murala
- Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern (UTSW) Medical Center, 5959 Harry Hines Blvd., 10th Floor, Suite HP10.110, Dallas, TX 75390 USA
| | - William Michael Whited
- Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern (UTSW) Medical Center, 5959 Harry Hines Blvd., 10th Floor, Suite HP10.110, Dallas, TX 75390 USA
| | - Amit Banga
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Texas Southwestern (UTSW) Medical Center, Dallas, TX USA
| | - Robert Castillo
- Cardiovascular Intensive Care Unit and Previous EVLP Nursing Lead, University of Texas Southwestern Medical Center, Dallas, TX USA
| | - Matthias Peltz
- Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern (UTSW) Medical Center, 5959 Harry Hines Blvd., 10th Floor, Suite HP10.110, Dallas, TX 75390 USA
| | - Lynn Custer Huffman
- Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern (UTSW) Medical Center, 5959 Harry Hines Blvd., 10th Floor, Suite HP10.110, Dallas, TX 75390 USA
| | - Amy Elizabeth Hackmann
- Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern (UTSW) Medical Center, 5959 Harry Hines Blvd., 10th Floor, Suite HP10.110, Dallas, TX 75390 USA
| | - Michael Erik Jessen
- Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern (UTSW) Medical Center, 5959 Harry Hines Blvd., 10th Floor, Suite HP10.110, Dallas, TX 75390 USA
| | - Fernando Torres
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Texas Southwestern (UTSW) Medical Center, Dallas, TX USA
| | - Michael Alton Wait
- Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern (UTSW) Medical Center, 5959 Harry Hines Blvd., 10th Floor, Suite HP10.110, Dallas, TX 75390 USA
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18
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Piechura LM, Rinewalt DE, Mallidi HR. Advanced Surgical and Percutaneous Approaches to Pulmonary Vascular Disease. Clin Chest Med 2021; 42:143-154. [PMID: 33541608 DOI: 10.1016/j.ccm.2020.10.003] [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] [Indexed: 11/17/2022]
Abstract
Despite progress in modern medical therapy, pulmonary hypertension remains an unremitting disease. Once severe or refractory to medical therapy, advanced percutaneous and surgical interventions can palliate right ventricular overload, bridge to transplantation, and overall extend a patient's course. These approaches include atrial septostomy, Potts shunt, and extracorporeal life support. Bilateral lung transplantation is the ultimate treatment for eligible patients, although the need for suitable lungs continues to outpace availability. Measures such as ex vivo lung perfusion are ongoing to expand donor lung availability, increase rates of transplant, and decrease waitlist mortality.
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Affiliation(s)
- Laura M Piechura
- Division of Cardiac Surgery, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA; Division of Thoracic Surgery, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Daniel E Rinewalt
- Division of Cardiac Surgery, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Hari R Mallidi
- Division of Cardiac Surgery, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA; Division of Thoracic Surgery, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA.
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19
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Wang L, Thompson E, Bates L, Pither TL, Hosgood SA, Nicholson ML, Watson CJ, Wilson C, Fisher AJ, Ali S, Dark JH. Flavin Mononucleotide as a Biomarker of Organ Quality-A Pilot Study. Transplant Direct 2020; 6:e600. [PMID: 32904032 PMCID: PMC7447496 DOI: 10.1097/txd.0000000000001046] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 07/09/2020] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Flavin mononucleotide (FMN), released from damaged mitochondrial complex I during hypothermic liver perfusion, has been shown to be predictive of 90-day graft loss. Normothermic machine perfusion (NMP) and normothermic regional perfusion (NRP) are used for organ reconditioning and quality assessment before transplantation. This pilot study aimed to investigate the changes of FMN levels during normothermic reperfusion of kidneys, livers, and lungs and examine whether FMN could serve as a biomarker to predict posttransplant allograft quality. METHODS FMN concentrations, in perfusates collected during NMP of kidneys, abdominal NRP, and ex vivo lung perfusion, were measured using fluorescence spectrometry and correlated to the available perfusion parameters and clinical outcomes. RESULTS Among 7 transplanted kidneys out of the 11 kidneys that underwent NMP, FMN levels at 60 minutes of NMP were significantly higher in the allografts that developed delayed graft function and primary nonfunction (P = 0.02). Fifteen livers from 23 circulatory death donors that underwent NRP were deemed suitable for transplantation. Their FMN levels at 30 minutes of NRP were significantly lower than those not procured for transplantation (P = 0.004). In contrast, little FMN was released during the 8 lung perfusions. CONCLUSIONS This proof of concept study suggested that FMN in the perfusates of kidney NMP has the potential to predict posttransplant renal function, whereas FMN at 30 minutes of NRP predicts whether a liver would be accepted for transplantation. More work is required to validate the role of FMN as a putative biomarker to facilitate safe and reliable decision-making before embarking on transplantation.
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Affiliation(s)
- Lu Wang
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Emily Thompson
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Lucy Bates
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Thomas L. Pither
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Sarah A. Hosgood
- Department of Surgery, University of Cambridge, Cambridge, United Kingdom
| | | | | | - Colin Wilson
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Andrew J. Fisher
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Simi Ali
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - John H. Dark
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
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20
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Ex vivo repair of human donor lungs for transplantation. Nat Med 2020; 26:1015-1016. [PMID: 32651577 DOI: 10.1038/s41591-020-0967-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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21
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Chakos A, Ferret P, Muston B, Yan TD, Tian DH. Ex-vivo lung perfusion versus standard protocol lung transplantation-mid-term survival and meta-analysis. Ann Cardiothorac Surg 2020; 9:1-9. [PMID: 32175234 PMCID: PMC7049550 DOI: 10.21037/acs.2020.01.02] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Accepted: 01/06/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND While extended criteria lung donation has helped expand the lung donor pool, utilization of lungs from donors of at least one other solid organ is still limited to around 15-30%. Ex-vivo lung perfusion (EVLP) offers the ability to expand the number of useable lung grafts through assessment and reconditioning of explanted lungs, particularly those not initially meeting criteria for transplantation. This meta-analysis aimed to examine the mid- to long-term survival and other short-term outcomes of patients transplanted with EVLP-treated lungs versus standard/cold-storage protocol lungs. METHODS Literature search of ten medical databases was conducted for original studies involving "ex-vivo lung perfusion" and "EVLP". Included articles were assessed by two independent researchers, survival data from Kaplan-Meier curves digitized, and individual patient data imputed to conduct aggregated survival analysis. Meta-analyses of suitably reported outcomes were conducted using a random-effects model. RESULTS Thirteen studies met inclusion criteria, with a total of 407 EVLP lung transplants and 1,765 as per standard/cold storage protocol. One study was a randomized controlled trial while the remainder were single-institution cohort series of varying design. The majority of donor lungs were from brain death donors, with EVLP lungs having significantly worse PaO2/FiO2 ratio and significantly greater rate of abnormal chest X-ray. Aggregated survival analysis of all included studies revealed no significant survival difference for EVLP or standard protocol lungs (hazard ratio 1.00; 95% confidence interval: 0.79-1.27, P=0.981). Survival at 12, 24, and 36 months for the EVLP cohort was 84%, 79%, and 74%, respectively. Survival at 12, 24, and 36 months for the standard protocol cohort was 85%, 79%, and 73%, respectively. Meta-analysis did not find a significant difference in risk of 30-day mortality or primary graft dysfunction grade 3 at 72 hours between cohorts. CONCLUSIONS There was no significant difference in mid- to long-term survival of EVLP lung transplant patients when compared to standard protocol donor lungs. The incidence of 30-day mortality and primary graft dysfunction grade 3 at 72 hours did not differ significantly between groups. EVLP offers the potential to increase lung donor utilization while providing similar short-term outcomes and mid- to long-term survival.
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Affiliation(s)
- Adam Chakos
- The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - Paule Ferret
- The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia
| | - Benjamin Muston
- The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia
| | - Tristan D. Yan
- The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
- Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, Sydney, Australia
| | - David H. Tian
- The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia
- Department of Anaesthesia and Perioperative Medicine, Westmead Hospital, Sydney, Australia
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22
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Okamoto T, Niikawa H, Ayyat K, Sakanoue I, Said S, McCurry KR. Machine Perfusion of Lungs. CURRENT TRANSPLANTATION REPORTS 2019. [DOI: 10.1007/s40472-019-00258-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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23
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Optimizing organs for transplantation; advancements in perfusion and preservation methods. Transplant Rev (Orlando) 2019; 34:100514. [PMID: 31645271 DOI: 10.1016/j.trre.2019.100514] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 06/20/2019] [Accepted: 10/11/2019] [Indexed: 02/06/2023]
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24
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Utilization and Cost Analysis of Lung Transplantation and Survival After 10 Years of Adapting the Lung Allocation Score. Transplantation 2019; 103:638-646. [PMID: 29697575 DOI: 10.1097/tp.0000000000002227] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Lungs are allocated in the United States using the lung allocation score (LAS). We investigated the effect of LAS trends on lung transplant-related costs, healthcare utilization, and mortality. METHODS Utilization data from Mayo Clinic (Florida and Minnesota) from 2005 to 2015 were obtained from the electronic health records (N = 465). Costs were categorized as 1-year posttransplant or transplant episode and standardized using 2015 Medicare reimbursement and cost-to-charge ratios. Regression analysis was used to assess the relationship of LAS to length of stay (LOS), mortality, and cost of transplant. RESULTS The mean LAS at transplant increased from 45.7 to 58.3 during the study period, whereas the 1-year survival improved from 88.1% to 92.5% (P < 0.0001). The proportion of patients transplanted with LAS of 60 or greater increased from 16.9% to 33.3%. Posttransplant, overall, and intensive care unit LOS increased with increasing LAS. Patients with higher LAS had substantially higher transplant episode costs. An increase of LAS at transplant by 10 points increased inflation-adjusted costs by 12.0% (95% confidence interval, 9.3%-14.5%). CONCLUSIONS The mean LAS at transplant has significantly increased over time associated with increases in LOS, resource utilization and cost. Lung allocation score has not jeopardized overall survival, but a high LAS (>60) at transplant is associated with increased mortality.
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25
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McMeekin N, Chrysos AE, Vale L, Fisher AJ. Incorporating ex-vivo lung perfusion into the UK adult lung transplant service: an economic evaluation and decision analytic model. BMC Health Serv Res 2019; 19:326. [PMID: 31117992 PMCID: PMC6532206 DOI: 10.1186/s12913-019-4154-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 05/08/2019] [Indexed: 11/10/2022] Open
Abstract
Background An estimated 20–30% of end-stage lung disease patients awaiting lung transplant die whilst on the waiting list due to a shortage of suitable donor lungs. Ex-Vivo Lung Perfusion is a technique that reconditions donor lungs initially not deemed usable in order to make them suitable for transplantation, thereby increasing the donor pool. In this study, an economic evaluation was conducted as part of DEVELOP-UK, a multi-centre study assessing the clinical and cost-effectiveness of the Ex-Vivo Lung Perfusion technique in the United Kingdom. Methods We estimated the cost-effectiveness of a UK adult lung transplant service combining both standard and Ex-Vivo Lung Perfusion transplants compared to a service including only standard lung transplants. A Markov model was developed and populated with a combination of DEVELOP-UK, published and clinical routine data, and extrapolated to a lifetime horizon. Probabilistic sensitivity and scenario analyses were used to explore uncertainty in the final outcomes. Results Base-case model results estimated life years gained of 0.040, quality-adjusted life-years (QALYs) gained of 0.045 and an incremental cost per QALY of £90,000 for Ex-Vivo Lung Perfusion. Scenario analyses carried out suggest that an improved rate of converting unusable donor lungs using Ex-Vivo Lung Perfusion, similar resource use post-transplant for both standard and EVLP lung transplant and applying increased waiting list costs would reduce ICERs to approximately £30,000 or below. Conclusion DEVELOP-UK base-case results suggest that incorporating Ex-Vivo Lung Perfusion into the UK adult lung transplant service is more effective, increasing the number of donor lungs available for transplant, but would not currently be considered cost-effective in the UK using the present NICE threshold. However, results were sensitive to change in some model parameters and in several plausible scenario analyses results indicate that a service incorporating Ex-vivo lung perfusion would be considered cost-effective . Trial registration ISRCTN registry number: ISRCTN44922411. Date of registration: 06/02/2012. Retrospectively registered.
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Affiliation(s)
- N McMeekin
- HEHTA, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK.
| | - A E Chrysos
- Health Economics Group, Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK.,Population Health Sciences, Bristol Medical School, Canynge Hall, University of Bristol, Bristol, UK
| | - L Vale
- Health Economics Group, Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - A J Fisher
- Institute of Transplantation, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.,Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
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26
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Nilsson T, Wallinder A, Henriksen I, Nilsson JC, Ricksten SE, Møller-Sørensen H, Riise GC, Perch M, Dellgren G. Lung transplantation after ex vivo lung perfusion in two Scandinavian centres. Eur J Cardiothorac Surg 2019; 55:766-772. [PMID: 30376058 PMCID: PMC6421510 DOI: 10.1093/ejcts/ezy354] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Revised: 09/03/2018] [Accepted: 09/04/2018] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES We reviewed our combined clinical outcome in patients who underwent lung transplantation after ex vivo lung perfusion (EVLP) and compared it to the contemporary control group. METHODS At 2 Scandinavian centres, lungs from brain-dead donors, not accepted for donation but with potential for improvement, were subjected to EVLP (n = 61) and were transplanted if predefined criteria were met. Transplantation outcome was compared with that of the contemporary control group consisting of patients (n = 271) who were transplanted with conventional donor lungs. RESULTS Fifty-four recipients from the regular waiting list underwent transplantation with lungs subjected to EVLP (1 bilateral lobar, 7 single and 46 double). In the EVLP and control groups, arterial oxygen tension/inspired oxygen fraction ratio at arrival in the intensive care unit (ICU) was 30 ± 14 kPa compared to 36 ± 14 (P = 0.005); median time to extubation was 18 h (range 2-912) compared to 7 (range 0-2280) (P = 0.002); median ICU length of stay was 4 days (range 2-65) compared to 3 days (range 1-156) (P = 0.002); Percentage of expected forced expiratory volume at 1s (FEV1.0%) at 1 year was 75 ± 29 compared to 81 ± 26 (P = 0.18); and the 1-year survival rate was 87% [confidence interval (CI) 82-92%] compared to 83% (CI 81-85), respectively. Follow-up to a maximum of 5 years did not show any significant difference in survival between groups (log rank, P = 0.63). CONCLUSIONS Patients transplanted with lungs after EVLP showed outcomes comparable to patients who received conventional organs at medium-term follow-up. Although early outcome immediately after transplantation showed worse lung function in the EVLP group, no differences were observed at a later stage, and we consider EVLP to be a safe method for increasing the number of transplantable organs.
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Affiliation(s)
- Tobias Nilsson
- Department of Cardiothoracic Anaesthesia and Intensive Care, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Andreas Wallinder
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Ian Henriksen
- Department of Cardiothoracic Anesthesiology, Rigshospitalet, Denmark
| | | | - Sven-Erik Ricksten
- Department of Cardiothoracic Anaesthesia and Intensive Care, Sahlgrenska University Hospital, Gothenburg, Sweden
| | | | - Gerdt C Riise
- Department of Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Pulmonary Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Michael Perch
- Department of Cardiology, Section for Lung Transplantation, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Göran Dellgren
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden
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27
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Proteome Investigation of Rat Lungs subjected to Ex Vivo Perfusion (EVLP). Molecules 2018; 23:molecules23123061. [PMID: 30467300 PMCID: PMC6321151 DOI: 10.3390/molecules23123061] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Revised: 11/14/2018] [Accepted: 11/21/2018] [Indexed: 11/23/2022] Open
Abstract
Ex vivo lung perfusion (EVLP) is an emerging procedure that allows organ preservation, assessment and reconditioning, increasing the number of marginal donor lungs for transplantation. However, physiological and airflow measurements are unable to unveil the molecular mechanisms responsible of EVLP beneficial effects on lung graft and monitor the proper course of the treatment. Thus, it is urgent to find specific biomarkers that possess these requirements but also accurate and reliable techniques that identify them. The purpose of this study is to give an overview on the potentiality of shotgun proteomic platforms in characterizing the status and the evolution of metabolic pathways during EVLP in order to find new potential EVLP-related biomarkers. A nanoLC-MS/MS system was applied to the proteome analysis of lung tissues from an optimized rat model in three experimental groups: native, pre- and post-EVLP. Technical and biological repeatability were evaluated and, together with clustering analysis, underlined the good quality of data produced. In-house software and bioinformatics tools allowed the label-free extraction of differentially expressed proteins among the three examined conditions and the network visualization of the pathways mainly involved. These promising findings encourage further proteomic investigations of the molecular mechanisms behind EVLP procedure.
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28
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Vieira RF, Breithaupt-Faloppa AC, Matsubara BC, Rodrigues G, Sanches MP, Armstrong-Jr R, Ferreira SG, Correia CDJ, Moreira LFP, Sannomiya P. 17β-Estradiol protects against lung injuries after brain death in male rats. J Heart Lung Transplant 2018; 37:1381-1387. [PMID: 30139547 DOI: 10.1016/j.healun.2018.06.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Revised: 04/09/2018] [Accepted: 06/21/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Brain death elicits microvascular dysfunction and inflammation, and thereby compromises lung viability for transplantation. As 17β-estradiol was shown to be anti-inflammatory and vascular protective, we investigated its effects on lung injury after brain death in male rats. METHODS Wistar rats were assigned to: sham-operation by trepanation only (SH, n = 7); brain death (BD, n = 7); administration of 17β-estradiol (280 μg/kg, iv) at 60 minutes after brain death (BD-E2, n = 7). Experiments were performed 180 minutes thereafter. Histopathological changes in the lung were evaluated by histomorphometry. Gene expression of inducible nitric oxide synthase (iNOS), endothelial nitric oxide synthase (eNOS), and endothelin-1 was measured by real-time polymerase chain reaction. Protein expression of NO synthases, endothelin-1, platelet endothelial cell adhesion molecule-1 (PECAM-1), vascular cell adhesion molecule-1 (VCAM-1), intercellular adhesion molecule-1 (ICAM-1), BCL-2, and caspase 3 was assessed by immunohistochemistry. Cytokines were quantified by enzyme-linked immunosorbent assay. RESULTS Treatment with 17β-estradiol after brain death decreased lung edema and hemorrhage (p < 0.0001), and serum levels of cytokine-induced neutrophil chemoattractant-1 (CINC-1; p = 0.0020). iNOS (p < 0.0001) and VCAM-1 (p < 0.0001) also diminished at protein levels, while eNOS accumulated (p = 0.0002). However, gene expression of iNOS, eNOS, and endothelin-1 was comparable among groups, as was protein expression of endothelin-1, ICAM-1, BCL-2, and caspase 3. CONCLUSIONS 17β-Estradiol effectively reduces lung injury in brain-dead rats mainly due to its ability to regulate NO synthases. Thus, the drug may improve lung viability for transplantation.
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Affiliation(s)
- Roberta Figueiredo Vieira
- Laboratório Cirúrgico de Pesquisa Cardiovascular, Instituto do Coração, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Ana Cristina Breithaupt-Faloppa
- Laboratório Cirúrgico de Pesquisa Cardiovascular, Instituto do Coração, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Bruno Carvalho Matsubara
- Laboratório Cirúrgico de Pesquisa Cardiovascular, Instituto do Coração, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Geovana Rodrigues
- Laboratório Cirúrgico de Pesquisa Cardiovascular, Instituto do Coração, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Marcelo Petrof Sanches
- Laboratório Cirúrgico de Pesquisa Cardiovascular, Instituto do Coração, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Roberto Armstrong-Jr
- Laboratório Cirúrgico de Pesquisa Cardiovascular, Instituto do Coração, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Sueli Gomes Ferreira
- Laboratório Cirúrgico de Pesquisa Cardiovascular, Instituto do Coração, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Cristiano de Jesus Correia
- Laboratório Cirúrgico de Pesquisa Cardiovascular, Instituto do Coração, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Luiz Felipe P Moreira
- Laboratório Cirúrgico de Pesquisa Cardiovascular, Instituto do Coração, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Paulina Sannomiya
- Laboratório Cirúrgico de Pesquisa Cardiovascular, Instituto do Coração, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil.
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Abstract
This article summarizes recent knowledge and clinical advances in machine perfusion (MP) of thoracic organs. MP of thoracic organs has gained much attention during the last decade. Clinical studies are investigating the role of MP to preserve, resuscitate, and assess heart and lungs prior to transplantation. Currently, MP of the cardiac allograft is essential in all type DCD heart transplantation while MP of the pulmonary allograft is mandatory in uncontrolled DCD lung transplantation. MP of thoracic organs also offers an exciting platform to further investigate downregulation of the innate and adaptive immunity prior to reperfusion of the allograft in recipients. MP provides a promising technology that allows pre-transplant preservation, resuscitation, assessment, repair, and conditioning of cardiac and pulmonary allografts outside the body in a near physiologic state prior to planned transplantation. Results of ongoing clinical trials are awaited to estimate the true clinical value of this new technology in advancing the field of heart and lung transplantation by increasing the total number and the quality of available organs and by further improving recipient early and long-term outcome.
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Affiliation(s)
- Dirk Van Raemdonck
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Chronic Diseases, KU Leuven University, Leuven, Belgium
| | - Filip Rega
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Cardiovascular Sciences, KU Leuven University, Leuven, Belgium
| | - Steffen Rex
- Department of Cardiovascular Sciences, KU Leuven University, Leuven, Belgium.,Department of Anaesthesiology, University Hospitals Leuven, Leuven, Belgium
| | - Arne Neyrinck
- Department of Cardiovascular Sciences, KU Leuven University, Leuven, Belgium.,Department of Anaesthesiology, University Hospitals Leuven, Leuven, Belgium
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Fisher A, Andreasson A, Chrysos A, Lally J, Mamasoula C, Exley C, Wilkinson J, Qian J, Watson G, Lewington O, Chadwick T, McColl E, Pearce M, Mann K, McMeekin N, Vale L, Tsui S, Yonan N, Simon A, Marczin N, Mascaro J, Dark J. An observational study of Donor Ex Vivo Lung Perfusion in UK lung transplantation: DEVELOP-UK. Health Technol Assess 2018; 20:1-276. [PMID: 27897967 DOI: 10.3310/hta20850] [Citation(s) in RCA: 92] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Many patients awaiting lung transplantation die before a donor organ becomes available. Ex vivo lung perfusion (EVLP) allows initially unusable donor lungs to be assessed and reconditioned for clinical use. OBJECTIVE The objective of the Donor Ex Vivo Lung Perfusion in UK lung transplantation study was to evaluate the clinical effectiveness and cost-effectiveness of EVLP in increasing UK lung transplant activity. DESIGN A multicentre, unblinded, non-randomised, non-inferiority observational study to compare transplant outcomes between EVLP-assessed and standard donor lungs. SETTING Multicentre study involving all five UK officially designated NHS adult lung transplant centres. PARTICIPANTS Patients aged ≥ 18 years with advanced lung disease accepted onto the lung transplant waiting list. INTERVENTION The study intervention was EVLP assessment of donor lungs before determining suitability for transplantation. MAIN OUTCOME MEASURES The primary outcome measure was survival during the first 12 months following lung transplantation. Secondary outcome measures were patient-centred outcomes that are influenced by the effectiveness of lung transplantation and that contribute to the health-care costs. RESULTS Lungs from 53 donors unsuitable for standard transplant were assessed with EVLP, of which 18 (34%) were subsequently transplanted. A total of 184 participants received standard donor lungs. Owing to the early closure of the study, a non-inferiority analysis was not conducted. The Kaplan-Meier estimate of survival at 12 months was 0.67 [95% confidence interval (CI) 0.40 to 0.83] for the EVLP arm and 0.80 (95% CI 0.74 to 0.85) for the standard arm. The hazard ratio for overall 12-month survival in the EVLP arm relative to the standard arm was 1.96 (95% CI 0.83 to 4.67). Patients in the EVLP arm required ventilation for a longer period and stayed longer in an intensive therapy unit (ITU) than patients in the standard arm, but duration of overall hospital stay was similar in both groups. There was a higher rate of very early grade 3 primary graft dysfunction (PGD) in the EVLP arm, but rates of PGD did not differ between groups after 72 hours. The requirement for extracorporeal membrane oxygenation (ECMO) support was higher in the EVLP arm (7/18, 38.8%) than in the standard arm (6/184, 3.2%). There were no major differences in rates of chest radiograph abnormalities, infection, lung function or rejection by 12 months. The cost of EVLP transplants is approximately £35,000 higher than the cost of standard transplants, as a result of the cost of the EVLP procedure, and the increased ECMO use and ITU stay. Predictors of cost were quality of life on joining the waiting list, type of transplant and number of lungs transplanted. An exploratory model comparing a NHS lung transplant service that includes EVLP and standard lung transplants with one including only standard lung transplants resulted in an incremental cost-effectiveness ratio of £73,000. Interviews showed that patients had a good understanding of the need for, and the processes of, EVLP. If EVLP can increase the number of usable donor lungs and reduce waiting, it is likely to be acceptable to those waiting for lung transplantation. Study limitations include small numbers in the EVLP arm, limiting analysis to descriptive statistics and the EVLP protocol change during the study. CONCLUSIONS Overall, one-third of donor lungs subjected to EVLP were deemed suitable for transplant. Estimated survival over 12 months was lower than in the standard group, but the data were also consistent with no difference in survival between groups. Patients receiving these additional transplants experience a higher rate of early graft injury and need for unplanned ECMO support, at increased cost. The small number of participants in the EVLP arm because of early study termination limits the robustness of these conclusions. The reason for the increased PGD rates, high ECMO requirement and possible differences in lung injury between EVLP protocols needs evaluation. TRIAL REGISTRATION Current Controlled Trials ISRCTN44922411. FUNDING This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 85. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Andrew Fisher
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.,Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Anders Andreasson
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.,Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Alexandros Chrysos
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Joanne Lally
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | | | - Catherine Exley
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | | | - Jessica Qian
- Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Gillian Watson
- Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | | | - Thomas Chadwick
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Elaine McColl
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK.,Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Mark Pearce
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Kay Mann
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Nicola McMeekin
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Luke Vale
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Steven Tsui
- Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Nizar Yonan
- University Hospital of South Manchester NHS Foundation Trust, Manchester, UK
| | - Andre Simon
- Royal Brompton and Harefield Hospital NHS Foundation Trust, London, UK
| | - Nandor Marczin
- Royal Brompton and Harefield Hospital NHS Foundation Trust, London, UK
| | - Jorge Mascaro
- Queen Elizabeth Hospital NHS Foundation Trust, Birmingham, UK
| | - John Dark
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.,Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
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Cotter EKH, Banayan JM, Song TH, Chaney MA, Ko H, Cantu E, Diamond J, Weiss SJ, Cypel M, Keshavjee S. Lung in a Box: Ex Vivo Lung Transplantation. J Cardiothorac Vasc Anesth 2017; 32:1971-1981. [PMID: 29449154 DOI: 10.1053/j.jvca.2017.12.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Indexed: 12/18/2022]
Affiliation(s)
| | - Jennifer M Banayan
- Department of Anesthesia and Critical Care, The University of Chicago, Chicago, IL
| | - Tae H Song
- Department of Surgery, The University of Chicago, Chicago, IL
| | - Mark A Chaney
- Department of Anesthesia and Critical Care, The University of Chicago, Chicago, IL.
| | - Hanjo Ko
- Department of Anesthesiology and Critical Care, University of Pennsylvania Health System, Philadelphia, PA
| | - Edward Cantu
- Department of Cardiovascular Surgery, University of Pennsylvania Health System, Philadelphia, PA
| | - Joshua Diamond
- Department of Medicine, University of Pennsylvania Health System, Philadelphia, PA
| | - Stuart J Weiss
- Department of Anesthesiology and Critical Care, University of Pennsylvania Health System, Philadelphia, PA
| | - Marcelo Cypel
- ECLS Program University Health Network, Division of Thoracic Surgery, University of Toronto, Toronto ON, Canada
| | - Shaf Keshavjee
- University Health Network, Toronto Lung Transplant Program, University of Toronto, Toronto ON Canada
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Gilljam M, Nyström U, Dellgren G, Skog I, Hansson L. Survival after lung transplantation for cystic fibrosis in Sweden. Eur J Cardiothorac Surg 2017; 51:571-576. [PMID: 28364441 DOI: 10.1093/ejcts/ezw328] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Accepted: 08/29/2016] [Indexed: 01/27/2023] Open
Abstract
Objectives In Sweden, lung transplantation has been performed in patients with end-stage lung disease since 1990. We assessed survival after lung transplantation for cystic fibrosis (CF) with focus on early mortality and outcome for patients infected with certain multiresistant bacteria, considered a relative contraindication for lung transplantation. Methods Review of CF and transplant databases and patient charts. The Kaplan-Meier method and log-rank test were used for survival analysis and group comparison. Results From November 1991 to December 2014, 115 transplantations were performed in 106 CF patients (9 retransplantations): 3 heart-lung, 106 double lung-, 1 double lobar- and 5 single lung transplantations, constituting 13% (115/909) of all lung-transplant procedures performed in Sweden. The mean age at surgery was 31 (SD 10, range 10-61) years and there were 48% females. Overall 1-year survival after lung transplantation for CF was 86.4%, 5-year survival was 73.7% and 10-year survival was 62.4%. The mean and median survival after transplantation were 13.1 (95% confidence interval (CI): 11-15.3) and 14.6 (95% CI: 9.3-19.8) years, respectively, and there was no significant difference for gender or transplant centre. Extracorporeal membrane oxygenation was used as a bridge to transplantation in 11 cases and five patients received reconditioned lungs. Vascular and infectious complications contributed to eight deaths within the first three postoperative months. The mean survival for 14 patients infected pretransplant with Mycobacterium abscessus or Burkholderia cepacia complex was 8.8 (95% CI: 6.1-11.6) years compared to 13.2 (95% CI: 10.9-15.8) years for patients negative for these bacteria. Nineteen patients (14% of all listed), of whom three were listed for retransplantation, died while waiting a median time of 94 days (range 4 days-2.5 years) after listing. Conclusions Survival after lung transplantation in Sweden is good, also for patients with pretransplant infection with M. abscessus or B. cepacia complex, and comparable to international data.
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Affiliation(s)
- Marita Gilljam
- Department of Respiratory Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Ulla Nyström
- Department of Cardiothoracic Surgery and Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Göran Dellgren
- Department of Cardiothoracic Surgery and Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Ingrid Skog
- Department of Respiratory Medicine and Allergology, Skåne University Hospital, Lund, Sweden
| | - Lennart Hansson
- Department of Respiratory Medicine and Allergology, Skåne University Hospital, Lund, Sweden
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Andreasson ASI, Karamanou DM, Gillespie CS, Özalp F, Butt T, Hill P, Jiwa K, Walden HR, Green NJ, Borthwick LA, Clark SC, Pauli H, Gould KF, Corris PA, Ali S, Dark JH, Fisher AJ. Profiling inflammation and tissue injury markers in perfusate and bronchoalveolar lavage fluid during human ex vivo lung perfusion. Eur J Cardiothorac Surg 2017; 51:577-586. [PMID: 28082471 PMCID: PMC5400024 DOI: 10.1093/ejcts/ezw358] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 08/12/2016] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES: Availability of donor lungs suitable for transplant falls short of current demand and contributes to waiting list mortality. Ex vivo lung perfusion (EVLP) offers the opportunity to objectively assess and recondition organs unsuitable for immediate transplant. Identifying robust biomarkers that can stratify donor lungs during EVLP to use or non-use or for specific interventions could further improve its clinical impact. METHODS: In this pilot study, 16 consecutive donor lungs unsuitable for immediate transplant were assessed by EVLP. Key inflammatory mediators and tissue injury markers were measured in serial perfusate samples collected hourly and in bronchoalveolar lavage fluid (BALF) collected before and after EVLP. Levels were compared between donor lungs that met criteria for transplant and those that did not. RESULTS: Seven of the 16 donor lungs (44%) improved during EVLP and were transplanted with uniformly good outcomes. Tissue and vascular injury markers lactate dehydrogenase, HMGB-1 and Syndecan-1 were significantly lower in perfusate from transplanted lungs. A model combining IL-1β and IL-8 concentrations in perfusate could predict final EVLP outcome after 2 h assessment. In addition, perfusate IL-1β concentrations showed an inverse correlation to recipient oxygenation 24 h post-transplant. CONCLUSIONS: This study confirms the feasibility of using inflammation and tissue injury markers in perfusate and BALF to identify donor lungs most likely to improve for successful transplant during clinical EVLP. These results support examining this issue in a larger study.
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Affiliation(s)
- Anders S I Andreasson
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK.,Cardiopulmonary Transplantation, Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
| | - Danai M Karamanou
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Colin S Gillespie
- School of Mathematics & Statistics, Newcastle University, Newcastle upon Tyne, UK
| | - Faruk Özalp
- Cardiopulmonary Transplantation, Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
| | - Tanveer Butt
- Cardiopulmonary Transplantation, Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
| | - Paul Hill
- Cardiopulmonary Transplantation, Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
| | - Kasim Jiwa
- Cardiopulmonary Transplantation, Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
| | - Hannah R Walden
- Department of Applied Sciences, Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, UK
| | - Nicola J Green
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK.,Cardiopulmonary Transplantation, Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
| | - Lee A Borthwick
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Stephen C Clark
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK.,Cardiopulmonary Transplantation, Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
| | - Henning Pauli
- Cardiopulmonary Transplantation, Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
| | - Kate F Gould
- Cardiopulmonary Transplantation, Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
| | - Paul A Corris
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK.,Cardiopulmonary Transplantation, Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
| | - Simi Ali
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - John H Dark
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK.,Cardiopulmonary Transplantation, Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
| | - Andrew J Fisher
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK.,Cardiopulmonary Transplantation, Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
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Report of the ISHLT Working Group on primary lung graft dysfunction Part IV: Prevention and treatment: A 2016 Consensus Group statement of the International Society for Heart and Lung Transplantation. J Heart Lung Transplant 2017; 36:1121-1136. [DOI: 10.1016/j.healun.2017.07.013] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2017] [Accepted: 07/16/2017] [Indexed: 12/14/2022] Open
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Andreasson ASI, Dark JH, Fisher AJ. Reply to Mohamed S.A. Mohamed. Eur J Cardiothorac Surg 2017; 52:607-608. [PMID: 28430998 DOI: 10.1093/ejcts/ezx111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2017] [Accepted: 03/23/2017] [Indexed: 11/13/2022] Open
Affiliation(s)
- Anders S I Andreasson
- Institute of Transplantation, Newcastle University, Newcastle upon Tyne, UK.,Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - John H Dark
- Institute of Transplantation, Newcastle University, Newcastle upon Tyne, UK.,Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Andrew J Fisher
- Institute of Transplantation, Newcastle University, Newcastle upon Tyne, UK.,Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
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Nilsson T, Gielis JF, Slama A, Hansson C, Wallinder A, Ricksten SE, Dellgren G. Comparison of two strategies for ex vivo lung perfusion. J Heart Lung Transplant 2017; 37:S1053-2498(17)31883-1. [PMID: 28756120 DOI: 10.1016/j.healun.2017.07.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 06/03/2017] [Accepted: 07/03/2017] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Two clinically used strategies for ex vivo lung perfusion (EVLP) were compared in a porcine model with respect to lung function, metabolism, inflammatory response, oxidative stress, and cell viability. METHODS Porcine lungs (n = 20) were preserved, harvested, and kept cooled for 2 hours. After randomization, EVLP was performed using a cellular perfusate and open left atrium (COA group) or an acellular perfusate and a closed left atrium (ACA group). Oxygenation (partial pressure of arterial oxygen/fraction of inspired oxygen), compliance, dead space, weight, and perfusate oncotic pressure were registered before and after a 4-hour period of reconditioning. Lung tissue samples were collected before and after EVLP for quantitative polymerase chain reaction analysis of gene expression for inflammatory markers, measurement of tissue hypoxia (hypoxia inducible factor-1α) and oxidative stress (ascorbyl radical), and viability (trypan blue staining) and lung histopathology. RESULTS In 3 of 10 lungs undergoing EVLP in the ACA group, EVLP was terminated prematurely because of severe lung edema and inability to perfuse the lungs. There were no significant differences in changes of lung oxygenation or pulmonary vascular resistance between groups. Compliance decreased and lung weights increased in both groups, but more in the ACA group (p = 0.083 and p = 0.065, respectively). There was no obvious difference in gene expression for hypoxia inducible factor-1α, inflammatory markers, free radicals, or lung injury between groups. CONCLUSIONS Lung edema formation and decreased lung compliance occurs with both EVLP techniques but were more pronounced in the ACA group. Otherwise, there were no differences in lung function, inflammatory response, ischemia/reperfusion injury, or histopathologic changes between the EVLP techniques.
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Affiliation(s)
- Tobias Nilsson
- Department of Cardiothoracic Anesthesia and Intensive Care, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Anesthesiology and Intensive Care Medicine, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Jan F Gielis
- Laboratory for Microbiology, Parasitology and Hygiene, Antwerp University, Antwerp, Belgium
| | - Alexis Slama
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria; Department of Thoracic Surgery and Surgical Endoscopy, Ruhrlandklinik, University Clinic Essen, Essen, Germany
| | - Christoffer Hansson
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Andreas Wallinder
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Sven-Erik Ricksten
- Department of Cardiothoracic Anesthesia and Intensive Care, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Anesthesiology and Intensive Care Medicine, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Göran Dellgren
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden; Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden.
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Andreasson ASI, Borthwick LA, Gillespie C, Jiwa K, Scott J, Henderson P, Mayes J, Romano R, Roman M, Ali S, Fildes JE, Marczin N, Dark JH, Fisher AJ. The role of interleukin-1β as a predictive biomarker and potential therapeutic target during clinical ex vivo lung perfusion. J Heart Lung Transplant 2017; 36:985-995. [PMID: 28551353 PMCID: PMC5578478 DOI: 10.1016/j.healun.2017.05.012] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Revised: 04/09/2017] [Accepted: 05/09/2017] [Indexed: 11/23/2022] Open
Abstract
Background Extended criteria donor lungs deemed unsuitable for immediate transplantation can be reconditioned using ex vivo lung perfusion (EVLP). Objective identification of which donor lungs can be successfully reconditioned and will function well post-operatively has not been established. This study assessed the predictive value of markers of inflammation and tissue injury in donor lungs undergoing EVLP as part of the DEVELOP-UK study. Methods Longitudinal samples of perfusate, bronchoalveolar lavage, and tissue from 42 human donor lungs undergoing clinical EVLP assessments were analyzed for markers of inflammation and tissue injury. Levels were compared according to EVLP success and post-transplant outcomes. Neutrophil adhesion to human pulmonary microvascular endothelial cells (HPMECs) conditioned with perfusates from EVLP assessments was investigated on a microfluidic platform. Results The most effective markers to differentiate between in-hospital survival and non-survival post-transplant were perfusate interleukin (IL)-1β (area under the curve = 1.00, p = 0.002) and tumor necrosis factor-α (area under the curve = 0.95, p = 0.006) after 30 minutes of EVLP. IL-1β levels in perfusate correlated with upregulation of intracellular adhesion molecule-1 in donor lung vasculature (R2 = 0.68, p < 0.001) and to a lesser degree upregulation of intracellular adhesion molecule-1 (R2 = 0.30, p = 0.001) and E-selectin (R2 = 0.29, p = 0.001) in conditioned HPMECs and neutrophil adhesion to conditioned HPMECs (R2 = 0.33, p < 0.001). Neutralization of IL-1β in perfusate effectively inhibited neutrophil adhesion to conditioned HPMECs (91% reduction, p = 0.002). Conclusions Donor lungs develop a detectable and discriminatory pro-inflammatory signature in perfusate during EVLP. Blocking the IL-1β pathway during EVLP may reduce endothelial activation and subsequent neutrophil adhesion on reperfusion; this requires further investigation in vivo.
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Affiliation(s)
- Anders S I Andreasson
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, United Kingdom; Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Lee A Borthwick
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Colin Gillespie
- School of Mathematics & Statistics, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Kasim Jiwa
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Jonathan Scott
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Paul Henderson
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Jonny Mayes
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | | | | | - Simi Ali
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - James E Fildes
- University Hospital of South Manchester, Manchester, United Kingdom; Manchester Collaborative Centre for Inflammation Research, University of Manchester, Manchester, United Kingdom
| | | | - John H Dark
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, United Kingdom; Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Andrew J Fisher
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, United Kingdom; Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom.
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39
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Levin K, Kotecha S, Westall G, Snell G. How can we improve the quality of transplantable lungs? Expert Rev Respir Med 2016; 10:1155-1161. [PMID: 27656957 DOI: 10.1080/17476348.2016.1240035] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
INTRODUCTION Optimization of lungs for organ donation is becoming increasingly important as donation rates stagnate despite growing waiting lists. Improving procurement and utilization of donated lungs has the ability to reduce mortality and time on the lung transplantation (LTx) waiting list. Additionally, assessment and optimization of donor lungs can reduce both early and late post-LTx morbidity and mortality, as well as reduce overall costs and resource utility. Areas covered: Strategies that we will discuss in detail include intensive care management practices, such as targeted ventilation protocols and therapeutic bronchoscopy, as well as the ever expanding possibilities within the arena of ex vivo lung perfusion (EVLP). Expert commentary: Donor lung quality is currently optimized both in vivo prior to organ procurement, and also via EVLP circuits. Despite good evidence demonstrating the utility of both approaches, data remain elusive as to whether EVLP is beneficial for all donor lungs prior to implantation, or instead as a tool by which we can evaluate and recondition sub-optimal donor lungs.
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Affiliation(s)
- Kovi Levin
- a Alfred Hospital - Lung Transplant Service , Department of Respiratory Medicine , Melbourne , Australia
| | - Sakhee Kotecha
- a Alfred Hospital - Lung Transplant Service , Department of Respiratory Medicine , Melbourne , Australia
| | - Glen Westall
- a Alfred Hospital - Lung Transplant Service , Department of Respiratory Medicine , Melbourne , Australia
| | - Gregory Snell
- a Alfred Hospital - Lung Transplant Service , Department of Respiratory Medicine , Melbourne , Australia
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Debaty G, Maignan M, Perrin B, Brouta A, Guergour D, Trocme C, Bach V, Tanguy S, Briot R. Cardiopulmonary responses during the cooling and the extracorporeal life support rewarming phases in a porcine model of accidental deep hypothermic cardiac arrest. Scand J Trauma Resusc Emerg Med 2016; 24:91. [PMID: 27391370 PMCID: PMC4939029 DOI: 10.1186/s13049-016-0283-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Accepted: 06/28/2016] [Indexed: 05/29/2023] Open
Abstract
Background This study aimed to assess cardiac and pulmonary pathophysiological responses during cooling and extracorporeal life support (ECLS) rewarming in a porcine model of deep hypothermic cardiac arrest (DHCA). In addition, we evaluated whether providing a lower flow rate of ECLS during the rewarming phase might attenuate cardiopulmonary injuries. Methods Twenty pigs were cannulated for ECLS, cooled until DHCA occurred and subjected to 30 min of cardiac arrest. In order to assess the physiological impact of ECLS on cardiac output we measured flow in the pulmonary artery using Doppler echocardiography as well as a modified thermodilution technique using the Swan-Ganz catheter (injection site in the right ventricle). The animals were randomized into two groups during rewarming: a group with a low blood flow rate of 1.5 L/min (LF group) and a group with a normal flow rate of 3.0 L/min (NF group). The ECLS temperature was adjusted to 5 °C above the central core. Cardiac output, hemodynamics and pulmonary function parameters were evaluated. Results During the cooling phase, cardiac output, heart rhythm and blood pressure decreased continuously. Pulmonary artery pressure tended to increase at 32 °C compared to the initial value (20.2 ± 1.7 mmHg vs. 29.1 ± 5.6 mmHg, p = 0.09). During rewarming, arterial blood pressure was higher in the NF than in the LF group at 20° and 25 °C (p = 0.003 and 0.05, respectively). After rewarming to 35 °C, cardiac output was 3.9 ± 0.5 L/min in the NF group vs. 2.7 ± 0.5 L/min in LF group (p = 0.06). At the end of rewarming under ECLS cardiac output was inversely proportional to the ECLS flow rate. Moreover, the ECLS flow rate did not significantly change pulmonary vascular resistance. Discussion Using a newly developed experimental model of DHCA treated by ECLS, we assessed the cardiac and pulmonary pathophysiological response during the cooling phase and the ECLS rewarming phase. Despite lower metabolic need during hypothermia, a low ECLS blood flow rate during rewarming did not improved cardiopulmonary injuries after rewarming. Conclusion A low ECLS flow rate during the rewarming phase did not attenuate pulmonary lesions, increased blood lactate level and tended to decrease cardiac output after rewarming. A normal ECLS flow rate did not increase pulmonary vascular resistance compared to a low flow rate. This experimental model on pigs contributes a number of pathophysiological findings relevant to the rewarming strategy for patients who have undergone accidental DHCA.
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Affiliation(s)
- Guillaume Debaty
- Department of Emergency Medicine, SAMU 38, University Hospital of Grenoble, Grenoble, France. .,University Grenoble Alps/CNRS/TIMC-IMAG UMR 5525/Team PRETA, Grenoble, F-38041, France.
| | - Maxime Maignan
- Department of Emergency Medicine, SAMU 38, University Hospital of Grenoble, Grenoble, France
| | - Bertrand Perrin
- University Grenoble Alps/CNRS/TIMC-IMAG UMR 5525/Team PRETA, Grenoble, F-38041, France
| | - Angélique Brouta
- University Grenoble Alps/CNRS/TIMC-IMAG UMR 5525/Team PRETA, Grenoble, F-38041, France
| | - Dorra Guergour
- Department of Biochemistry Toxicology and Pharmacology, University Hospital of Grenoble, Grenoble, France
| | - Candice Trocme
- Department of Biochemistry Toxicology and Pharmacology, University Hospital of Grenoble, Grenoble, France
| | - Vincent Bach
- Department of cardiac surgery, University Hospital of Grenoble, Grenoble, France
| | - Stéphane Tanguy
- University Grenoble Alps/CNRS/TIMC-IMAG UMR 5525/Team PRETA, Grenoble, F-38041, France
| | - Raphaël Briot
- Department of Emergency Medicine, SAMU 38, University Hospital of Grenoble, Grenoble, France.,University Grenoble Alps/CNRS/TIMC-IMAG UMR 5525/Team PRETA, Grenoble, F-38041, France
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Zeriouh M, Sabashnikov A, Mohite PN, Zych B, Patil NP, García-Sáez D, Koch A, Weymann A, Soresi S, Wippermann J, Wahlers T, De Robertis F, Popov AF, Simon AR. Utilization of the organ care system for bilateral lung transplantation: preliminary results of a comparative study. Interact Cardiovasc Thorac Surg 2016; 23:351-7. [DOI: 10.1093/icvts/ivw135] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 03/18/2016] [Indexed: 11/13/2022] Open
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Ex vivo lung graft perfusion. Anaesth Crit Care Pain Med 2016; 35:123-31. [DOI: 10.1016/j.accpm.2015.09.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Accepted: 09/25/2015] [Indexed: 01/08/2023]
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Wagner FM, Reichenspurner H. Ex vivo lung perfusion: The magic bullet to cure sick donor lungs? J Thorac Cardiovasc Surg 2016; 151:547-8. [DOI: 10.1016/j.jtcvs.2015.10.052] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Accepted: 10/14/2015] [Indexed: 10/22/2022]
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What's new in pulmonary transplantation: Finding the right lung for every patient. J Thorac Cardiovasc Surg 2015; 151:315-6. [PMID: 26806506 DOI: 10.1016/j.jtcvs.2015.09.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Accepted: 09/03/2015] [Indexed: 11/21/2022]
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Abstract
PURPOSE OF REVIEW Shortage of donor organs has increased consideration for use of historically excluded grafts. Ex-vivo machine perfusion is an emerging technology that holds the potential for organ resuscitation and reconditioning, potentially increasing the quality and number of organs available for transplantation. This article aims to review the recent advances in machine perfusion and organ preservation solutions. RECENT FINDINGS Flow and pressure-based machine perfusion has shown improved kidney graft function and survival, especially among expanded criteria donors. Pressure-based machine perfusion is demonstrating promising results in preservation and resuscitation of liver, pancreas, heart, and also lung grafts. August 2014 marked Food and Drug Administration approval of XPS XVIVO Perfusion System (XVIVO Perfusion Inc., Englewood, Colorado, USA), a device for preserving and resuscitating lung allografts initially considered unsuitable for transplantation. Although there is no consensus among physicians about the optimal preservation solution, adding antiapoptotic and cell protective agents to preservation solutions is an interesting research area that offers potential to improve preservation. SUMMARY Ex-vivo machine perfusion of solid organs is a promising method that provides the opportunity for resuscitation and reconditioning of suboptimal grafts, expanding the number and quality of donor organs.
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Abstract
PURPOSE OF REVIEW To summarize the history of organ preservation and place into this context the current trends in preservation. RECENT FINDINGS Multiple large retrospective studies have analyzed cold preservation solutions in an attempt to determine superiority with largely negative results. Experimental and some clinical studies have examined machine perfusion of procured grafts, in both hypothermic and normothermic contexts with variable, but promising, results. Lastly, there are experimental efforts to evaluate mesenchymal stem cell therapy on rehabilitation of marginal donor organs. SUMMARY New trends in organ preservation may soon translate into more efficient use of the limited donor pool.
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Bennett D, Fossi A, Bargagli E, Refini RM, Pieroni M, Luzzi L, Ghiribelli C, Paladini P, Voltolini L, Rottoli P. Mortality on the Waiting List for Lung Transplantation in Patients with Idiopathic Pulmonary Fibrosis: A Single-Centre Experience. Lung 2015. [PMID: 26216722 DOI: 10.1007/s00408-015-9767-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE Lung transplantation (LTX) is nowadays accepted as a treatment option for selected patients with end-stage pulmonary disease. Idiopathic pulmonary fibrosis (IPF) is characterized by the radiological and histologic appearance of usual interstitial pneumonia. It is associated with a poor prognosis, and LTX is considered an effective treatment to significantly modify the natural history of this disease. The aim of the present study was to analyse mortality during the waiting list in IPF patients at a single institution. METHODS A retrospective analysis on IPF patients (n = 90) referred to our Lung Transplant Program in the period 2001-2014 was performed focusing on patients' characteristics and associated risk factors. RESULTS Diagnosis of IPF was associated with high mortality on the waiting list with respect to other diagnosis (p < 0.05). No differences in demographic, clinical, radiological data and time spent on the waiting list were observed between IPF patients who underwent to LTX or lost on the waiting list. Patients who died showed significant higher levels of pCO2 and needed higher flows of O2-therapy on effort (p < 0.05). Pulmonary function tests failed to predict mortality and no other medical conditions were associated with survival. CONCLUSIONS Patients newly diagnosed with IPF, especially in small to medium lung transplant volume centres and in Countries where a long waiting list is expected, should be immediately referred to transplantation, delay results in increased mortality. Early identification of IPF patients with a rapid progressive phenotype is strongly needed.
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Affiliation(s)
- David Bennett
- Respiratory Diseases and Lung Transplantation Unit, Internal and Specialist Medicine Department, Azienda Ospedaliera Universitaria Senese (AOUS), Viale Bracci n° 16, 2nd Floor, 3rd Building, 53100, Siena, Italy.
| | - Antonella Fossi
- Respiratory Diseases and Lung Transplantation Unit, Internal and Specialist Medicine Department, Azienda Ospedaliera Universitaria Senese (AOUS), Viale Bracci n° 16, 2nd Floor, 3rd Building, 53100, Siena, Italy
| | - Elena Bargagli
- Respiratory Diseases and Lung Transplantation Unit, Internal and Specialist Medicine Department, Azienda Ospedaliera Universitaria Senese (AOUS), Viale Bracci n° 16, 2nd Floor, 3rd Building, 53100, Siena, Italy
| | - Rosa Metella Refini
- Respiratory Diseases and Lung Transplantation Unit, Internal and Specialist Medicine Department, Azienda Ospedaliera Universitaria Senese (AOUS), Viale Bracci n° 16, 2nd Floor, 3rd Building, 53100, Siena, Italy
| | - Maria Pieroni
- Respiratory Diseases and Lung Transplantation Unit, Internal and Specialist Medicine Department, Azienda Ospedaliera Universitaria Senese (AOUS), Viale Bracci n° 16, 2nd Floor, 3rd Building, 53100, Siena, Italy
| | - Luca Luzzi
- Thoracic Surgery Unit, Cardio-Thoracic-Vascular Department, Azienda Ospedaliera Universitaria Senese (AOUS), Siena, Italy
| | - Claudia Ghiribelli
- Thoracic Surgery Unit, Cardio-Thoracic-Vascular Department, Azienda Ospedaliera Universitaria Senese (AOUS), Siena, Italy
| | - Piero Paladini
- Thoracic Surgery Unit, Cardio-Thoracic-Vascular Department, Azienda Ospedaliera Universitaria Senese (AOUS), Siena, Italy
| | - Luca Voltolini
- Thoracic Surgery Unit, Cardio-Thoracic-Vascular Department, Azienda Ospedaliera Universitaria Senese (AOUS), Siena, Italy
| | - Paola Rottoli
- Respiratory Diseases and Lung Transplantation Unit, Internal and Specialist Medicine Department, Azienda Ospedaliera Universitaria Senese (AOUS), Viale Bracci n° 16, 2nd Floor, 3rd Building, 53100, Siena, Italy
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Aigner C, Slama A. Towards a better understanding of ex vivo lung perfusion. Eur J Cardiothorac Surg 2014; 46:800-801. [DOI: 10.1093/ejcts/ezu297] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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