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Feng S, Roll GR, Rouhani FJ, Sanchez Fueyo A. The future of liver transplantation. Hepatology 2024; 80:674-697. [PMID: 38537154 DOI: 10.1097/hep.0000000000000873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 03/02/2024] [Indexed: 06/15/2024]
Abstract
Over the last 50 years, liver transplantation has evolved into a procedure routinely performed in many countries worldwide. Those able to access this therapy frequently experience a miraculous risk-benefit ratio, particularly if they face the imminently life-threatening disease. Over the decades, the success of liver transplantation, with dramatic improvements in early posttransplant survival, has aggressively driven demand. However, despite the emergence of living donors to augment deceased donors as a source of organs, supply has lagged far behind demand. As a result, rationing has been an unfortunate focus in recent decades. Recent shifts in the epidemiology of liver disease combined with transformative innovations in liver preservation suggest that the underlying premise of organ shortage may erode in the foreseeable future. The focus will sharpen on improving equitable access while mitigating constraints related to workforce training, infrastructure for organ recovery and rehabilitation, and their associated costs. Research efforts in liver preservation will undoubtedly blossom with the aim of optimizing both the timing and conditions of transplantation. Coupled with advances in genetic engineering, regenerative biology, and cellular therapies, the portfolio of innovation, both broad and deep, offers the promise that, in the future, liver transplantation will not only be broadly available to those in need but also represent a highly durable life-saving therapy.
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Affiliation(s)
- Sandy Feng
- Department of Surgery, Division of Transplant Surgery, University of California, San Francisco, California, USA
| | - Garrett R Roll
- Department of Surgery, Division of Transplant Surgery, University of California, San Francisco, California, USA
| | - Foad J Rouhani
- Tissue Regeneration and Clonal Evolution Laboratory, The Francis Crick Institute, London, UK
- Institute of Liver Studies, King's College London, King's College Hospital, NHS Foundation Trust, London, UK
| | - Alberto Sanchez Fueyo
- Institute of Liver Studies, King's College London, King's College Hospital, NHS Foundation Trust, London, UK
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2
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Wehrle CJ, Zhang M, Khalil M, Pita A, Modaresi Esfeh J, Diago-Uso T, Kim J, Aucejo F, Kwon DCH, Ali K, Cazzaniga B, Miyazaki Y, Liu Q, Fares S, Hong H, Tuul M, Jiao C, Sun K, Fairchild RL, Quintini C, Fujiki M, Pinna AD, Miller C, Hashimoto K, Schlegel A. Impact of Back-to-Base Normothermic Machine Perfusion on Complications and Costs: A Multicenter, Real-World Risk-Matched Analysis. Ann Surg 2024; 280:300-310. [PMID: 38557793 DOI: 10.1097/sla.0000000000006291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
OBJECTIVE Assess cost and complication outcomes after liver transplantation (LT) using normothermic machine perfusion (NMP). BACKGROUND End-ischemic NMP is often used to aid logistics, yet its impact on outcomes after LT remains unclear, as does its true impact on costs associated with transplantation. METHODS Deceased donor liver recipients at 2 centers (January 1, 2019, to June 30, 2023) were included. Retransplants, splits, and combined grafts were excluded. End-ischemic NMP (OrganOx-Metra) was implemented in October 2022 for extended-criteria donation after brain death (DBDs), all donations after circulatory deaths (DCDs), and logistics. NMP cases were matched 1:2 with static cold storage controls (SCS) using the Balance-of-Risk [donation after brain death (DBD)-grafts] and UK-DCD Score (DCD-grafts). RESULTS Overall, 803 transplantations were included, 174 (21.7%) receiving NMP. Matching was achieved between 118 NMP-DBDs with 236 SCS; and 37 NMP-DCD with 74 corresponding SCS. For both graft types, median inpatient comprehensive complications index values were comparable between groups. DCD-NMP grafts experienced reduced cumulative 90-day comprehensive complications index (27.6 vs 41.9, P =0.028). NMP also reduced the need for early relaparotomy and renal replacement therapy, with subsequently less frequent major complications (Clavien-Dindo ≥IVa). This effect was more pronounced in DCD transplants. NMP had no protective effect on early biliary complications. Organ acquisition/preservation costs were higher with NMP, yet NMP-treated grafts had lower 90-day pretransplant costs in the context of shorter waiting list times. Overall costs were comparable for both cohorts. CONCLUSIONS This is the first risk-adjusted outcome and cost analysis comparing NMP and SCS. In addition to logistical benefits, NMP was associated with a reduction in relaparotomy and bleeding in DBD grafts, and overall complications and post-LT renal replacement for DCDs. While organ acquisition/preservation was more costly with NMP, overall 90-day health care costs-per-transplantation were comparable.
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Affiliation(s)
| | | | | | | | - Jamak Modaresi Esfeh
- Department of Gastroenterology and Transplant Hepatology, Cleveland Clinic, Cleveland, OH
| | - Teresa Diago-Uso
- Department of Liver Transplantation, Cleveland Clinic Abu Dhabi, Cleveland, OH
| | - Jaekeun Kim
- Transplantation Center, Cleveland Clinic, OH
| | | | | | - Khaled Ali
- Transplantation Center, Cleveland Clinic, OH
| | | | | | - Qiang Liu
- Transplantation Center, Cleveland Clinic, OH
| | - Sami Fares
- Transplantation Center, Cleveland Clinic, OH
| | - Hanna Hong
- Transplantation Center, Cleveland Clinic, OH
| | | | - Chunbao Jiao
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland, OH
| | - Keyue Sun
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland, OH
| | - Robert L Fairchild
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland, OH
| | - Cristiano Quintini
- Department of Liver Transplantation, Cleveland Clinic Abu Dhabi, Cleveland, OH
| | | | | | | | - Koji Hashimoto
- Transplantation Center, Cleveland Clinic, OH
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland, OH
| | - Andrea Schlegel
- Transplantation Center, Cleveland Clinic, OH
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland, OH
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3
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Wehrle CJ, Jiao C, Sun K, Zhang M, Fairchild RL, Miller C, Hashimoto K, Schlegel A. Machine perfusion in liver transplantation: recent advances and coming challenges. Curr Opin Organ Transplant 2024; 29:228-238. [PMID: 38726745 DOI: 10.1097/mot.0000000000001150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/03/2024]
Abstract
PURPOSE OF REVIEW Machine perfusion has been adopted into clinical practice in Europe since the mid-2010s and, more recently, in the United States (US) following approval of normothermic machine perfusion (NMP). We aim to review recent advances, provide discussion of potential future directions, and summarize challenges currently facing the field. RECENT FINDINGS Both NMP and hypothermic-oxygenated perfusion (HOPE) improve overall outcomes after liver transplantation versus traditional static cold storage (SCS) and offer improved logistical flexibility. HOPE offers additional protection to the biliary system stemming from its' protection of mitochondria and lessening of ischemia-reperfusion injury. Normothermic regional perfusion (NRP) is touted to offer similar protective effects on the biliary system, though this has not been studied prospectively.The most critical question remaining is the optimal use cases for each of the three techniques (NMP, HOPE, and NRP), particularly as HOPE and NRP become more available in the US. There are additional questions regarding the most effective criteria for viability assessment and the true economic impact of these techniques. Finally, with each technique purported to allow well tolerated use of riskier grafts, there is an urgent need to define terminology for graft risk, as baseline population differences make comparison of current data challenging. SUMMARY Machine perfusion is now widely available in all western countries and has become an essential tool in liver transplantation. Identification of the ideal technique for each graft, optimization of viability assessment, cost-effectiveness analyses, and proper definition of graft risk are the next steps to maximizing the utility of these powerful tools.
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Affiliation(s)
| | - Chunbao Jiao
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland, Ohio, USA
| | - Keyue Sun
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland, Ohio, USA
| | - Mingyi Zhang
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland, Ohio, USA
| | - Robert L Fairchild
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland, Ohio, USA
| | | | - Koji Hashimoto
- Transplantation Center, Cleveland Clinic
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland, Ohio, USA
| | - Andrea Schlegel
- Transplantation Center, Cleveland Clinic
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland, Ohio, USA
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Piella G, Farré N, Esono D, Cordobés MÁ, Vázquez-Corral J, Bilbao I, Gómez-Gavara C. LiverColor: An Artificial Intelligence Platform for Liver Graft Assessment. Diagnostics (Basel) 2024; 14:1654. [PMID: 39125531 PMCID: PMC11312121 DOI: 10.3390/diagnostics14151654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2024] [Revised: 07/29/2024] [Accepted: 07/30/2024] [Indexed: 08/12/2024] Open
Abstract
Hepatic steatosis, characterized by excess fat in the liver, is the main reason for discarding livers intended for transplantation due to its association with increased postoperative complications. The current gold standard for evaluating hepatic steatosis is liver biopsy, which, despite its accuracy, is invasive, costly, slow, and not always feasible during liver procurement. Consequently, surgeons often rely on subjective visual assessments based on the liver's colour and texture, which are prone to errors and heavily depend on the surgeon's experience. The aim of this study was to develop and validate a simple, rapid, and accurate method for detecting steatosis in donor livers to improve the decision-making process during liver procurement. We developed LiverColor, a co-designed software platform that integrates image analysis and machine learning to classify a liver graft into valid or non-valid according to its steatosis level. We utilized an in-house dataset of 192 cases to develop and validate the classification models. Colour and texture features were extracted from liver photographs, and graft classification was performed using supervised machine learning techniques (random forests and support vector machine). The performance of the algorithm was compared against biopsy results and surgeons' classifications. Usability was also assessed in simulated and real clinical settings using the Mobile Health App Usability Questionnaire. The predictive models demonstrated an area under the receiver operating characteristic curve of 0.82, with an accuracy of 85%, significantly surpassing the accuracy of visual inspections by surgeons. Experienced surgeons rated the platform positively, appreciating not only the hepatic steatosis assessment but also the dashboarding functionalities for summarising and displaying procurement-related data. The results indicate that image analysis coupled with machine learning can effectively and safely identify valid livers during procurement. LiverColor has the potential to enhance the accuracy and efficiency of liver assessments, reducing the reliance on subjective visual inspections and improving transplantation outcomes.
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Affiliation(s)
- Gemma Piella
- Engineering Department, Universitat Pompeu Fabra, 08018 Barcelona, Spain (M.Á.C.)
| | - Nicolau Farré
- Engineering Department, Universitat Pompeu Fabra, 08018 Barcelona, Spain (M.Á.C.)
| | - Daniel Esono
- Engineering Department, Universitat Pompeu Fabra, 08018 Barcelona, Spain (M.Á.C.)
| | | | - Javier Vázquez-Corral
- Computer Vision Center and Computer Sciences Department, Universitat Autònoma de Barcelona, 08193 Barcelona, Spain;
| | - Itxarone Bilbao
- Servicio de Cirugía HBP y Trasplante, Hospital Universitari Vall d’Hebron, Vall d’Hebron Institute of Research (VHIR), 08035 Barcelona, Spain (C.G.-G.)
| | - Concepción Gómez-Gavara
- Servicio de Cirugía HBP y Trasplante, Hospital Universitari Vall d’Hebron, Vall d’Hebron Institute of Research (VHIR), 08035 Barcelona, Spain (C.G.-G.)
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5
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Robinson T, Vargas PA, Yemini R, Goldaracena N, Pelletier S. Are we on track to increase organ utilization? An analysis of machine perfusion preservation for liver transplantation in the United States. Artif Organs 2024. [PMID: 39034871 DOI: 10.1111/aor.14812] [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: 01/09/2024] [Revised: 05/17/2024] [Accepted: 06/11/2024] [Indexed: 07/23/2024]
Abstract
BACKGROUND Efforts to improve the quality of marginal grafts for transplantation are essential. Machine perfusion preservation appears as a promising solution. METHODS The United Network for Organ Sharing (UNOS) database was queried for deceased liver donor records between 2016 and 2022. The primary outcome of interest was the organ nonutilization rate. Long-term graft and patient survival among extended criteria donors (ECDs) were also analyzed. RESULTS During the study period, out of 54 578 liver grafts recovered for transplant, 5085 (9.3%) were nonutilized. Multivariable analysis identified normothermic machine perfusion (NMP) preservation as the only predictor associated with a reduction in graft nonutilization (OR = 0.12; 95% CI = 0.06-0.023, p < 0.001). Further analysis of ECD grafts that were transplanted revealed comparable 1-,2- and 3-years graft survival (89%/88%/82% vs. 90%/85%/81%, p = 0.60), and patient survival (92%/91%/84% vs. 92%/88%/84%, p = 0.65) between grafts that underwent MP vs. those who did not, respectively. CONCLUSIONS Liver nonutilization rates in the United States are at an all-time high. Available data, most likely including cases from clinical trials, showed that NMP reduced the odds of organ nonutilization by 12% among the entire deceased donor pool and by 16% among grafts from ECD. Collective efforts and further evidence reflecting day-to-day clinical practice are needed to fully reach the potential of MP for liver transplant.
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Affiliation(s)
- Todd Robinson
- Division of Transplant Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Paola A Vargas
- Division of Transplant Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Renana Yemini
- Division of Transplant Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Nicolas Goldaracena
- Division of Transplant Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Shawn Pelletier
- Division of Transplant Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
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Risbey CWG, Lau NS, Niu A, Zhang WB, Crawford M, Pulitano C. Return of the cold: How hypothermic oxygenated machine perfusion is changing liver transplantation. Transplant Rev (Orlando) 2024; 38:100853. [PMID: 38581881 DOI: 10.1016/j.trre.2024.100853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 03/28/2024] [Accepted: 04/01/2024] [Indexed: 04/08/2024]
Abstract
Hypothermic Oxygenated machine PErfusion (HOPE) has recently emerged as a preservation technique which can reduce ischemic injury and improve clinical outcomes following liver transplantation. First developed with the advent solid organ transplantation techniques, hypothermic machine perfusion largely fell out of favour following the development of preservation solutions which can satisfactorily preserve grafts using the cheap and simple method, static cold storage (SCS). However, with an increasing need to develop techniques to reduce graft injury and better utilise marginal and donation after circulatory death (DCD) grafts, HOPE has emerged as a relatively simple and safe technique to optimise clinical outcomes following liver transplantation. Perfusing the graft with cold, acellular, oxygenated perfusate either via the portal vein (PV) alone, or via both the PV and hepatic artery (HA), HOPE is generally commenced for a period of 1-2 h immediately prior to implantation. The technique has been validated by multiple randomised control trials, and pre-clinical evidence suggests HOPE primarily reduces graft injury by decreasing the accumulation of harmful mitochondrial intermediates, and subsequently, the severity of post-reperfusion injury. HOPE can also facilitate real time graft assessment, most notably via the measurement of flavin mononucleotide (FMN) in the perfusate, allowing transplant teams to make better informed clinical decisions prior to transplantation. HOPE may also provide a platform to administer novel therapeutic agents to ex situ organs without risk of systemic side effects. As such, HOPE is uniquely positioned to revolutionise how liver transplantation is approached and facilitate optimised clinical outcomes for liver transplant recipients.
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Affiliation(s)
- Charles W G Risbey
- Department of Transplant Surgery, Royal Prince Alfred Hospital, 50 Missenden Rd, Camperdown 2050, NSW, Australia; Centre for Organ Assessment, Repair, & Optimization (COARO), 145 Missenden Rd, Camperdown 2050, NSW, Australia; Royal Prince Alfred Hospital Transplant Institute (RPATI), 145 Missenden Rd, Camperdown 2050, NSW, Australia; Central Clinical School, The University of Sydney, John Hopkins Dr, Camperdown 2050, NSW, Australia
| | - Ngee-Soon Lau
- Department of Transplant Surgery, Royal Prince Alfred Hospital, 50 Missenden Rd, Camperdown 2050, NSW, Australia; Centre for Organ Assessment, Repair, & Optimization (COARO), 145 Missenden Rd, Camperdown 2050, NSW, Australia; Royal Prince Alfred Hospital Transplant Institute (RPATI), 145 Missenden Rd, Camperdown 2050, NSW, Australia
| | - Anita Niu
- Department of Transplant Surgery, Royal Prince Alfred Hospital, 50 Missenden Rd, Camperdown 2050, NSW, Australia; Centre for Organ Assessment, Repair, & Optimization (COARO), 145 Missenden Rd, Camperdown 2050, NSW, Australia; Royal Prince Alfred Hospital Transplant Institute (RPATI), 145 Missenden Rd, Camperdown 2050, NSW, Australia
| | - Wesley B Zhang
- Centre for Organ Assessment, Repair, & Optimization (COARO), 145 Missenden Rd, Camperdown 2050, NSW, Australia
| | - Michael Crawford
- Department of Transplant Surgery, Royal Prince Alfred Hospital, 50 Missenden Rd, Camperdown 2050, NSW, Australia; Centre for Organ Assessment, Repair, & Optimization (COARO), 145 Missenden Rd, Camperdown 2050, NSW, Australia; Royal Prince Alfred Hospital Transplant Institute (RPATI), 145 Missenden Rd, Camperdown 2050, NSW, Australia; Central Clinical School, The University of Sydney, John Hopkins Dr, Camperdown 2050, NSW, Australia
| | - Carlo Pulitano
- Department of Transplant Surgery, Royal Prince Alfred Hospital, 50 Missenden Rd, Camperdown 2050, NSW, Australia; Centre for Organ Assessment, Repair, & Optimization (COARO), 145 Missenden Rd, Camperdown 2050, NSW, Australia; Royal Prince Alfred Hospital Transplant Institute (RPATI), 145 Missenden Rd, Camperdown 2050, NSW, Australia; Central Clinical School, The University of Sydney, John Hopkins Dr, Camperdown 2050, NSW, Australia.
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7
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Wehrle CJ, Hong H, Gross A, Liu Q, Ali K, Cazzaniga B, Miyazaki Y, Tuul M, Modaresi Esfeh J, Khalil M, Pita A, Fernandes E, Kim J, Diago-Uso T, Aucejo F, Kwon DCH, Fujiki M, Quintini C, Schlegel A, Pinna A, Miller C, Hashimoto K. The impact of normothermic machine perfusion and acuity circles on waitlist time, mortality, and cost in liver transplantation: A multicenter experience. Liver Transpl 2024:01445473-990000000-00397. [PMID: 38833290 DOI: 10.1097/lvt.0000000000000412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Accepted: 05/13/2024] [Indexed: 06/06/2024]
Abstract
Ex situ normothermic machine perfusion (NMP) helps increase the use of extended criteria donor livers. However, the impact of an NMP program on waitlist times and mortality has not been evaluated. Adult patients listed for liver transplant (LT) at 2 academic centers from January 1, 2015, to September 1, 2023, were included (n=2773) to allow all patients ≥6 months follow-up from listing. Routine NMP was implemented on October 14, 2022. Waitlist outcomes were compared from pre-NMP pre-acuity circles (n=1460), pre-NMP with acuity circles (n=842), and with NMP (n=381). Median waitlist time was 79 days (IQR: 20-232 d) at baseline, 49 days (7-182) with acuity circles, and 14 days (5-56) with NMP ( p <0.001). The rate of transplant-per-100-person-years improved from 61-per-100-person-years to 99-per-100-person-years with acuity circles and 194-per-100-person-years with NMP ( p <0.001). Crude mortality without transplant decreased from 18.3% (n=268/1460) to 13.3% (n=112/843), to 6.3% (n=24/381) ( p <0.001) with NMP. The incidence of mortality without LT was 15-per-100-person-years before acuity circles, 19-per-100 with acuity circles, and 9-per-100-person-years after NMP ( p <0.001). Median Model for End-Stage Liver Disease at LT was lowest with NMP, but Model for End-Stage Liver Disease at listing was highest in this era ( p <0.0001). The median donor risk index of transplanted livers at baseline was 1.54 (1.27-1.82), 1.66 (1.42-2.16) with acuity circles, and 2.06 (1.63-2.46) with NMP ( p <0.001). Six-month post-LT survival was not different between eras ( p =0.322). The total cost of health care while waitlisted was lowest in the NMP era ($53,683 vs. $32,687 vs. $23,688, p <0.001); cost-per-day did not differ between eras ( p =0.152). The implementation of a routine NMP program was associated with reduced waitlist time and mortality without compromising short-term survival after liver transplant despite increased use of riskier grafts. Routine NMP use enables better waitlist management with reduced health care costs.
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Affiliation(s)
- Chase J Wehrle
- Department of General Surgery, Cleveland Clinic, Digestive Disease & Surgery Institute, Cleveland, Ohio, USA
| | - Hanna Hong
- Department of General Surgery, Cleveland Clinic, Digestive Disease & Surgery Institute, Cleveland, Ohio, USA
| | - Abby Gross
- Department of General Surgery, Cleveland Clinic, Digestive Disease & Surgery Institute, Cleveland, Ohio, USA
| | - Qiang Liu
- Department of General Surgery, Cleveland Clinic, Digestive Disease & Surgery Institute, Cleveland, Ohio, USA
| | - Khaled Ali
- Department of General Surgery, Cleveland Clinic, Digestive Disease & Surgery Institute, Cleveland, Ohio, USA
| | - Beatrice Cazzaniga
- Department of General Surgery, Cleveland Clinic, Digestive Disease & Surgery Institute, Cleveland, Ohio, USA
| | - Yuki Miyazaki
- Department of General Surgery, Cleveland Clinic, Digestive Disease & Surgery Institute, Cleveland, Ohio, USA
| | - Munkhbold Tuul
- Department of General Surgery, Cleveland Clinic, Digestive Disease & Surgery Institute, Cleveland, Ohio, USA
| | - Jamak Modaresi Esfeh
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Mazhar Khalil
- Department of General Surgery, Cleveland Clinic, Digestive Disease & Surgery Institute, Cleveland, Ohio, USA
| | - Alejandro Pita
- Department of General Surgery, Cleveland Clinic, Digestive Disease & Surgery Institute, Cleveland, Ohio, USA
| | - Eduardo Fernandes
- Cleveland Clinic Florida, Abdominal Transplant Center, Weston, Florida, USA
| | - Jaekeun Kim
- Department of General Surgery, Cleveland Clinic, Digestive Disease & Surgery Institute, Cleveland, Ohio, USA
| | - Teresa Diago-Uso
- Cleveland Clinic Abu Dhabi, Digestive Disease Institute, Abu Dhabi, United Arab Emirates
| | - Federico Aucejo
- Department of General Surgery, Cleveland Clinic, Digestive Disease & Surgery Institute, Cleveland, Ohio, USA
| | - David C H Kwon
- Department of General Surgery, Cleveland Clinic, Digestive Disease & Surgery Institute, Cleveland, Ohio, USA
| | - Masato Fujiki
- Department of General Surgery, Cleveland Clinic, Digestive Disease & Surgery Institute, Cleveland, Ohio, USA
| | - Cristiano Quintini
- Cleveland Clinic Abu Dhabi, Digestive Disease Institute, Abu Dhabi, United Arab Emirates
| | - Andrea Schlegel
- Department of General Surgery, Cleveland Clinic, Digestive Disease & Surgery Institute, Cleveland, Ohio, USA
| | - Antonio Pinna
- Cleveland Clinic Abu Dhabi, Digestive Disease Institute, Abu Dhabi, United Arab Emirates
| | - Charles Miller
- Department of General Surgery, Cleveland Clinic, Digestive Disease & Surgery Institute, Cleveland, Ohio, USA
| | - Koji Hashimoto
- Department of General Surgery, Cleveland Clinic, Digestive Disease & Surgery Institute, Cleveland, Ohio, USA
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8
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Lindemann J, Yu J, Doyle MM. Normothermic machine perfusion for liver transplantation: current state and future directions. Curr Opin Organ Transplant 2024; 29:186-194. [PMID: 38483109 DOI: 10.1097/mot.0000000000001141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/30/2024]
Abstract
PURPOSE OF REVIEW The number of patients on the liver transplant waitlist continues to grow and far exceeds the number of livers available for transplantation. Normothermic machine perfusion (NMP) allows for ex-vivo perfusion under physiologic conditions with the potential to significantly increase organ yield and expand the donor pool. RECENT FINDINGS Several studies have found increased utilization of donation after cardiac death and extended criteria brain-dead donor livers with implementation of NMP, largely due to the ability to perform viability testing during machine perfusion. Recently, proposed viability criteria include lactate clearance, maintenance of perfusate pH more than 7.2, ALT less than 6000 u/l, evidence of glucose metabolism and bile production. Optimization of liver grafts during NMP is an active area of research and includes interventions for defatting steatotic livers, preventing ischemic cholangiopathy and rejection, and minimizing ischemia reperfusion injury. SUMMARY NMP has resulted in increased organ utilization from marginal donors with acceptable outcomes. The added flexibility of prolonged organ storage times has the potential to improve time constraints and transplant logistics. Further research to determine ideal viability criteria and investigate ways to optimize marginal and otherwise nontransplantable liver grafts during NMP is warranted.
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Affiliation(s)
- Jessica Lindemann
- Department of Surgery, Section of Abdominal Organ Transplantation, Washington University School of Medicine, Saint Louis, Missouri, USA
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9
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De Goeij FHC, De Meijer V, Mergental H, Guarrera JV, Asthana S, Ghinolfi D, Boteon YL, Selzner N, Kalisvaart M, Pulitano C, Sonnenday C, Martins PN, Berlakovich G, Schlegel A. Challenges With the Implementation of Machine Perfusion in Clinical Liver Transplantation. Transplantation 2024; 108:1296-1307. [PMID: 38057969 DOI: 10.1097/tp.0000000000004872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/08/2023]
Abstract
Dynamic organ preservation is a relatively old technique which has regained significant interest in the last decade. Machine perfusion (MP) techniques are applied in various fields of solid organ transplantation today. The first clinical series of ex situ MP in liver transplantation was presented in 2010. Since then, the number of research and clinical applications has substantially increased. Despite the notable beneficial effect on organ quality and recipient outcome, MP is still not routinely used in liver transplantation. Based on the enormous need to better preserve organs and the subsequent demand to continuously innovate and develop perfusion equipment further, this technology is also beneficial to test and deliver future therapeutic strategies to livers before implantation. This article summarizes the various challenges observed during the current shift from static to dynamic liver preservation in the clinical setting. The different organ perfusion strategies are discussed first, together with ongoing clinical trials and future study design. The current status of research and the impact of costs and regulations is highlighted next. Factors contributing to costs and other required resources for a worldwide successful implementation and reimbursement are presented third. The impact of research on cost-utility and effectivity to guide the tailored decision-making regarding the optimal perfusion strategy is discussed next. Finally, this article provides potential solutions to the challenging field of innovation in healthcare considering the various social and economic factors and the role of clinical, regulatory, and financial stakeholders worldwide.
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Affiliation(s)
- Femke H C De Goeij
- Department of Surgery, Division of Hepatopancreatobiliary and Transplant Surgery, Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Vincent De Meijer
- Department of Surgery, Section of Hepatobiliary Surgery and Liver Transplantation, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
- Department of Surgery, Surgical Research Laboratory, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Hynek Mergental
- The Liver Unit, Queen Elizabeth University Hospital, Birmingham, United Kingdom
- The Liver Unit, Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - James V Guarrera
- Division of Abdominal Transplant Surgery, Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ
| | | | - Davide Ghinolfi
- Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
| | - Yuri L Boteon
- Instituto Israelita de Ensino e Pesquisa Albert Einstein, Faculdade Israelita de Ciências da Saúde Albert Einstein, São Paulo, Brazil
| | - Nazia Selzner
- Ajmera Transplant Center, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Marit Kalisvaart
- Department of Surgery and Transplantation, Swiss HPB Centre, University Hospital Zurich, Zurich, Switzerland
| | - Carlo Pulitano
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital and Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | | | - Paulo N Martins
- Division of Organ Transplantation, Department of Surgery, University of Massachusetts Memorial Hospital, University of Massachusetts, Worcester, MA
| | - Gabriela Berlakovich
- Division of Transplantation, Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - Andrea Schlegel
- Transplantation Center, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
- Department of Immunology, Lerner Research Institute, Cleveland Clinic, Cleveland, OH
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10
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de la Plaza Llamas R, Ortega Azor L, Hernández Yuste M, Gorini L, Latorre-Fragua RA, Díaz Candelas DA, Al Shwely Abduljabar F, Gemio del Rey IA. Quality-adjusted life years and surgical waiting list: Systematic review of the literature. World J Gastrointest Surg 2024; 16:1155-1164. [PMID: 38690041 PMCID: PMC11056653 DOI: 10.4240/wjgs.v16.i4.1155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 01/26/2024] [Accepted: 02/25/2024] [Indexed: 04/22/2024] Open
Abstract
BACKGROUND The quality-adjusted life year (QALY) is a metric that is increasingly used today in the field of health economics to evaluate the value of different medical treatments and procedures. Surgical waiting lists (SWLs) represent a pressing problem in public healthcare. The QALY measure has rarely been used in the context of surgery. It would be interesting to know how many QALYs are lost by patients on SWLs. AIM To investigate the relationship between QALYs and SWLs in a systematic review of the scientific literature. METHODS The study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement. An unlimited search was carried out in PubMed, updated on January 19, 2024. Data on the following variables were investigated and analyzed: Specialty, country of study, procedure under study, scale used to measure QALYs, the use of a theoretical or real-life model, objectives of the study and items measured, the economic value assigned to the QALY in the country in question, and the results and conclusions published. RESULTS Forty-eight articles were selected for the study. No data were found regarding QALYs lost on SWLs. The specialties in which QALYs were studied the most in relation to the waiting list were urology and general surgery, with 15 articles each. The country in which the most studies of QALYs were carried out was the United States (n = 21), followed by the United Kingdom (n = 9) and Canada (n = 7). The most studied procedure was organ transplantation (n = 39), including 15 kidney, 14 liver, 5 heart, 4 lung, and 1 intestinal. Arthroplasty (n = 4), cataract surgery (n = 2), bariatric surgery (n = 1), mosaicplasty (n = 1), and septoplasty (n = 1) completed the surgical interventions included. Thirty-nine of the models used were theoretical (the most frequently applied being the Markov model, n = 34), and nine were real-life. The survey used to measure quality of life in 11 articles was the European Quality of Life-5 dimensions, but in 32 articles the survey was not specified. The willingness-to-pay per QALY gained ranged from $100000 in the United States to €20000 in Spain. CONCLUSION The relationship between QALYs and SWLs has only rarely been studied in the literature. The rate of QALYs lost on SWLs has not been determined. Future research is warranted to address this issue.
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Affiliation(s)
- Roberto de la Plaza Llamas
- Department of General and Digestive Surgery, Hospital Universitario de Guadalajara, Guadalajara 19002, Spain
- Department of Surgery, Medical and Social Sciences, Faculty of Medicine and Health Sciences, University of Alcalá, Alcalá de Henares 28871, Madrid, Spain
| | - Lorena Ortega Azor
- Department of Surgery, Medical and Social Sciences, Faculty of Medicine and Health Sciences, University of Alcalá, Alcalá de Henares 28871, Madrid, Spain
| | - Marina Hernández Yuste
- Department of Surgery, Medical and Social Sciences, Faculty of Medicine and Health Sciences, University of Alcalá, Alcalá de Henares 28871, Madrid, Spain
| | - Ludovica Gorini
- Department of General and Digestive Surgery, Hospital Universitario de Guadalajara, Guadalajara 19002, Spain
| | - Raquel Aránzazu Latorre-Fragua
- Department of General and Digestive Surgery, Hospital Universitario de Guadalajara, Guadalajara 19002, Spain
- Department of Surgery, Medical and Social Sciences, Faculty of Medicine and Health Sciences, University of Alcalá, Alcalá de Henares 28871, Madrid, Spain
| | | | - Farah Al Shwely Abduljabar
- Department of General and Digestive Surgery, Hospital Universitario de Guadalajara, Guadalajara 19002, Spain
- Department of Surgery, Medical and Social Sciences, Faculty of Medicine and Health Sciences, University of Alcalá, Alcalá de Henares 28871, Madrid, Spain
| | - Ignacio Antonio Gemio del Rey
- Department of General and Digestive Surgery, Hospital Universitario de Guadalajara, Guadalajara 19002, Spain
- Department of Surgery, Medical and Social Sciences, Faculty of Medicine and Health Sciences, University of Alcalá, Alcalá de Henares 28871, Madrid, Spain
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11
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Abbas SH, Ceresa CDL, Pollok JM. Steatotic Donor Transplant Livers: Preservation Strategies to Mitigate against Ischaemia-Reperfusion Injury. Int J Mol Sci 2024; 25:4648. [PMID: 38731866 PMCID: PMC11083584 DOI: 10.3390/ijms25094648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 04/21/2024] [Accepted: 04/22/2024] [Indexed: 05/13/2024] Open
Abstract
Liver transplantation (LT) is the only definitive treatment for end-stage liver disease, yet the UK has seen a 400% increase in liver disease-related deaths since 1970, constrained further by a critical shortage of donor organs. This shortfall has necessitated the use of extended criteria donor organs, including those with evidence of steatosis. The impact of hepatic steatosis (HS) on graft viability remains a concern, particularly for donor livers with moderate to severe steatosis which are highly sensitive to the process of ischaemia-reperfusion injury (IRI) and static cold storage (SCS) leading to poor post-transplantation outcomes. This review explores the pathophysiological predisposition of steatotic livers to IRI, the limitations of SCS, and alternative preservation strategies, including novel organ preservation solutions (OPS) and normothermic machine perfusion (NMP), to mitigate IRI and improve outcomes for steatotic donor livers. By addressing these challenges, the liver transplant community can enhance the utilisation of steatotic donor livers which is crucial in the context of the global obesity crisis and the growing need to expand the donor pool.
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Affiliation(s)
- Syed Hussain Abbas
- Oxford Transplant Centre, Nuffield Department of Surgical Sciences, University of Oxford, Oxford OX1 2JD, UK;
| | - Carlo Domenico Lorenzo Ceresa
- Department of Hepatopancreatobiliary and Liver Transplant Surgery, Royal Free Hospital, Pond Street, Hampstead, London NW3 2QG, UK;
| | - Joerg-Matthias Pollok
- Department of Hepatopancreatobiliary and Liver Transplant Surgery, Royal Free Hospital, Pond Street, Hampstead, London NW3 2QG, UK;
- Division of Surgery & Interventional Science, University College London, Gower Street, London WC1E 6BT, UK
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12
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Abou Taka M, Dugbartey GJ, Richard-Mohamed M, McLeod P, Jiang J, Major S, Arp J, O’Neil C, Liu W, Gabril M, Moussa M, Luke P, Sener A. Evaluating the Effects of Kidney Preservation at 10 °C with Hemopure and Sodium Thiosulfate in a Rat Model of Syngeneic Orthotopic Kidney Transplantation. Int J Mol Sci 2024; 25:2210. [PMID: 38396887 PMCID: PMC10889495 DOI: 10.3390/ijms25042210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 01/29/2024] [Accepted: 02/02/2024] [Indexed: 02/25/2024] Open
Abstract
Kidney transplantation is preferred for end-stage renal disease. The current gold standard for kidney preservation is static cold storage (SCS) at 4 °C. However, SCS contributes to renal graft damage through ischemia-reperfusion injury (IRI). We previously reported renal graft protection after SCS with a hydrogen sulfide donor, sodium thiosulfate (STS), at 4 °C. Therefore, this study aims to investigate whether SCS at 10 °C with STS and Hemopure (blood substitute), will provide similar protection. Using in vitro model of IRI, we subjected rat renal proximal tubular epithelial cells to hypoxia-reoxygenation for 24 h at 10 °C with or without STS and measured cell viability. In vivo, we preserved 36 donor kidneys of Lewis rats for 24 h in a preservation solution at 10 °C supplemented with STS, Hemopure, or both followed by transplantation. Tissue damage and recipient graft function parameters, including serum creatinine, blood urea nitrogen, urine osmolality, and glomerular filtration rate (GFR), were evaluated. STS-treated proximal tubular epithelial cells exhibited enhanced viability at 10 °C compared with untreated control cells (p < 0.05). Also, STS and Hemopure improved renal graft function compared with control grafts (p < 0.05) in the early time period after the transplant, but long-term function did not reach significance. Overall, renal graft preservation at 10 °C with STS and Hemopure supplementation has the potential to enhance graft function and reduce kidney damage, suggesting a novel approach to reducing IRI and post-transplant complications.
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Affiliation(s)
- Maria Abou Taka
- Department of Microbiology and Immunology, Schulich School of Medicine and Dentistry, Western University, London, ON N6A 5C1, Canada;
- Matthew Mailing Centre for Translational Transplant Studies, London Health Sciences Centre, London, ON N6A 5A5, Canada; (G.J.D.); (M.R.-M.); (P.L.)
| | - George J. Dugbartey
- Matthew Mailing Centre for Translational Transplant Studies, London Health Sciences Centre, London, ON N6A 5A5, Canada; (G.J.D.); (M.R.-M.); (P.L.)
- Multi-Organ Transplant Program, London Health Sciences Centre, London, ON N6A 5A5, Canada
- Department of Pharmacology and Toxicology, School of Pharmacy, College of Health Sciences, University of Ghana, Legon, Accra P.O. Box LG 1181, Ghana
- London Health Sciences Centre, Department of Surgery, Division of Urology, London, ON N6A 5A5, Canada
| | - Mahms Richard-Mohamed
- Matthew Mailing Centre for Translational Transplant Studies, London Health Sciences Centre, London, ON N6A 5A5, Canada; (G.J.D.); (M.R.-M.); (P.L.)
- Multi-Organ Transplant Program, London Health Sciences Centre, London, ON N6A 5A5, Canada
| | - Patrick McLeod
- Matthew Mailing Centre for Translational Transplant Studies, London Health Sciences Centre, London, ON N6A 5A5, Canada; (G.J.D.); (M.R.-M.); (P.L.)
| | - Jifu Jiang
- Matthew Mailing Centre for Translational Transplant Studies, London Health Sciences Centre, London, ON N6A 5A5, Canada; (G.J.D.); (M.R.-M.); (P.L.)
| | - Sally Major
- Matthew Mailing Centre for Translational Transplant Studies, London Health Sciences Centre, London, ON N6A 5A5, Canada; (G.J.D.); (M.R.-M.); (P.L.)
| | - Jacqueline Arp
- Matthew Mailing Centre for Translational Transplant Studies, London Health Sciences Centre, London, ON N6A 5A5, Canada; (G.J.D.); (M.R.-M.); (P.L.)
| | - Caroline O’Neil
- The Molecular Pathology Core, Robarts Research Institute, London, ON N6A 5A5, Canada
| | - Winnie Liu
- London Health Sciences Centre, Department of Pathology and Laboratory Medicine, London, ON N6A 5A5, Canada (M.G.); (M.M.)
| | - Manal Gabril
- London Health Sciences Centre, Department of Pathology and Laboratory Medicine, London, ON N6A 5A5, Canada (M.G.); (M.M.)
| | - Madeleine Moussa
- London Health Sciences Centre, Department of Pathology and Laboratory Medicine, London, ON N6A 5A5, Canada (M.G.); (M.M.)
| | - Patrick Luke
- Matthew Mailing Centre for Translational Transplant Studies, London Health Sciences Centre, London, ON N6A 5A5, Canada; (G.J.D.); (M.R.-M.); (P.L.)
- Multi-Organ Transplant Program, London Health Sciences Centre, London, ON N6A 5A5, Canada
- London Health Sciences Centre, Department of Surgery, Division of Urology, London, ON N6A 5A5, Canada
- London Health Sciences Centre, Department of Pathology and Laboratory Medicine, London, ON N6A 5A5, Canada (M.G.); (M.M.)
| | - Alp Sener
- Department of Microbiology and Immunology, Schulich School of Medicine and Dentistry, Western University, London, ON N6A 5C1, Canada;
- Matthew Mailing Centre for Translational Transplant Studies, London Health Sciences Centre, London, ON N6A 5A5, Canada; (G.J.D.); (M.R.-M.); (P.L.)
- Multi-Organ Transplant Program, London Health Sciences Centre, London, ON N6A 5A5, Canada
- London Health Sciences Centre, Department of Surgery, Division of Urology, London, ON N6A 5A5, Canada
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13
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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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14
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Shimada S, Yoshida A, Abouljoud M, Miyake K, Ivanics T, Shamaa T, Venkat D, Moonka D, Trudeau S, Reed E, Nagai S. Post-transplant outcomes and financial burden of donation after circulatory death donor liver transplant after the implementation of acuity circle policy. Clin Transplant 2024; 38:e15190. [PMID: 37964683 DOI: 10.1111/ctr.15190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 09/30/2023] [Accepted: 10/28/2023] [Indexed: 11/16/2023]
Abstract
BACKGROUND After implementation of the Acuity Circles (AC) allocation policy, use of DCD liver grafts has increased in the United States. METHODS We evaluated the impact of AC on rates of DCD-liver transplants (LT), their outcomes, and medical costs in a single practice. Adult LT patients were classified into three eras: Era 1 (pre-AC, 1/01/2015-12/31/2017); Era 2 (late pre-AC era, 1/01/2018-02/03/2020); and Era 3 (AC era, 05/10/2020-09/30/2021). RESULTS A total of 520 eligible LTs were performed; 87 were DCD, and 433 were DBD. With each successive era, the proportion of DCD increased (Era 1: 11%; Era 2: 20%; Era 3: 24%; p < .001). DCD recipients had longer ICU stays, higher re-admission/re-operation rates, and higher incidence of ischemic cholangiopathy compared to those with DBD. Direct, surgical, and ICU costs during first admission were higher with DCD than DBD (+8.0%, p < .001; +4.2%, p < .001; and +33.3%, p = .001). DCD-related costs increased after Era 1 (Direct: +4.9% [Era 2 vs. 1] and +12.4% [Era 3 vs. 1], p = .04; Surgical: +17.7% and +21.7%, p < .001). In the AC era, there was a significantly higher proportion of donors ≥50 years, and more national organ sharing. Compared to DCD from donors <50 years, DCD from donors ≥50 years was associated with significantly higher total direct, surgical, and ICU costs (+12.6%, p = .01; +9.5%, p = .01; +84.6%, p = .03). CONCLUSIONS The proportion of DCD-LT, especially from older donors, has increased after the implementation of AC policies. These changes are likely to be associated with higher costs in the AC era.
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Affiliation(s)
- Shingo Shimada
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Health, Detroit, Michigan, USA
| | - Atsushi Yoshida
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Health, Detroit, Michigan, USA
| | - Marwan Abouljoud
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Health, Detroit, Michigan, USA
| | - Katsunori Miyake
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Health, Detroit, Michigan, USA
| | - Tommy Ivanics
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Health, Detroit, Michigan, USA
| | - Tayseer Shamaa
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Health, Detroit, Michigan, USA
| | - Deepak Venkat
- Division of Gastroenterology and Hepatology, Henry Ford Health, Detroit, Michigan, USA
| | - Dilip Moonka
- Division of Gastroenterology and Hepatology, Henry Ford Health, Detroit, Michigan, USA
| | - Sheri Trudeau
- Department of Public Health Sciences, Henry Ford Health, Detroit, Michigan, USA
| | - Elizabeth Reed
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Health, Detroit, Michigan, USA
| | - Shunji Nagai
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Health, Detroit, Michigan, USA
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15
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Cacciola R, Leonardis F, Gitto L, Favi E, Gruttadauria S, Clancy M, Veroux M, Angelico R, Pagano D, Mazzeo C, Cacciola I, Santoro D, Toti L, Tisone G, Cucinotta E. Health economics aspects of kidney transplantation in Sicily: a benchmark analysis on activity and estimated savings. Front Public Health 2023; 11:1222069. [PMID: 38162608 PMCID: PMC10757609 DOI: 10.3389/fpubh.2023.1222069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Accepted: 11/24/2023] [Indexed: 01/03/2024] Open
Abstract
Background International and national registries consistently report substantial differences in kidney transplant (KT) activity despite demonstrable clinical and financial benefits. The study aims to estimate the financial resources gained by KT and produce a benchmark analysis that would inform adequate strategies for the growth of the service. Methods We analyzed the KT activity in our region between 2017 and 2019. The benchmark analysis was conducted with programs identified from national and international registries. The estimate of financial resources was obtained by applying the kidney transplant coefficient of value; subsequently, we compared the different activity levels and savings generated by the three KT programs. Findings The KT activity in the region progressively declined in the study years, producing a parallel reduction of the estimated savings. Such savings were substantially inferior when compared to those generated by benchmark programs (range €18-22 million less). Interpretation The factors influencing the reduced KT activity in the study period with the related "foregone savings" are multiple, as well as interdependent. Organ donation, access to the transplant waiting list, and KT from living donors appear to be the most prominent determinants of the observed different levels of activities. International experience suggests that a comprehensive strategy in the form of a "task force" may successfully address the critical areas of the service reversing the observed trend. The financial impact of a progressively reduced KT activity may be as critical as its clinical implications, jeopardizing the actual sustainability of services for patients with end-stage kidney disease.
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Affiliation(s)
- Roberto Cacciola
- Department of Surgical Sciences, Tor Vergata University, Rome, Italy
| | - Francesca Leonardis
- Department of Surgical Sciences, Tor Vergata University, Rome, Italy
- Intensive Care Unit, Organ and Tissue Procurement Policlinico Tor Vergata, Rome, Italy
| | - Lara Gitto
- Dipartimento di Economia, Università Degli Studi di Messina, Messina, Italy
| | - Evaldo Favi
- General Surgery and Kidney Transplantation, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Clinical Sciences and Community Health, Università Degli Studi di Milano, Milan, Italy
| | - Salvatore Gruttadauria
- Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, University of Istituto di Ricovero e Cura a Carattere Scientifico – Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione, University of Pittsburgh Medical Center Italy, Palermo, Italy
- Department of Surgery and Surgical and Medical Specialties, University of Catania, Catania, Italy
| | - Marc Clancy
- Institute of Cardiovascular and Molecular Sciences, Glasgow University, Glasgow, United Kingdom
| | - Massimiliano Veroux
- General Surgery Unit, Organ Transplant Unit, University Hospital of Catania, Catania, Italy
| | - Roberta Angelico
- Department of Surgical Sciences, Tor Vergata University, Rome, Italy
| | - Duilio Pagano
- Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, University of Istituto di Ricovero e Cura a Carattere Scientifico – Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione, University of Pittsburgh Medical Center Italy, Palermo, Italy
| | - Carmelo Mazzeo
- Department of Human Pathology, Emergency Surgery Unit, Università Degli Studi di Messina, Messina, Italy
| | - Irene Cacciola
- Department of Clinical and Experimental Medicine, Medicine and Hepatology Unit, Università Degli Studi di Messina, Messina, Italy
| | - Domenico Santoro
- Department of Clinical and Experimental Medicine, Nephrology and Dialysis Unit, Università Degli Studi di Messina, Messina, Italy
| | - Luca Toti
- Department of Surgical Sciences, Tor Vergata University, Rome, Italy
| | - Giuseppe Tisone
- Department of Surgical Sciences, Tor Vergata University, Rome, Italy
| | - Eugenio Cucinotta
- General Surgery Unit, Organ Transplant Unit, University Hospital of Catania, Catania, Italy
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16
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Unes M, Kurashima K, Caliskan Y, Portz E, Jain A, Nazzal M. Normothermic ex vivo perfusion of deceased donor kidneys and its clinical potential in kidney transplantation outcomes. Int J Artif Organs 2023; 46:618-628. [PMID: 37897367 DOI: 10.1177/03913988231207719] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/30/2023]
Abstract
In recent years, normothermic machine perfusion (NMP) has emerged in conversation surrounding organ preservation and transplantation techniques with the goal of improving patient and clinical outcomes. This is in great attempt to address the rate of non-utilization and the shortage of available organs in kidney transplantation. This focus in mind, normothermic perfusion presents itself as a potential tool to mimic physiological conditions and improve current preservation methods, such as static cold storage. This review serves to improve understanding of the observed connection between the consequences of ischemia and reperfusion injury and traditional preservation techniques as well as how renal NMP may mitigate these issues. Previous studies suggest that reducing time in static cold storage methods by promoting the normothermic perfusion model results in decreased delayed graft function and post-transplant complications. This review also aims to present the immense clinical potential NMP has on future kidney transplantation success and what this means for the fields of nephrology and transplantation. While great strides have been made to evaluate normothermic perfusion's impact on kidney graft viability and transplant success, future research into unified protocol, clinically relevant biomarkers, cost-utility analysis, and use with associated therapeutic and imaging modalities is paramount.
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Affiliation(s)
| | - Kento Kurashima
- Department of Pediatrics, SSM Saint Louis University School of Medicine, Saint Louis, MO, USA
| | - Yasar Caliskan
- Division of Nephrology, SSM Saint Louis University Hospital, Saint Louis, MO, USA
| | | | - Ajay Jain
- Department of Pediatrics, SSM Saint Louis University School of Medicine, Saint Louis, MO, USA
| | - Mustafa Nazzal
- Department of Surgery, SSM Saint Louis University Hospital, Saint Louis, MO, USA
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17
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Angelico R, Sensi B, Quaranta C, Orsi M, Parente A, Schlegel A, Tisone G, Manzia TM. The impact of center volume on the utilization and outcomes of machine perfusion technology in liver transplantation: An international survey. Artif Organs 2023; 47:1773-1785. [PMID: 37635420 DOI: 10.1111/aor.14635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 07/11/2023] [Accepted: 08/14/2023] [Indexed: 08/29/2023]
Abstract
INTRODUCTION Machine perfusion (MP) was developed to expand the donor pool and improve liver transplantation (LT) outcomes. Despite optimal results in clinical trials, the real-world MP benefit in centers with low-/mid-volume activity (LVCs) is still being determined. METHODS Online survey on MP for LT, distributed to worldwide LT-centers representatives. Variables of interest included logistics, technicalities, and outcomes. Responders were grouped into high-volume centers (HVCs) (>60 LTs/year) and LVCs and results compared. RESULTS Sixty-seven centers were included, 36 HVCs and 31 LVCs. Significant differences in MP regarded: (I) existence of an established program (80.6% vs. 41.9%; p = 0.02), (II) presence of a dedicated perfusionist (58.3% vs. 22.6%; p = 0.006), (III) duration (>4 h: 47.2% vs. 16.1%; p = 0.01), (IV) routine use (20%-40% vs. 5%-20%; p = 0.002), (V) graft utilization (>50%: 75% vs. 51.6%; p = 0.009), (VI) 90-day patient-survival (90%-100% vs. 50%-90%; p = 0.001) and (VII) subjectively perceived benefit (always vs. only in selected ECD; p = 0.009). Concordance was found for indications, type, viability tests, graft-salvage, 90-day graft-loss, and major-complications. CONCLUSIONS This study captured a picture of MP in real-world LT-practice. Significant disparities have surfaced between LVCs and HVCs regarding logistics, utilization, and results. To close this gap, efforts should be made to more efficiently deliver dedicated support, training and mentoring to LVC teams adopting MP technology.
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Affiliation(s)
- Roberta Angelico
- Department of Surgery Sciences, Transplant and HPB Unit, University of Rome Tor Vergata, Rome, Italy
| | - Bruno Sensi
- Department of Surgery Sciences, Transplant and HPB Unit, University of Rome Tor Vergata, Rome, Italy
| | - Claudia Quaranta
- Department of Surgery Sciences, Transplant and HPB Unit, University of Rome Tor Vergata, Rome, Italy
| | - Michela Orsi
- Department of Surgery Sciences, Transplant and HPB Unit, University of Rome Tor Vergata, Rome, Italy
| | - Alessandro Parente
- Department of Surgery Sciences, Transplant and HPB Unit, University of Rome Tor Vergata, Rome, Italy
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of medicine, Seoul, Korea
| | - Andrea Schlegel
- Centre of Preclinical Research, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Giuseppe Tisone
- Department of Surgery Sciences, Transplant and HPB Unit, University of Rome Tor Vergata, Rome, Italy
| | - Tommaso M Manzia
- Department of Surgery Sciences, Transplant and HPB Unit, University of Rome Tor Vergata, Rome, Italy
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18
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Yilma M, Dalal N, Wadhwani SI, Hirose R, Mehta N. Geographic disparities in access to liver transplantation. Liver Transpl 2023; 29:987-997. [PMID: 37232214 PMCID: PMC10914246 DOI: 10.1097/lvt.0000000000000182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 04/08/2023] [Indexed: 05/27/2023]
Abstract
Since the Final Rule regarding transplantation was published in 1999, organ distribution policies have been implemented to reduce geographic disparity. While a recent change in liver allocation, termed acuity circles, eliminated the donor service area as a unit of distribution to decrease the geographic disparity of waitlisted patients to liver transplantation, recently published results highlight the complexity of addressing geographic disparity. From geographic variation in donor supply, as well as liver disease burden and differing model for end-stage liver disease (MELD) scores of candidates and MELD scores necessary to receive liver transplantation, to the urban-rural disparity in specialty care access, and to neighborhood deprivation (community measure of socioeconomic status) in liver transplant access, addressing disparities of access will require a multipronged approach at the patient, transplant center, and national level. Herein, we review the current knowledge of these disparities-from variation in larger (regional) to smaller (census tract or zip code) levels to the common etiologies of liver disease, which are particularly affected by these geographic boundaries. The geographic disparity in liver transplant access must balance the limited organ supply with the growing demand. We must identify patient-level factors that contribute to their geographic disparity and incorporate these findings at the transplant center level to develop targeted interventions. We must simultaneously work at the national level to standardize and share patient data (including socioeconomic status and geographic social deprivation indices) to better understand the factors that contribute to the geographic disparity. The complex interplay between organ distribution policy, referral patterns, and variable waitlisting practices with the proportion of high MELD patients and differences in potential donor supply must all be considered to create a national policy strategy to address the inequities in the system.
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Affiliation(s)
- Mignote Yilma
- Department of Surgery, University of California San Francisco
- National Clinician Scholars Program, University of California San Francisco
| | - Nicole Dalal
- Department of Medicine, University of California San Francisco
| | | | - Ryutaro Hirose
- Department of Transplant, University of California San Francisco
| | - Neil Mehta
- Department of Medicine, University of California San Francisco
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19
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Hosgood SA, Callaghan CJ, Wilson CH, Smith L, Mullings J, Mehew J, Oniscu GC, Phillips BL, Bates L, Nicholson ML. Normothermic machine perfusion versus static cold storage in donation after circulatory death kidney transplantation: a randomized controlled trial. Nat Med 2023; 29:1511-1519. [PMID: 37231075 PMCID: PMC10287561 DOI: 10.1038/s41591-023-02376-7] [Citation(s) in RCA: 34] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 04/28/2023] [Indexed: 05/27/2023]
Abstract
Kidney transplantation is the optimal treatment for end-stage renal disease, but it is still severely limited by a lack of suitable organ donors. Kidneys from donation after circulatory death (DCD) donors have been used to increase transplant rates, but these organs are susceptible to cold ischemic injury in the storage period before transplantation, the clinical consequence of which is high rates of delayed graft function (DGF). Normothermic machine perfusion (NMP) is an emerging technique that circulates a warmed, oxygenated red-cell-based perfusate through the kidney to maintain near-physiological conditions. We conducted a randomized controlled trial to compare the outcome of DCD kidney transplants after conventional static cold storage (SCS) alone or SCS plus 1-h NMP. A total of 338 kidneys were randomly allocated to SCS (n = 168) or NMP (n = 170), and 277 kidneys were included in the final intention-to-treat analysis. The primary endpoint was DGF, defined as the requirement for dialysis in the first 7 d after transplant. The rate of DGF was 82 of 135 (60.7%) in NMP kidneys versus 83 of 142 (58.5%) in SCS kidneys (adjusted odds ratio (95% confidence interval) 1.13 (0.69-1.84); P = 0.624). NMP was not associated with any increase in transplant thrombosis, infectious complications or any other adverse events. A 1-h period of NMP at the end of SCS did not reduce the rate of DGF in DCD kidneys. NMP was demonstrated to be feasible, safe and suitable for clinical application. Trial registration number: ISRCTN15821205 .
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Affiliation(s)
- Sarah A Hosgood
- Department of Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK.
| | - Christopher J Callaghan
- Department of Nephrology and Transplantation, Guy's Hospital, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Colin H Wilson
- Freeman Hospital, Institute of Transplantation, Newcastle upon Tyne Hospitals NHS Trust and Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Laura Smith
- NHS Blood and Transplant (NHSBT) Clinical Trials Unit, NHSBT Stoke Gifford, Bristol, UK
| | - Joanne Mullings
- NHS Blood and Transplant (NHSBT) Clinical Trials Unit, NHSBT Stoke Gifford, Bristol, UK
| | - Jennifer Mehew
- NHS Blood and Transplant (NHSBT) Clinical Trials Unit, NHSBT Stoke Gifford, Bristol, UK
| | - Gabriel C Oniscu
- Edinburgh Transplant Centre, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Benedict L Phillips
- Department of Nephrology and Transplantation, Guy's Hospital, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Lucy Bates
- Freeman Hospital, Institute of Transplantation, Newcastle upon Tyne Hospitals NHS Trust and Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Michael L Nicholson
- Department of Surgery, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
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20
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Staubli SM, Ceresa CDL, Pollok JM. The Current Role and Future Applications of Machine Perfusion in Liver Transplantation. Bioengineering (Basel) 2023; 10:bioengineering10050593. [PMID: 37237663 DOI: 10.3390/bioengineering10050593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 04/07/2023] [Accepted: 04/25/2023] [Indexed: 05/28/2023] Open
Abstract
The relative paucity of donor livers suitable for transplantation has sparked innovations to preserve and recondition organs to expand the pool of transplantable organs. Currently, machine perfusion techniques have led to the improvement of the quality of marginal livers and to prolonged cold ischemia time and have allowed for the prediction of graft function through the analysis of the organ during perfusion, improving the rate of organ use. In the future, the implementation of organ modulation might expand the scope of machine perfusion beyond its current usage. The aim of this review was to provide an overview of the current clinical use of machine perfusion devices in liver transplantation and to provide a perspective for future clinical use, including therapeutic interventions in perfused donor liver grafts.
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Affiliation(s)
- Sebastian M Staubli
- HPB and Liver Transplantation Service, Royal Free London NHS Foundation Trust, Pond Street, London NW3 QG, UK
| | - Carlo D L Ceresa
- HPB and Liver Transplantation Service, Royal Free London NHS Foundation Trust, Pond Street, London NW3 QG, UK
- Oxford University Hospitals NHS Foundation Trust, University of Oxford, Oxfordshire OX3 9DU, UK
| | - Joerg M Pollok
- HPB and Liver Transplantation Service, Royal Free London NHS Foundation Trust, Pond Street, London NW3 QG, UK
- Division of Surgery & Interventional Science, University College London, London WC1E 6BT, UK
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21
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Olumba FC, Zhou F, Park Y, Chapman WC. Normothermic Machine Perfusion for Declined Livers: A Strategy to Rescue Marginal Livers for Transplantation. J Am Coll Surg 2023; 236:614-625. [PMID: 36728302 DOI: 10.1097/xcs.0000000000000555] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Organ waste is a major cause of the donor liver shortage. Roughly 67% of recovered organ donors have liver utilization annually. A new technology called normothermic machine perfusion (NMP) offers a way to recover marginal and declined livers for transplant. We report interim results of the RESTORE trial (FDA investigational drug exemption trial NCT04483102) that aims to transplant NMP-treated livers that would otherwise be discarded. STUDY DESIGN Declined livers were screened for NMP eligibility (eg donation after circulatory death [DCD] grafts with warm ischemic time <40 minutes, donation after brain death [DBD] grafts with cold ischemic time <8 hours). Livers meeting pre-NMP eligibility criteria received NMP using the OrganOx metra device for a minimum of 4 hours. All NMP-treated livers meeting the viability criteria were transplanted to consented recipients. RESULTS Over 22 months, 60 declined livers from three organ procurement organizations (OPOs; 40 DCD and 20 DBD donor livers) were offered, and 22 livers (10 DCD and 12 DBD livers) met the pre-NMP eligibility. After NMP, 16 of 22 livers passed viability testing and were transplanted into needy recipients (median Model for End-Stage Liver Disease [MELD] score of 8, range 6 to 24), resulting in a 72.7% rescue rate (50% DCD, 91.7% DBD). The rate of early allograft dysfunction was 31.3%, but there were no graft-related deaths, primary nonfunction, or instances of nonanastomotic biliary strictures. CONCLUSIONS Interim results of the RESTORE trial suggest that a sizable number of declined livers can be reclaimed. They are safe for transplantation and can enable lower MELD patients at high risk of morbidity and mortality to receive lifesaving grafts while offering OPOs a way to allocate more livers and reduce organ waste.
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Affiliation(s)
- Franklin C Olumba
- From the Department of Abdominal Organ Transplantation Surgery, Washington University School of Medicine, St Louis, MO (Olumba, Zhou, Chapman)
| | - Fangyu Zhou
- From the Department of Abdominal Organ Transplantation Surgery, Washington University School of Medicine, St Louis, MO (Olumba, Zhou, Chapman)
| | - Yikyung Park
- the Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St Louis, MO (Park)
| | - William C Chapman
- From the Department of Abdominal Organ Transplantation Surgery, Washington University School of Medicine, St Louis, MO (Olumba, Zhou, Chapman)
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22
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Brandman D. Progress in liver transplantation, but better access is needed. Liver Transpl 2023; 29:347-348. [PMID: 36724442 DOI: 10.1097/lvt.0000000000000081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 01/10/2023] [Indexed: 02/03/2023]
Affiliation(s)
- Danielle Brandman
- Department of Medicine, Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, New York, USA
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23
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Handley TJ, Arnow KD, Melcher ML. Despite Increasing Costs, Perfusion Machines Expand the Donor Pool of Livers and Could Save Lives. J Surg Res 2023; 283:42-51. [PMID: 36368274 DOI: 10.1016/j.jss.2022.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 08/27/2022] [Accepted: 10/07/2022] [Indexed: 11/11/2022]
Abstract
INTRODUCTION Liver transplantation is a highly successful treatment for liver failure and disease. However, demand continues to outstrip our ability to provide transplantation as a treatment. Many livers initially considered for transplantation are not used because of concerns about their viability or logistical issues. Recent clinical trials have shown discarded livers may be viable if they undergo machine perfusion, which allows a more objective assessment of liver quality. METHODS Using the Scientific Registry of Transplant Recipients dataset, we examined discarded and unretrieved organs to determine their eligibility for perfusion. We then used a Markov decision-analytic model to perform a cost-effectiveness analysis of two competing transplant strategies: Static Cold Storage (SCS) alone versus Static Cold Storage and Normothermic Machine Perfusion (NMP) of discarded organs. RESULTS The average predicted successful transplants after perfusion was 385, representing a 5.8% increase in the annual yield of liver transplants. Our cost-effectiveness analysis found that the SCS strategy generated 4.64 quality-adjusted life years (QALYs) and cost $479,226. The combined SCS + NMP strategy generated 4.72 QALYs and cost $481,885. The combined SCS + NMP strategy had an incremental cost-effectiveness ratio of $33,575 per additional QALY over the 10-year study horizon. CONCLUSIONS Machine perfusion of livers currently not considered viable for transplant could increase the number of transplantable grafts by approximately 5% per year and is cost-effective compared to Static Cold Storage alone.
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Affiliation(s)
- Thomas J Handley
- Department of Health Policy, Stanford University School of Medicine, Stanford, California; Stanford-Surgery Policy Improvement Research & Education Center (S-SPIRE), Stanford, California; Department of Surgery, Stanford University School of Medicine, Stanford, California.
| | - Katherine D Arnow
- Stanford-Surgery Policy Improvement Research & Education Center (S-SPIRE), Stanford, California
| | - Marc L Melcher
- Department of Surgery, Stanford University School of Medicine, Stanford, California
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24
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Riveros S, Marino C, Ochoa G, Soto D, Alegría L, Zenteno MJ, San Martín S, Brañes A, Achurra P, Rebolledo R. Customized normothermic machine perfusion decreases ischemia-reperfusion injury compared with static cold storage in a porcine model of liver transplantation. Artif Organs 2023; 47:148-159. [PMID: 36007920 DOI: 10.1111/aor.14390] [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: 05/01/2022] [Revised: 07/20/2022] [Accepted: 08/09/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND Liver transplantation has been demonstrated to be the best treatment for several liver diseases, while grafts are limited. This has caused an increase in waiting lists, making it necessary to find ways to expand the number of organs available for transplantation. Normothermic perfusion (NMP) of liver grafts has been established as an alternative to static cold storage (SCS), but only a small number of perfusion machines are commercially available. METHODS Using a customized ex situ machine perfusion, we compared the results between ex situ NMP and SCS preservation in a porcine liver transplant model. RESULTS During NMP, lactate concentrations were 80% lower after the 3-h perfusion period, compared with SCS. Bile production had a 2.5-fold increase during the NMP period. After transplantation, aspartate transaminase (AST) and alanine transaminase (ALT) levels were 35% less in the NMP group, compared to the SCS group. In pathologic analyses of grafts after transplant, tissue oxidation did not change between groups, but the ischemia-reperfusion injury score was lower in the NMP group. CONCLUSION NMP reduced hepatocellular damage and ischemia-reperfusion injury when compared to SCS using a customized perfusion machine. This could be an alternative for low-income countries to include machine perfusion in their therapeutic options.
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Affiliation(s)
- Sergio Riveros
- Department of Digestive Surgery, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Carlo Marino
- Department of Digestive Surgery, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Gabriela Ochoa
- Department of Digestive Surgery, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Dagoberto Soto
- Department of Intensive Care Unit, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Leyla Alegría
- Department of Intensive Care Unit, Pontificia Universidad Católica de Chile, Santiago, Chile
| | | | - Sebastián San Martín
- Biomedical Research Center, School of Medicine, Universidad de Valparaíso, Valparaíso, Chile
| | - Alejandro Brañes
- Hepato-Pancreato-Biliary Surgery Unit, Surgery Service, Complejo Asistencial Dr. Sótero Del Río, Santiago, Chile
| | - Pablo Achurra
- Department of Digestive Surgery, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Rolando Rebolledo
- Hepato-Pancreato-Biliary Surgery Unit, Surgery Service, Complejo Asistencial Dr. Sótero Del Río, Santiago, Chile.,Institute for Biological and Medical Engineering, Schools of Engineering, Medicine and Biological Sciences, Pontificia Universidad Católica de Chile, Santiago, Chile
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25
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Ramírez-Del Val A, Guarrera J, Porte RJ, Selzner M, Spiro M, Raptis DA, Friend PJ, Nasralla D. Does machine perfusion improve immediate and short-term outcomes by enhancing graft function and recipient recovery after liver transplantation? A systematic review of the literature, meta-analysis and expert panel recommendations. Clin Transplant 2022; 36:e14638. [PMID: 35279883 DOI: 10.1111/ctr.14638] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 02/28/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Recent evidence supports the use of machine perfusion technologies (MP) for marginal liver grafts. Their effect on enhanced recovery, however, remains uncertain. OBJECTIVES To identify areas in which MP might contribute to an ERAS program and to provide expert panel recommendations. DATA SOURCES Ovid MEDLINE, Embase, Scopus, Google Scholar, and Cochrane Central. METHODS Systematic review and meta-analysis following PRISMA guidelines and recommendations using the GRADE approach. CRD42021237713 RESULTS: Both hypothermic (HMP) and normothermic (NMP) machine perfusion demonstrated significant benefits in preventing postreperfusion syndrome (PRS) (HMP OR .33, .15-.75 CI; NMP OR .51, .29-.90 CI) and early allograft dysfunction (EAD) (HMP OR .51, .35-.75 CI; NMP OR .66, .45-.97 CI), while shortening LOS (HMP MD -3.9; NMP MD -12.41). Only NMP showed a significant decrease in the length of ICU stay (L-ICU) (MD -7.07, -8.76; -5.38 CI), while only HMP diminishes the likelihood of major complications. Normothermic regional perfusion (NRP) reduces EAD (OR .52, .38-.70 CI) and primary nonfunction (PNF) (OR .51, .27-.98 CI) without effect on L-ICU and LOS. CONCLUSIONS The use of HMP decreases PRS and EAD, specifically for marginal grafts. This is supported by a shorter LOS and a lower rate of major postoperative complications (QOE; moderate | Recommendation; Strong). NMP reduces the incidence of PRS and EAD with associated shortening in L-ICU for both DBD and DCD grafts (QOE; moderate | Recommendation; High) This technology also shortens the length of hospital stay (QOE; low | Recommendation; Strong). NRP decreases the likelihood of EAD (QOE; moderate) and the risk of PNF (QOE; low) when compared to both DBD and SRR-DCD grafts preserved in SCS. (Recommendation; Strong).
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Affiliation(s)
| | - James Guarrera
- Division of Liver Transplantation and Hepatobiliary Surgery at Rutgers, New Jersey Medical School, Newark, New Jersey, USA
| | - Robert J Porte
- Department of Surgery, University of Groningen, Groningen, The Netherlands
| | - Markus Selzner
- Department of Abdominal Transplant, Toronto General Hospital, Toronto, Ontario, Canada
| | - Michael Spiro
- Department of Anaesthesia and Intensive Care Medicine, Royal Free Hospital, London, UK.,Division of Surgery and Interventional Science, University College London, London, UK
| | - Dimitri Aristotle Raptis
- Division of Surgery and Interventional Science, University College London, London, UK.,Clinical Service of HPB Surgery and Liver Transplantation, Royal Free Hospital, London, UK
| | - Peter J Friend
- Transplant Unit, Churchill Hospital, Oxford University Hospitals, Oxford, UK.,Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - David Nasralla
- Division of Surgery and Interventional Science, University College London, London, UK.,Clinical Service of HPB Surgery and Liver Transplantation, Royal Free Hospital, London, UK
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26
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Muller X, Rossignol G, Mohkam K, Mabrut JY. Novel strategies in liver graft preservation - The French perspective. J Visc Surg 2022; 159:389-398. [PMID: 36109331 DOI: 10.1016/j.jviscsurg.2022.06.006] [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: 10/14/2022]
Abstract
Given the increasing graft shortage, the transplant community is forced to use so called marginal liver grafts with a higher susceptibility to ischemia-reperfusion injury. This exposes the recipient to a higher risk of graft failure and post-transplant complications. While static cold storage remains the gold standard in low-risk transplant scenarios, dynamic preservation strategies may allow to improve outcomes after transplantation of marginal liver grafts. Two dynamic preservation strategies, end-ischemic hypothermic oxygenated perfusion (HOPE) and continuous normothermic machine perfusion (cNMP), have been evaluated in randomized clinical trials. The results show improved preservation of liver grafts after cNMP and reduction of post-transplant biliary complications after HOPE. In comparison to cNMP, HOPE has the advantage of requiring less logistics and expertise with the possibility to return to default static cold storage. Both strategies allow to assess graft viability prior to transplantation and may thus contribute to optimizing graft selection and reducing discard rates. The use of dynamic preservation is rapidly increasing in France and results from a national randomized trial on the use of HOPE in marginal grafts will soon be available. Future applications should focus on controlled donation after circulatory death liver grafts, split grafts and graft treatment during perfusion. The final aim of dynamic liver graft preservation is to improve post-transplant outcomes, increase the number of transplanted grafts and allow expansion of transplant indications.
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Affiliation(s)
- X Muller
- Department of General Surgery and Liver Transplantation, Croix-Rousse University Hospital, Hospices Civils de Lyon, Lyon, France; The Lyon Cancer Research Centre, Inserm U1052 UMR 5286, Lyon, France; ED 340 BMIC, Claude-Bernard Lyon 1 University, 69622 Villeurbanne, France.
| | - G Rossignol
- Department of General Surgery and Liver Transplantation, Croix-Rousse University Hospital, Hospices Civils de Lyon, Lyon, France; The Lyon Cancer Research Centre, Inserm U1052 UMR 5286, Lyon, France; ED 340 BMIC, Claude-Bernard Lyon 1 University, 69622 Villeurbanne, France; Department of Pediatric Surgery and Liver Transplantation, Femme-Mère-Enfant University Hospital, Hospices Civils de Lyon, Lyon, France
| | - K Mohkam
- Department of General Surgery and Liver Transplantation, Croix-Rousse University Hospital, Hospices Civils de Lyon, Lyon, France; The Lyon Cancer Research Centre, Inserm U1052 UMR 5286, Lyon, France; Department of Pediatric Surgery and Liver Transplantation, Femme-Mère-Enfant University Hospital, Hospices Civils de Lyon, Lyon, France
| | - J Y Mabrut
- Department of General Surgery and Liver Transplantation, Croix-Rousse University Hospital, Hospices Civils de Lyon, Lyon, France; The Lyon Cancer Research Centre, Inserm U1052 UMR 5286, Lyon, France
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27
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Luo Z, Liao T, Zhang Y, Zheng H, Sun Q, Han F, Ma M, Ye Y, Sun Q. Ex vivo anchored PD-L1 functionally prevent in vivo renal allograft rejection. Bioeng Transl Med 2022; 7:e10316. [PMID: 36176616 PMCID: PMC9472007 DOI: 10.1002/btm2.10316] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 03/20/2022] [Accepted: 03/22/2022] [Indexed: 11/09/2022] Open
Abstract
Organ transplantation is the optimal treatment for patients with end-stage diseases. T cell activation is a major contributing factor toward the trigger of rejection. Induction therapy with T cell depleting agent is a common option but increases the risk of severe systemic infections. The ideal therapy should precisely target the allograft. Here, we developed a membrane-anchored-protein PD-L1 (map-PD-L1), which effectively anchored onto the surface of rat glomerular endothelial cells (rgEC). The expression of PD-L1 increased directly with map-PD-L1 concentration and incubation time. Moreover, map-PD-L1 was even stably anchored to rgEC at low temperature. Map-PD-L1 could bind to PD-1 and significantly promote T cell apoptosis and inhibited T cell activation. Using kidney transplantation models, we found that ex vivo perfusion of donor kidneys with map-PD-L1 significantly protected grafts against acute injury without using any immunosuppressant. We found map-PD-L1 could reduce T cell graft infiltration and increase intragraft Treg infiltration, suggesting a long-term effect in allograft protection. More importantly, modifying donor organs in vitro was not only safe, but also significantly reduced the side effects of systemic application. Our results suggested that ex vivo perfusion of donor organ with map-PD-L1 might provide a viable clinical option for organ-targeted induction therapy in organ transplantation.
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Affiliation(s)
- Zihuan Luo
- Department of Renal TransplantationGuangdong Provincial People's Hospital, Guangdong Academy of Medical SciencesGuangzhouGuangdongChina
- The Second School of Clinical MedicineSouthern Medical UniversityGuangzhouGuangdongChina
| | - Tao Liao
- Department of Renal TransplantationGuangdong Provincial People's Hospital, Guangdong Academy of Medical SciencesGuangzhouGuangdongChina
- The Second School of Clinical MedicineSouthern Medical UniversityGuangzhouGuangdongChina
| | - Yannan Zhang
- Department of Renal TransplantationGuangdong Provincial People's Hospital, Guangdong Academy of Medical SciencesGuangzhouGuangdongChina
- The Second School of Clinical MedicineSouthern Medical UniversityGuangzhouGuangdongChina
| | - Haofeng Zheng
- Department of Renal TransplantationGuangdong Provincial People's Hospital, Guangdong Academy of Medical SciencesGuangzhouGuangdongChina
- The Second School of Clinical MedicineSouthern Medical UniversityGuangzhouGuangdongChina
| | - Qipeng Sun
- Department of Renal TransplantationGuangdong Provincial People's Hospital, Guangdong Academy of Medical SciencesGuangzhouGuangdongChina
- The Second School of Clinical MedicineSouthern Medical UniversityGuangzhouGuangdongChina
| | - Fei Han
- Organ Transplantation Research InstituteThe Third Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouGuangdongChina
| | - Maolin Ma
- Organ Transplantation Research InstituteThe Third Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouGuangdongChina
| | - Yongrong Ye
- Organ Transplantation Research InstituteThe Third Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouGuangdongChina
| | - Qiquan Sun
- Department of Renal TransplantationGuangdong Provincial People's Hospital, Guangdong Academy of Medical SciencesGuangzhouGuangdongChina
- The Second School of Clinical MedicineSouthern Medical UniversityGuangzhouGuangdongChina
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28
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De Simone P, Ghinolfi D. Hospital-Based Health Technology Assessment of Machine Perfusion Systems for Human Liver Transplantation. Transpl Int 2022; 35:10405. [PMID: 35692735 PMCID: PMC9184439 DOI: 10.3389/ti.2022.10405] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 05/05/2022] [Indexed: 01/14/2023]
Abstract
Based on published data, we have carried out a hospital-based health technology assessment of machine perfusion in adult liver transplantation using cold storage as a comparator, and within the perspective of a national health system-based hospital practice and disease-related group reimbursement policy. A systematic literature review on machine perfusion for adult liver transplantation was conducted exploring the Pubmed, CINAHL, Scopus, Embase, and Cochrane databases. The literature was analyzed with the intent to provide information on 6 dimensions and 19 items of the hospital-based health technology assessment framework derived from previous studies. Out of 705 references, 47 (6.7%) were retained for current analysis. Use of machine perfusion was associated with advantages over cold storage, i.e., a 10%–50% reduced risk for early allograft dysfunction, 7%–15% less ischemia reperfusion injury; 7%–50% fewer ischemic biliary complications, comparable or improved 1-year graft and patient survival, and up to a 50% lower graft discard rate. Hospital stay was not longer, and technical failures were anecdotal. Information on costs of machine perfusion is limited, but this technology is projected to increase hospital costs while cost-effectiveness analysis requires data over the transplant patient lifetime. No hospital-based health technology assessment study on machine perfusion in liver transplantation was previously conducted. From the hospital perspective, there is evidence of the clinical advantages of this novel technology, but strategies to counterbalance the increased costs of liver transplantation are urgently needed. Further studies should focus on the ethical, social, and organizational issues related to machine perfusion.
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Affiliation(s)
- Paolo De Simone
- Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
- Department of Surgical, Medical, Biomolecular Pathology and Intensive Care Unit, University of Pisa, Pisa, Italy
- *Correspondence: Paolo De Simone,
| | - Davide Ghinolfi
- Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
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