1
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Longchamp A, Fontan FM, Aburawi MM, Eymard C, Karimian N, Detelich D, Pendexter C, Cronin S, Agius T, Nagpal S, Banik PD, Tessier SN, Ozer S, Delmonico FL, Uygun K, Yeh H, Markmann JF. Acellular Perfusate is an Adequate Alternative to Packed Red Blood Cells During Normothermic Human Kidney Perfusion. Transplant Direct 2024; 10:e1609. [PMID: 38481967 PMCID: PMC10936975 DOI: 10.1097/txd.0000000000001609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 12/26/2023] [Accepted: 01/06/2024] [Indexed: 03/17/2024] Open
Abstract
Background Brief normothermic machine perfusion is increasingly used to assess and recondition grafts before transplant. During normothermic machine perfusion, metabolic activity is typically maintained using red blood cell (RBC)-based solutions. However, the utilization of RBCs creates important logistical constraints. This study explored the feasibility of human kidney normothermic perfusion using William's E-based perfusate with no additional oxygen carrier. Methods Sixteen human kidneys declined for transplant were perfused with a perfusion solution containing packed RBCs or William's E medium only for 6 h using a pressure-controlled system. The temperature was set at 37 °C. Renal artery resistance, oxygen extraction, metabolic activity, energy metabolism, and histological features were evaluated. Results Baseline donor demographics were similar in both groups. Throughout perfusion, kidneys perfused with William's E exhibited improved renal flow (P = 0.041) but similar arterial resistance. Lactic acid levels remained higher in kidneys perfused with RBCs during the first 3 h of perfusion but were similar thereafter (P = 0.95 at 6 h). Throughout perfusion, kidneys from both groups exhibited comparable behavior regarding oxygen consumption (P = 0.41) and reconstitution of ATP tissue concentration (P = 0.55). Similarly, nicotinamide adenine dinucleotide levels were preserved during perfusion. There was no evidence of histological damage caused by either perfusate. Conclusions In human kidneys, William's E medium provides a logistically convenient, off-the-shelf alternative to packed RBCs for up to 6 h of normothermic machine perfusion.
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Affiliation(s)
- Alban Longchamp
- Division of Transplantation, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
- Department of Surgery, Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Fermin M. Fontan
- Division of Transplantation, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Mohamed M. Aburawi
- Division of Transplantation, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Corey Eymard
- Division of Transplantation, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
- Department of Surgery, Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Negin Karimian
- Division of Transplantation, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
- Department of Surgery, Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Danielle Detelich
- Department of Surgery, Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Casie Pendexter
- Department of Surgery, Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Stephanie Cronin
- Department of Surgery, Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Thomas Agius
- Division of Transplantation, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
- Department of Surgery, Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Sonal Nagpal
- Department of Surgery, Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Peony Dutta Banik
- Department of Surgery, Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Shannon N. Tessier
- Department of Surgery, Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Sinan Ozer
- Department of Surgery, Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Francis L. Delmonico
- Division of Transplantation, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
- New England Donor Services, Waltham, MA
| | - Korkut Uygun
- Division of Transplantation, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
- Department of Surgery, Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Heidi Yeh
- Division of Transplantation, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
- Department of Surgery, Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - James F. Markmann
- Division of Transplantation, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
- Department of Surgery, Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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2
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Agius T, Emsley R, Lyon A, MacArthur MR, Kiesworo K, Faivre A, Stavart L, Lambelet M, Legouis D, de Seigneux S, Golshayan D, Lazeyras F, Yeh H, Markmann JF, Uygun K, Ocampo A, Mitchell SJ, Allagnat F, Déglise S, Longchamp A. Short-term hypercaloric carbohydrate loading increases surgical stress resilience by inducing FGF21. Nat Commun 2024; 15:1073. [PMID: 38316771 PMCID: PMC10844297 DOI: 10.1038/s41467-024-44866-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 01/08/2024] [Indexed: 02/07/2024] Open
Abstract
Dietary restriction promotes resistance to surgical stress in multiple organisms. Counterintuitively, current medical protocols recommend short-term carbohydrate-rich drinks (carbohydrate loading) prior to surgery, part of a multimodal perioperative care pathway designed to enhance surgical recovery. Despite widespread clinical use, preclinical and mechanistic studies on carbohydrate loading in surgical contexts are lacking. Here we demonstrate in ad libitum-fed mice that liquid carbohydrate loading for one week drives reductions in solid food intake, while nearly doubling total caloric intake. Similarly, in humans, simple carbohydrate intake is inversely correlated with dietary protein intake. Carbohydrate loading-induced protein dilution increases expression of hepatic fibroblast growth factor 21 (FGF21) independent of caloric intake, resulting in protection in two models of surgical stress: renal and hepatic ischemia-reperfusion injury. The protection is consistent across male, female, and aged mice. In vivo, amino acid add-back or genetic FGF21 deletion blocks carbohydrate loading-mediated protection from ischemia-reperfusion injury. Finally, carbohydrate loading induction of FGF21 is associated with the induction of the canonical integrated stress response (ATF3/4, NF-kB), and oxidative metabolism (PPARγ). Together, these data support carbohydrate loading drinks prior to surgery and reveal an essential role of protein dilution via FGF21.
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Affiliation(s)
- Thomas Agius
- Department of Vascular Surgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
- Transplant Center, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Center for Engineering in Medicine, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Raffaella Emsley
- Department of Vascular Surgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Arnaud Lyon
- Department of Vascular Surgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Michael R MacArthur
- Lewis-Sigler Institute for Integrative Genomics, Princeton University, Princeton, NJ, USA
| | - Kevin Kiesworo
- Department of Vascular Surgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Anna Faivre
- Laboratory of Nephrology, Department of Internal Medicine Specialties and Department of Cell Physiology and Metabolism, University of Geneva, Geneva, Switzerland
- Service of Nephrology, Department of Internal Medicine Specialties, University Hospital of Geneva, Geneva, Switzerland
| | - Louis Stavart
- Transplantation Center, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), Lausanne, Switzerland
| | - Martine Lambelet
- Department of Vascular Surgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - David Legouis
- Laboratory of Nephrology, Department of Internal Medicine Specialties and Department of Cell Physiology and Metabolism, University of Geneva, Geneva, Switzerland
- Division of Intensive Care, Department of Acute Medicine, University Hospital of Geneva, Geneva, Switzerland
| | - Sophie de Seigneux
- Laboratory of Nephrology, Department of Internal Medicine Specialties and Department of Cell Physiology and Metabolism, University of Geneva, Geneva, Switzerland
- Service of Nephrology, Department of Internal Medicine Specialties, University Hospital of Geneva, Geneva, Switzerland
| | - Déla Golshayan
- Transplantation Center, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), Lausanne, Switzerland
| | - Francois Lazeyras
- Department of Radiology and Medical Informatics, University of Geneva, Geneva, Switzerland
- Center for Biomedical Imaging (CIBM), Geneva, Switzerland
| | - Heidi Yeh
- Transplant Center, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Center for Engineering in Medicine, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - James F Markmann
- Transplant Center, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Center for Engineering in Medicine, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Korkut Uygun
- Transplant Center, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Center for Engineering in Medicine, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Alejandro Ocampo
- Department of Biomedical Sciences, University of Lausanne, Lausanne, Switzerland
| | - Sarah J Mitchell
- Lewis-Sigler Institute for Integrative Genomics, Princeton University, Princeton, NJ, USA
| | - Florent Allagnat
- Department of Vascular Surgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
- Department of Biomedical Sciences, University of Lausanne, Lausanne, Switzerland
| | - Sébastien Déglise
- Department of Vascular Surgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Alban Longchamp
- Department of Vascular Surgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland.
- Transplant Center, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
- Center for Engineering in Medicine, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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3
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Longchamp A, Nakamura T, Uygun K, Markmann JF. Role of Machine Perfusion in Liver Transplantation. Surg Clin North Am 2024; 104:45-65. [PMID: 37953040 DOI: 10.1016/j.suc.2023.07.001] [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: 11/14/2023]
Abstract
Given the current severe shortage of available livers for transplantation, there is an urgent need to maximize the utilization of donor organs. One of the strategies to increase the number of available livers for transplantation is to improve organ utilization through the use of elderly, overweight, or organs donated after circulatory death. However, the utilization of these "marginal" organs was associated with an increased risk of early allograft dysfunction, primary nonfunction, ischemic biliary complications, or even re-transplantation. Ischemia-reperfusion injury is a key mechanism in the pathogenesis of these complications.
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Affiliation(s)
- Alban Longchamp
- Division of Transplant Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Department of Surgery, Center for Engineering in Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Tsukasa Nakamura
- Division of Transplant Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Korkut Uygun
- Division of Transplant Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Department of Surgery, Center for Engineering in Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - James F Markmann
- Division of Transplant Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Department of Surgery, Center for Engineering in Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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4
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Agius T, Songeon J, Lyon A, Longchamp J, Ruttimann R, Allagnat F, Déglise S, Corpataux JM, Golshayan D, Buhler L, Meier R, Yeh H, Markmann JF, Uygun K, Toso C, Klauser A, Lazeyras F, Longchamp A. Sodium Hydrosulfide Treatment During Porcine Kidney Ex Vivo Perfusion and Transplantation. Transplant Direct 2023; 9:e1508. [PMID: 37915463 PMCID: PMC10617874 DOI: 10.1097/txd.0000000000001508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 05/01/2023] [Accepted: 05/16/2023] [Indexed: 11/03/2023] Open
Abstract
Background In rodents, hydrogen sulfide (H2S) reduces ischemia-reperfusion injury and improves renal graft function after transplantation. Here, we hypothesized that the benefits of H2S are conserved in pigs, a more clinically relevant model. Methods Adult porcine kidneys retrieved immediately or after 60 min of warm ischemia (WI) were exposed to 100 µM sodium hydrosulfide (NaHS) (1) during the hypothermic ex vivo perfusion only, (2) during WI only, and (3) during both WI and ex vivo perfusion. Kidney perfusion was evaluated with dynamic contrast-enhanced MRI. MRI spectroscopy was further employed to assess energy metabolites including ATP. Renal biopsies were collected at various time points for histopathological analysis. Results Perfusion for 4 h pig kidneys with Belzer MPS UW + NaHS resulted in similar renal perfusion and ATP levels than perfusion with UW alone. Similarly, no difference was observed when NaHS was administered in the renal artery before ischemia. After autotransplantation, no improvement in histologic lesions or cortical/medullary kidney perfusion was observed upon H2S administration. In addition, AMP and ATP levels were identical in both groups. Conclusions In conclusion, treatment of porcine kidney grafts using NaHS did not result in a significant reduction of ischemia-reperfusion injury or improvement of kidney metabolism. Future studies will need to define the benefits of H2S in human, possibly using other molecules as H2S donors.
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Affiliation(s)
- Thomas Agius
- Department of Vascular Surgery, Lausanne University Hospital, Lausanne, Switzerland
- Department of Surgery, Transplant Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA
- Department of Surgery, Center for Engineering in Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Julien Songeon
- Department of Radiology and Medical Informatics, University of Geneva, Geneva, Switzerland
| | - Arnaud Lyon
- Department of Vascular Surgery, Lausanne University Hospital, Lausanne, Switzerland
- Department of Medicine, Transplantation Centre, Lausanne University Hospital, Lausanne, Switzerland
| | - Justine Longchamp
- Department of Vascular Surgery, Lausanne University Hospital, Lausanne, Switzerland
| | - Raphael Ruttimann
- Visceral and Transplant Surgery, Department of Surgery, Geneva University Hospitals and Medical School, Geneva, Switzerland
| | - Florent Allagnat
- Department of Vascular Surgery, Lausanne University Hospital, Lausanne, Switzerland
| | - Sébastien Déglise
- Department of Vascular Surgery, Lausanne University Hospital, Lausanne, Switzerland
| | - Jean-Marc Corpataux
- Department of Vascular Surgery, Lausanne University Hospital, Lausanne, Switzerland
| | - Déla Golshayan
- Department of Medicine, Transplantation Centre, Lausanne University Hospital, Lausanne, Switzerland
| | - Léo Buhler
- Section of Medicine, Faculty of Science and Medicine, University of Fribourg, Switzerland
| | - Raphael Meier
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Heidi Yeh
- Department of Surgery, Transplant Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA
- Department of Surgery, Center for Engineering in Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - James F. Markmann
- Department of Surgery, Transplant Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA
- Department of Surgery, Center for Engineering in Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Korkut Uygun
- Department of Surgery, Center for Engineering in Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Christian Toso
- Visceral and Transplant Surgery, Department of Surgery, Geneva University Hospitals and Medical School, Geneva, Switzerland
| | - Antoine Klauser
- Department of Radiology and Medical Informatics, University of Geneva, Geneva, Switzerland
- CIBM Center for Biomedical Imaging, Geneva, Switzerland
| | - Francois Lazeyras
- Department of Radiology and Medical Informatics, University of Geneva, Geneva, Switzerland
- CIBM Center for Biomedical Imaging, Geneva, Switzerland
| | - Alban Longchamp
- Department of Vascular Surgery, Lausanne University Hospital, Lausanne, Switzerland
- Department of Surgery, Transplant Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA
- Department of Surgery, Center for Engineering in Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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5
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Verstraeten L, Den Abt R, Ghesquière B, Jochmans I. Current Insights into the Metabolome during Hypothermic Kidney Perfusion-A Scoping Review. J Clin Med 2023; 12:jcm12113613. [PMID: 37297808 DOI: 10.3390/jcm12113613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 05/16/2023] [Accepted: 05/20/2023] [Indexed: 06/12/2023] Open
Abstract
This scoping review summarizes what is known about kidney metabolism during hypothermic perfusion preservation. Papers studying kidney metabolism during hypothermic (<12 °C) perfusion were identified (PubMed, Embase, Web of Science, Cochrane). Out of 14,335 initially identified records, 52 were included [dog (26/52), rabbit (2/52), pig (20/52), human (7/52)]. These were published between 1970-2023, partially explaining study heterogeneity. There is a considerable risk of bias in the reported studies. Studies used different perfusates, oxygenation levels, kidney injury levels, and devices and reported on perfusate and tissue metabolites. In 11 papers, (non)radioactively labeled metabolites (tracers) were used to study metabolic pathways. Together these studies show that kidneys are metabolically active during hypothermic perfusion, regardless of the perfusion setting. Although tracers give us more insight into active metabolic pathways, kidney metabolism during hypothermic perfusion is incompletely understood. Metabolism is influenced by perfusate composition, oxygenation levels, and likely also by pre-existing ischemic injury. In the modern era, with increasing donations after circulatory death and the emergence of hypothermic oxygenated perfusion, the focus should be on understanding metabolic perturbations caused by pre-existing injury levels and the effect of perfusate oxygen levels. The use of tracers is indispensable to understanding the kidney's metabolism during perfusion, given the complexity of interactions between different metabolites.
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Affiliation(s)
- Laurence Verstraeten
- Laboratory of Abdominal Transplantation KU Leuven, Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, 3000 Leuven, Belgium
| | - Rutger Den Abt
- Laboratory of Abdominal Transplantation KU Leuven, Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, 3000 Leuven, Belgium
| | - Bart Ghesquière
- Metabolomics Expertise Center, Center for Cancer Biology, VIB, 3000 Leuven, Belgium
- Laboratory of Applied Mass Spectrometry, Department of Cellular and Molecular Medicine, KU Leuven, 3000 Leuven, Belgium
| | - Ina Jochmans
- Laboratory of Abdominal Transplantation KU Leuven, Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, 3000 Leuven, Belgium
- Department of Abdominal Transplant Surgery, University Hospitals Leuven, 3000 Leuven, Belgium
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6
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Humphries TLR, Vesey DA, Galloway GJ, Gobe GC, Francis RS. Identifying disease progression in chronic kidney disease using proton magnetic resonance spectroscopy. PROGRESS IN NUCLEAR MAGNETIC RESONANCE SPECTROSCOPY 2023; 134-135:52-64. [PMID: 37321758 DOI: 10.1016/j.pnmrs.2023.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 02/16/2023] [Accepted: 04/01/2023] [Indexed: 06/17/2023]
Abstract
Chronic kidney disease (CKD) affects approximately 10% of the world population, higher still in some developing countries, and can cause irreversible kidney damage eventually leading to kidney failure requiring dialysis or kidney transplantation. However, not all patients with CKD will progress to this stage, and it is difficult to distinguish between progressors and non-progressors at the time of diagnosis. Current clinical practice involves monitoring estimated glomerular filtration rate and proteinuria to assess CKD trajectory over time; however, there remains a need for novel, validated methods that differentiate CKD progressors and non-progressors. Nuclear magnetic resonance techniques, including magnetic resonance spectroscopy and magnetic resonance imaging, have the potential to improve our understanding of CKD progression. Herein, we review the application of magnetic resonance spectroscopy both in preclinical and clinical settings to improve the diagnosis and surveillance of patients with CKD.
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Affiliation(s)
- Tyrone L R Humphries
- Kidney Disease Research Collaborative, University of Queensland and Translational Research Institute, Brisbane, Queensland 4102, Australia; Department of Nephrology, Princess Alexandra Hospital, Woolloongabba, Queensland 4102, Australia.
| | - David A Vesey
- Kidney Disease Research Collaborative, University of Queensland and Translational Research Institute, Brisbane, Queensland 4102, Australia; Department of Nephrology, Princess Alexandra Hospital, Woolloongabba, Queensland 4102, Australia
| | - Graham J Galloway
- Kidney Disease Research Collaborative, University of Queensland and Translational Research Institute, Brisbane, Queensland 4102, Australia
| | - Glenda C Gobe
- Kidney Disease Research Collaborative, University of Queensland and Translational Research Institute, Brisbane, Queensland 4102, Australia
| | - Ross S Francis
- Kidney Disease Research Collaborative, University of Queensland and Translational Research Institute, Brisbane, Queensland 4102, Australia; Department of Nephrology, Princess Alexandra Hospital, Woolloongabba, Queensland 4102, Australia
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7
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Schutter R, van Varsseveld OC, Lantinga VA, Pool MBF, Hamelink TH, Potze JH, Leuvenink HGD, Laustsen C, Borra RJH, Moers C. Magnetic resonance imaging during warm ex vivo kidney perfusion. Artif Organs 2023; 47:105-116. [PMID: 35996889 PMCID: PMC10086841 DOI: 10.1111/aor.14391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 06/30/2022] [Accepted: 08/02/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND The shortage of donor organs for transplantation remains a worldwide problem. The utilization of suboptimal deceased donors enlarges the pool of potential organs, yet consequently, clinicians face the difficult decision of whether these sub-optimal organs are of sufficient quality for transplantation. Novel technologies could play a pivotal role in making pre-transplant organ assessment more objective and reliable. METHODS Ex vivo normothermic machine perfusion (NMP) at temperatures around 35-37°C allows organ quality assessment in a near-physiological environment. Advanced magnetic resonance imaging (MRI) techniques convey unique information about an organ's structural and functional integrity. The concept of applying magnetic resonance imaging during renal normothermic machine perfusion is novel in both renal and radiological research and we have developed the first MRI-compatible NMP setup for human-sized kidneys. RESULTS We were able to obtain a detailed and real-time view of ongoing processes inside renal grafts during ex vivo perfusion. This new technique can visualize structural abnormalities, quantify regional flow distribution, renal metabolism, and local oxygen availability, and track the distribution of ex vivo administered cellular therapy. CONCLUSION This platform allows for advanced pre-transplant organ assessment, provides a new realistic tool for studies into renal physiology and metabolism, and may facilitate therapeutic tracing of pharmacological and cellular interventions to an isolated kidney.
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Affiliation(s)
- Rianne Schutter
- Department of Surgery - Organ Donation and Transplantation, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Otis C van Varsseveld
- Department of Surgery - Organ Donation and Transplantation, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Veerle A Lantinga
- Department of Surgery - Organ Donation and Transplantation, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Merel B F Pool
- Department of Surgery - Organ Donation and Transplantation, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Tim H Hamelink
- Department of Surgery - Organ Donation and Transplantation, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Jan Hendrik Potze
- Department of Radiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Henri G D Leuvenink
- Department of Surgery - Organ Donation and Transplantation, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Christoffer Laustsen
- Department of Clinical Medicine, The MR Research Center, Aarhus University, Aarhus, Denmark
| | - Ronald J H Borra
- Department of Radiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Cyril Moers
- Department of Surgery - Organ Donation and Transplantation, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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8
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Subnormothermic Ex Vivo Porcine Kidney Perfusion Improves Energy Metabolism: Analysis Using 31P Magnetic Resonance Spectroscopic Imaging. Transplant Direct 2022; 8:e1354. [PMID: 36176724 PMCID: PMC9514833 DOI: 10.1097/txd.0000000000001354] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 05/24/2022] [Indexed: 11/26/2022] Open
Abstract
The ideal preservation temperature for donation after circulatory death kidney grafts is unknown. We investigated whether subnormothermic (22 °C) ex vivo kidney machine perfusion could improve kidney metabolism and reduce ischemia-reperfusion injury.
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9
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CD73-Adenosinergic Axis Mediates the Protective Effect of Extracellular Vesicles Derived from Mesenchymal Stromal Cells on Ischemic Renal Damage in a Rat Model of Donation after Circulatory Death. Int J Mol Sci 2022; 23:ijms231810681. [PMID: 36142593 PMCID: PMC9501320 DOI: 10.3390/ijms231810681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 09/09/2022] [Accepted: 09/10/2022] [Indexed: 11/21/2022] Open
Abstract
We propose a new organ-conditioning strategy based on mesenchymal stromal cell (MSCs)/extracellular vesicle (EVs) delivery during hypothermic perfusion. MSCs/EVs marker CD73 is present on renal proximal tubular cells, and it protects against renal ischemia-reperfusion injury by converting adenosine monophosphate into adenosine (ADO). In this study, after checking if CD73-silenced EVs (EVsi) would impact in vitro tubular-cell proliferation, we perfused kidneys of a rat model of donation after circulatory death, with Belzer solution (BS) alone, BS supplemented with MSCs, EVs, or EVsi. The ADO and ATP levels were measured in the effluents and tissues. Global renal ischemic damage score (GRS), and tubular cell proliferation index (IPT) were evaluated in the tissue. EVsi did not induce cell proliferation in vitro. Ex vivo kidneys perfused with BS or BS + EVsi showed the worst GRS and higher effluent ADO levels than the MSC- and EV-perfused kidneys. In the EV-perfused kidneys, the tissue and effluent ATP levels and IPT were the highest, but not if CD73 was silenced. Tissue ATP content was positively correlated with tissue ADO content and negatively correlated with effluent ADO level in all groups. In conclusion, kidney conditioning with EVs protects against ischemic damage by activating the CD73/ADO system.
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10
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Exploring Porcine Precision-Cut Kidney Slices as a Model for Transplant-Related Ischemia-Reperfusion Injury. TRANSPLANTOLOGY 2022. [DOI: 10.3390/transplantology3020015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Marginal donor kidneys are more likely to develop ischemia-reperfusion injury (IRI), resulting in inferior long-term outcomes. Perfusion techniques are used to attenuate IRI and improve graft quality. However, machine perfusion is still in its infancy, and more research is required for optimal conditions and potential repairing therapies. Experimental machine perfusion using porcine kidneys is a great way to investigate transplant-related IRI, but these experiments are costly and time-consuming. Therefore, an intermediate model to study IRI would be of great value. We developed a precision-cut kidney slice (PCKS) model that resembles ischemia-reperfusion and provides opportunities for studying multiple interventions simultaneously. Porcine kidneys were procured from a local slaughterhouse, exposed to 30 min of warm ischemia, and cold preserved. Subsequently, PCKS were prepared and incubated under various conditions. Adenosine triphosphate (ATP) levels and histological tissue integrity were assessed for renal viability and injury. Slicing did not influence tissue viability, and PCKS remained viable up to 72 h incubation with significantly increased ATP levels. Hypothermic and normothermic incubation led to significantly higher ATP levels than baseline. William’s medium E supplemented with Ciprofloxacin (and Amphotericin-B) provided the most beneficial condition for incubation of porcine PCKS. The porcine PCKS model can be used for studying transplant IRI.
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11
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Verstraeten L, Jochmans I. Sense and Sensibilities of Organ Perfusion as a Kidney and Liver Viability Assessment Platform. Transpl Int 2022; 35:10312. [PMID: 35356401 PMCID: PMC8958413 DOI: 10.3389/ti.2022.10312] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 01/26/2022] [Indexed: 12/13/2022]
Abstract
Predicting organ viability before transplantation remains one of the most challenging and ambitious objectives in transplant surgery. Waitlist mortality is high while transplantable organs are discarded. Currently, around 20% of deceased donor kidneys and livers are discarded because of “poor organ quality”, Decisions to discard are still mainly a subjective judgement since there are only limited reliable tools predictive of outcome available. Organ perfusion technology has been posed as a platform for pre-transplant organ viability assessment. Markers of graft injury and function as well as perfusion parameters have been investigated as possible viability markers during ex-situ hypothermic and normothermic perfusion. We provide an overview of the available evidence for the use of kidney and liver perfusion as a tool to predict posttransplant outcomes. Although evidence shows post-transplant outcomes can be predicted by both injury markers and perfusion parameters during hypothermic kidney perfusion, the predictive accuracy is too low to warrant clinical decision making based upon these parameters alone. In liver, further evidence on the usefulness of hypothermic perfusion as a predictive tool is needed. Normothermic perfusion, during which the organ remains fully metabolically active, seems a more promising platform for true viability assessment. Although we do not yet fully understand “on-pump” organ behaviour at normothermia, initial data in kidney and liver are promising. Besides the need for well-designed (registry) studies to advance the field, the catch-22 of selection bias in clinical studies needs addressing.
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Affiliation(s)
- Laurence Verstraeten
- Lab of Abdominal Transplantation, Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Ina Jochmans
- Lab of Abdominal Transplantation, Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- Department of Abdominal Transplantation, University Hospitals Leuven, Leuven, Belgium
- *Correspondence: Ina Jochmans,
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12
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Hamelink TL, Ogurlu B, De Beule J, Lantinga VA, Pool MBF, Venema LH, Leuvenink HGD, Jochmans I, Moers C. Renal Normothermic Machine Perfusion: The Road Toward Clinical Implementation of a Promising Pretransplant Organ Assessment Tool. Transplantation 2022; 106:268-279. [PMID: 33979315 DOI: 10.1097/tp.0000000000003817] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The increased utilization of high-risk renal grafts for transplantation requires optimization of pretransplant organ assessment strategies. Current decision-making methods to accept an organ for transplantation lack overall predictive power and always contain an element of subjectivity. Normothermic machine perfusion (NMP) creates near-physiological conditions, which might facilitate a more objective assessment of organ quality before transplantation. NMP is rapidly gaining popularity, with various transplant centers developing their own NMP protocols and renal viability criteria. However, to date, no validated sets of on-pump viability markers exist nor are there unified NMP protocols. This review provides a critical overview of the fundamentals of current renal NMP protocols and proposes a framework to approach further development of ex vivo organ evaluation. We also comment on the potential logistical implications of routine clinical use of NMP, which is a more complex procedure compared with static cold storage or even hypothermic machine perfusion.
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Affiliation(s)
- Tim L Hamelink
- Department of Surgery-Organ Donation and Transplantation, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Baran Ogurlu
- Department of Surgery-Organ Donation and Transplantation, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Julie De Beule
- Laboratory of Abdominal Transplantation, Transplantation Research Group, Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium
| | - Veerle A Lantinga
- Department of Surgery-Organ Donation and Transplantation, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Merel B F Pool
- Department of Surgery-Organ Donation and Transplantation, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Leonie H Venema
- Department of Surgery-Organ Donation and Transplantation, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Henri G D Leuvenink
- Department of Surgery-Organ Donation and Transplantation, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Ina Jochmans
- Laboratory of Abdominal Transplantation, Transplantation Research Group, Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium
- Department of Abdominal Transplant Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Cyril Moers
- Department of Surgery-Organ Donation and Transplantation, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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A Review of Current and Emerging Trends in Donor Graft-Quality Assessment Techniques. J Clin Med 2022; 11:jcm11030487. [PMID: 35159939 PMCID: PMC8836899 DOI: 10.3390/jcm11030487] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 01/12/2022] [Accepted: 01/14/2022] [Indexed: 02/07/2023] Open
Abstract
The number of patients placed on kidney transplant waiting lists is rapidly increasing, resulting in a growing gap between organ demand and the availability of kidneys for transplantation. This organ shortage has forced medical professionals to utilize marginal kidneys from expanded criteria donors (ECD) to broaden the donor pool and shorten wait times for patients with end-stage renal disease. However, recipients of ECD kidney grafts tend to have worse outcomes compared to those receiving organs from standard criteria donors (SCD), specifically increased risks of delayed graft function (DGF) and primary nonfunction incidence. Thus, representative methods for graft-quality assessment are strongly needed, especially for ECDs. Currently, graft-quality evaluation is limited to interpreting the donor’s recent laboratory tests, clinical risk scores, the visual evaluation of the organ, and, in some cases, a biopsy and perfusion parameters. The last few years have seen the emergence of many new technologies designed to examine organ function, including new imaging techniques, transcriptomics, genomics, proteomics, metabolomics, lipidomics, and new solutions in organ perfusion, which has enabled a deeper understanding of the complex mechanisms associated with ischemia-reperfusion injury (IRI), inflammatory process, and graft rejection. This review summarizes and assesses the strengths and weaknesses of current conventional diagnostic methods and a wide range of new potential strategies (from the last five years) with respect to donor graft-quality assessment, the identification of IRI, perfusion control, and the prediction of DGF.
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Abstract
Hypothermic and normothermic machine perfusion in kidney transplantation are purported to exert a beneficial effect on post-transplant outcomes compared to the traditionally used method of static cold storage. Kidney perfusion techniques provide a window for organ reconditioning and quality assessment. However, how best to deliver these preservation methods or improve organ quality has not yet been conclusively defined. This review summarises the promising advances in machine perfusion science in recent years, which have the potential to further improve early graft function and prolong graft survival.
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Kidney Transplantation and Diagnostic Imaging: The Early Days and Future Advancements of Transplant Surgery. Diagnostics (Basel) 2020; 11:diagnostics11010047. [PMID: 33396860 PMCID: PMC7823312 DOI: 10.3390/diagnostics11010047] [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: 12/03/2020] [Revised: 12/27/2020] [Accepted: 12/28/2020] [Indexed: 12/23/2022] Open
Abstract
The first steps for modern organ transplantation were taken by Emerich Ullmann (Vienne, Austria) in 1902, with a dog-to-dog kidney transplant, and ultimate success was achieved by Joseph Murray in 1954, with the Boston twin brothers. In the same time period, the ground-breaking work of Wilhelm C. Röntgen (1895) and Maria Sklodowska-Curie (1903), on X-rays and radioactivity, enabled the introduction of diagnostic imaging. In the years thereafter, kidney transplantation and diagnostic imaging followed a synergistic path for their development, with key discoveries in transplant rejection pathways, immunosuppressive therapies, and the integration of diagnostic imaging in transplant programs. The first image of a transplanted kidney, a urogram with intravenous contrast, was shown to the public in 1956, and the first recommendations for transplantation diagnostic imaging were published in 1958. Transplant surgeons were eager to use innovative diagnostic modalities, with renal scintigraphy in the 1960s, as well as ultrasound and computed tomography in the 1970s. The use of innovative diagnostic modalities has had a great impact on the reduction of post-operative complications in kidney transplantation, making it one of the key factors for successful transplantation. For the new generation of transplant surgeons, the historical alignment between transplant surgery and diagnostic imaging can be a motivator for future innovations.
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