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Martins B, Mossemann J, Aguilar F, Zhao S, Bilan PJ, Sayed BA. Liver Transplantation: A Test of Cellular Physiology, Preservation, and Injury. Physiology (Bethesda) 2024; 39:401-411. [PMID: 39078382 DOI: 10.1152/physiol.00020.2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Revised: 07/26/2024] [Accepted: 07/26/2024] [Indexed: 07/31/2024] Open
Abstract
Liver transplantation has evolved into a mature clinical field, but scarcity of usable organs poses a unique challenge. Expanding the donor pool requires novel approaches for protecting hepatic physiology and cellular homeostasis. Here we define hepatocellular injury during transplantation, with an emphasis on modifiable cell death pathways as future therapeutics.
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Affiliation(s)
- B Martins
- Cell Biology Program, Hospital for Sick Children, Toronto, Ontario, Canada
| | - J Mossemann
- Cell Biology Program, Hospital for Sick Children, Toronto, Ontario, Canada
| | - F Aguilar
- Cell Biology Program, Hospital for Sick Children, Toronto, Ontario, Canada
| | - S Zhao
- Neuroscience and Mental Health Program, Hospital for Sick Children, Toronto, Ontario, Canada
| | - P J Bilan
- Cell Biology Program, Hospital for Sick Children, Toronto, Ontario, Canada
| | - B A Sayed
- Cell Biology Program, Hospital for Sick Children, Toronto, Ontario, Canada
- Division of General Surgery, Hospital for Sick Children, Toronto, Ontario, Canada
- Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
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2
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Eggenhofer E, Proneth B. Ferroptosis Inhibition: A Key Opportunity for the Treatment of Ischemia/Reperfusion Injury in Liver Transplantation. Transplantation 2024:00007890-990000000-00874. [PMID: 39294870 DOI: 10.1097/tp.0000000000005199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/21/2024]
Abstract
The outcome after liver transplantation has improved in recent years, which can be attributed to superior storage and transportation conditions of the organs, as well as better peri- and postoperative management and advancements in surgical techniques. Nevertheless, there is an increasing discrepancy between the need for organs and their availability. Consequently, the mortality rate on the waiting list is high and continues to rise. One way of counteracting this trend is to increase the use of "expanded criteria donors." This means that more and more donors will be included, especially those who are older and having additional comorbidities (eg, steatosis). A major complication of any transplantation is the occurrence of ischemia/reperfusion injury (IRI), which often leads to liver dysfunction and failure. However, there have been various promising approaches to minimize IRI in recent years, but an effective and clinically applicable method to achieve a better outcome for patients after liver transplantation is still missing. Thereby, the so-called marginal organs are predominantly affected by IRI; thus, it is crucial to develop suitable and effective treatment options for patients. Recently, regulated cell death mechanisms, particularly ferroptosis, have been implicated to play a major role in IRI, including the liver. Therefore, inhibiting this kind of cell death modality presents a promising therapeutic approach for the management of this yet untreatable condition. Thus, this review provides an overview of the role of ferroptosis in liver IRI and transplantation and discusses possible therapeutic solutions based on ferroptosis inhibition to restrain IRI in marginal organs (especially steatosis and donation after circulatory death organs).
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Affiliation(s)
- Elke Eggenhofer
- Department of Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Bettina Proneth
- Institute of Metabolism and Cell Death, Helmholtz Munich, Neuherberg, Germany
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3
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Canizares S, Montalvan A, Chumdermpadetsuk R, Modest A, Eckhoff D, Lee DD. Liver machine perfusion technology: Expanding the donor pool to improve access to liver transplantation. Am J Transplant 2024; 24:1664-1674. [PMID: 38508317 DOI: 10.1016/j.ajt.2024.03.013] [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: 10/14/2023] [Revised: 03/01/2024] [Accepted: 03/11/2024] [Indexed: 03/22/2024]
Abstract
The imbalance between organ supply and demand continues to limit the broader benefits of organ transplantation. Machine perfusion (MP) may increase the supply of donor livers by expanding the use of extended-criteria donors. Using the United Network for Organ Sharing/Organ Procurement and Transplantation Network and the Standard Transplant Analysis and Research dataset, we reviewed the effect of MP implementation on the behavior of transplant centers. We identified 15 high-utilizing MP centers that were matched to suitable controls based on volume and geographical proximity. We conducted a differences-in-differences analysis using linear regression to estimate the impact of MP adoption on the transplant centers' donor utilization. We found a significant increase in cold ischemia time and organs with donor warm ischemia time over 30 minutes (P < .05). After removing one outlier center, the analysis showed that these centers through MP accepted overall more donation after circulatory death donors, donation after circulatory death donors over 50 years old, donors with macrovesicular steatosis greater than 30% on liver biopsy, and donor warm ischemia time over 30 minutes (P < .05). MP has allowed centers to expand their use of extended-criteria donors beyond traditional cutoffs and to increase patient access to liver transplantation.
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Affiliation(s)
- Stalin Canizares
- Division of Transplant Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Adriana Montalvan
- Division of Transplant Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Ritah Chumdermpadetsuk
- Division of Transplant Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Anna Modest
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA; Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Boston, Massachusetts, USA
| | - Devin Eckhoff
- Division of Transplant Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - David D Lee
- Division of Transplant Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.
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4
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Mastrovangelis C, Frost C, Hort A, Laurence J, Pang T, Pleass H. Normothermic Regional Perfusion in Controlled Donation After Circulatory Death Liver Transplantation: A Systematic Review and Meta-Analysis. Transpl Int 2024; 37:13263. [PMID: 39246548 PMCID: PMC11377255 DOI: 10.3389/ti.2024.13263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Accepted: 08/13/2024] [Indexed: 09/10/2024]
Abstract
Liver grafts from controlled donation after circulatory death (cDCD) donors have lower utilization rates due to inferior graft and patient survival rates, largely attributable to the increased incidence of ischemic cholangiopathy, when compared with grafts from brain dead donors (DBD). Normothermic regional perfusion (NRP) may improve the quality of cDCD livers to allow for expansion of the donor pool, helping to alleviate the shortage of transplantable grafts. A systematic review and metanalysis was conducted comparing NRP cDCD livers with both non-NRP cDCD livers and DBD livers. In comparison to non-NRP cDCD outcomes, NRP cDCD grafts had lower rates of ischemic cholangiopathy [RR = 0.23, 95% CI (0.11, 0.49), p = 0.0002], primary non-function [RR = 0.51, 95% CI (0.27, 0.97), p = 0.04], and recipient death [HR = 0.5, 95% CI (0.36, 0.69), p < 0.0001]. There was no difference in outcomes between NRP cDCD donation compared to DBD liver donation. In conclusion, NRP improved the quality of cDCD livers compared to their non-NRP counterparts. NRP cDCD livers had similar outcomes to DBD grafts. This provides further evidence supporting the continued use of NRP in cDCD liver transplantation and offers weight to proposals for its more widespread adoption.
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Affiliation(s)
- Carly Mastrovangelis
- Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Charles Frost
- Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Amy Hort
- Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Department of Surgery, Westmead Hospital, Westmead, NSW, Australia
| | - Jerome Laurence
- Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Department of Surgery, Westmead Hospital, Westmead, NSW, Australia
- Department of Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Tony Pang
- Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Department of Surgery, Westmead Hospital, Westmead, NSW, Australia
- Surgical Innovations Unit, Westmead Hospital, Westmead, NSW, Australia
| | - Henry Pleass
- Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Department of Surgery, Westmead Hospital, Westmead, NSW, Australia
- Department of Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
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Ozgur OS, Taggart MS, Mojoudi M, Pendexter C, Kharga A, Yeh H, Toner M, Longchamp A, Tessier SN, Uygun K. Optimized Partial Freezing Protocol Enables 10-Day Storage of Rat Livers. RESEARCH SQUARE 2024:rs.3.rs-4584242. [PMID: 39011100 PMCID: PMC11247935 DOI: 10.21203/rs.3.rs-4584242/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/17/2024]
Abstract
Preserving organs at subzero temperatures with halted metabolic activity holds the potential to prolong preservation and expand the donor organ pool for transplant. Our group recently introduced partial freezing, a novel approach in high-subzero storage at -15°C, enabling 5 days storage of rodent livers through precise control over ice nucleation and unfrozen fraction. However, increased vascular resistance and tissue edema suggested a need for improvements to extend viable preservation. Here, we describe an optimized partial freezing protocol with key optimizations including increased concentration of propylene glycol to reduce ice recrystallization and maintained osmotic balance through an increase in bovine serum albumin, all while minimizing sheer stress during cryoprotectant unloading with an acclimation period. These approaches ensured the viability during preservation and recovery processes, promoting liver function and ensuring optimal preservation. This was evidenced by increased oxygen consumption, decreased vascular resistance and edema. Ultimately, we show that using the optimized protocol, livers can be stored for 10 days with comparable vascular resistance and lactate levels to 5 days, outperforming the viability of time-matched cold stored livers as the current gold standard. This study represents a significant advancement in expanding organ availability through prolonged preservation and thereby revolutionizing transplant medicine.
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Affiliation(s)
| | | | | | | | - Anil Kharga
- Massachusetts General Hospital, Harvard Medical School
| | - Heidi Yeh
- Massachusetts General Hospital, Harvard Medical School
| | - Mehmet Toner
- Massachusetts General Hospital, Harvard Medical School
| | | | | | - Korkut Uygun
- Massachusetts General Hospital, Harvard Medical School
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6
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Mahboub P, Aburawi M, Ozgur OS, Pendexter C, Cronin S, Lin FM, Jain R, Karabacak MN, Karimian N, Tessier SN, Markmann JF, Yeh H, Uygun K. Gradual rewarming with a hemoglobin-based oxygen carrier improves viability of donation after circulatory death in rat livers. FRONTIERS IN TRANSPLANTATION 2024; 3:1353124. [PMID: 38993754 PMCID: PMC11235298 DOI: 10.3389/frtra.2024.1353124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Accepted: 06/10/2024] [Indexed: 07/13/2024]
Abstract
Background Donation after circulatory death (DCD) grafts are vital for increasing available donor organs. Gradual rewarming during machine perfusion has proven effective in mitigating reperfusion injury and enhancing graft quality. Limited data exist on artificial oxygen carriers as an effective solution to meet the increasing metabolic demand with temperature changes. The aim of the present study was to assess the efficacy and safety of utilizing a hemoglobin-based oxygen carrier (HBOC) during the gradual rewarming of DCD rat livers. Methods Liver grafts were procured after 30 min of warm ischemia. The effect of 90 min of oxygenated rewarming perfusion from ice cold temperatures (4 °C) to 37 °C with HBOC after cold storage was evaluated and the results were compared with cold storage alone. Reperfusion at 37 °C was performed to assess the post-preservation recovery. Results Gradual rewarming with HBOC significantly enhanced recovery, demonstrated by markedly lower lactate levels and reduced vascular resistance compared to cold-stored liver grafts. Increased bile production in the HBOC group was noted, indicating improved liver function and bile synthesis capacity. Histological examination showed reduced cellular damage and better tissue preservation in the HBOC-treated livers compared to those subjected to cold storage alone. Conclusion This study suggests the safety of using HBOC during rewarming perfusion of rat livers as no harmful effect was detected. Furthermore, the viability assessment indicated improvement in graft function.
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Affiliation(s)
- Paria Mahboub
- Department of Surgery, University Medical Center Groningen, Groningen, Netherlands
- Center for Engineering in Medicine and Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
- Department of Research, Shriners Hospitals for Children, Boston, MA, United States
| | - Mohamed Aburawi
- Department of Research, Shriners Hospitals for Children, Boston, MA, United States
- Transplant Center, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - O Sila Ozgur
- Center for Engineering in Medicine and Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
- Department of Research, Shriners Hospitals for Children, Boston, MA, United States
| | - Casie Pendexter
- Center for Engineering in Medicine and Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
- Department of Research, Shriners Hospitals for Children, Boston, MA, United States
| | - Stephanie Cronin
- Center for Engineering in Medicine and Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
- Department of Research, Shriners Hospitals for Children, Boston, MA, United States
| | - Florence Min Lin
- Department of Research, Shriners Hospitals for Children, Boston, MA, United States
| | - Rohil Jain
- Center for Engineering in Medicine and Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
- Department of Research, Shriners Hospitals for Children, Boston, MA, United States
| | - Murat N Karabacak
- Center for Engineering in Medicine and Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
- Department of Research, Shriners Hospitals for Children, Boston, MA, United States
| | - Negin Karimian
- Center for Engineering in Medicine and Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
- Department of Research, Shriners Hospitals for Children, Boston, MA, United States
| | - Shannon N Tessier
- Center for Engineering in Medicine and Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
- Department of Research, Shriners Hospitals for Children, Boston, MA, United States
| | - James F Markmann
- Transplant Center, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Heidi Yeh
- Transplant Center, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Korkut Uygun
- Center for Engineering in Medicine and Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
- Department of Research, Shriners Hospitals for Children, Boston, MA, United States
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Srivastava A, Manchel A, Waters J, Ambelil M, Barnhart BK, Hoek JB, Shah AP, Vadigepalli R. Integrated transcriptomics and histopathology approach identifies a subset of rejected donor livers with potential suitability for transplantation. BMC Genomics 2024; 25:437. [PMID: 38698335 PMCID: PMC11067109 DOI: 10.1186/s12864-024-10362-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Accepted: 04/29/2024] [Indexed: 05/05/2024] Open
Abstract
BACKGROUND Liver transplantation is an effective treatment for liver failure. There is a large unmet demand, even as not all donated livers are transplanted. The clinical selection criteria for donor livers based on histopathological evaluation and liver function tests are variable. We integrated transcriptomics and histopathology to characterize donor liver biopsies obtained at the time of organ recovery. We performed RNA sequencing as well as manual and artificial intelligence-based histopathology (10 accepted and 21 rejected for transplantation). RESULTS We identified two transcriptomically distinct rejected subsets (termed rejected-1 and rejected-2), where rejected-2 exhibited a near-complete transcriptomic overlap with the accepted livers, suggesting acceptability from a molecular standpoint. Liver metabolic functional genes were similarly upregulated, and extracellular matrix genes were similarly downregulated in the accepted and rejected-2 groups compared to rejected-1. The transcriptomic pattern of the rejected-2 subset was enriched for a gene expression signature of graft success post-transplantation. Serum AST, ALT, and total bilirubin levels showed similar overlapping patterns. Additional histopathological filtering identified cases with borderline scores and extensive molecular overlap with accepted donor livers. CONCLUSIONS Our integrated approach identified a subset of rejected donor livers that are likely suitable for transplantation, demonstrating the potential to expand the pool of transplantable livers.
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Affiliation(s)
- Ankita Srivastava
- Daniel Baugh Institute for Functional Genomics and Computational Biology, Department of Pathology and Genomic Medicine, Thomas Jefferson University, Philadelphia, PA, 19107, USA
| | - Alexandra Manchel
- Daniel Baugh Institute for Functional Genomics and Computational Biology, Department of Pathology and Genomic Medicine, Thomas Jefferson University, Philadelphia, PA, 19107, USA
| | - John Waters
- Daniel Baugh Institute for Functional Genomics and Computational Biology, Department of Pathology and Genomic Medicine, Thomas Jefferson University, Philadelphia, PA, 19107, USA
| | - Manju Ambelil
- Daniel Baugh Institute for Functional Genomics and Computational Biology, Department of Pathology and Genomic Medicine, Thomas Jefferson University, Philadelphia, PA, 19107, USA
| | - Benjamin K Barnhart
- Daniel Baugh Institute for Functional Genomics and Computational Biology, Department of Pathology and Genomic Medicine, Thomas Jefferson University, Philadelphia, PA, 19107, USA
| | - Jan B Hoek
- Daniel Baugh Institute for Functional Genomics and Computational Biology, Department of Pathology and Genomic Medicine, Thomas Jefferson University, Philadelphia, PA, 19107, USA
| | - Ashesh P Shah
- Department of Surgery, Thomas Jefferson University Hospital, Jefferson University Hospitals, Philadelphia, PA, USA
| | - Rajanikanth Vadigepalli
- Daniel Baugh Institute for Functional Genomics and Computational Biology, Department of Pathology and Genomic Medicine, Thomas Jefferson University, Philadelphia, PA, 19107, USA.
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Mojoudi M, Taggart MS, Kharga A, Chen H, Dinicu AT, Wilks BT, Markmann JF, Toner M, Tessier SN, Yeh H, Uygun K. Anti-apoptotic treatment of warm ischemic male rat livers in machine perfusion improves symptoms of ischemia-reperfusion injury. Heliyon 2024; 10:e29519. [PMID: 38660283 PMCID: PMC11040033 DOI: 10.1016/j.heliyon.2024.e29519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 04/08/2024] [Accepted: 04/09/2024] [Indexed: 04/26/2024] Open
Abstract
Background Liver donation after cardiac death (DCD) makes up a small percentage of the organs used in transplantation and poses a higher risk of graft loss compared to donation after brain death (DBD); this is a result of ischemia reperfusion for which the exact injury mechanisms are currently not fully understood. However, reperfusion injury has been shown to lead to necrosis as well as apoptosis through oxidative stress and mitochondrial dysfunction. In this work, we propose that use of the pro-survival, anti-apoptotic CEPT cocktail in post-ischemia normothermic machine perfusion (NMP) may improve recovery in rat livers subjected to extended durations of warm ischemia. Materials and Methods Livers procured from male Lewis rats were subjected to 90 min of warm ischemia, followed by 6 h of NMP where they were treated either with the survival-enhancing anti-apoptotic cocktail (CEPT), the vehicle (DMSO) or the base media with no additives. Results The CEPT-treated group exhibited lower expression of hepatic injury biomarkers, and improvement in a range of hepatocellular symptoms associated with the hepatic parenchyma, biliary epithelium and the sinusoidal endothelium, including recovery of bile secretion and lowered vascular resistance. Conclusions This study's findings suggest apoptosis plays a more significant role in ischemia-reperfusion injury than previously understood, and provide useful insight for further investigation of the specific underlying mechanisms and development of novel treatment methods.
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Affiliation(s)
- Mohammadreza Mojoudi
- Center for Engineering in Medicine and Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Shriners Children's, Boston, MA, USA
| | - McLean S. Taggart
- Center for Engineering in Medicine and Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Shriners Children's, Boston, MA, USA
| | - Anil Kharga
- Center for Engineering in Medicine and Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Shriners Children's, Boston, MA, USA
| | - Huyun Chen
- Center for Engineering in Medicine and Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Shriners Children's, Boston, MA, USA
| | - Antonia T. Dinicu
- Center for Engineering in Medicine and Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Shriners Children's, Boston, MA, USA
| | - Benjamin T. Wilks
- Center for Engineering in Medicine and Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Shriners Children's, Boston, MA, USA
| | - James F. Markmann
- Harvard Medical School, Boston, MA, USA
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Mehmet Toner
- Center for Engineering in Medicine and Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Shriners Children's, Boston, MA, USA
| | - Shannon N. Tessier
- Center for Engineering in Medicine and Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Shriners Children's, Boston, MA, USA
| | - Heidi Yeh
- Harvard Medical School, Boston, MA, USA
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Korkut Uygun
- Center for Engineering in Medicine and Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Shriners Children's, Boston, MA, USA
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9
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Blandon C, Karp SJ, Shah M, Lynch RJ, Goldberg DS. Assessing LSAM's ability to account for changes in organ donation and transplant center behavior. Liver Transpl 2024:01445473-990000000-00368. [PMID: 38669601 DOI: 10.1097/lvt.0000000000000385] [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: 02/16/2024] [Accepted: 04/11/2024] [Indexed: 04/28/2024]
Abstract
The Liver Simulated Allocation Model (LSAM) is used to evaluate proposed organ allocation policies. Although LSAM has been shown to predict the directionality of changes in transplants and nonused organs, the magnitude is often overestimated. One reason is that policymakers and researchers using LSAM assume static levels of organ donation and center behavior because of challenges with predicting future behavior. We sought to assess the ability of LSAM to account for changes in organ donation and organ acceptance behavior using LSAM 2019. We ran 1-year simulations with the default model and then ran simulations changing donor arrival rates (ie, organ donation) and center acceptance behavior. Changing the donor arrival rate was associated with a progressive simulated increase in transplants, with corresponding simulated decreases in waitlist deaths. Changing parameters related to organ acceptance was associated with important changes in transplants, nonused organs, and waitlist deaths in the expected direction in data simulations, although to a much lesser degree than changing the donor arrival rate. Increasing the donor arrival rate was associated with a marked decrease in the travel distance of donor livers in simulations. In conclusion, we demonstrate that LSAM can account for changes in organ donation and organ acceptance in a manner aligned with historical precedent that can inform future policy analyses. As Scientific Registry of Transplant Recipients develops new simulation programs, the importance of considering changes in donation and center practice is critical to accurately estimate the impact of new allocation policies.
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Affiliation(s)
- Catherine Blandon
- Department of Medicine, Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Seth J Karp
- Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Malay Shah
- Division of Abdominal Transplant Surgery, Department of Surgery, University of Kentucky, Lexington, Kentucky, USA
| | - Raymond J Lynch
- Departments of Surgery and Public Health, Pennsylvania State University College of Medicine, Hershey, Pennsylvania
| | - David S Goldberg
- Department of Medicine, Division of Digestive Health and Liver Diseases, University of Miami Miller School of Medicine, Miami, Florida, USA
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10
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Xiang Z, Li J, Zeng H, Xiang X, Gao F, Wang K, Wei X, Zheng S, Xu X. Current Understanding of Marginal Grafts in Liver Transplantation. Aging Dis 2024:AD.2024.0214. [PMID: 38607739 DOI: 10.14336/ad.2024.0214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Accepted: 02/14/2024] [Indexed: 04/14/2024] Open
Abstract
End-stage liver disease (ESLD), stemming from a spectrum of chronic liver pathologies including chronic liver failure, acute cirrhosis decompensation and hepatocellular carcinoma, imposes a significant global healthcare burden. Liver transplantation (LT) remains the only treatment for ESLD. However, the escalating mortality on transplant waitlists has prompted the utilization of marginal liver grafts in LT procedures. These grafts primarily encompass elderly livers, steatotic livers, livers from donation after circulatory death, split livers and those infected with the hepatitis virus. While the expansion of the donor pool offers promise, it also introduces concomitant risks. These encompass graft failure, biliary and cardiovascular complications, the recurrence of liver disease and reduced patient and graft survival. Consequently, various established strategies, ranging from improved donor-recipient matching to surgical interventions, have emerged to mitigate these risks. This article undertakes a comprehensive assessment of the current landscape, evaluating the viability of diverse marginal liver grafts. Additionally, it synthesizes approaches aimed at enhancing the quality of such marginal liver grafts. The overarching objective is to augment the donor pool and ameliorate the risk factors associated with the shortage of liver grafts.
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Affiliation(s)
- Ze Xiang
- Department of Hepatobiliary and Pancreatic Surgery, Hangzhou First People's Hospital, Hangzhou 310006, China
- Zhejiang University School of Medicine, Hangzhou 310058, China
| | - Jiarui Li
- Zhejiang University School of Medicine, Hangzhou 310058, China
| | - Huixuan Zeng
- Zhejiang University School of Medicine, Hangzhou 310058, China
| | - Xiaonan Xiang
- Zhejiang University School of Medicine, Hangzhou 310058, China
- Department of Surgery, University of Cambridge and NIHR Cambridge Biomedical Research Centre, Cambridge, Cambridgeshire, UK
| | - Fengqiang Gao
- Department of Hepatobiliary and Pancreatic Surgery, Hangzhou First People's Hospital, Hangzhou 310006, China
- Zhejiang University School of Medicine, Hangzhou 310058, China
| | - Kai Wang
- Department of Hepatobiliary and Pancreatic Surgery, Hangzhou First People's Hospital, Hangzhou 310006, China
- Zhejiang University School of Medicine, Hangzhou 310058, China
| | - Xuyong Wei
- Department of Hepatobiliary and Pancreatic Surgery, Hangzhou First People's Hospital, Hangzhou 310006, China
| | - Shusen Zheng
- Zhejiang University School of Medicine, Hangzhou 310058, China
- Shulan (Hangzhou) Hospital, Zhejiang Shuren University School of Medicine, Hangzhou 310022, China
- NHC Key Laboratory of Combined Multi-organ Transplantation, Hangzhou 310003, China
| | - Xiao Xu
- Zhejiang University School of Medicine, Hangzhou 310058, China
- NHC Key Laboratory of Combined Multi-organ Transplantation, Hangzhou 310003, China
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11
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Ali H, Begum Ozturk N, Herdan NE, Luu H, Simsek C, Kazancioglu R, Gurakar A. Current status of simultaneous liver-kidney transplantation. HEPATOLOGY FORUM 2024; 5:207-210. [PMID: 39355834 PMCID: PMC11440222 DOI: 10.14744/hf.2023.2023.0071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 01/05/2024] [Accepted: 01/23/2024] [Indexed: 10/03/2024]
Abstract
Simultaneous liver-kidney transplantation (SLK) is a feasible option for patients with end-stage liver disease and concomitant renal dysfunction or end-stage renal disease. SLK has gained significant attention primarily due to multiple alterations in the allocation criteria over the past two decades. This review aims to summarize the most recent updates and outcomes of the SLK allocation policy, comparing SLK outcomes with those of liver transplantation alone and exploring the implications of donation after cardiac death in SLK procedures.
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Affiliation(s)
- Hamit Ali
- Division of Gastroenterology & Hepatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Nazli Begum Ozturk
- Department of Internal Medicine, Beaumont Hospital, Royal Oak, Michigan, USA
| | - N Emre Herdan
- Division of Gastroenterology & Hepatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Harry Luu
- Division of Gastroenterology & Hepatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Cem Simsek
- Division of Gastroenterology & Hepatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Rumeyza Kazancioglu
- Division of Nephrology, Faculty of Medicine, Bezmialem Vakif University, Istanbul, Turkiye
| | - Ahmet Gurakar
- Division of Gastroenterology & Hepatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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12
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Kim SC, Foley DP. Strategies to Improve the Utilization and Function of DCD Livers. Transplantation 2024; 108:625-633. [PMID: 37496117 DOI: 10.1097/tp.0000000000004739] [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: 07/28/2023]
Abstract
Despite the increased usage of livers from donation after circulatory death (DCD) donors in the last decade, many patients remaining on the waitlist who need a liver transplant. Recent efforts have focused on maximizing the utilization and outcomes of these allografts using advances in machine perfusion technology and other perioperative strategies such as normothermic regional perfusion (NRP). In addition to the standard donor and recipient matching that is required with DCD donation, new data regarding the impact of graft steatosis, extensive European experience with NRP, and the increasing use of normothermic and hypothermic machine perfusion have shown immense potential in increasing DCD organ overall utilization and improved outcomes. These techniques, along with viability testing of extended criteria donors, have generated early promising data to consider the use of higher-risk donor organs and more widespread adoption of these techniques in the United States. This review explores the most recent international literature regarding strategies to optimize the utilization and outcomes of DCD liver allografts, including donor-recipient matching, perioperative strategies including NRP versus rapid controlled DCD recovery, viability assessment of discarded livers, and postoperative strategies including machine perfusion versus pharmacologic interventions.
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Affiliation(s)
- Steven C Kim
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - David P Foley
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
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13
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Ruch B, Kumm K, Arias S, Katariya NN, Mathur AK. Donation After Circulatory Death Liver Transplantation: Early Challenges, Clinical Improvement, and Future Directions. Surg Clin North Am 2024; 104:27-44. [PMID: 37953039 DOI: 10.1016/j.suc.2023.08.001] [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
Donation after circulatory death (DCD) liver allografts remain a widely underutilized source of donor organs for transplantation. Although initially linked with inferior outcomes, DCD liver transplant can achieve excellent patient and graft survival with suitable matching of donor and recipient characteristics, rapid donor recovery and precise donor assessment, and appropriate perioperative management. The advent of clinical liver perfusion modalities promises to redefine the viability parameters for DCD liver allografts and hopefully will encourage more widespread usage of this growing source of donor livers.
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Affiliation(s)
- Brianna Ruch
- Department of Surgery, Division of Transplant Surgery, Mayo Clinic, Phoenix, AZ, USA. https://twitter.com/BriannaCRuch
| | - Kayla Kumm
- Department of Surgery, Division of Transplant Surgery, Mayo Clinic, Phoenix, AZ, USA. https://twitter.com/Kayla_Kumm
| | - Sandra Arias
- Department of Surgery, Division of Transplant Surgery, Mayo Clinic, Phoenix, AZ, USA
| | - Nitin N Katariya
- Department of Surgery, Division of Transplant Surgery, Mayo Clinic, Phoenix, AZ, USA. https://twitter.com/nnk_tx_hpb
| | - Amit K Mathur
- Department of Surgery, Division of Transplant Surgery, Mayo Clinic, Phoenix, AZ, USA.
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14
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Haque OJ, Roth EM, Lee DD. Modern-Day Practice of DCD Liver Transplantation: Controversies, Innovations, and Future Directions. Curr Gastroenterol Rep 2023; 25:413-420. [PMID: 37897687 DOI: 10.1007/s11894-023-00902-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/07/2023] [Indexed: 10/30/2023]
Abstract
PURPOSE OF REVIEW Over the past decade, donation after circulatory death (DCD) liver transplantation has expanded in the United States due to improved surgical experience and perioperative management. Despite these advances, there remains a reluctance towards broader utilization of DCD liver allografts due to lack of standardized donation process, concern for inferior graft survival, and risk of ischemic cholangiopathy associated with temporary lack of oxygenated perfusion during withdrawal of life-supporting treatment during procurement. RECENT FINDINGS New perfusion technologies offer potential therapeutic options to mitigate biliary complications and expand utilization of marginal DCD grafts. As these modalities enter routine clinical practice, DCD utilization will continue to increase, and liver allocation policies in turn will evolve to reflect this growing practice. This review describes recent progress in DCD LT, current challenges with utilization of DCD liver allografts, and how novel technologies and policies could impact the future of the field.
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Affiliation(s)
- Omar J Haque
- Department of Surgery, Beth Israel Deaconess Medical Center, Lowry Building 7th Floor, 110 Francis St, Boston, MA, 02215, USA
| | - Eve M Roth
- Department of Surgery, Beth Israel Deaconess Medical Center, Lowry Building 7th Floor, 110 Francis St, Boston, MA, 02215, USA
| | - David D Lee
- Department of Surgery, Beth Israel Deaconess Medical Center, Lowry Building 7th Floor, 110 Francis St, Boston, MA, 02215, USA.
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15
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Affiliation(s)
- Michael R Lucey
- From the Department of Medicine, Division of Gastroenterology and Hepatology (M.R.L.), the Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition (K.N.F.), and the Department of Surgery, Division of Transplantation (D.P.F.), University of Wisconsin, Madison
| | - Katryn N Furuya
- From the Department of Medicine, Division of Gastroenterology and Hepatology (M.R.L.), the Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition (K.N.F.), and the Department of Surgery, Division of Transplantation (D.P.F.), University of Wisconsin, Madison
| | - David P Foley
- From the Department of Medicine, Division of Gastroenterology and Hepatology (M.R.L.), the Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition (K.N.F.), and the Department of Surgery, Division of Transplantation (D.P.F.), University of Wisconsin, Madison
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16
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Fallani G, Stocco A, Siniscalchi A, Antonini MV, Stella AP, Amato A, Prosperi E, Turco L, Morelli MC, Cescon M, Ravaioli M. Beyond the Concepts of Elder and Marginal in DCD Liver Transplantation: A Prospective Observational Matched-Cohort Study in the Italian Clinical Setting. Transpl Int 2023; 36:11697. [PMID: 37736400 PMCID: PMC10511003 DOI: 10.3389/ti.2023.11697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 08/21/2023] [Indexed: 09/23/2023]
Abstract
Donation after circulatory determination of death (DCD) is a valuable strategy to increase the availability of grafts for liver transplantation (LT). As the average age of populations rises, the donor pool is likely to be affected by a potential increase in DCD donor age in the near future. We conducted a prospective cohort study to evaluate post-transplantation outcomes in recipients of grafts from elderly DCD donors compared with younger DCD donors, and elderly donors after brainstem determination of death (DBD). From August 2020 to May 2022, consecutive recipients of deceased donor liver-only transplants were enrolled in the study. DCD recipients were propensity score matched 1:3 to DBD recipients. One-hundred fifty-seven patients were included, 26 of whom (16.6%) were transplanted with a DCD liver graft. After propensity score matching and stratification, three groups were obtained: 15 recipients of DCD donors ≥75 years, 11 recipients of DCD donors <75 years, and 28 recipients of DBD donors ≥75 years. Short-term outcomes, as well as 12 months graft survival rates (93.3%, 100%, and 89.3% respectively), were comparable among the groups. LT involving grafts retrieved from very elderly DCD donors was feasible and safe in an experienced high-volume center, with outcomes comparable to LTs from younger DCD donors and age-matched DBD donors.
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Affiliation(s)
- Guido Fallani
- Department of Hepatobiliary Surgery and Transplantation, Policlinico di Sant’Orsola, Istituto di Ricovero e Cura a Carattere Scientifico, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Alberto Stocco
- Department of Hepatobiliary Surgery and Transplantation, Policlinico di Sant’Orsola, Istituto di Ricovero e Cura a Carattere Scientifico, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Antonio Siniscalchi
- Department of Transplant Intensive Care Unit, Policlinico di Sant’Orsola, Istituto di Ricovero e Cura a Carattere Scientifico, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Marta Velia Antonini
- Ospedale “Maurizio Bufalini”—Azienda Unità Sanitaria Locale Romagna, Cesena, Italy
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Adriano Pasquale Stella
- Department of Hepatobiliary Surgery and Transplantation, Policlinico di Sant’Orsola, Istituto di Ricovero e Cura a Carattere Scientifico, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Alessio Amato
- Department of Hepatobiliary Surgery and Transplantation, Policlinico di Sant’Orsola, Istituto di Ricovero e Cura a Carattere Scientifico, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Enrico Prosperi
- Department of Hepatobiliary Surgery and Transplantation, Policlinico di Sant’Orsola, Istituto di Ricovero e Cura a Carattere Scientifico, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Laura Turco
- Department of Internal Medicine for the Treatment of Severe Organ Failure, Policlinico di Sant’Orsola, Istituto di Ricovero e Cura a Carattere Scientifico, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Maria Cristina Morelli
- Department of Internal Medicine for the Treatment of Severe Organ Failure, Policlinico di Sant’Orsola, Istituto di Ricovero e Cura a Carattere Scientifico, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Matteo Cescon
- Department of Hepatobiliary Surgery and Transplantation, Policlinico di Sant’Orsola, Istituto di Ricovero e Cura a Carattere Scientifico, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Matteo Ravaioli
- Department of Hepatobiliary Surgery and Transplantation, Policlinico di Sant’Orsola, Istituto di Ricovero e Cura a Carattere Scientifico, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
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17
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Mojoudi M, Taggart MS, Kharga A, Chen H, Dinicu AT, Wilks BT, Markmann JF, Toner M, Tessier SN, Yeh H, Uygun K. Anti-apoptotic treatment of warm ischemic male rat livers in machine perfusion improves symptoms of ischemia-reperfusion injury. RESEARCH SQUARE 2023:rs.3.rs-3260870. [PMID: 37674730 PMCID: PMC10479447 DOI: 10.21203/rs.3.rs-3260870/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/08/2023]
Abstract
Liver donation after cardiac death (DCD) makes up a small percentage of the donor pool and poses a higher risk of graft loss compared to donation after brain death (DBD); this is a result of ischemia reperfusion for which the exact injury mechanisms are currently not fully understood. However, reperfusion injury has been shown to lead to necrosis as well as apoptosis at the cellular level. In this work, we propose that use of the pro-survival, anti-apoptotic CEPT cocktail in post-ischemia normothermic machine perfusion (NMP) may improve recovery in rat livers subjected to extended durations of warm ischemia. Livers procured from male lewis rats were subjected to 90 minutes of warm ischemia, followed by 6 hours of NMP where they were treated with the survival-enhancing anti-apoptotic cocktail (CEPT), the vehicle (DMSO) or the base media with no additives. The CEPT-treated group exhibited lower expression of hepatic injury biomarkers, and improvement in a range of hepatocellular functions associated with the hepatic parenchyma, biliary epithelium and especially the sinusoidal endothelium. This study's findings provide useful insight for further investigation of the extent of apoptotic contribution to ischemia reperfusion injury (IRI).
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Affiliation(s)
- Mohammadreza Mojoudi
- Center for Engineering in Medicine and Surgery, Department of Surgery, Massachusetts General Hospital
| | - McLean S Taggart
- Center for Engineering in Medicine and Surgery, Department of Surgery, Massachusetts General Hospital
| | - Anil Kharga
- Center for Engineering in Medicine and Surgery, Department of Surgery, Massachusetts General Hospital
| | - Huyun Chen
- Center for Engineering in Medicine and Surgery, Department of Surgery, Massachusetts General Hospital
| | - Antonia T Dinicu
- Center for Engineering in Medicine and Surgery, Department of Surgery, Massachusetts General Hospital
| | - Benjamin T Wilks
- Center for Engineering in Medicine and Surgery, Department of Surgery, Massachusetts General Hospital
| | - James F Markmann
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital
| | - Mehmet Toner
- Center for Engineering in Medicine and Surgery, Department of Surgery, Massachusetts General Hospital
| | - Shannon N Tessier
- Center for Engineering in Medicine and Surgery, Department of Surgery, Massachusetts General Hospital
| | - Heidi Yeh
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital
| | - Korkut Uygun
- Center for Engineering in Medicine and Surgery, Department of Surgery, Massachusetts General Hospital
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18
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Stewart D, Hasz R, Lonze B. Beyond donation to organ utilization in the USA. Curr Opin Organ Transplant 2023; 28:197-206. [PMID: 36912063 DOI: 10.1097/mot.0000000000001060] [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: 03/14/2023]
Abstract
PURPOSE OF REVIEW The deceased donor organ pool has broadened beyond young, otherwise healthy head trauma victims. But an abundance of donated organs only benefits patients if they are accepted, expeditiously transported and actually transplanted. This review focuses on postdonation challenges and opportunities to increase the number of transplants through improved organ utilization. RECENT FINDINGS We build upon recently proposed changes in terminology for measuring organ utilization. Among organs recovered for transplant, the nonuse rate (NUR REC ) has risen above 25% for kidneys and pancreata. Among donors, the nonuse rate (NUR DON ) has risen to 40% for livers and exceeds 70% for thoracic organs. Programme-level variation in offer acceptance rates vastly exceeds variation in the traditional, 1-year survival benchmark. Key opportunities to boost utilization include donation after circulatory death and hepatitis C virus (HCV)+ organs; acute kidney injury and suboptimal biopsy kidneys; older and steatotic livers. SUMMARY Underutilization of less-than-ideal, yet transplant-worthy organs remains an obstacle to maximizing the impact of the U.S. transplant system. The increased risk of inferior posttransplant outcomes must always be weighed against the risks of remaining on the waitlist. Advanced perfusion technologies; tuning allocation systems for placement efficiency; and data-driven clinical decision support have the potential to increase utilization of medically complex organs.
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Affiliation(s)
- Darren Stewart
- Department of Surgery, NYU Langone Health, New York, New York
| | - Richard Hasz
- Gift of Life Donor Program, Philadelphia, Pennsylvania, USA
| | - Bonnie Lonze
- Department of Surgery, NYU Langone Health, New York, New York
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19
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Ganni S, Handing G, Anand A, Barrett S, Galvan NTN, O’Mahony C, Goss JA, Cotton RT, Rana A. Selecting DCD Recipients Using Predictive Indices. Transplant Direct 2023; 9:e1467. [PMID: 37009165 PMCID: PMC10065835 DOI: 10.1097/txd.0000000000001467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 01/27/2023] [Accepted: 01/28/2023] [Indexed: 04/04/2023] Open
Abstract
Donation after circulatory death (DCD) allografts might represent one of the largest untapped sources of liver allografts. Our aim was to identify independent recipient risk factors that predict mortality in DCD allograft recipients to preselect optimal candidates for successful transplantation. Furthermore, we compared the application of our newly constructed DCD Recipient Selector Index (RSI) score to previously developed models to determine superiority in predicting recipient survival. Methods Using the Organ Procurement and Transplantation Network database, we performed univariate and multivariate retrospective analyses on 4228 DCD liver allograft recipients. Results We identified 8 significant factors and incorporated them into the weighted RSI to predict 3-mo survival following DCD liver transplantation with a C-statistic of 0.6971. The most significant recipient risk factors were recipient serum sodium levels >150 mEq/L at transplant, recipient albumin <2.0 g/dL at transplant, and a history of portal vein thrombosis. Because Model for End-Stage Liver Disease (MELD) score components were included as individual predictors, the DCD RSI predicts survival independently of MELD. Upon comparison with 3 previous recipient risk scores-Balance of Risk, Renal Risk Index, Patient-Survival Outcomes Following Liver Transplantation-the DCD RSI was determined to be superior at selecting optimal candidates pre-DCD transplantation, yielding a C-statistic of 0.6971. Conclusions After verifying the performance of predictive indices for selection of DCD recipients, the DCD RSI is best used to preselect patients for optimized outcomes after DCD transplantation. This can increase utilization of DCD donors by improving outcomes.
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Affiliation(s)
- Saif Ganni
- Division of Abdominal Transplant, Department of Surgery, Michael E DeBakey, Houston, TX
| | - Greta Handing
- Department of Student Affairs, Baylor College of Medicine, Houston, TX
- Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Adrish Anand
- Department of Student Affairs, Baylor College of Medicine, Houston, TX
- Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Spencer Barrett
- Department of Student Affairs, Baylor College of Medicine, Houston, TX
- Department of Medicine, Baylor College of Medicine, Houston, TX
| | | | - Christine O’Mahony
- Division of Abdominal Transplant, Department of Surgery, Michael E DeBakey, Houston, TX
| | - John A. Goss
- Division of Abdominal Transplant, Department of Surgery, Michael E DeBakey, Houston, TX
| | - Ronald T. Cotton
- Division of Abdominal Transplant, Department of Surgery, Michael E DeBakey, Houston, TX
| | - Abbas Rana
- Division of Abdominal Transplant, Department of Surgery, Michael E DeBakey, Houston, TX
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20
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Azizieh Y, Westhaver LP, Badrudin D, Boudreau JE, Gala-Lopez BL. Changing liver utilization and discard rates in clinical transplantation in the ex-vivo machine preservation era. FRONTIERS IN MEDICAL TECHNOLOGY 2023; 5:1079003. [PMID: 36908294 PMCID: PMC9996101 DOI: 10.3389/fmedt.2023.1079003] [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: 10/24/2022] [Accepted: 01/30/2023] [Indexed: 02/25/2023] Open
Abstract
Liver transplantation is a well-established treatment for many with end-stage liver disease. Unfortunately, the increasing organ demand has surpassed the donor supply, and approximately 30% of patients die while waiting for a suitable liver. Clinicians are often forced to consider livers of inferior quality to increase organ donation rates, but ultimately, many of those organs end up being discarded. Extensive testing in experimental animals and humans has shown that ex-vivo machine preservation allows for a more objective characterization of the graft outside the body, with particular benefit for suboptimal organs. This review focuses on the history of the implementation of ex-vivo liver machine preservation and how its enactment may modify our current concept of organ acceptability. We provide a brief overview of the major drivers of organ discard (age, ischemia time, steatosis, etc.) and how this technology may ultimately revert such a trend. We also discuss future directions for this technology, including the identification of new markers of injury and repair and the opportunity for other ex-vivo regenerative therapies. Finally, we discuss the value of this technology, considering current and future donor characteristics in the North American population that may result in a significant organ discard.
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Affiliation(s)
- Yara Azizieh
- Department of Pathology, Dalhousie University, Halifax, NS, Canada
| | | | - David Badrudin
- Department of Surgery, Université de Montréal, Montréal, QC, Canada
| | - Jeanette E Boudreau
- Department of Pathology, Dalhousie University, Halifax, NS, Canada.,Department of Microbiology and Immunology, Dalhousie University, Halifax, NS, Canada.,Beatrice Hunter Cancer Research Institute, Halifax, NS, Canada
| | - Boris L Gala-Lopez
- Department of Pathology, Dalhousie University, Halifax, NS, Canada.,Department of Microbiology and Immunology, Dalhousie University, Halifax, NS, Canada.,Beatrice Hunter Cancer Research Institute, Halifax, NS, Canada.,Department of Surgery, Dalhousie University, Halifax, NS, Canada
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21
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Where are we today with machine perfusion of liver in donation after circulatory death liver transplantation? TRANSPLANTATION REPORTS 2022. [DOI: 10.1016/j.tpr.2022.100111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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22
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Siddiqui F, Al-Adwan Y, Subramanian J, Henry ML. Contemporary Considerations in Solid Organ Transplantation Utilizing DCD Donors. TRANSPLANTATION REPORTS 2022. [DOI: 10.1016/j.tpr.2022.100118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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23
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Sousa Da Silva RX, Weber A, Dutkowski P, Clavien PA. Machine perfusion in liver transplantation. Hepatology 2022; 76:1531-1549. [PMID: 35488496 DOI: 10.1002/hep.32546] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 02/24/2022] [Accepted: 02/24/2022] [Indexed: 12/29/2022]
Abstract
Although liver transplantation is a true success story, many patients still die awaiting an organ. The increasing need for liver grafts therefore remains an unsolved challenge to the transplant community. To address this, transplant donor criteria have been expanded and, for example, more liver grafts with significant steatosis or from donors with circulatory death are being used. These marginal grafts, however, carry an increased risk of graft-associated complications, such as primary nonfunction, delayed graft function, or late biliary injuries. Therefore, reliable assessment of graft viability before use is essential for further success. To achieve this, machine liver perfusion, a procedure developed more than 50 years ago but almost forgotten at the end of the last century, is again of great interest. We describe in this review the clinical most applied machine perfusion techniques, their mechanistic background, and a novel concept of combining immediate organ assessment during hypothermic oxygenated perfusion, followed by an extended phase of normothermic machine perfusion, with simultaneous ex situ treatment of the perfused liver. Such a new approach may allow the pool of usable livers to dramatically increase and improve outcomes for recipients.
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Affiliation(s)
- Richard X Sousa Da Silva
- Department of Surgery and Transplantation, Swiss Hepato-Pancreato-Biliary and Transplant Center, University Hospital Zurich, Zurich, Switzerland.,Wyss Zurich Translational Center, Swiss Federal Institute of Technology ETH Zurich/University of Zurich, Zurich, Switzerland
| | - Achim Weber
- Department of Pathology and Molecular Pathology, Institute of Molecular Cancer Research, University Hospital Zurich and University Zurich, Zurich, Switzerland
| | - Philipp Dutkowski
- Department of Surgery and Transplantation, Swiss Hepato-Pancreato-Biliary and Transplant Center, University Hospital Zurich, Zurich, Switzerland
| | - Pierre-Alain Clavien
- Department of Surgery and Transplantation, Swiss Hepato-Pancreato-Biliary and Transplant Center, University Hospital Zurich, Zurich, Switzerland.,Wyss Zurich Translational Center, Swiss Federal Institute of Technology ETH Zurich/University of Zurich, Zurich, Switzerland
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24
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Patrono D, Zanierato M, Vergano M, Magaton C, Diale E, Rizza G, Catalano S, Mirabella S, Cocchis D, Potenza R, Livigni S, Balagna R, Romagnoli R. Normothermic Regional Perfusion and Hypothermic Oxygenated Machine Perfusion for Livers Donated After Controlled Circulatory Death With Prolonged Warm Ischemia Time: A Matched Comparison With Livers From Brain-Dead Donors. Transpl Int 2022; 35:10390. [PMID: 35529593 PMCID: PMC9072630 DOI: 10.3389/ti.2022.10390] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 03/31/2022] [Indexed: 12/29/2022]
Abstract
Prolonged warm ischemia time (WIT) has a negative prognostic value in liver transplantation (LT) using grafts procured after circulatory death (DCD). To assess the value of abdominal normothermic regional perfusion (A-NRP) associated with dual hypothermic oxygenated machine perfusion (D-HOPE) in controlled DCD LT, prospectively collected data on LTs performed between January 2016 and July 2021 were analyzed. Outcome of controlled DCD LTs performed using A-NRP + D-HOPE (n = 20) were compared to those performed with grafts procured after brain death (DBD) (n = 40), selected using propensity-score matching. DCD utilization rate was 59.5%. In the DCD group, median functional WIT, A-NRP and D-HOPE time was 43, 246, and 205 min, respectively. Early outcomes of DCD grafts recipients were comparable to those of matched DBD LTs. In DCD and DBD group, incidence of anastomotic biliary complications and ischemic cholangiopathy was 15% versus 22% (p = 0.73) and 5% versus 2% (p = 1), respectively. One-year patient and graft survival was 100% versus 95% (p = 0.18) and 90% versus 95% (p = 0.82). In conclusion, the association of A-NRP + D-HOPE in DCD LT with prolonged WIT allows achieving comparable outcomes to DBD LT.
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Affiliation(s)
- Damiano Patrono
- General Surgery 2U-Liver Transplant Unit, A.O.U. Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Marinella Zanierato
- Department of Anesthesia and Critical Care, Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Marco Vergano
- Department of Anesthesia and Intensive Care, San Giovanni Bosco Hospital, Turin, Italy
| | - Chiara Magaton
- General Surgery 2U-Liver Transplant Unit, A.O.U. Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Enrico Diale
- General Surgery 2U-Liver Transplant Unit, A.O.U. Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Giorgia Rizza
- General Surgery 2U-Liver Transplant Unit, A.O.U. Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Silvia Catalano
- General Surgery 2U-Liver Transplant Unit, A.O.U. Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Stefano Mirabella
- General Surgery 2U-Liver Transplant Unit, A.O.U. Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Donatella Cocchis
- General Surgery 2U-Liver Transplant Unit, A.O.U. Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
| | - Raffaele Potenza
- Regional Procurement Organization, Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Sergio Livigni
- Department of Anesthesia and Intensive Care, San Giovanni Bosco Hospital, Turin, Italy
| | - Roberto Balagna
- Anesthesia Department 2, A.O.U. Città Della Salute e Della Scienza di Torino, Turin, Italy
| | - Renato Romagnoli
- General Surgery 2U-Liver Transplant Unit, A.O.U. Città della Salute e della Scienza di Torino, University of Turin, Turin, Italy
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25
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Seth AK, Mohanka R, Navin S, Gokhale AGK, Sharma A, Kumar A, Ramachandran B, Balakrishnan KR, Mirza D, Mehta D, Zirpe KG, Dhital K, Sahay M, Simha S, Sundaram R, Pandit R, Mani RK, Gursahani R, Gupta S, Kute VB, Shroff S. Organ Donation after Circulatory Determination of Death in India: A Joint Position Paper. Indian J Crit Care Med 2022; 26:421-438. [PMID: 35656056 PMCID: PMC9067489 DOI: 10.5005/jp-journals-10071-24198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Avnish K Seth
- Manipal Organ Sharing and Transplant (MOST), Manipal Hospital, New Delhi, India
| | - Ravi Mohanka
- Department of Liver Transplant and HPB Surgery, Reliance Foundation Hospital, Mumbai, Maharashtra, India
- Ravi Mohanka, Department of Liver Transplant and HPB Surgery, Reliance Foundation Hospital, Mumbai, Maharashtra, India, Phone: +91 7506668666, e-mail:
| | | | | | - Ashish Sharma
- Department of Renal Transplant Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Anil Kumar
- Ministry of Health and Family Welfare, Government of India, New Delhi, India
| | - Bala Ramachandran
- Department of Pediatric Intensive Care, Kanchi Kamakoti CHILDS Trust Hospital, Chennai, Tamil Nadu, India
| | | | - Darius Mirza
- University of Birmingham, United Kingdom and Apollo Hospitals, Navi Mumbai, Maharashtra, India
| | | | - Kapil G Zirpe
- Department of Neuro Trauma Unit, Grant Medical Foundation, Pune, Maharashtra, India
| | - Kumud Dhital
- Department of Heart and Lung Transplantation, SS Sparsh Hospital, Bengaluru, Karnataka, India
| | - Manisha Sahay
- Osmania Medical College and Hospital, Hyderabad, Telangana, India
| | - Srinagesh Simha
- Department of Palliative Care, Karunashraya, Bengaluru, Karnataka, India
| | | | | | - Raj K Mani
- Department of Critical Care and Pulmonology, Yashoda Super Specialty Hospital, Ghaziabad, Uttar Pradesh, India
| | - Roop Gursahani
- Department of Neurology, PD Hinduja National Hospital, Mumbai, Maharashtra, India
| | - Subash Gupta
- Max Centre for Liver and Biliary Sciences, New Delhi, India
| | - Vivek B Kute
- Department of Nephrology, Institute of Kidney Diseases and Research Center, Dr HL Trivedi Institute of Transplantation Sciences (IKDRC-ITS), Ahmedabad, Gujarat, India
| | - Sunil Shroff
- Madras Medical Mission, Chennai, Tamil Nadu, India
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26
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Comments on "Regulations and Procurement Surgery in DCD Liver Transplantation: Expert Consensus Guidance From the International Liver Transplantation Society". Transplantation 2021; 105:e405-e406. [PMID: 34818311 DOI: 10.1097/tp.0000000000003868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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27
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Haque O, Pendexter CA, Wilks BT, Hafiz EOA, Markmann JF, Uygun K, Yeh H, Tessier SN. The effect of blood cells retained in rat livers during static cold storage on viability outcomes during normothermic machine perfusion. Sci Rep 2021; 11:23128. [PMID: 34848781 PMCID: PMC8633375 DOI: 10.1038/s41598-021-02417-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 11/01/2021] [Indexed: 12/03/2022] Open
Abstract
In transplantation, livers are transported to recipients using static cold storage (SCS), whereby livers are exposed to cold ischemic injury that contribute to post-transplant risk factors. We hypothesized that flushing organs during procurement with cold preservation solutions could influence the number of donor blood cells retained in the allograft thereby exacerbating cold ischemic injury. We present the results of rat livers that underwent 24 h SCS after being flushed with a cold University of Wisconsin (UW) solution versus room temperature (RT) lactated ringers (LR) solution. These results were compared to livers that were not flushed prior to SCS and thoroughly flushed livers without SCS. We used viability and injury metrics collected during normothermic machine perfusion (NMP) and the number of retained peripheral cells (RPCs) measured by histology to compare outcomes. Compared to the cold UW flush group, livers flushed with RT LR had lower resistance, lactate, AST, and ALT at 6 h of NMP. The number of RPCs also had significant positive correlations with resistance, lactate, and potassium levels and a negative correlation with energy charge. In conclusion, livers exposed to cold UW flush prior to SCS appear to perform worse during NMP, compared to RT LR flush.
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Affiliation(s)
- Omar Haque
- Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, 51 Blossom St, Boston, MA, 02114, USA
- Shriners Hospitals for Children, Boston, MA, USA
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Department of Surgery, Division of Transplantation, Center for Transplantation Science, Massachusetts General Hospital, 32 Fruit Street, Boston, MA, 02114, USA
- Harvard Medical School, Boston, MA, USA
| | - Casie A Pendexter
- Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, 51 Blossom St, Boston, MA, 02114, USA
- Shriners Hospitals for Children, Boston, MA, USA
| | - Benjamin T Wilks
- Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, 51 Blossom St, Boston, MA, 02114, USA
- Shriners Hospitals for Children, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Ehab O A Hafiz
- Department of Electron Microscopy Research, Theodor Bilharz Research Institute, Giza, Egypt
| | - James F Markmann
- Department of Surgery, Division of Transplantation, Center for Transplantation Science, Massachusetts General Hospital, 32 Fruit Street, Boston, MA, 02114, USA
- Harvard Medical School, Boston, MA, USA
| | - Korkut Uygun
- Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, 51 Blossom St, Boston, MA, 02114, USA
- Shriners Hospitals for Children, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Heidi Yeh
- Department of Surgery, Division of Transplantation, Center for Transplantation Science, Massachusetts General Hospital, 32 Fruit Street, Boston, MA, 02114, USA.
- Harvard Medical School, Boston, MA, USA.
| | - Shannon N Tessier
- Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, 51 Blossom St, Boston, MA, 02114, USA.
- Shriners Hospitals for Children, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
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28
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de Vries RJ, Cronin SEJ, Romfh P, Pendexter CA, Jain R, Wilks BT, Raigani S, van Gulik TM, Chen P, Yeh H, Uygun K, Tessier SN. Non-invasive quantification of the mitochondrial redox state in livers during machine perfusion. PLoS One 2021; 16:e0258833. [PMID: 34705828 PMCID: PMC8550443 DOI: 10.1371/journal.pone.0258833] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 10/06/2021] [Indexed: 11/19/2022] Open
Abstract
Ischemia reperfusion injury (IRI) is a critical problem in liver transplantation that can lead to life-threatening complications and substantially limit the utilization of livers for transplantation. However, because there are no early diagnostics available, fulminant injury may only become evident post-transplant. Mitochondria play a central role in IRI and are an ideal diagnostic target. During ischemia, changes in the mitochondrial redox state form the first link in the chain of events that lead to IRI. In this study we used resonance Raman spectroscopy to provide a rapid, non-invasive, and label-free diagnostic for quantification of the hepatic mitochondrial redox status. We show this diagnostic can be used to significantly distinguish transplantable versus non-transplantable ischemically injured rat livers during oxygenated machine perfusion and demonstrate spatial differences in the response of mitochondrial redox to ischemia reperfusion. This novel diagnostic may be used in the future to predict the viability of human livers for transplantation and as a tool to better understand the mechanisms of hepatic IRI.
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Affiliation(s)
- Reinier J. de Vries
- Center for Engineering in Medicine and Surgery, Harvard Medical School and Massachusetts General Hospital, Boston, MA, United States of America
- Shriners Hospitals for Children—Boston, Boston, MA, United States of America
- Department of Surgery, Amsterdam University Medical Centers–Location AMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Stephanie E. J. Cronin
- Center for Engineering in Medicine and Surgery, Harvard Medical School and Massachusetts General Hospital, Boston, MA, United States of America
- Shriners Hospitals for Children—Boston, Boston, MA, United States of America
| | - Padraic Romfh
- Pendar Technologies, Cambridge, MA, United States of America
| | - Casie A. Pendexter
- Center for Engineering in Medicine and Surgery, Harvard Medical School and Massachusetts General Hospital, Boston, MA, United States of America
- Shriners Hospitals for Children—Boston, Boston, MA, United States of America
| | - Rohil Jain
- Center for Engineering in Medicine and Surgery, Harvard Medical School and Massachusetts General Hospital, Boston, MA, United States of America
- Shriners Hospitals for Children—Boston, Boston, MA, United States of America
| | - Benjamin T. Wilks
- Center for Engineering in Medicine and Surgery, Harvard Medical School and Massachusetts General Hospital, Boston, MA, United States of America
- Shriners Hospitals for Children—Boston, Boston, MA, United States of America
| | - Siavash Raigani
- Center for Engineering in Medicine and Surgery, Harvard Medical School and Massachusetts General Hospital, Boston, MA, United States of America
- Shriners Hospitals for Children—Boston, Boston, MA, United States of America
- Division of Transplantation, Department of Surgery, Massachusetts General Hospital, Boston, MA, United States of America
| | - Thomas M. van Gulik
- Department of Surgery, Amsterdam University Medical Centers–Location AMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Peili Chen
- Pendar Technologies, Cambridge, MA, United States of America
| | - Heidi Yeh
- Division of Transplantation, Department of Surgery, Massachusetts General Hospital, Boston, MA, United States of America
| | - Korkut Uygun
- Center for Engineering in Medicine and Surgery, Harvard Medical School and Massachusetts General Hospital, Boston, MA, United States of America
- Shriners Hospitals for Children—Boston, Boston, MA, United States of America
| | - Shannon N. Tessier
- Center for Engineering in Medicine and Surgery, Harvard Medical School and Massachusetts General Hospital, Boston, MA, United States of America
- Shriners Hospitals for Children—Boston, Boston, MA, United States of America
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