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Hurst DJ, Padilla L, Merlocco A, Rodger D, Bobier C, Gray WH, Sorabella R, Cooper DKC, Pierson RN. Pediatric Cardiac Xenotransplantation: Recommendations for the Ethical Design of Clinical Trials. Transplantation 2024; 108:e292-e300. [PMID: 38419158 DOI: 10.1097/tp.0000000000004968] [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: 03/02/2024]
Abstract
For children with complex congenital heart problems, cardiac allotransplantation is sometimes the best therapeutic option. However, availability of hearts for pediatric patients is limited, resulting in a long and growing waitlist, and a high mortality rate while waiting. Cardiac xenotransplantation has been proposed as one therapeutic alternative for neonates and infants, either in lieu of allotransplantation or as a bridge until an allograft becomes available. Scientific and clinical developments in xenotransplantation appear likely to permit cardiac xenotransplantation clinical trials in adults in the coming years. The ethical issues around xenotransplantation of the heart and other organs and tissues have recently been examined, but to date, only limited literature is available on the ethical issues that are attendant with pediatric heart xenotransplantation. Here, we summarize the ethical issues, focusing on (1) whether cardiac xenotransplantation should proceed in adults or children first, (2) pediatric recipient selection for initial xenotransplantation trials, (3) special problems regarding informed consent in this context, and (4) related psychosocial and public perception considerations. We conclude with specific recommendations regarding ethically informed design of pediatric heart xenotransplantation trials.
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Affiliation(s)
- Daniel J Hurst
- Department of Family Medicine, Rowan-Virtua School of Osteopathic Medicine, Stratford, NJ
| | - Luz Padilla
- Department of Surgery, Division of Cardiothoracic Surgery, The University of Alabama at Birmingham, Birmingham, AL
| | - Anthony Merlocco
- Department of Cardiology, University of Tennessee Health Science Center, Memphis, TN
| | - Daniel Rodger
- Institute of Health and Social Care, School of Allied and Community Health, London South Bank University, London, United Kingdom
- Department of Psychological Sciences, Birkbeck College, University of London, London, United Kingdom
| | - Christopher Bobier
- Department of Theology and Philosophy, Saint Mary's University of Minnesota, Winona, MN
| | - William H Gray
- Department of Surgery, Division of Cardiothoracic Surgery, The University of Alabama at Birmingham, Birmingham, AL
| | - Robert Sorabella
- Department of Surgery, Division of Cardiothoracic Surgery, The University of Alabama at Birmingham, Birmingham, AL
| | - David K C Cooper
- Center for Transplantation Sciences, Massachusetts General Hospital/Harvard Medical School, Boston, MN
| | - Richard N Pierson
- Center for Transplantation Sciences, Massachusetts General Hospital/Harvard Medical School, Boston, MN
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John MM, Zinyandu T, Rosenblum JM, Shashidharan S, Chai PJ, Shaw FR. Neonatal heart transplantation in the United States: Trends and outcomes. Pediatr Transplant 2024; 28:e14792. [PMID: 38808741 DOI: 10.1111/petr.14792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 05/01/2024] [Accepted: 05/14/2024] [Indexed: 05/30/2024]
Abstract
BACKGROUND Heart transplantation in the neonatal period is associated with excellent survival. However, outcomes data are scant and have been obtained primarily from two single-center reports within the United States. We sought to analyze the outcomes of all neonatal heart transplants performed in the United States using the United Network for Organ Sharing (UNOS) dataset. METHODS The UNOS dataset was queried for patients who underwent infant heart transplantation from 1987 to 2021. Patients were divided into two groups based on age - neonates (<=31 days), and older infants (32 days-365 days). Demographic and clinical characteristics were analyzed and compared, along with follow up survival data. RESULTS Overall, 474 newborns have undergone heart transplantation in the United States since 1987. Freedom from death or re-transplantation for neonates was 63.5%, 58.8% and 51.6% at 5, 10, and 20 years, respectively. Patients in the newborn group had lower unadjusted survival compared to older infants (p < .001), but conditional 1-year survival was higher in neonates (p = .03). On multivariable analysis, there was no significant difference in survival between the two age groups (p = .43). Black race, congenital heart disease diagnosis, earlier surgical era, and preoperative mechanical circulatory support use were associated with lower survival among infant transplants (p < .05). CONCLUSIONS Neonatal heart transplantation is associated with favorable long-term clinical outcomes. Neonates do not have a significant survival advantage over older infants. Widespread applicability is limited by the small number of available donors. Efforts to expand the donor pool to include non-standard donor populations ought to be considered.
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Affiliation(s)
- Mohan M John
- Division of Cardiothoracic Surgery, Children's Healthcare of Atlanta/Emory University School of Medicine, Atlanta, Georgia, USA
| | - Tawanda Zinyandu
- Division of Cardiothoracic Surgery, Children's Healthcare of Atlanta/Emory University School of Medicine, Atlanta, Georgia, USA
| | - Joshua M Rosenblum
- Division of Cardiothoracic Surgery, Children's Healthcare of Atlanta/Emory University School of Medicine, Atlanta, Georgia, USA
| | - Subhadra Shashidharan
- Division of Cardiothoracic Surgery, Children's Healthcare of Atlanta/Emory University School of Medicine, Atlanta, Georgia, USA
| | - Paul J Chai
- Division of Cardiothoracic Surgery, Children's Healthcare of Atlanta/Emory University School of Medicine, Atlanta, Georgia, USA
| | - Fawwaz R Shaw
- Division of Cardiothoracic Surgery, Children's Healthcare of Atlanta/Emory University School of Medicine, Atlanta, Georgia, USA
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Cleveland JD, Mitchell C, Cooper DKC, Cleveland DC. The potential of cardiac xenotransplantation for management of infants with complex congenital heart disease. Transl Pediatr 2023; 12:2247-2255. [PMID: 38197100 PMCID: PMC10772834 DOI: 10.21037/tp-22-664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 12/08/2023] [Indexed: 01/11/2024] Open
Abstract
Gene editing of the porcine genome has enabled the production of pigs that do not express the three known carbohydrate antigens that are associated with hyperacute rejection of a pig organ xenotransplant. In addition, it is now possible to insert a variety of human transgenes to protect against the human immune response, e.g., to protect from complement and coagulation activation. As a result, cardiac xenotransplantation of the gene-edited porcine heart is progressing towards clinical application. Many hope that it will definitively address the disparity between organ supply and demand. The role of cardiac xenotransplantation in pediatric care remains controversial but we believe there is an infant patient population with complex congenital heart disease (CHD) (not optimally managed by conventional surgical approaches) that is ideally suited to initial clinical application of this new technology. The most efficacious start would be to initiate clinical use as a short-term bridge to allotransplantation, particularly in infants with single ventricle pathology and significant risk factors for first stage Norwood palliation. Infants with end-stage heart failure after first stage palliation would represent a second target population. Infants experience unacceptably high mortality and morbidity when placed on mechanical circulatory support as a bridge to allotransplant. Effectively bridging these vulnerable populations could promote acceptance of cardiac xenotransplantation, allowing indications and use to expand, e.g., by (I) bridging patients with failed second and third stage single ventricle disease, or (II) with complex biventricular CHD, or (III) those with a restrictive or dilated cardiomyopathy. Finally, there is a reasonable expectation that the immunologic privilege of infants will allow porcine heart xenotransplantation to be destination therapy for some patients. In summary, heart allotransplantation in infants offers superior outcomes when compared to three-stage single ventricle palliation, but there is a continual shortage of deceased human donor organs. We should pursue research towards the application of xenotransplantation in patients with single ventricle pathology, in whom the results of staged palliation are likely to be suboptimal. There are many remaining issues to be resolved before cardiac xenotransplantation enters regular pediatric clinical use, but experience in this field is progressing rapidly.
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Affiliation(s)
- John D. Cleveland
- Division of Cardiothoracic Surgery, Department of Surgery, Heart Institute, Children’s Hospital of Los Angeles (CHLA), University of Southern California (USC), Los Angeles, CA, USA
| | - Chace Mitchell
- Division of Cardiothoracic Surgery, Department of Surgery, Heart Institute, Children’s Hospital of Los Angeles (CHLA), University of Southern California (USC), Los Angeles, CA, USA
| | - David K. C. Cooper
- Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA
| | - David C. Cleveland
- Division of Cardiothoracic Surgery, Department of Surgery, Heart Institute, Children’s Hospital of Los Angeles (CHLA), University of Southern California (USC), Los Angeles, CA, USA
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Li R, Qiu S, Yang W, Rao Z, Chen J, Yang Y, Zhu Q, Liu X, Bai Y, Quan D. A comparative study of human and porcine-derived decellularised nerve matrices. BIOMATERIALS TRANSLATIONAL 2023; 4:180-195. [PMID: 38283091 PMCID: PMC10817779 DOI: 10.12336/biomatertransl.2023.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 12/06/2022] [Accepted: 03/08/2023] [Indexed: 01/30/2024]
Abstract
Decellularised extracellular matrix (dECM) biomaterials originating from allogeneic and xenogeneic tissues have been broadly studied in the field of regenerative medicine and have already been used in clinical treatments. Allogeneic dECMs are considered more compatible, but they have the drawback of extremely limited human tissue sources. Their availability is also restricted by the health and age of the donors. To investigate the viability of xenogeneic tissues as a substitute for human tissues, we fabricated both porcine decellularised nerve matrix (pDNM) and human decellularised nerve matrix for a comprehensive comparison. Photomicrographs showed that both dECM scaffolds retained the ECM microstructures of native human nerve tissues. Proteomic analysis demonstrated that the protein compositions of both dECMs were also very similar to each other. Their functional ECM contents effectively promoted the proliferation, migration, and maturation of primary human Schwann cells in vitro. However, pDNM contained a few antigens that induced severe host immune responses in humanised mice. Interestingly, after removing the α-galactosidase antigen, the immune responses were highly alleviated and the pre-treated pDNM maintained a human decellularised nerve matrix-like pro-regenerative phenotype. Therefore, we believe that an α-galactosidase-free pDNM may serve as a viable substitute for human decellularised nerve matrix in future clinical applications.
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Affiliation(s)
- Rui Li
- Guangdong Engineering Technology Research Centre for Functional Biomaterials, School of Materials Science and Engineering, Sun Yat-sen University, Guangzhou, Guangdong Province, China
- Key Laboratory for Polymeric Composite & Functional Materials of Ministry of Education, School of Chemistry, Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Shuai Qiu
- Guangdong Engineering Technology Research Centre for Peripheral Nerve Tissue, Department of Orthopaedic and Microsurgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Weihong Yang
- Key Laboratory for Polymeric Composite & Functional Materials of Ministry of Education, School of Chemistry, Sun Yat-sen University, Guangzhou, Guangdong Province, China
- Guangzhou Zhongda Medical Equipment Co., Ltd., Guangzhou, Guangdong Province, China
| | - Zilong Rao
- Guangdong Engineering Technology Research Centre for Functional Biomaterials, School of Materials Science and Engineering, Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Jiaxin Chen
- Guangdong Engineering Technology Research Centre for Functional Biomaterials, School of Materials Science and Engineering, Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Yuexiong Yang
- Guangzhou Zhongda Medical Equipment Co., Ltd., Guangzhou, Guangdong Province, China
| | - Qingtang Zhu
- Guangdong Engineering Technology Research Centre for Peripheral Nerve Tissue, Department of Orthopaedic and Microsurgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Xiaolin Liu
- Guangdong Engineering Technology Research Centre for Peripheral Nerve Tissue, Department of Orthopaedic and Microsurgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Ying Bai
- Guangdong Engineering Technology Research Centre for Functional Biomaterials, School of Materials Science and Engineering, Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Daping Quan
- Guangdong Engineering Technology Research Centre for Functional Biomaterials, School of Materials Science and Engineering, Sun Yat-sen University, Guangzhou, Guangdong Province, China
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Konstantinov IE, Cooper DKC, Adachi I, Bacha E, Bleiweis MS, Chinnock R, Cleveland D, Cowan PJ, Fynn-Thompson F, Morales DLS, Mohiuddin MM, Reichart B, Rothblatt M, Roy N, Turek JW, Urschel S, West L, Wolf E. Consensus statement on heart xenotransplantation in children: Toward clinical translation. J Thorac Cardiovasc Surg 2023; 166:960-967. [PMID: 36184321 PMCID: PMC10124772 DOI: 10.1016/j.jtcvs.2022.09.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Accepted: 09/01/2022] [Indexed: 10/14/2022]
Affiliation(s)
- Igor E Konstantinov
- Royal Children's Hospital, University of Melbourne, Murdoch Children's Research Institute, Melbourne Centre for Cardiovascular Genomics and Regenerative Medicine, Melbourne, Australia.
| | - David K C Cooper
- Center for Transplantation Sciences, Massachusetts General Hospital/Harvard Medical School, Boston, Mass
| | - Iki Adachi
- Texas Children's Hospital, Baylor College of Medicine, Houston, Tex
| | - Emile Bacha
- Columbia University Medical Center, Morgan Stanley Children's Hospital, New York, NY
| | | | | | - David Cleveland
- Department of Surgery, University of Alabama, Birmingham, Ala
| | - Peter J Cowan
- Immunology Research Centre, St. Vincent's Hospital, University of Melbourne, Melbourne, Australia
| | | | - David L S Morales
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Muhammad M Mohiuddin
- Program in Cardiac Xenotransplantation, University of Maryland School of Medicine, Baltimore, Md
| | - Bruno Reichart
- Transregional Collaborative Research Center, Walter Brendel Centre of Experimental Medicine, Ludwig Maximilians University, Munich, Germany
| | | | - Nathalie Roy
- Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Joseph W Turek
- Department of Surgery, Duke University Medical Center, Durham, NC
| | - Simon Urschel
- Pediatric Cardiac Transplantation Program, Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - Lori West
- Pediatric Cardiac Transplantation Program, Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada; Canadian Donation and Transplantation Research Program, Alberta Transplant Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Eckhard Wolf
- Gene Center and Department of Veterinary Sciences, Ludwig Maximilians University, Munich, Germany
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Cooper DKC, Pierson RN. Milestones on the path to clinical pig organ xenotransplantation. Am J Transplant 2023; 23:326-335. [PMID: 36775767 PMCID: PMC10127379 DOI: 10.1016/j.ajt.2022.12.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 12/20/2022] [Accepted: 12/28/2022] [Indexed: 01/19/2023]
Abstract
Progress in pig organ xenotransplantation has been made largely through (1) genetic engineering of the organ-source pig to protect its tissues from the human innate immune response, and (2) development of an immunosuppressive regimen based on blockade of the CD40/CD154 costimulation pathway to prevent the adaptive immune response. In the 1980s, after transplantation into nonhuman primates (NHPs), wild-type (genetically unmodified) pig organs were rejected within minutes or hours. In the 1990s, organs from pigs expressing a human complement-regulatory protein (CD55) transplanted into NHPs receiving intensive conventional immunosuppressive therapy functioned for days or weeks. When costimulation blockade was introduced in 2000, the adaptive immune response was suppressed more readily. The identification of galactose-α1,3-galactose as the major antigen target for human and NHP anti-pig antibodies in 1991 allowed for deletion of expression of galactose-α1,3-galactose in 2003, extending pig graft survival for up to 6 months. Subsequent gene editing to overcome molecular incompatibilities between the pig and primate coagulation systems proved additionally beneficial. The identification of 2 further pig carbohydrate xenoantigens allowed the production of 'triple-knockout' pigs that are preferred for clinical organ transplantation. These combined advances enabled the first clinical pig heart transplant to be performed and opened the door to formal clinical trials.
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Affiliation(s)
- David K C Cooper
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA.
| | - Richard N Pierson
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
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7
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Oscherwitz M, Nguyen HQ, Raza SS, Cleveland DC, Padilla LA, Sorabella RA, Ayares D, Maxwell K, Rhodes LA, Cooper DKC, Hara H. Will previous palliative surgery for congenital heart disease be detrimental to subsequent pig heart xenotransplantation? Transpl Immunol 2022; 74:101661. [PMID: 35787933 PMCID: PMC9762890 DOI: 10.1016/j.trim.2022.101661] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 06/27/2022] [Accepted: 06/28/2022] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Pig heart xenotransplantation might act as a bridge in infants with complex congenital heart disease (CHD) until a deceased human donor heart becomes available. Infants develop antibodies to wild-type (WT, i.e., genetically-unmodified) pig cells, but rarely to cells in which expression of the 3 known carbohydrate xenoantigens has been deleted by genetic engineering (triple-knockout [TKO] pigs). Our objective was to test sera from children who had undergone palliative surgery for complex CHD (and who potentially might need a pig heart transplant) to determine whether they had serum cytotoxic antibodies against TKO pig cells. METHODS Sera were obtained from children with CHD undergoing Glenn or Fontan operation (n = 14) and healthy adults (n = 8, as controls). All of the children had complex CHD and had undergone some form of cardiac surgery. Seven had received human blood transfusions and 3 bovine pericardial patch grafts. IgM and IgG binding to WT and TKO pig red blood cells (RBCs) and peripheral blood mononuclear cells (PBMCs) were measured by flow cytometry, and killing of PBMCs by a complement-dependent cytotoxicity assay. RESULTS Almost all children and adults demonstrated relatively high IgM/IgG binding to WT RBCs, but minimal binding to TKO RBCs (p < 0.0001 vs WT), although IgG binding was greater in children than adults (p < 0.01). All sera showed IgM/IgG binding to WT PBMCs, but this was much lower to TKO PBMCs (p < 0.0001 vs WT) and was greater in children than in adults (p < 0.05). Binding to both WT and TKO PBMCs was greater than to RBCs. Mean serum cytotoxicity to WT PBMCs was 90% in both children and adults, whereas to TKO PBMCs it was only 20% and < 5%, respectively. The sera from 6/14 (43%) children were cytotoxic to TKO PBMCs, but no adult sera were cytotoxic. CONCLUSIONS Although no children had high levels of antibodies to TKO RBCs, 13/14 demonstrated antibodies to TKO PBMCs, in 6 of these showed mild cytotoxicity. As no adults had cytotoxic antibodies to TKO PBMCs, the higher incidence in children may possibly be associated with their exposure to previous cardiac surgery and biological products. However, the numbers were too small to determine the influence of such past exposures. Before considering pig heart xenotransplantation for children with CHD, testing for antibody binding may be warranted.
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Affiliation(s)
- Max Oscherwitz
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Huy Quoc Nguyen
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Syed Sikandar Raza
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - David C Cleveland
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Luz A Padilla
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Robert A Sorabella
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Kathryn Maxwell
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Leslie A Rhodes
- Department of Pediatric Cardiology, Division of Critical Care, University of Alabama at Birmingham, Birmingham, AL, USA
| | - David K C Cooper
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Hidetaka Hara
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA.
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Chaban R, Cooper DKC, Pierson RN. Pig heart and lung xenotransplantation: Present status. J Heart Lung Transplant 2022; 41:1014-1022. [PMID: 35659792 PMCID: PMC10124776 DOI: 10.1016/j.healun.2022.04.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 04/14/2022] [Accepted: 04/24/2022] [Indexed: 11/19/2022] Open
Abstract
The recent pig heart transplant in a patient at the University of Maryland Medical Center has stimulated renewed interest in the xenotransplantation of organs from genetically engineered pigs. The barriers to the use of pigs as sources of organs have largely been overcome by 2 approaches - (1) the deletion of expression of the three known pig carbohydrate xenoantigens against which humans have preformed antibodies, and (2) the transgenic introduction of human 'protective' proteins, such as complement-regulatory proteins. These gene modifications, coupled with immunosuppressive therapy based on blockade of the CD40/CD154 costimulation pathway, have resulted in survival of baboons with life-supporting pig heart grafts for almost 9 months. The initial clinical success at the University of Maryland reinforces encouraging preclinical results. It suggests that pig hearts are likely to provide an effective bridge to an allotransplant, but their utility for destination therapy remains uncertain. Because of additional complex immunobiological problems, the same approach has been less successful in preclinical lung xenograft transplantation, where survival is still measured in days or weeks. The first formal clinical trials of pig heart transplantation may include patients who do not have access to an allotransplant, those with contraindications for mechanical circulatory support, those in need of retransplantation or with a high level of panel-reactive antibodies. Infants with complex congenital heart disease, should also be considered.
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Affiliation(s)
- Ryan Chaban
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Department of Cardiovascular Surgery, University Hospital of Johannes Gutenberg University, Mainz, Germany.
| | - David K C Cooper
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Richard N Pierson
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
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9
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Raza SS, Hara H, Cleveland DC, Cooper DKC. The potential of genetically engineered pig heart transplantation in infants with complex congenital heart disease. Pediatr Transplant 2022; 26:e14260. [PMID: 35233893 PMCID: PMC10124767 DOI: 10.1111/petr.14260] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 02/15/2022] [Accepted: 02/16/2022] [Indexed: 12/16/2022]
Abstract
Despite advances in surgical and medical techniques, complex congenital heart disease in neonates and infants continues to be associated with significant mortality and morbidity. More than 500 infants in the USA are placed on the cardiac transplantation wait-list annually. However, there remains a critical shortage of deceased human donor organs for transplantation with a median wait-time of 4 months. Hence, infant mortality on the heart transplant wait-list in the USA is higher than for any other solid organ transplant group. Orthotopic transplantation of a pig heart as a bridge to allotransplantation might offer the best prospect of long-term survival of these patients. In recent years, there have been several advances in genetic engineering of pigs to mitigate the vigorous antibody-mediated rejection of a pig heart transplanted into a nonhuman primate. In this review, we briefly highlight (i) the history of clinical heart xenotransplantation, (ii) current advances and techniques of genetically engineering pigs, (iii) the current status of pig orthotopic cardiac graft survival in nonhuman primates, and (iv) progress toward pursuing clinical trials of cardiac xenotransplantation. Ultimately, we argue that pig heart xenotransplantation should initially be used as a bridge to cardiac allotransplantation in neonates and infants.
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Affiliation(s)
- Syed Sikandar Raza
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Hidetaka Hara
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - David C Cleveland
- Department of Cardiothoracic Surgery, Children's of Alabama, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - David K C Cooper
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
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10
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Jalali S, Harpur CM, Piers AT, Auladell M, Perriman L, Li S, An K, Anderson J, Berzins SP, Licciardi PV, Ashhurst TM, Konstantinov IE, Pellicci DG. A high-dimensional cytometry atlas of peripheral blood over the human life span. Immunol Cell Biol 2022; 100:805-821. [PMID: 36218032 PMCID: PMC9828744 DOI: 10.1111/imcb.12594] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 10/04/2022] [Accepted: 10/10/2022] [Indexed: 11/07/2022]
Abstract
Age can profoundly affect susceptibility to a broad range of human diseases. Children are more susceptible to some infectious diseases such as diphtheria and pertussis, while in others, such as coronavirus disease 2019 and hepatitis A, they are more protected compared with adults. One explanation is that the composition of the immune system is a major contributing factor to disease susceptibility and severity. While most studies of the human immune system have focused on adults, how the immune system changes after birth remains poorly understood. Here, using high-dimensional spectral flow cytometry and computational methods for data integration, we analyzed more than 50 populations of immune cells in the peripheral blood, generating an immune cell atlas that defines the healthy human immune system from birth up to 75 years of age. We focused our efforts on children under 18 years old, revealing major changes in immune cell populations after birth and in children of schooling age. Specifically, CD4+ T effector memory cells, Vδ2+ gamma delta (γδ)T cells, memory B cells, plasmablasts, CD11c+ B cells and CD16+ CD56bright natural killer (NK) cells peaked in children aged 5-9 years old, whereas frequencies of T helper 1, T helper 17, dendritic cells and CD16+ CD57+ CD56dim NK cells were highest in older children (10-18 years old). The frequency of mucosal-associated invariant T cells was low in the first several years of life and highest in adults between 19 and 30 years old. Late adulthood was associated with fewer mucosal-associated invariant T cells and Vδ2+ γδ T cells but with increased frequencies of memory subsets of B cells, CD4+ and CD8+ T cells and CD57+ NK cells. This human immune cell atlas provides a critical resource to understand changes to the immune system during life and provides a reference for investigating the immune system in the context of human disease. This work may also help guide future therapies that target specific populations of immune cells to protect at-risk populations.
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Affiliation(s)
- Sedigheh Jalali
- Murdoch Children's Research InstituteMelbourneVICAustralia,Department of PaediatricsUniversity of MelbourneMelbourneVICAustralia
| | | | - Adam T Piers
- Murdoch Children's Research InstituteMelbourneVICAustralia,Melbourne Centre for Cardiovascular Genomics and Regenerative MedicineMelbourneVICAustralia
| | - Maria Auladell
- Department of Microbiology and Immunology, Peter Doherty Institute for Infection and ImmunityUniversity of MelbourneMelbourneVICAustralia,Global Product Development Consulting for Infectious DiseasesPharmaceutical Product Development (PPD), Part of Thermo Fisher ScientificBennekomThe Netherlands
| | - Louis Perriman
- Murdoch Children's Research InstituteMelbourneVICAustralia,The Fiona Elsey Cancer Research InstituteBallaratVICAustralia,Federation UniversityBallaratVICAustralia
| | - Shuo Li
- Murdoch Children's Research InstituteMelbourneVICAustralia
| | - Kim An
- Murdoch Children's Research InstituteMelbourneVICAustralia,Melbourne Centre for Cardiovascular Genomics and Regenerative MedicineMelbourneVICAustralia
| | - Jeremy Anderson
- Murdoch Children's Research InstituteMelbourneVICAustralia,Department of PaediatricsUniversity of MelbourneMelbourneVICAustralia
| | - Stuart P Berzins
- Department of Microbiology and Immunology, Peter Doherty Institute for Infection and ImmunityUniversity of MelbourneMelbourneVICAustralia,The Fiona Elsey Cancer Research InstituteBallaratVICAustralia,Federation UniversityBallaratVICAustralia
| | - Paul V Licciardi
- Murdoch Children's Research InstituteMelbourneVICAustralia,Department of PaediatricsUniversity of MelbourneMelbourneVICAustralia
| | - Thomas M Ashhurst
- Sydney Cytometry Core Research FacilityThe University of Sydney and Centenary InstituteSydneyNSWAustralia,School of Medical Sciences, Faculty of Medicine and HealthThe University of SydneySydneyNSWAustralia
| | - Igor E Konstantinov
- Murdoch Children's Research InstituteMelbourneVICAustralia,Melbourne Centre for Cardiovascular Genomics and Regenerative MedicineMelbourneVICAustralia,Cardiothoracic SurgeryRoyal Children's HospitalMelbourneVICAustralia
| | - Daniel G Pellicci
- Murdoch Children's Research InstituteMelbourneVICAustralia,Department of PaediatricsUniversity of MelbourneMelbourneVICAustralia,Melbourne Centre for Cardiovascular Genomics and Regenerative MedicineMelbourneVICAustralia,Department of Microbiology and Immunology, Peter Doherty Institute for Infection and ImmunityUniversity of MelbourneMelbourneVICAustralia
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11
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Hurst DJ, Padilla LA, Cooper DKC, Paris W. Scientific and psychosocial ethical considerations for initial clinical trials of kidney xenotransplantation. Xenotransplantation 2021; 29:e12722. [PMID: 34800313 DOI: 10.1111/xen.12722] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 09/23/2021] [Accepted: 10/21/2021] [Indexed: 12/28/2022]
Abstract
The initial clinical trials of pig solid organ xenotransplantation (XTx) are drawing closer and could begin in the coming years. The first clinical trials may aim to transplant genetically-modified pig kidneys into adult humans. The impetus for beginning these first-in-human trials is the severe lack of deceased donor kidneys for transplantation and the number of patients with end-stage renal disease currently on transplant waitlists, which in the USA approaches 100 000. The majority of patients on the kidney transplant waitlist receive continuous renal replacement therapy. In the United States, for patients on the kidney waitlist, the median wait-time to receive a deceased human donor organ is approximately 4.5 years for patients aged 45-74, with a 5-year mortality (or removal from the waitlist because of deteriorating health) of approximately 40%. XTx has the potential to reduce the kidney waitlist morbidity and mortality while improving quality of life. By focusing on scientific and psychosocial criteria, we present ethical considerations of certain inclusion and exclusion criteria for these first-in-human clinical trials that we suggest have not yet been fully explored.
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Affiliation(s)
- Daniel J Hurst
- Department of Family Medicine, Rowan University School of Osteopathic Medicine, Stratford, New Jersey, USA
| | - Luz A Padilla
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - David K C Cooper
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Wayne Paris
- School of Social Work, Abilene Christian University, Abilene, Texas, USA
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12
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Cooper DKC, Cleveland DC. The first clinical trial-Kidney or heart? Xenotransplantation 2020; 28:e12644. [PMID: 33336862 DOI: 10.1111/xen.12644] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
- David K C Cooper
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - David C Cleveland
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA.,Children's Hospital of Alabama, Birmingham, AL, USA
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