1
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Saito S, Miyagawa S, Kawamura T, Yoshioka D, Kawamura M, Kawamura A, Misumi Y, Taguchi T, Yamauchi T, Miyagawa S. How should cardiac xenotransplantation be initiated in Japan? Surg Today 2024; 54:829-838. [PMID: 38733536 PMCID: PMC11266268 DOI: 10.1007/s00595-024-02861-7] [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: 02/13/2024] [Accepted: 04/07/2024] [Indexed: 05/13/2024]
Abstract
The world's first clinical cardiac xenotransplantation, using a genetically engineered pig heart with 10 gene modifications, prolonged the life of a 57-year-old man with no other life-saving options, by 60 days. It is foreseeable that xenotransplantation will be introduced in clinical practice in the United States. However, little clinical or regulatory progress has been made in the field of xenotransplantation in Japan in recent years. Japan seems to be heading toward a "device lag", and the over-importation of medical devices and technology in the medical field is becoming problematic. In this review, we discuss the concept of pig-heart xenotransplantation, including the pathobiological aspects related to immune rejection, coagulation dysregulation, and detrimental heart overgrowth, as well as genetic modification strategies in pigs to prevent or minimize these problems. Moreover, we summarize the necessity for and current status of xenotransplantation worldwide, and future prospects in Japan, with the aim of initiating xenotransplantation in Japan using genetically modified pigs without a global delay. It is imperative that this study prompts the initiation of preclinical xenotransplantation research using non-human primates and leads to clinical studies.
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Affiliation(s)
- Shunsuke Saito
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka, 565-0871, Japan.
| | - Shuji Miyagawa
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, 565-0871, Japan
| | - Takuji Kawamura
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka, 565-0871, Japan
| | - Daisuke Yoshioka
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka, 565-0871, Japan
| | - Masashi Kawamura
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka, 565-0871, Japan
| | - Ai Kawamura
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka, 565-0871, Japan
| | - Yusuke Misumi
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka, 565-0871, Japan
| | | | - Takashi Yamauchi
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka, 565-0871, Japan
| | - Shigeru Miyagawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka, 565-0871, Japan
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2
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Fishman JA, Mueller NJ. Infectious Diseases and Clinical Xenotransplantation. Emerg Infect Dis 2024; 30:1311-1318. [PMID: 38916550 PMCID: PMC11210669 DOI: 10.3201/eid3007.240273] [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: 06/26/2024] Open
Abstract
Xenotransplantation, transplantation into humans of vascularized organs or viable cells from nonhuman species, is a potential solution to shortages of transplantable human organs. Among challenges to application of clinical xenotransplantation are unknown risks of transmission of animal microbes to immunosuppressed recipients or the community. Experience in allotransplantation and in preclinical models suggests that viral infections are the greatest concern. Worldwide, the distribution of swine pathogens is heterogeneous and cannot be fully controlled by international agricultural regulations. It is possible to screen source animals for potential human pathogens before procuring organs in a manner not possible within the time available for surveillance testing in allotransplantation. Infection control measures require microbiological assays for surveillance of source animals and xenograft recipients and research into zoonotic potential of porcine organisms. Available data suggest that infectious risks of xenotransplantation are manageable and that clinical trials can advance with appropriate protocols for microbiological monitoring of source animals and recipients.
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3
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Otaka A, Yamamoto T, Yamaoka T. High pressure pasteurization: Simultaneous native tissue decellularization and sterilization. Regen Ther 2024; 26:2-8. [PMID: 38361603 PMCID: PMC10864870 DOI: 10.1016/j.reth.2024.01.012] [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: 10/20/2023] [Revised: 12/21/2023] [Accepted: 01/25/2024] [Indexed: 02/17/2024] Open
Abstract
Introduction Terminal sterilization is important for the clinical applicability of decellularized xenografts. High hydrostatic pressurization (HHP) process is a potential strategy for decellularization and decontamination of xenografts; however, its disinfection efficiency remains poorly elucidated. This study investigated the disinfection efficacy of the HHP process at physiologically relevant 36 °C against difficult-to-kill spore-forming bacteria. Methods Bacillus atrophaeus and Geobacillus stearothermophilus were suspended in a pressurization medium with or without antibiotic agents and pressurized under two different HHP procedures: repeated and sustained pressurization. Results The sustained pressurizing conditions, exploited for the conventional tissue decellularization, did not effectively eliminate the bacteria; however, repeated pressurization greatly increased the disinfection effect. Moreover, the antibiotic-containing pressurization medium further increased the disinfection efficiency to the level required for sterilization. Conclusions The optimized high hydrostatic pressurization can be used to sterilize biological tissues during the decellularization process and is a promising strategy for manufacturing tissue-derived healthcare products.
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Affiliation(s)
- Akihisa Otaka
- Department of Biomedical Engineering, National Cerebral and Cardiovascular Center Research Institute, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Takashi Yamamoto
- Research & Development, JMS Co. Ltd, 12-17 Kako-machi, Naka-ku, Hiroshima, Japan
| | - Tetsuji Yamaoka
- Department of Biomedical Engineering, National Cerebral and Cardiovascular Center Research Institute, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
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4
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Hurst DJ, Cooper DKC. Pressing ethical issues relating to clinical pig organ transplantation studies. Xenotransplantation 2024; 31:e12848. [PMID: 38407936 DOI: 10.1111/xen.12848] [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: 11/20/2023] [Revised: 01/25/2024] [Accepted: 02/01/2024] [Indexed: 02/27/2024]
Abstract
Clinical pig heart transplant experiments have been undertaken, and further clinical experiments and/or clinical trials of gene-edited pig organ xenotransplantation are anticipated. The ethical issues relating to xenotransplantation have been discussed for decades but with little resolution. Consideration of certain ethical issues is more urgent than others, and the need to attain consensus is important. These issues include: (i) patient selection criteria for expanded access and/or clinical trials; (ii) appropriate protection of the patient from xenozoonoses, that is, infections caused by pig microorganisms transferred with the organ graft, (iii) minimization of the risk of a xenozoonosis to bystanders, and (iv) the need for additional public perception studies. We discuss why it is important and urgent to achieve consensus on these ethical issues prior to carrying out further expanded access experiments or initiating formal clinical trials. The ways forward on each issue are proposed.
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Affiliation(s)
- Daniel J Hurst
- Department of Family Medicine, Rowan-Virtua School of Osteopathic Medicine, Stratford, New Jersey, USA
| | - David K C Cooper
- Center for Transplantation Sciences, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
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5
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Malyukov M, Gelfgat E, Ruiz-Babot G, Schmid J, Lehmann S, Spinas G, Beuschlein F, Hantel C, Reisch N, Nawroth PP, Bornstein SR, Steenblock C, Ludwig B. Transplantation of porcine adrenal spheroids for the treatment of adrenal insufficiency. Xenotransplantation 2023; 30:e12819. [PMID: 37548062 DOI: 10.1111/xen.12819] [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: 03/29/2023] [Revised: 07/05/2023] [Accepted: 07/26/2023] [Indexed: 08/08/2023]
Abstract
Primary adrenal insufficiency is a life-threatening disorder, which requires lifelong hormone replacement therapy. Transplantation of xenogeneic adrenal cells is a potential alternative approach for the treatment of adrenal insufficiency. For a successful outcome of this replacement therapy, transplanted cells should provide adequate hormone secretion and respond to adrenal physiological stimuli. Here, we describe the generation and characterization of primary porcine adrenal spheroids capable of replacing the function of adrenal glands in vivo. Cells within the spheroids morphologically resembled adult adrenocortical cells and synthesized and secreted adrenal steroid hormones in a regulated manner. Moreover, the embedding of the spheroids in alginate led to the formation of cellular elongations of steroidogenic cells migrating centripetally towards the inner part of the slab, similar to zona Fasciculata cells in the intact organ. Finally, transplantation of adrenal spheroids in adrenalectomized SCID mice reversed the adrenal insufficiency phenotype, which significantly improved animals' survival. Overall, such adrenal models could be employed for disease modeling and drug testing, and represent the first step toward potential clinical trials in the future.
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Affiliation(s)
- Maria Malyukov
- Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technical, University Dresden, Dresden, Germany
| | - Evgeny Gelfgat
- Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technical, University Dresden, Dresden, Germany
| | - Gerard Ruiz-Babot
- Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technical, University Dresden, Dresden, Germany
| | - Janine Schmid
- Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technical, University Dresden, Dresden, Germany
| | - Susann Lehmann
- Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technical, University Dresden, Dresden, Germany
| | - Giatgen Spinas
- Medical Faculty, University Hospital Zürich, Zürich, Switzerland
| | - Felix Beuschlein
- Department of Endocrinology, Diabetology and Clinical Nutrition, University Hospital Zürich, Zürich, Switzerland
| | - Constanze Hantel
- Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technical, University Dresden, Dresden, Germany
- Department of Endocrinology, Diabetology and Clinical Nutrition, University Hospital Zürich, Zürich, Switzerland
| | - Nicole Reisch
- Medizinische Klinik IV, Klinikum der Universität München, Munich, Germany
| | - Peter P Nawroth
- Medical Faculty Heidelberg, University Hospital Heidelberg, Heidelberg, Germany
| | - Stefan R Bornstein
- Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technical, University Dresden, Dresden, Germany
- Faculty of Life Sciences & Medicine, School of Cardiovascular and Metabolic Medicine and Sciences, King's College London, London, UK
| | - Charlotte Steenblock
- Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technical, University Dresden, Dresden, Germany
| | - Barbara Ludwig
- Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technical, University Dresden, Dresden, Germany
- Department of Endocrinology, Diabetology and Clinical Nutrition, University Hospital Zürich, Zürich, Switzerland
- Paul Langerhans Institute Dresden of Helmholtz Centre Munich at University Hospital Carl Gustav Carus of TU Dresden Faculty of Medicine, Dresden, Germany
- DFG-Center for Regenerative Therapies Dresden, Technical University Dresden, Dresden, Germany
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6
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Groenendaal H, Costard S, Ballard R, Bienhoff S, Challen DC, Dominguez BJ, Kern DR, Miller D, Noordergraaf J, Rudenko L, Schuurman HJ, Spizzo T, Sturos M, Zollers B, Fishman JA. Expert opinion on the identification, risk assessment, and mitigation of microorganisms and parasites relevant to xenotransplantation products from pigs. Xenotransplantation 2023; 30:e12815. [PMID: 37616183 DOI: 10.1111/xen.12815] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 05/18/2023] [Accepted: 07/13/2023] [Indexed: 08/26/2023]
Abstract
Xenotransplantation has the potential to address shortages of organs available for clinical transplantation, but concerns exist regarding potential risks posed by porcine microorganisms and parasites (MP) to the health of human recipients. In this study, a risk-based framework was developed, and expert opinion was elicited to evaluate porcine MP based on swine exposure and risk to human health. Experts identified 255 MP to include in the risk assessment. These were rated by experts for five criteria regarding potential swine exposure in the USA and human health risks. MP were subsequently categorized into three risk mitigation groups according to pre-defined rules: disqualifying porcine MP (due to their pathogenic potential, n = 130); non-disqualifying porcine MP (still relevant to consider for biosecurity or monitoring efforts, n = 40); and alert/watch list (not reported in the USA or MP not in swine, n = 85). Most disqualifying (n = 126) and non-disqualifying (n = 36) porcine MP can effectively be eliminated with high biosecurity programs. This approach supports surveillance and risk mitigation strategies for porcine MP in swine produced for xenotransplantation, such as documentation of freedom from porcine MP, or use of porcine MP screening, monitoring, or elimination options. To the authors' knowledge, this is the first effort to comprehensively identify all relevant porcine MP systematically and transparently evaluate the risk of infection of both donor animals and immunosuppressed human recipients, and the potential health impacts for immunosuppressed human recipients from infected xenotransplantation products from pigs.
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Affiliation(s)
| | | | - Reid Ballard
- Colorado State University, Fort Collins, Colorado, USA
| | | | | | | | | | - Dan Miller
- Excorp Biomedical International Pte. Ltd., Singapore
| | | | - Larisa Rudenko
- BioPolicy Solutions, LLC, Ventura, California, USA; Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | | | - Tom Spizzo
- Spring Point Project, Minneapolis, Minnesota, USA
| | - Matthew Sturos
- Veterinary Diagnostic Laboratory, University of Minnesota, St. Paul, Minnesota, USA
| | - Bill Zollers
- Argenta Clinical US, New Brunswick, New Jersey, USA
| | - Jay A Fishman
- Transplant Center and Division of Infectious Diseases, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
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7
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Li Y, An S, Deng C, Xiao S. Human Acellular Amniotic Membrane as Skin Substitute and Biological Scaffold: A Review of Its Preparation, Preclinical Research, and Clinical Application. Pharmaceutics 2023; 15:2249. [PMID: 37765218 PMCID: PMC10534359 DOI: 10.3390/pharmaceutics15092249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 08/25/2023] [Accepted: 08/28/2023] [Indexed: 09/29/2023] Open
Abstract
Human acellular amniotic membrane (HAAM) has emerged as a promising tool in the field of regenerative medicine, particularly for wound healing and tissue regeneration. HAAM provides a natural biological scaffold with low immunogenicity and good anti-infective and anti-scarring results. Despite its potential, the clinic application of HAAM faces challenges, particularly with respect to the preparation methods and its low mechanical strength. This review provides a comprehensive overview of HAAM, covering its preparation, sterilization, preclinical research, and clinical applications. This review also discusses promising decellularization and sterilization methods, such as Supercritical Carbon Dioxide (SC-CO2), and the need for further research into the regenerative mechanisms of HAAM. In addition, we discuss the potential of HAAM as a skin dressing and cell delivery system in preclinical research and clinical applications. Both the safety and effectiveness of HAAM have been validated by extensive research, which provides a robust foundation for its clinical application.
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Affiliation(s)
- Yanqi Li
- Department of Burns and Plastic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi 563000, China;
| | - Siyu An
- The Collaborative Innovation Center of Tissue Damage Repair and Regeneration Medicine of Zunyi Medical University, Zunyi 563000, China;
| | - Chengliang Deng
- Department of Burns and Plastic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi 563000, China;
- The Collaborative Innovation Center of Tissue Damage Repair and Regeneration Medicine of Zunyi Medical University, Zunyi 563000, China;
| | - Shune Xiao
- Department of Burns and Plastic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi 563000, China;
- The Collaborative Innovation Center of Tissue Damage Repair and Regeneration Medicine of Zunyi Medical University, Zunyi 563000, China;
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8
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Mehta SA, Saharia KK, Nellore A, Blumberg EA, Fishman JA. Infection and clinical xenotransplantation: Guidance from the Infectious Disease Community of Practice of the American Society of Transplantation. Am J Transplant 2023; 23:309-315. [PMID: 36695690 DOI: 10.1016/j.ajt.2022.12.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 11/20/2022] [Accepted: 12/10/2022] [Indexed: 01/04/2023]
Abstract
This guidance was developed to summarize current approaches to the potential transmission of swine-derived organisms to xenograft recipients, health care providers, or the public in clinical xenotransplantation. Limited specific data are available on the zoonotic potential of pig pathogens. It is anticipated that the risk of zoonotic infection in xenograft recipients will be determined by organisms present in source animals and relate to the nature and intensity of the immunosuppression used to maintain xenograft function. Based on experience in allotransplantation and with preclinical models, viral infections are of greatest concern, including porcine cytomegalovirus, porcine lymphotropic herpesvirus, and porcine endogenous retroviruses. Sensitive and specific microbiological assays are required for routine microbiological surveillance of source animals and xenograft recipients. Archiving of blood samples from recipients, contacts, and hospital staff may provide a basis for microbiological investigations if infectious syndromes develop. Carefully implemented infection control practices are required to prevent zoonotic pathogen exposures by clinical care providers. Informed consent practices for recipients and their close contacts must convey the lack of specific data for infectious risk assessment. Available data suggest that infectious risks of xenotransplantation are manageable and that clinical trials can advance with carefully developed protocols for pretransplant assessment, syndrome evaluation, and microbiological monitoring.
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Affiliation(s)
- Sapna A Mehta
- Transplant Infectious Diseases, NYU Langone Transplant Institute and NYU Grossman School of Medicine, New York, New York, USA
| | - Kapil K Saharia
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Anoma Nellore
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Emily A Blumberg
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jay A Fishman
- Transplant and Compromised Host Infectious Disease Program and MGH Transplant Center, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA.
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9
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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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10
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Rivera NT, Baran DA. Expanding heart transplantation in 2022 and beyond. Curr Opin Cardiol 2023; 38:130-135. [PMID: 36598449 DOI: 10.1097/hco.0000000000001023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
PURPOSE OF REVIEW Despite advances in the technology of mechanical circulatory support, the need for heart transplantation continues to grow. The longevity of heart transplants continues to be superior to mechanical solutions, though the short-term differences are shrinking. In this review, we cover three timely developments and summarize the recent literature. RECENT FINDINGS After stagnant rates of heart transplant activity for some years, recently, transplant volume has increased. The developments that have ignited interest have been the use of hepatitis C infected donors, which can now be safely transplanted with the advent of curative oral regimens, and the worldwide use of donors following withdrawal of life support as opposed to traditional brain death donors. In addition, the recent experience of human cardiac xenotransplantation has been very exciting, and though it is not of clinical utility yet, it holds the promise for a virtually unlimited supply of organs at some time in the future. SUMMARY Much work remains to be done, but together, all three of these developments are exciting and important to be aware of in the future. Each will contribute to additional donors for human heart transplantation and hopefully will alleviate suffering and death on the waiting list.
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11
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Chan JCY, Chaban R, Chang SH, Angel LF, Montgomery RA, Pierson RN. Future of Lung Transplantation: Xenotransplantation and Bioengineering Lungs. Clin Chest Med 2023; 44:201-214. [PMID: 36774165 PMCID: PMC11078107 DOI: 10.1016/j.ccm.2022.11.003] [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] [Indexed: 02/11/2023]
Abstract
Xenotransplantation promises to alleviate the issue of donor organ shortages and to decrease waiting times for transplantation. Recent advances in genetic engineering have allowed for the creation of pigs with up to 16 genetic modifications. Several combinations of genetic modifications have been associated with extended graft survival and life-supporting function in experimental heart and kidney xenotransplants. Lung xenotransplantation carries specific challenges related to the large surface area of the lung vascular bed, its innate immune system's intrinsic hyperreactivity to perceived 'danger', and its anatomic vulnerability to airway flooding after even localized loss of alveolocapillary barrier function. This article discusses the current status of lung xenotransplantation, and challenges related to immunology, physiology, anatomy, and infection. Tissue engineering as a feasible alternative to develop a viable lung replacement solution is discussed.
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Affiliation(s)
- Justin C Y Chan
- NYU Transplant Institute, New York University, 530 1st Avenue, Suite 7R, New York, NY 10016, USA.
| | - Ryan Chaban
- Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA; Department of Cardiovascular Surgery, University Hospital of Johannes Gutenberg University, Langenbeckstr. 1, Bau 505, 5. OG55131 Mainz, Germany
| | - Stephanie H Chang
- NYU Transplant Institute, New York University, 530 1st Avenue, Suite 7R, New York, NY 10016, USA
| | - Luis F Angel
- NYU Transplant Institute, New York University, 530 1st Avenue, Suite 7R, New York, NY 10016, USA
| | - Robert A Montgomery
- NYU Transplant Institute, New York University, 530 1st Avenue, Suite 7R, New York, NY 10016, USA
| | - Richard N Pierson
- Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
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12
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Reichart B, Cooper DKC, Längin M, Tönjes RR, Pierson RN, Wolf E. Cardiac xenotransplantation: from concept to clinic. Cardiovasc Res 2023; 118:3499-3516. [PMID: 36461918 PMCID: PMC9897693 DOI: 10.1093/cvr/cvac180] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 10/17/2022] [Accepted: 10/21/2022] [Indexed: 12/05/2022] Open
Abstract
For many patients with terminal/advanced cardiac failure, heart transplantation is the most effective, durable treatment option, and offers the best prospects for a high quality of life. The number of potentially life-saving donated human organs is far fewer than the population who could benefit from a new heart, resulting in increasing numbers of patients awaiting replacement of their failing heart, high waitlist mortality, and frequent reliance on interim mechanical support for many of those deemed among the best candidates but who are deteriorating as they wait. Currently, mechanical assist devices supporting left ventricular or biventricular heart function are the only alternative to heart transplant that is in clinical use. Unfortunately, the complication rate with mechanical assistance remains high despite advances in device design and patient selection and management, and the quality of life of the patients even with good outcomes is only moderately improved. Cardiac xenotransplantation from genetically multi-modified (GM) organ-source pigs is an emerging new option as demonstrated by the consistent long-term success of heterotopic (non-life-supporting) abdominal and life-supporting orthotopic porcine heart transplantation in baboons, and by a recent 'compassionate use' transplant of the heart from a GM pig with 10 modifications into a terminally ill patient who survived for 2 months. In this review, we discuss pig heart xenotransplantation as a concept, including pathobiological aspects related to immune rejection, coagulation dysregulation, and detrimental overgrowth of the heart, as well as GM strategies in pigs to prevent or minimize these problems. Additional topics discussed include relevant results of heterotopic and orthotopic heart transplantation experiments in the pig-to-baboon model, microbiological and virologic safety concepts, and efficacy requirements for initiating formal clinical trials. An adequate regulatory and ethical framework as well as stringent criteria for the selection of patients will be critical for the safe clinical development of cardiac xenotransplantation, which we expect will be clinically tested during the next few years.
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Affiliation(s)
- Bruno Reichart
- Walter Brendel Centre for Experimental Medicine, Ludwig-Maximilians-Universität München, Munich 81377, Germany
| | - David K C Cooper
- Center for Transplantation Sciences, Massachusetts General Hospital/Harvard Medical School, Boston, MA 02129, USA
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA 02114, USA
| | - Matthias Längin
- Department of Anaesthesiology, University Hospital, Ludwig-Maximilians-Universität München, Munich 81377, Germany
| | - Ralf R Tönjes
- Division of Medical Biotechnology, Paul-Ehrlich-Institute, Langen 63225, Germany
| | - Richard N Pierson
- Center for Transplantation Sciences, Massachusetts General Hospital/Harvard Medical School, Boston, MA 02129, USA
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA 02114, USA
| | - Eckhard Wolf
- Gene Centre and Centre for Innovative Medical Models (CiMM), Ludwig-Maximilians-Universität München, Munich 81377, Germany
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13
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Galvao FHF, Grinberg M. Bioethics and xenotransplantation from pig to human. Clinics (Sao Paulo) 2023; 78:100170. [PMID: 36738646 PMCID: PMC9932344 DOI: 10.1016/j.clinsp.2023.100170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 01/05/2023] [Indexed: 02/05/2023] Open
Affiliation(s)
- Flavio Henrique Ferreira Galvao
- Departamento de Gastroenterologia, Disciplina de Transplanre de Órgãos do Aparelho Digestivo, Laboratório de Investigação Medical (LIM) 37, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (USP), São Paulo, SP, Brazil; Bioethical Committee from Hospital das Clínicas, Faculdade de Medicina, Universidade de Sao Paulo (USP), São Paulo, SP, Brazil.
| | - Max Grinberg
- Departamento de Gastroenterologia, Disciplina de Transplanre de Órgãos do Aparelho Digestivo, Laboratório de Investigação Medical (LIM) 37, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (USP), São Paulo, SP, Brazil; Departamento de Cardiologia, Instituto do Coração Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (USP), São Paulo, SP, Brazil; Bioethical Committee from Hospital das Clínicas, Faculdade de Medicina, Universidade de Sao Paulo (USP), São Paulo, SP, Brazil
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14
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Nellore A, Walker J, Kahn MJ, Fishman JA. Moving xenotransplantation from bench to bedside: Managing infectious risk. Transpl Infect Dis 2022; 24:e13909. [PMID: 35870125 DOI: 10.1111/tid.13909] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 06/26/2022] [Accepted: 07/01/2022] [Indexed: 12/24/2022]
Abstract
Xenotransplantation of organs from swine in immunosuppressed human recipients poses many of the same challenges of allotransplantation relative to the risk for infection, malignancy, or graft rejection in proportion to the degree of immunosuppression and epidemiologic exposures. The unique features of xenotransplantation from pigs relative to infectious risk center on the potential for unusual organisms derived from swine causing productive infection, "xenosis" or "xenozoonosis," in the host. Based on experience in allotransplantation, the greatest hazard is due to viruses, due to the relative lack of information regarding the behavior of these potential pathogens in humans, the absence of validated serologic and molecular assays for swine-derived pathogens, and uncertainty regarding the efficacy of therapeutic agents for these organisms. Other known, potential pathogens (i.e., bacteria, fungi, parasites) tend to be comparable to those of humans. Concerns remain for unknown organisms in swine that may replicate in immunosuppressed humans. Clinical trials of genetically modified organs sourced from swine in immunosuppressed humans with organ failure are under development. Such trials require informed consent regarding potential infectious risks to the recipient, determination of breeding characteristics of swine, assessments of potential risks to the public and healthcare providers, consideration of ethical issues posed by this novel therapy, and defined strategies to monitor and address infectious episodes that may be encountered by healthcare teams. Clinical trials in xenotransplantation will allow improved definition of potential infectious risks.
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Affiliation(s)
- Anoma Nellore
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jeremey Walker
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Mauricio J Kahn
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jay A Fishman
- Division of Infectious Diseases and Transplant Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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15
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Cooper DK. Advancing Xenotransplantation to the Clinic: How Relevant Is the Pig-to-nonhuman Primate Kidney Transplantation Model Today? Transplantation 2022; 106:1717-1719. [PMID: 35323162 PMCID: PMC10124766 DOI: 10.1097/tp.0000000000004097] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- David K.C. Cooper
- Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital, Boston, MA
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16
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Virus Safety of Xenotransplantation. Viruses 2022; 14:v14091926. [PMID: 36146732 PMCID: PMC9503113 DOI: 10.3390/v14091926] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 08/29/2022] [Accepted: 08/29/2022] [Indexed: 01/06/2023] Open
Abstract
The practice of xenotransplantation using pig islet cells or organs is under development to alleviate the shortage of human donor islet cells or organs for the treatment of diabetes or organ failure. Multiple genetically modified pigs were generated to prevent rejection. Xenotransplantation may be associated with the transmission of potentially zoonotic porcine viruses. In order to prevent this, we developed highly sensitive PCR-based, immunologicals and other methods for the detection of numerous xenotransplantation-relevant viruses. These methods were used for the screening of donor pigs and xenotransplant recipients. Of special interest are the porcine endogenous retroviruses (PERVs) that are integrated in the genome of all pigs, which are able to infect human cells, and that cannot be eliminated by methods that other viruses can. We showed, using droplet digital PCR, that the number of PERV proviruses is different in different pigs (usually around 60). Furthermore, the copy number is different in different organs of a single pig, indicating that PERVs are active in the living animals. We showed that in the first clinical trials treating diabetic patients with pig islet cells, no porcine viruses were transmitted. However, in preclinical trials transplanting pig hearts orthotopically into baboons, porcine cytomegalovirus (PCMV), a porcine roseolovirus (PCMV/PRV), and porcine circovirus 3 (PCV3), but no PERVs, were transmitted. PCMV/PRV transmission resulted in a significant reduction of the survival time of the xenotransplant. PCMV/PRV was also transmitted in the first pig heart transplantation to a human patient and possibly contributed to the death of the patient. Transmission means that the virus was detected in the recipient, however it remains unclear whether it can infect primate cells, including human cells. We showed previously that PCMV/PRV can be eliminated from donor pigs by early weaning. PERVs were also not transmitted by inoculation of human cell-adapted PERV into small animals, rhesus monkey, baboons and cynomolgus monkeys, even when pharmaceutical immunosuppression was applied. Since PERVs were not transmitted in clinical, preclinical, or infection experiments, it remains unclear whether they should be inactivated in the pig genome by CRISPR/Cas. In summary, by using our sensitive methods, the safety of xenotransplantation can be ensured.
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17
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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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18
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Goerlich CE, Singh AK, Griffith BP, Mohiuddin MM. The immunobiology and clinical use of genetically engineered porcine hearts for cardiac xenotransplantation. NATURE CARDIOVASCULAR RESEARCH 2022; 1:715-726. [PMID: 36895262 PMCID: PMC9994617 DOI: 10.1038/s44161-022-00112-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
A summary of the scientific rationale of the advancements that led to the first genetically modified pig-to-human cardiac xenotransplantation is lacking in a complex and rapidly evolving field. Here, we aim to aid the general readership in the understanding of the gradual progression of cardiac (xeno)transplantation research, the immunobiology of cardiac xenotransplantation (including the latest immunosuppression, cardiac preservation and genetic engineering required for successful transplantation) and the regulatory landscape related to the clinical application of cardiac xenotransplantation for people with end-stage heart failure. Finally, we provide an overview of the outcomes and lessons learned from the first genetically modified pig-to-human cardiac heart xenotransplantation.
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Affiliation(s)
- Corbin E Goerlich
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Avneesh K Singh
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Bartley P Griffith
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Muhammad M Mohiuddin
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
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19
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Ganchiku Y, Riella LV. Pig-to-human kidney transplantation using brain-dead donors as recipients: One giant leap, or only one small step for transplantkind? Xenotransplantation 2022; 29:e12748. [PMID: 35616243 DOI: 10.1111/xen.12748] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 04/28/2022] [Accepted: 04/28/2022] [Indexed: 12/11/2022]
Abstract
Pig kidney xenotransplantation is increasingly regarded as a realistic solution to the current shortage of human organ donors for patients with end-stage organ failure. Recently, the news of three pig-to-human transplantation cases has awakened public interest. Notably, the case by the Alabama team reported detailed and important findings for the xenotransplantation field. Using a genetically modified pig, two porcine kidneys were transplanted into a brain-dead recipient. They applied several approaches established in the preclinical NHP study, including gene-edited pig kidney graft and preoperative laboratory inspection such as crossmatching and infection screening. The pig-to-human kidney xenotransplantation had no unexpected events during surgery or evidence of hyperacute rejection. Unfortunately, the grafts did not work appropriately, and the study had to be terminated due to the decompensation of the recipient. While this study demonstrated the outstanding achievement in this research area, it also revealed remaining gaps to move xenotransplantation to the clinic. While brain-dead human recipients could reinforce the compatibility achievements of gene-edited pigs in NHP, their pro-inflammatory and pro-coagulant environment, in combination with short-duration of experiments will limit the assessment of kidney function, infection and rejection risk post-transplant, in particular antibody-mediated rejection. The use of successful immunosuppressive protocols of non-human primates xenotransplant experiments including anti-CD154 antibody will be critical to maximize the success in the first in-human trials.
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Affiliation(s)
- Yoshikazu Ganchiku
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Leonardo V Riella
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.,Division of Nephrology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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20
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Entwistle JW, Sade RM, Drake DH. Clinical xenotransplantation seems close: Ethical issues persist. Artif Organs 2022; 46:987-994. [PMID: 35451522 DOI: 10.1111/aor.14255] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 03/23/2022] [Indexed: 01/25/2023]
Abstract
Scientific barriers that have prevented successful xenotransplantation are being breached, yet many ethical issues remain. Some are broad issues that accompany the adoption of novel and expensive technologies, and some are unique to xenotransplantation. Major ethical questions include areas such as: viral transmission; zoonoses and lifetime surveillance; interfering with nature; efficacy, access, and expense; treatment of animals; regulation and oversight.
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Affiliation(s)
- John W Entwistle
- Department of Surgery, Division of Cardiothoracic Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Robert M Sade
- Department of Surgery, Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Daniel H Drake
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, Michigan, USA
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21
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Cooper DKC. The 2021 IXA Keith Reemtsma Lecture: Moving xenotransplantation to the clinic. Xenotransplantation 2022; 29:e12723. [PMID: 34967057 PMCID: PMC8995333 DOI: 10.1111/xen.12723] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 12/05/2021] [Indexed: 01/03/2023]
Abstract
Keith Reemtsma was a pioneer in xenotransplantation, the Honorary Founding President of the International Xenotransplantation Association (in 1998), and a wonderful personality. It is a privilege to be invited to give this lecture in his memory. If he were alive today, he would be delighted to see the progress that has been made in pig organ transplantation into nonhuman primate recipients. This progress has largely resulted from two major advances: (i) the increasing availability of pigs with multiple genetic manipulations aimed at protecting the cells of the organ from the primate immune response and (ii) the introduction of novel immunosuppressive agents that block the CD40/CD154 costimulation pathway. There is strong evidence from numerous in vitro studies that the transplantation of a triple-knockout pig organ, particularly if expressing several human protective proteins, into a patient is likely to be significantly more successful than if that same organ is transplanted into a nonhuman primate recipient. With this fact in mind, and in view of the advances currently being made, the time has surely come when we need to consider moving from the laboratory to the clinic. However, there are still questions we need to definitively resolve: (i) What exact genetic modifications do we need in the organ-source pig? (ii) What exact immunosuppressive regimen will we choose? (iii) How will we monitor the immune response and diagnose and treat rejection? and (iv) How do we plan to prevent or treat potential infectious complications? Furthermore, when these matters have been resolved, which patients will be offered a pig organ in the first trial? We have suggested that patients who are very unlikely to survive until a suitable deceased human donor kidney becomes available are those who should be considered for the initial trials. Assessing public attitudes to xenotransplantation is also important before embarking on a clinical trial. I suggest that progress is much more likely to be made from a small clinical trial than if we persist in carrying out experiments in an animal model that no longer mimics the clinical situation.
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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
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22
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Cozzi E, Schneeberger S, Bellini MI, Berglund E, Böhmig G, Fowler K, Hoogduijn M, Jochmans I, Marckmann G, Marson L, Neuberger J, Oberbauer R, Pierson RN, Reichart B, Scobie L, White C, Naesens M. Organ transplants of the future: planning for innovations including xenotransplantation. Transpl Int 2021; 34:2006-2018. [PMID: 34459040 DOI: 10.1111/tri.14031] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 08/10/2021] [Accepted: 08/24/2021] [Indexed: 12/15/2022]
Abstract
The future clinical application of animal-to-human transplantation (xenotransplantation) is of importance to society as a whole. Favourable preclinical data relevant to cell, tissue and solid organ xenotransplants have been obtained from many animal models utilizing genetic engineering and protocols of pathogen-free husbandry. Findings have reached a tipping point, and xenotransplantation of solid organs is approaching clinical evaluation, the process of which now requires close deliberation. Such discussions include considering when there is sufficient evidence from preclinical animal studies to start first-in-human xenotransplantation trials. The present article is based on evidence and opinions formulated by members of the European Society for Organ Transplantation who are involved in the Transplantation Learning Journey project. The article includes a brief overview of preclinical concepts and biology of solid organ xenotransplantation, discusses the selection of candidates for first-in-human studies and considers requirements for study design and conduct. In addition, the paper emphasizes the need for a regulatory framework for xenotransplantation of solid organs and the essential requirement for input from public and patient stakeholders.
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Affiliation(s)
- Emanuele Cozzi
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, Transplant Immunology Unit, Padua University Hospital, Padua, Italy
| | - Stefan Schneeberger
- Department of Visceral, Transplant and Thoracic Surgery, Innsbruck Medical University, Innsbruck, Austria
| | - Maria Irene Bellini
- Department of Surgical Sciences, Sapienza University of Rome, Rome, Italy
- Department of Emergency Medicine and Surgery, Azienda Ospedaliera San Camillo Forlanini, Rome, Italy
| | - Erik Berglund
- Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Transplantation Surgery, Karolinska Institute and ITB-MED, Stockholm, Sweden
| | - Georg Böhmig
- Division of Nephrology and Dialysis, Medical University Vienna, Vienna, Austria
| | - Kevin Fowler
- The Voice of the Patient, Inc., Chicago, IL, USA
| | - Martin Hoogduijn
- Department of Internal Medicine, Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Ina Jochmans
- Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Georg Marckmann
- Institute of Ethics, History and Theory of Medicine, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Lorna Marson
- The Edinburgh Transplant Centre, Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | | | - Richard N Pierson
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Bruno Reichart
- Walter Brendel Center for Experimental Medicine, LMU Munich, Munich, Germany
| | - Linda Scobie
- Department of Biological and Biomedical Sciences, Glasgow Caledonian University, Glasgow, UK
| | | | - Maarten Naesens
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
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23
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Denner J. Porcine Endogenous Retroviruses and Xenotransplantation, 2021. Viruses 2021; 13:v13112156. [PMID: 34834962 PMCID: PMC8625113 DOI: 10.3390/v13112156] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 10/06/2021] [Accepted: 10/20/2021] [Indexed: 12/25/2022] Open
Abstract
Porcine endogenous retroviruses (PERVs) are integrated in the genome of all pigs, and some of them are able to infect human cells. Therefore, PERVs pose a risk for xenotransplantation, the transplantation of pig cells, tissues, or organ to humans in order to alleviate the shortage of human donor organs. Up to 2021, a huge body of knowledge about PERVs has been accumulated regarding their biology, including replication, recombination, origin, host range, and immunosuppressive properties. Until now, no PERV transmission has been observed in clinical trials transplanting pig islet cells into diabetic humans, in preclinical trials transplanting pig cells and organs into nonhuman primates with remarkable long survival times of the transplant, and in infection experiments with several animal species. Nevertheless, in order to prevent virus transmission to the recipient, numerous strategies have been developed, including selection of PERV-C-free animals, RNA interference, antiviral drugs, vaccination, and genome editing. Furthermore, at present there are no more experimental approaches to evaluate the full risk until we move to the clinic.
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Affiliation(s)
- Joachim Denner
- Department of Veterinary Medicine, Institute of Virology, Free University Berlin, 14163 Berlin, Germany
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24
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Reichart B, Längin M, Denner J, Schwinzer R, Cowan PJ, Wolf E. Pathways to Clinical Cardiac Xenotransplantation. Transplantation 2021; 105:1930-1943. [PMID: 33350675 DOI: 10.1097/tp.0000000000003588] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Heart transplantation is the only long-lasting lifesaving option for patients with terminal cardiac failure. The number of available human organs is however far below the actual need, resulting in substantial mortality of patients while waiting for a human heart. Mechanical assist devices are used to support cardiac function but are associated with a high risk of severe complications and poor quality of life for the patients. Consistent success in orthotopic transplantation of genetically modified pig hearts into baboons indicates that cardiac xenotransplantation may become a clinically applicable option for heart failure patients who cannot get a human heart transplant. In this overview, we project potential paths to clinical cardiac xenotransplantation, including the choice of genetically modified source pigs; associated requirements of microbiological, including virological, safety; optimized matching of source pig and recipient; and specific treatments of the donor heart after explantation and of the recipients. Moreover, selection of patients and the regulatory framework will be discussed.
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Affiliation(s)
- Bruno Reichart
- Walter Brendel Center for Experimental Medicine, LMU Munich, Munich, Germany
| | - Matthias Längin
- Department of Anaesthesiology, University Hospital, LMU Munich, Munich, Germany
| | - Joachim Denner
- Institute of Virology, Free University Berlin, Berlin, Germany
| | - Reinhard Schwinzer
- Department of General-, Visceral-, and Transplantation Surgery, Transplant Laboratory, Hannover Medical School, Hannover, Germany
| | - Peter J Cowan
- Immunology Research Centre, St. Vincent's Hospital Melbourne, Victoria, Australia
- Department of Medicine, University of Melbourne, VIC, Australia
| | - Eckhard Wolf
- Institute of Molecular Animal Breeding and Biotechnology, Gene Center, LMU Munich, Munich, Germany
- Department of Veterinary Sciences, and Center for Innovative Medical Models (CiMM), LMU Munich, Munich, Germany
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25
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Cooper DKC, Hara H. "You cannot stay in the laboratory forever"*: Taking pig kidney xenotransplantation from the laboratory to the clinic. EBioMedicine 2021; 71:103562. [PMID: 34517284 PMCID: PMC8441149 DOI: 10.1016/j.ebiom.2021.103562] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 08/02/2021] [Accepted: 08/16/2021] [Indexed: 11/18/2022] Open
Abstract
Progress in life-supporting kidney transplantation in the genetically-engineered pig-to-nonhuman primate model has been encouraging, with pig kidneys sometimes supporting life for > 1 year. What steps need to be taken by (i) the laboratory team, and (ii) the clinical team to prepare for the first clinical trial? The major topics include (i) what currently-available genetic modifications are optimal to reduce the possibility of graft rejection, (ii) what immunosuppressive therapeutic regimen is optimal, and (iii) what steps need to be taken to minimize the risk of transfer of an infectious microorganism with the graft. We suggest that patients who are unlikely to live long enough to receive a kidney from a deceased human donor would benefit from the opportunity of a period of dialysis-free support by a pig kidney, and the experience gained would enable xenotransplantation to progress much more rapidly than if we remain in the laboratory.
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Affiliation(s)
- David K C Cooper
- Xenotransplantation Program, Division of Transplantation, Department of Surgery, University of Alabama at Birmingham, 752 Lyons-Harrison Research Building, 701 19th Street South, Birmingham, AL 35294, USA.
| | - Hidetaka Hara
- Xenotransplantation Program, Division of Transplantation, Department of Surgery, University of Alabama at Birmingham, 752 Lyons-Harrison Research Building, 701 19th Street South, Birmingham, AL 35294, USA
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26
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Infectivity assessment of porcine endogenous retrovirus using high-throughput sequencing technologies. Biologicals 2021; 71:1-8. [PMID: 34039532 DOI: 10.1016/j.biologicals.2021.05.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 05/06/2021] [Accepted: 05/10/2021] [Indexed: 11/20/2022] Open
Abstract
Xenogenic cell-based therapeutic products are expected to alleviate the chronic shortage of human donor organs. For example, porcine islet cell products are currently under development for the treatment of human diabetes. As porcine cells possess endogenous retrovirus (PERV), which can replicate in human cells in vitro, the potential transmission of PERV has raised concerns in the case of products that use living pig cells as raw materials. Although several PERV sequences exist in the porcine genome, not all have the ability to infect human cells. Therefore, polymerase chain reaction analysis, which amplifies a portion of the target gene, may not accurately assess the infection risk. Here, we determined porcine genome sequences and evaluated the infectivity of PERVs using high-throughput sequencing technologies. RNA sequencing was performed on both PERV-infected human cells and porcine cells, and reads mapped to PERV sequences were examined. The normalized number of the reads mapped to PERV regions was able to predict the infectivity of PERVs, indicating that it would be useful for evaluation of the PERV infection risk prior to transplantation of porcine products.
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27
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Hawthorne WJ, Thomas A, Burlak C. Xenotransplantation literature update, November/December 2020. Xenotransplantation 2021; 28:e12674. [PMID: 33745161 DOI: 10.1111/xen.12674] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 01/07/2021] [Indexed: 12/27/2022]
Affiliation(s)
- Wayne J Hawthorne
- The Centre for Transplant & Renal Research, The Westmead Institute for Medical Research, Westmead, NSW, Australia.,The Department of Surgery, Westmead Hospital, University of Sydney, Westmead, NSW, Australia
| | - Adwin Thomas
- The Centre for Transplant & Renal Research, The Westmead Institute for Medical Research, Westmead, NSW, Australia
| | - Christopher Burlak
- Department of Surgery, Schulze Diabetes Institute, University of Minnesota Medical School, Minneapolis, MN, USA
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28
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Galow AM, Goldammer T, Hoeflich A. Xenogeneic and Stem Cell-Based Therapy for Cardiovascular Diseases: Genetic Engineering of Porcine Cells and Their Applications in Heart Regeneration. Int J Mol Sci 2020; 21:ijms21249686. [PMID: 33353186 PMCID: PMC7766969 DOI: 10.3390/ijms21249686] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 12/11/2020] [Accepted: 12/15/2020] [Indexed: 12/25/2022] Open
Abstract
Cardiovascular diseases represent a major health concern worldwide with few therapy options for ischemic injuries due to the limited regeneration potential of affected cardiomyocytes. Innovative cell replacement approaches could facilitate efficient regenerative therapy. However, despite extensive attempts to expand primary human cells in vitro, present technological limitations and the lack of human donors have so far prevented their broad clinical use. Cell xenotransplantation might provide an ethically acceptable unlimited source for cell replacement therapies and bridge the gap between waiting recipients and available donors. Pigs are considered the most suitable candidates as a source for xenogeneic cells and tissues due to their anatomical and physiological similarities with humans. The potential of porcine cells in the field of stem cell-based therapy and regenerative medicine is under intensive investigation. This review outlines the current progress and highlights the most promising approaches in xenogeneic cell therapy with a focus on the cardiovascular system.
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Affiliation(s)
- Anne-Marie Galow
- Institute of Genome Biology, Leibniz Institute for Farm Animal Biology, 18196 Dummerstorf, Germany; (T.G.); (A.H.)
- Correspondence: ; Tel.: +49-38208-68-723
| | - Tom Goldammer
- Institute of Genome Biology, Leibniz Institute for Farm Animal Biology, 18196 Dummerstorf, Germany; (T.G.); (A.H.)
- Molecular Biology and Fish Genetics Unit, Faculty of Agriculture and Environmental Sciences, University of Rostock, 18059 Rostock, Germany
| | - Andreas Hoeflich
- Institute of Genome Biology, Leibniz Institute for Farm Animal Biology, 18196 Dummerstorf, Germany; (T.G.); (A.H.)
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Kono K, Kataoka K, Yuan Y, Yusa K, Uchida K, Sato Y. A highly sensitive method for the detection of recombinant PERV-A/C env RNA using next generation sequencing technologies. Sci Rep 2020; 10:21935. [PMID: 33318655 PMCID: PMC7736861 DOI: 10.1038/s41598-020-78890-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 11/30/2020] [Indexed: 12/27/2022] Open
Abstract
Several xenogenic cell-based therapeutic products are currently under development around the world for the treatment of human diseases. Porcine islet cell products for treating human diabetes are a typical example. Since porcine cells possess endogenous retrovirus (PERV), which can replicate in human cells in vitro, the potential transmission of PERV has raised concerns in the development of these products. Four subgroups of infectious PERV have been identified, namely PERV-A, -B, -C, and recombinant PERV-A/C. Among them, PERV-A/C shows a high titre and there was a paper reported that an incidence of PERV-A/C viremia was increased in diseased pigs; thus, it would be important to monitor the emergence of PERV-A/C after transplantation of porcine products. In this study, we developed a highly sensitive method for the detection of PERV-A/C using next generation sequencing (NGS) technologies. A model PERV-C spiked with various doses of PERV-A/C were amplified by RT-PCR and the amplicons were analysed by NGS. We found that the NGS analysis allowed the detection of PERV-A/C at the abundance ratios of 1% and 0.1% with true positive rates of 100% and 57%, respectively, indicating that it would be useful for the rapid detection of PERV-A/C emergence after transplantation of porcine products.
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Affiliation(s)
- Ken Kono
- Division of Cell-Based Therapeutic Products, National Institute of Health Sciences, 3-25-26 Tonomachi, Kawasaki Ward, Kawasaki City, Kanagawa, 210-9501, Japan
| | - Kiyoko Kataoka
- Division of Cell-Based Therapeutic Products, National Institute of Health Sciences, 3-25-26 Tonomachi, Kawasaki Ward, Kawasaki City, Kanagawa, 210-9501, Japan
| | - Yuzhe Yuan
- Graduate School of Science, Technology and Innovation, Kobe University, Hyogo, Japan
| | - Keisuke Yusa
- Graduate School of Science, Technology and Innovation, Kobe University, Hyogo, Japan
| | - Kazuhisa Uchida
- Graduate School of Science, Technology and Innovation, Kobe University, Hyogo, Japan
| | - Yoji Sato
- Division of Cell-Based Therapeutic Products, National Institute of Health Sciences, 3-25-26 Tonomachi, Kawasaki Ward, Kawasaki City, Kanagawa, 210-9501, Japan. .,Department of Translational Pharmaceutical Sciences, Graduate School of Pharmaceutical Sciences, Kyushu University, Fukuoka, Japan. .,Department of Cellular and Gene Therapy Products, Graduate School of Pharmaceutical Sciences, Osaka University, Osaka, Japan.
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Walters EM, Burlak C. Xenotransplantation literature update, May/June2020. Xenotransplantation 2020; 27:e12638. [PMID: 32896009 DOI: 10.1111/xen.12638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 10/11/2019] [Indexed: 11/29/2022]
Affiliation(s)
| | - Christopher Burlak
- Department of Surgery, Schultz Diabetes Institutes, University of Minnesota School of Medicine, Minneapolis, MN, USA
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Kalsi R, Messner F, Brandacher G. Skin xenotransplantation: technological advances and future directions. Curr Opin Organ Transplant 2020; 25:464-476. [PMID: 32773504 DOI: 10.1097/mot.0000000000000798] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW To summarize the evolution of skin xenotransplantation and contextualize technological advances and the status of clinically applicable large animal research as well as prospects for translation of this work as a viable future treatment option. RECENT FINDINGS Porcine xenografts at the start of the millennium were merely biologic dressings subject to rapid rejection. Since then, numerous important advances in swine to nonhuman primate models have yielded xenotransplant products at the point of clinical translation. Critical genetic modifications in swine from a designated pathogen-free donor herd have allowed xenograft survival reaching 30 days without preconditioning or maintenance immunosuppression. Further, xenograft coverage appears not to sensitize the recipient to subsequent allograft placement and vice versa, allowing for temporary coverage times to be doubled using both xeno and allografts. SUMMARY Studies in large animal models have led to significant progress in the creation of living, functional skin xenotransplants with clinically relevant shelf-lives to improve the management of patients with extensive burns.
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Affiliation(s)
- Richa Kalsi
- Department of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation (VCA) Laboratory, Johns Hopkins University School of Medicine.,Department of General Surgery, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Franka Messner
- Department of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation (VCA) Laboratory, Johns Hopkins University School of Medicine.,Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Gerald Brandacher
- Department of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation (VCA) Laboratory, Johns Hopkins University School of Medicine
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