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Kirste G. Cold but not too cold: advances in hypothermic and normothermic organ perfusion. KOREAN JOURNAL OF TRANSPLANTATION 2022; 36:2-14. [PMID: 35769433 PMCID: PMC9235527 DOI: 10.4285/kjt.22.0008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 02/21/2022] [Indexed: 11/24/2022] Open
Abstract
Transplantation is the method of choice and, in many cases, the only method of treatment for patients with end-stage organ disease. Excellent results have been achieved, and the main focus today is to extend the number of available donors. The use of extended-criteria donors or donors after circulatory death is standard, but is accompanied by an increased risk of ischemia reperfusion injury. This review presents newly developed machine perfusion techniques using hypothermic, subnormothermic, or normothermic conditions, with or without oxygenation. Possibilities for treatment and quality assessment in decision-making about organ acceptability are also discussed.
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Affiliation(s)
- Guenter Kirste
- Department of Surgery, University Hospital of Freiburg, Albert Ludwig University of Freiburg, Freiburg im Breisgau, Germany
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Abstract
Although lung transplant remains the only option for patients suffering from end-stage lung failure, donor supply is insufficient to meet demand. Static cold preservation is the most common method to preserve lungs in transport to the recipient; however, this method does not improve lung quality and only allows for 8 h of storage. This results in lungs which become available for donation but cannot be used due to failure to meet physiologic criteria or an inability to store them for a sufficient time to find a suitable recipient. Therefore, lungs lost due to failure to meet physiological or compatibility criteria may be mitigated through preservation methods which improve lung function and storage durations. Ex situ lung perfusion (ESLP) is a recently developed method which allows for longer storage times and has been demonstrated to improve lung function such that rejected lungs can be accepted for donation. Although greater use of ESLP will help to improve donor lung utilization, the ability to cryopreserve lungs would allow for organ banking to better utilize donor lungs. However, lung cryopreservation research remains underrepresented in the literature despite its unique advantages for cryopreservation over other organs. Therefore, this review will discuss the current techniques for lung preservation, static cold preservation and ESLP, and provide a review of the cryopreservation challenges and advantages unique to lungs.
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Lightle W, Daoud D, Loor G. Breathing lung transplantation with the Organ Care System (OCS) Lung: lessons learned and future implications. J Thorac Dis 2019; 11:S1755-S1760. [PMID: 31632752 PMCID: PMC6783715 DOI: 10.21037/jtd.2019.03.32] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 03/12/2019] [Indexed: 11/06/2022]
Abstract
Ex vivo lung perfusion (EVLP) represents a potentially important advancement in the preservation of donor lungs prior to transplantation. Portable EVLP or "Breathing Lung Transplantation" with the Organ Care System (OCS) Lung combines the fundamental components of EVLP with portability, thus reducing the total ischemic burden. The Food and Drug Administration (FDA) approved OCS for perfusion of standard donor lungs prior to transplant in 2018. The current review discusses the available literature on the clinical outcomes of OCS Lung as well as translational data.
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Affiliation(s)
- William Lightle
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Daoud Daoud
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Gabriel Loor
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
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5
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Ali A, Keshavjee S, Cypel M. Rising to the Challenge of Unmet Need: Expanding the Lung Donor Pool. CURRENT PULMONOLOGY REPORTS 2018. [DOI: 10.1007/s13665-018-0205-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
This article summarizes recent knowledge and clinical advances in machine perfusion (MP) of thoracic organs. MP of thoracic organs has gained much attention during the last decade. Clinical studies are investigating the role of MP to preserve, resuscitate, and assess heart and lungs prior to transplantation. Currently, MP of the cardiac allograft is essential in all type DCD heart transplantation while MP of the pulmonary allograft is mandatory in uncontrolled DCD lung transplantation. MP of thoracic organs also offers an exciting platform to further investigate downregulation of the innate and adaptive immunity prior to reperfusion of the allograft in recipients. MP provides a promising technology that allows pre-transplant preservation, resuscitation, assessment, repair, and conditioning of cardiac and pulmonary allografts outside the body in a near physiologic state prior to planned transplantation. Results of ongoing clinical trials are awaited to estimate the true clinical value of this new technology in advancing the field of heart and lung transplantation by increasing the total number and the quality of available organs and by further improving recipient early and long-term outcome.
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Affiliation(s)
- Dirk Van Raemdonck
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Chronic Diseases, KU Leuven University, Leuven, Belgium
| | - Filip Rega
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Cardiovascular Sciences, KU Leuven University, Leuven, Belgium
| | - Steffen Rex
- Department of Cardiovascular Sciences, KU Leuven University, Leuven, Belgium.,Department of Anaesthesiology, University Hospitals Leuven, Leuven, Belgium
| | - Arne Neyrinck
- Department of Cardiovascular Sciences, KU Leuven University, Leuven, Belgium.,Department of Anaesthesiology, University Hospitals Leuven, Leuven, Belgium
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O’Neill JD, Guenthart BA, Kim J, Chicotka S, Queen D, Fung K, Marboe C, Romanov A, Huang SXL, Chen YW, Snoeck HW, Bacchetta M, Vunjak-Novakovic G. Cross-circulation for extracorporeal support and recovery of the lung. Nat Biomed Eng 2017. [DOI: 10.1038/s41551-017-0037] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Schiavon M, Marulli G, Rebusso A, Calabrese F, Di Gregorio G, Serra E, Loy M, Lunardi F, Calabrese F, Rea F. Normothermic Perfusion of Donor Marginal Lungs With the Organ Care System Lung: Clinical and Morphologic Evaluation. J Cardiothorac Vasc Anesth 2016; 30:1032-7. [DOI: 10.1053/j.jvca.2015.10.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Indexed: 11/11/2022]
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Zeriouh M, Sabashnikov A, Mohite PN, Zych B, Patil NP, García-Sáez D, Koch A, Weymann A, Soresi S, Wippermann J, Wahlers T, De Robertis F, Popov AF, Simon AR. Utilization of the organ care system for bilateral lung transplantation: preliminary results of a comparative study. Interact Cardiovasc Thorac Surg 2016; 23:351-7. [DOI: 10.1093/icvts/ivw135] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 03/18/2016] [Indexed: 11/13/2022] Open
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Biniwale R, Ross D, Iyengar A, Kwon OJ, Hunter C, Aboulhosn J, Gjertson D, Ardehali A. Lung transplantation and concomitant cardiac surgery: Is it justified? J Thorac Cardiovasc Surg 2016; 151:560-6. [DOI: 10.1016/j.jtcvs.2015.10.027] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Revised: 08/05/2015] [Accepted: 10/01/2015] [Indexed: 01/24/2023]
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Abstract
Lung transplantation is an established life-saving therapy for patients with end-stage lung disease. Unfortunately, greater success in lung transplantation is hindered by a shortage of lung donors and the relatively poor early-, mid-, and long-term outcomes associated with severe primary graft dysfunction. Ex vivo lung perfusion has emerged as a modern preservation technique that allows for a more accurate lung assessment and improvement in lung quality. This review outlines the: (i) rationale behind the method; (ii) techniques and protocols; (iii) Toronto ex vivo lung perfusion method; (iv) devices available; and (v) clinical experience worldwide. We also highlight the potential of ex vivo lung perfusion in leading a new era of lung preservation.
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Affiliation(s)
- Jeremie Reeb
- Division of Thoracic Surgery, Toronto Lung Transplant Program, University of Toronto and Toronto Lung Transplant Program, Latner Thoracic Surgery Research Laboratories, Toronto, ON, Canada
| | - Marcelo Cypel
- Division of Thoracic Surgery, Toronto Lung Transplant Program, University of Toronto and Toronto Lung Transplant Program, Latner Thoracic Surgery Research Laboratories, Toronto, ON, Canada
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Hosgood SA, Barlow AD, Hunter JP, Nicholson ML. Ex vivo normothermic perfusion for quality assessment of marginal donor kidney transplants. Br J Surg 2015; 102:1433-40. [PMID: 26313559 DOI: 10.1002/bjs.9894] [Citation(s) in RCA: 88] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Revised: 03/16/2015] [Accepted: 06/10/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND A significant proportion of kidneys procured for transplantation are discarded because of concerns about their suitability. In this study ex vivo normothermic perfusion (EVNP) was used as a quality assessment device before renal transplantation. METHODS Seventy-four human kidneys deemed unsuitable for transplantation following retrieval underwent 60 min of EVNP with an oxygenated red cell-based solution at 36°C. Receiver operating characteristic (ROC) curves were used to identify thresholds of renal blood flow and urine output. These thresholds and a grading of macroscopic appearance were incorporated into an EVNP assessment score (highest quality, 1; lowest, 5). This was applied to a series of 36 kidneys transplanted after EVNP. RESULTS In the discarded kidney series, 60 (81 per cent) scored 1-4 and 14 (19 per cent) scored 5. Although none of these kidneys was transplanted, those with a score from 1 to 4 were considered suitable for transplantation. In the 36 transplanted kidneys, the score ranged between 1 and 3 (score 1, 17; score 2, 11; score 3, 8). All of these kidneys were transplanted without any complications or primary non-function. The delayed graft function rate was 6 per cent (1 of 17) in kidneys scoring 1, 0 per cent (0 of 11) in those scoring 2 and 38 per cent (3 of 8) in those scoring 3 (P = 0·024). The mean(s.d.) estimated glomerular filtration rate at 12 months was 51(16), 63(15) and 38(21) ml in kidneys scoring 1, 2 and 3 respectively (P = 0·015). CONCLUSION EVNP combined with a simple scoring system is an innovative technology for pretransplant assessment of kidney quality and acceptability for transplantation. This study suggests that a high percentage of retrieved kidneys are being discarded unnecessarily.
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Affiliation(s)
- S A Hosgood
- Department of Infection, Immunity and Inflammation, Transplant Group, University of Leicester, Leicester General Hospital, Leicester, UK
- Department of Surgery, University of Cambridge. Addenbrooke's Hospital, Cambridge, UK
| | - A D Barlow
- Department of Infection, Immunity and Inflammation, Transplant Group, University of Leicester, Leicester General Hospital, Leicester, UK
- Department of Surgery, University of Cambridge. Addenbrooke's Hospital, Cambridge, UK
| | - J P Hunter
- Department of Infection, Immunity and Inflammation, Transplant Group, University of Leicester, Leicester General Hospital, Leicester, UK
| | - M L Nicholson
- Department of Infection, Immunity and Inflammation, Transplant Group, University of Leicester, Leicester General Hospital, Leicester, UK
- Department of Surgery, University of Cambridge. Addenbrooke's Hospital, Cambridge, UK
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Sabashnikov A, Patil NP, Popov AF, Soresi S, Zych B, Weymann A, Mohite PN, García Sáez D, Zeriouh M, Wahlers T, Choi YH, Wippermann J, Wittwer T, De Robertis F, Bahrami T, Amrani M, Simon AR. Long-term results after lung transplantation using organs from circulatory death donors: a propensity score-matched analysis†. Eur J Cardiothorac Surg 2015; 49:46-53. [PMID: 25777057 DOI: 10.1093/ejcts/ezv051] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2014] [Accepted: 01/19/2015] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVES Due to organ shortage in lung transplantation (LTx), donation after circulatory death (DCD) has been implemented in several countries, contributing to an increasing number of organs transplanted. We sought to assess long-term outcomes after LTx with organs procured following circulatory death in comparison with those obtained from donors after brain death (DBD). METHODS Between January 2007 and November 2013, 302 LTxs were performed in our institution, whereby 60 (19.9%) organs were retrieved from DCD donors. We performed propensity score matching (DCD:DBD = 1:2) based on preoperative donor and recipient factors that were significantly different in univariate analysis. RESULTS After propensity matching, there were no statistically significant differences between the groups in terms of demographics and preoperative donor and recipient characteristics. There were no significant differences regarding intraoperative variables and total ischaemic time. Patients from the DCD group had significantly higher incidence of primary graft dysfunction grade 3 at the end of the procedure (P = 0.014), and significantly lower pO2/FiO2 ratio during the first 24 h after the procedure (P = 0.018). There was a trend towards higher incidence of the need for postoperative extracorporeal life support in the DCD group. Other postoperative characteristics were comparable. While the overall cumulative survival was not significantly different, the DCD group had significantly poorer results in terms of bronchiolitis obliterans syndrome (BOS)-free survival in the long-term follow-up. CONCLUSIONS Long-term results after LTx with organs procured following DCD are in general comparable with those obtained after DBD LTx. However, patients transplanted using organs from DCD donors have a predisposition for development of BOS in the longer follow-up.
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Affiliation(s)
- Anton Sabashnikov
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support, Royal Brompton and Harefield NHS Foundation Trust, Harefield Hospital, Harefield, Middlesex, UK
| | - Nikhil P Patil
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support, Royal Brompton and Harefield NHS Foundation Trust, Harefield Hospital, Harefield, Middlesex, UK
| | - Aron-Frederik Popov
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support, Royal Brompton and Harefield NHS Foundation Trust, Harefield Hospital, Harefield, Middlesex, UK
| | - Simona Soresi
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support, Royal Brompton and Harefield NHS Foundation Trust, Harefield Hospital, Harefield, Middlesex, UK
| | - Bartlomiej Zych
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support, Royal Brompton and Harefield NHS Foundation Trust, Harefield Hospital, Harefield, Middlesex, UK
| | - Alexander Weymann
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support, Royal Brompton and Harefield NHS Foundation Trust, Harefield Hospital, Harefield, Middlesex, UK
| | - Prashant N Mohite
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support, Royal Brompton and Harefield NHS Foundation Trust, Harefield Hospital, Harefield, Middlesex, UK
| | - Diana García Sáez
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support, Royal Brompton and Harefield NHS Foundation Trust, Harefield Hospital, Harefield, Middlesex, UK
| | - Mohamed Zeriouh
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support, Royal Brompton and Harefield NHS Foundation Trust, Harefield Hospital, Harefield, Middlesex, UK
| | - Thorsten Wahlers
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Yeong-Hoon Choi
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Jens Wippermann
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Thorsten Wittwer
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Fabio De Robertis
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support, Royal Brompton and Harefield NHS Foundation Trust, Harefield Hospital, Harefield, Middlesex, UK
| | - Toufan Bahrami
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support, Royal Brompton and Harefield NHS Foundation Trust, Harefield Hospital, Harefield, Middlesex, UK
| | - Mohamed Amrani
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support, Royal Brompton and Harefield NHS Foundation Trust, Harefield Hospital, Harefield, Middlesex, UK
| | - André R Simon
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support, Royal Brompton and Harefield NHS Foundation Trust, Harefield Hospital, Harefield, Middlesex, UK
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