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VanZalen JJ, Nakashima T, Phillips A, Hill JE, Westover AJ, Lou L, Liao J, Mergos J, Fogo G, Sanderson TH, Stacey WC, Tiba MH, Humes DH, Bartlett RH, Rojas-Peña A, Neumar RW. Leukocyte filtration and leukocyte modulation therapy during extracorporeal cardiopulmonary resuscitation in a porcine model of prolonged cardiac arrest. Sci Rep 2024; 14:13081. [PMID: 38844477 PMCID: PMC11156900 DOI: 10.1038/s41598-024-63522-w] [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: 03/14/2024] [Accepted: 05/29/2024] [Indexed: 06/09/2024] Open
Abstract
Extracorporeal cardiopulmonary resuscitation (ECPR) is emerging as a feasible and effective rescue strategy for prolonged cardiac arrest (CA). However, prolonged total body ischemia and reperfusion can cause microvascular occlusion that prevents organ reperfusion and recovery of function. One hypothesized mechanism of microvascular "no-reflow" is leukocyte adhesion and formation of neutrophil extracellular traps. In this study we tested the hypothesis that a leukocyte filter (LF) or leukocyte modulation device (L-MOD) could reduce NETosis and improve recovery of heart and brain function in a swine model of prolonged cardiac arrest treated with ECPR. Thirty-six swine (45.5 ± 2.5 kg, evenly distributed sex) underwent 8 min of untreated ventricular fibrillation CA followed by 30 min of mechanical CPR with subsequent 8 h of ECPR. Two females were later excluded from analysis due to CPR complications. Swine were randomized to standard care (Control group), LF, or L-MOD at the onset of CPR. NET formation was quantified by serum dsDNA and citrullinated histone as well as immunofluorescence staining of the heart and brain for citrullinated histone in the microvasculature. Primary outcomes included recovery of cardiac function based on cardiac resuscitability score (CRS) and recovery of neurologic function based on the somatosensory evoked potential (SSEP) N20 cortical response. In this model of prolonged CA treated with ECPR we observed significant increases in serum biomarkers of NETosis and immunohistochemical evidence of microvascular NET formation in the heart and brain that were not reduced by LF or L-MOD therapy. Correspondingly, there were no significant differences in CRS and SSEP recovery between Control, LF, and L-MOD groups 8 h after ECPR onset (CRS = 3.1 ± 2.7, 3.7 ± 2.6, and 2.6 ± 2.6 respectively; p = 0.606; and SSEP = 27.9 ± 13.0%, 36.7 ± 10.5%, and 31.2 ± 9.8% respectively, p = 0.194). In this model of prolonged CA treated with ECPR, the use of LF or L-MOD therapy during ECPR did not reduce microvascular NETosis or improve recovery of myocardial or brain function. The causal relationship between microvascular NETosis, no-reflow, and recovery of organ function after prolonged cardiac arrest treated with ECPR requires further investigation.
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Affiliation(s)
- Jensyn J VanZalen
- Department of Surgery and ECLS Laboratory, University of Michigan Medical School, Ann Arbor, MI, 48109, USA
| | - Takahiro Nakashima
- Department of Surgery and ECLS Laboratory, University of Michigan Medical School, Ann Arbor, MI, 48109, USA
- The Max Harry Weil Institute for Critical Care Research and Innovation, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Annie Phillips
- Department of Surgery and ECLS Laboratory, University of Michigan Medical School, Ann Arbor, MI, 48109, USA
| | - Joseph E Hill
- Department of Surgery and ECLS Laboratory, University of Michigan Medical School, Ann Arbor, MI, 48109, USA
| | - Angela J Westover
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, 48109, USA
| | - Liandi Lou
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, 48109, USA
| | - Jinhui Liao
- The Max Harry Weil Institute for Critical Care Research and Innovation, University of Michigan, Ann Arbor, MI, 48109, USA
- Department of Emergency Medicine, University of Michigan Medical School, 1500 E Medical Center Drive, Ann Arbor, MI, 48109-5303, USA
| | - Joshua Mergos
- Movement Science, University of Michigan School of Kinesiology, Ann Arbor, MI, 48109, USA
- Department of Neurology, University of Michigan Medical School, Ann Arbor, MI, 48109, USA
| | - Garrett Fogo
- The Max Harry Weil Institute for Critical Care Research and Innovation, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Thomas H Sanderson
- The Max Harry Weil Institute for Critical Care Research and Innovation, University of Michigan, Ann Arbor, MI, 48109, USA
- Department of Emergency Medicine, University of Michigan Medical School, 1500 E Medical Center Drive, Ann Arbor, MI, 48109-5303, USA
- Neuroscience Graduate Program, University of Michigan Medical School, Ann Arbor, MI, 48109, USA
- Department of Molecular and Integrative Physiology, University of Michigan Medical School, Ann Arbor, MI, 48109, USA
| | - William C Stacey
- Movement Science, University of Michigan School of Kinesiology, Ann Arbor, MI, 48109, USA
- Department of Neurology, University of Michigan Medical School, Ann Arbor, MI, 48109, USA
| | - Mohamad Hakam Tiba
- The Max Harry Weil Institute for Critical Care Research and Innovation, University of Michigan, Ann Arbor, MI, 48109, USA
- Department of Emergency Medicine, University of Michigan Medical School, 1500 E Medical Center Drive, Ann Arbor, MI, 48109-5303, USA
| | - David H Humes
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, 48109, USA
| | - Robert H Bartlett
- Department of Surgery and ECLS Laboratory, University of Michigan Medical School, Ann Arbor, MI, 48109, USA
| | - Alvaro Rojas-Peña
- Department of Surgery and ECLS Laboratory, University of Michigan Medical School, Ann Arbor, MI, 48109, USA
- The Max Harry Weil Institute for Critical Care Research and Innovation, University of Michigan, Ann Arbor, MI, 48109, USA
- Department of Surgery Section of Transplantation, University of Michigan Medical School, Ann Arbor, MI, 48109, USA
| | - Robert W Neumar
- The Max Harry Weil Institute for Critical Care Research and Innovation, University of Michigan, Ann Arbor, MI, 48109, USA.
- Department of Emergency Medicine, University of Michigan Medical School, 1500 E Medical Center Drive, Ann Arbor, MI, 48109-5303, USA.
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Wu WK, Stier MT, Stokes JW, Ukita R, Patel YJ, Cortelli M, Landstreet SR, Talackine JR, Cardwell NL, Simonds EM, Mentz M, Lowe C, Benson C, Demarest CT, Alexopoulos SP, Shaver CM, Bacchetta M. Immune characterization of a xenogeneic human lung cross-circulation support system. SCIENCE ADVANCES 2023; 9:eade7647. [PMID: 37000867 PMCID: PMC10065447 DOI: 10.1126/sciadv.ade7647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
Improved approaches to expanding the pool of donor lungs suitable for transplantation are critically needed for the growing population with end-stage lung disease. Cross-circulation (XC) of whole blood between swine and explanted human lungs has previously been reported to enable the extracorporeal recovery of donor lungs that declined for transplantation due to acute, reversible injuries. However, immunologic interactions of this xenogeneic platform have not been characterized, thus limiting potential translational applications. Using flow cytometry and immunohistochemistry, we demonstrate that porcine immune cell and immunoglobulin infiltration occurs in this xenogeneic XC system, in the context of calcineurin-based immunosuppression and complement depletion. Despite this, xenogeneic XC supported the viability, tissue integrity, and physiologic improvement of human donor lungs over 24 hours of xeno-support. These findings provide targets for future immunomodulatory strategies to minimize immunologic interactions on this organ support biotechnology.
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Affiliation(s)
- Wei K. Wu
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Surgery, Division of Hepatobiliary Surgery and Liver Transplantation, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Matthew T. Stier
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - John W. Stokes
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Rei Ukita
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Yatrik J. Patel
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Michael Cortelli
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Stuart R. Landstreet
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jennifer R. Talackine
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Nancy L. Cardwell
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Elizabeth M. Simonds
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Meredith Mentz
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Cindy Lowe
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Clayne Benson
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Caitlin T. Demarest
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sophoclis P. Alexopoulos
- Department of Surgery, Division of Hepatobiliary Surgery and Liver Transplantation, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ciara M. Shaver
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Corresponding author. (M.B.); (C.M.S.)
| | - Matthew Bacchetta
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Biomedical Engineering, Vanderbilt University, Nashville, TN, USA
- Corresponding author. (M.B.); (C.M.S.)
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Fodor M, Salcher S, Gottschling H, Mair A, Blumer M, Sopper S, Ebner S, Pircher A, Oberhuber R, Wolf D, Schneeberger S, Hautz T. The liver-resident immune cell repertoire - A boon or a bane during machine perfusion? Front Immunol 2022; 13:982018. [PMID: 36311746 PMCID: PMC9609784 DOI: 10.3389/fimmu.2022.982018] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 09/30/2022] [Indexed: 11/13/2022] Open
Abstract
The liver has been proposed as an important “immune organ” of the body, as it is critically involved in a variety of specific and unique immune tasks. It contains a huge resident immune cell repertoire, which determines the balance between tolerance and inflammation in the hepatic microenvironment. Liver-resident immune cells, populating the sinusoids and the space of Disse, include professional antigen-presenting cells, myeloid cells, as well as innate and adaptive lymphoid cell populations. Machine perfusion (MP) has emerged as an innovative technology to preserve organs ex vivo while testing for organ quality and function prior to transplantation. As for the liver, hypothermic and normothermic MP techniques have successfully been implemented in clinically routine, especially for the use of marginal donor livers. Although there is evidence that ischemia reperfusion injury-associated inflammation is reduced in machine-perfused livers, little is known whether MP impacts the quantity, activation state and function of the hepatic immune-cell repertoire, and how this affects the inflammatory milieu during MP. At this point, it remains even speculative if liver-resident immune cells primarily exert a pro-inflammatory and hence destructive effect on machine-perfused organs, or in part may be essential to induce liver regeneration and counteract liver damage. This review discusses the role of hepatic immune cell subtypes during inflammatory conditions and ischemia reperfusion injury in the context of liver transplantation. We further highlight the possible impact of MP on the modification of the immune cell repertoire and its potential for future applications and immune modulation of the liver.
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Affiliation(s)
- M. Fodor
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, organLife Laboratory, Medical University of Innsbruck, Innsbruck, Austria
- Department of Visceral, Transplant and Thoracic Surgery, Daniel Swarovski Research Laboratory, Medical University of Innsbruck, Innsbruck, Austria
| | - S. Salcher
- Department of Internal Medicine V, Hematology and Oncology, Comprehensive Cancer Center Innsbruck (CCCI), Medical University Innsbruck (MUI), Innsbruck, Austria
| | - H. Gottschling
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, organLife Laboratory, Medical University of Innsbruck, Innsbruck, Austria
- Department of Visceral, Transplant and Thoracic Surgery, Daniel Swarovski Research Laboratory, Medical University of Innsbruck, Innsbruck, Austria
| | - A. Mair
- Department of Internal Medicine V, Hematology and Oncology, Comprehensive Cancer Center Innsbruck (CCCI), Medical University Innsbruck (MUI), Innsbruck, Austria
| | - M. Blumer
- Department of Anatomy and Embryology, Medical University of Innsbruck, Innsbruck, Austria
| | - S. Sopper
- Department of Internal Medicine V, Hematology and Oncology, Comprehensive Cancer Center Innsbruck (CCCI), Medical University Innsbruck (MUI), Innsbruck, Austria
| | - S. Ebner
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, organLife Laboratory, Medical University of Innsbruck, Innsbruck, Austria
- Department of Visceral, Transplant and Thoracic Surgery, Daniel Swarovski Research Laboratory, Medical University of Innsbruck, Innsbruck, Austria
| | - A. Pircher
- Department of Internal Medicine V, Hematology and Oncology, Comprehensive Cancer Center Innsbruck (CCCI), Medical University Innsbruck (MUI), Innsbruck, Austria
| | - R. Oberhuber
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, organLife Laboratory, Medical University of Innsbruck, Innsbruck, Austria
- Department of Visceral, Transplant and Thoracic Surgery, Daniel Swarovski Research Laboratory, Medical University of Innsbruck, Innsbruck, Austria
| | - D. Wolf
- Department of Internal Medicine V, Hematology and Oncology, Comprehensive Cancer Center Innsbruck (CCCI), Medical University Innsbruck (MUI), Innsbruck, Austria
| | - S. Schneeberger
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, organLife Laboratory, Medical University of Innsbruck, Innsbruck, Austria
- Department of Visceral, Transplant and Thoracic Surgery, Daniel Swarovski Research Laboratory, Medical University of Innsbruck, Innsbruck, Austria
| | - T. Hautz
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, organLife Laboratory, Medical University of Innsbruck, Innsbruck, Austria
- Department of Visceral, Transplant and Thoracic Surgery, Daniel Swarovski Research Laboratory, Medical University of Innsbruck, Innsbruck, Austria
- *Correspondence: T. Hautz,
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Figueroa BA, Said SA, Ordenana C, Rezaei M, Orfahli LM, Dubé GP, Papay F, Brunengraber H, Dasarathy S, Rampazzo A, Gharb BB. Ex vivo normothermic preservation of amputated limbs with a hemoglobin-based oxygen carrier perfusate. J Trauma Acute Care Surg 2022; 92:388-397. [PMID: 34510075 DOI: 10.1097/ta.0000000000003395] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Ex vivo normothermic limb perfusion (EVNLP) preserves amputated limbs under near-physiologic conditions. Perfusates containing red blood cells (RBCs) have shown to improve outcomes during ex vivo normothermic organ perfusion, when compared with acellular perfusates. To avoid limitations associated with the use of blood-based products, we evaluated the feasibility of EVNLP using a polymerized hemoglobin-based oxygen carrier-201 (HBOC-201). METHODS Twenty-four porcine forelimbs were procured from Yorkshire pigs. Six forelimbs underwent EVNLP with an HBOC-201-based perfusate, six with an RBC-based perfusate, and 12 served as static cold storage (SCS) controls. Ex vivo normothermic limb perfusion was terminated in the presence of systolic arterial pressure of 115 mm Hg or greater, fullness of compartments, or drop of tissue oxygen saturation by 20%. Limb contractility, weight change, compartment pressure, tissue oxygen saturation, oxygen uptake rates (OURs) were assessed. Perfusate fluid-dynamics, gases, electrolytes, metabolites, methemoglobin, creatine kinase, and myoglobin concentration were measured. Uniformity of skin perfusion was assessed with indocyanine green angiography and infrared thermography. RESULTS Warm ischemia time before EVNLP was 35.50 ± 8.62 minutes (HBOC-201), 30.17 ± 8.03 minutes (RBC) and 37.82 ± 10.45 (SCS) (p = 0.09). Ex vivo normothermic limb perfusion duration was 22.5 ± 1.7 hours (HBOC-201) and 28.2 ± 7.3 hours (RBC) (p = 0.04). Vascular flow (325 ± 25 mL·min-1 vs. 444.7 ± 50.6 mL·min-1; p = 0.39), OUR (2.0 ± 1.45 mL O2·min-1·g-1 vs. 1.3 ± 0.92 mL O2·min-1·g-1 of tissue; p = 0.80), lactate (14.66 ± 4.26 mmol·L-1 vs. 13.11 ± 6.68 mmol·L-1; p = 0.32), perfusate pH (7.53 ± 0.25 HBOC-201; 7.50 ± 0.23 RBC; p = 0.82), flexor (28.3 ± 22.0 vs. 27.5 ± 10.6; p = 0.99), and extensor (31.5 ± 22.9 vs. 28.8 ± 14.5; p = 0.82) compartment pressures, and weight changes (23.1 ± 3.0% vs. 13.2 ± 22.7; p = 0.07) were not significantly different between HBOC-201 and RBC groups, respectively. In HBOC-201 perfused limbs, methemoglobin levels increased, reaching 47.8 ± 12.1% at endpoint. Methemoglobin saturation did not affect OUR (ρ = -0.15, r2 = 0.022; p = 0.45). A significantly greater number of necrotic myocytes was found in the SCS group at endpoint (SCS, 127 ± 17 cells; HBOC-201, 72 ± 30 cells; RBC-based, 56 ± 40 cells; vs. p = 0.003). CONCLUSION HBOC-201- and RBC-based perfusates similarly support isolated limb physiology, metabolism, and function.
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Affiliation(s)
- Brian A Figueroa
- From the Department of Plastic Surgery (B.A.F., S.A.S., C.O., M.R., L.M.O., F.P., A.R., B.B.G.), Cleveland Clinic; Department of Nutrition (H.B.), School of Medicine, Case Western Reserve University; Department of Gastroenterology (S.D.), Cleveland Clinic, Cleveland, Ohio; and Hemoglobin Oxygen Therapeutics, LLC (G.P.D.), Souderton, Pennsylvania
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