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Schmoeckel M, Längin M, Reichart B, Abicht JM, Bender M, Michel S, Kamla CE, Denner J, Tönjes RR, Schwinzer R, Marckmann G, Wolf E, Brenner P, Hagl C. Current Status of Cardiac Xenotransplantation: Report of a Workshop of the German Heart Transplant Centers, Martinsried, March 3, 2023. Thorac Cardiovasc Surg 2024; 72:273-284. [PMID: 38154473 PMCID: PMC11147670 DOI: 10.1055/a-2235-8854] [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: 09/25/2023] [Accepted: 11/22/2023] [Indexed: 12/30/2023]
Abstract
This report comprises the contents of the presentations and following discussions of a workshop of the German Heart Transplant Centers in Martinsried, Germany on cardiac xenotransplantation. The production and current availability of genetically modified donor pigs, preservation techniques during organ harvesting, and immunosuppressive regimens in the recipient are described. Selection criteria for suitable patients and possible solutions to the problem of overgrowth of the xenotransplant are discussed. Obviously microbiological safety for the recipient and close contacts is essential, and ethical considerations to gain public acceptance for clinical applications are addressed. The first clinical trial will be regulated and supervised by the Paul-Ehrlich-Institute as the National Competent Authority for Germany, and the German Heart Transplant Centers agreed to cooperatively select the first patients for cardiac xenotransplantation.
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Affiliation(s)
- Michael Schmoeckel
- Herzchirurgische Klinik und Poliklinik, LMU Klinikum, LMU München, Germany
| | - Matthias Längin
- Klinik für Anaesthesiologie, LMU Klinikum, LMU München, Germany
- DFG-Transregio-Sonderforschungsbereich TR127—Xenotransplantation, Walter-Brendel-Zentrum für Experimentelle Medizin, LMU München, Germany
| | - Bruno Reichart
- DFG-Transregio-Sonderforschungsbereich TR127—Xenotransplantation, Walter-Brendel-Zentrum für Experimentelle Medizin, LMU München, Germany
| | - Jan-Michael Abicht
- Klinik für Anaesthesiologie, LMU Klinikum, LMU München, Germany
- DFG-Transregio-Sonderforschungsbereich TR127—Xenotransplantation, Walter-Brendel-Zentrum für Experimentelle Medizin, LMU München, Germany
| | - Martin Bender
- Klinik für Anaesthesiologie, LMU Klinikum, LMU München, Germany
- DFG-Transregio-Sonderforschungsbereich TR127—Xenotransplantation, Walter-Brendel-Zentrum für Experimentelle Medizin, LMU München, Germany
| | - Sebastian Michel
- Herzchirurgische Klinik und Poliklinik, LMU Klinikum, LMU München, Germany
- DFG-Transregio-Sonderforschungsbereich TR127—Xenotransplantation, Walter-Brendel-Zentrum für Experimentelle Medizin, LMU München, Germany
| | | | - Joachim Denner
- DFG-Transregio-Sonderforschungsbereich TR127—Xenotransplantation, Walter-Brendel-Zentrum für Experimentelle Medizin, LMU München, Germany
- Institut für Virologie, Fachbereich für Veterinärmedizin, Freie Universität Berlin, Berlin, Germany
| | - Ralf Reinhard Tönjes
- DFG-Transregio-Sonderforschungsbereich TR127—Xenotransplantation, Walter-Brendel-Zentrum für Experimentelle Medizin, LMU München, Germany
- Paul-Ehrlich-Institut, Langen, Germany
| | - Reinhard Schwinzer
- DFG-Transregio-Sonderforschungsbereich TR127—Xenotransplantation, Walter-Brendel-Zentrum für Experimentelle Medizin, LMU München, Germany
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Medizinische Hochschule Hannover, Hannover, Germany
| | - Georg Marckmann
- DFG-Transregio-Sonderforschungsbereich TR127—Xenotransplantation, Walter-Brendel-Zentrum für Experimentelle Medizin, LMU München, Germany
- Institut für Ethik, Geschichte und Theorie der Medizin, LMU München, Germany
| | - Eckhard Wolf
- DFG-Transregio-Sonderforschungsbereich TR127—Xenotransplantation, Walter-Brendel-Zentrum für Experimentelle Medizin, LMU München, Germany
- Lehrstuhl für Molekulare Tierzucht und Biotechnologie, Genzentrum der LMU München, Germany
| | - Paolo Brenner
- Herzchirurgische Klinik und Poliklinik, LMU Klinikum, LMU München, Germany
- DFG-Transregio-Sonderforschungsbereich TR127—Xenotransplantation, Walter-Brendel-Zentrum für Experimentelle Medizin, LMU München, Germany
| | - Christian Hagl
- Herzchirurgische Klinik und Poliklinik, LMU Klinikum, LMU München, Germany
- DZHK (Deutsches Zentrum für Herz-Kreislauf-Forschung e.V.), Partner Site Munich, Germany
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Fang M, Yang YG, Hu Z. Current status and challenges of pig-to-human organ xenotransplantation. SCIENCE CHINA. LIFE SCIENCES 2024; 67:829-831. [PMID: 38198028 DOI: 10.1007/s11427-023-2500-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Accepted: 11/17/2023] [Indexed: 01/11/2024]
Affiliation(s)
- Minghui Fang
- Key Laboratory of Organ Regeneration & Transplantation of Ministry of Education, and National-Local Joint Engineering Laboratory of Animal Models for Human Diseases, The First Hospital of Jilin University, Changchun, 130061, China
| | - Yong-Guang Yang
- Key Laboratory of Organ Regeneration & Transplantation of Ministry of Education, and National-Local Joint Engineering Laboratory of Animal Models for Human Diseases, The First Hospital of Jilin University, Changchun, 130061, China
| | - Zheng Hu
- Key Laboratory of Organ Regeneration & Transplantation of Ministry of Education, and National-Local Joint Engineering Laboratory of Animal Models for Human Diseases, The First Hospital of Jilin University, Changchun, 130061, China.
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Habibabady Z, McGrath G, Kinoshita K, Maenaka A, Ikechukwu I, Elias GF, Zaletel T, Rosales I, Hara H, Pierson RN, Cooper DKC. Antibody-mediated rejection in xenotransplantation: Can it be prevented or reversed? Xenotransplantation 2023; 30:e12816. [PMID: 37548030 PMCID: PMC11101061 DOI: 10.1111/xen.12816] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Revised: 07/19/2023] [Accepted: 07/26/2023] [Indexed: 08/08/2023]
Abstract
Antibody-mediated rejection (AMR) is the commonest cause of failure of a pig graft after transplantation into an immunosuppressed nonhuman primate (NHP). The incidence of AMR compared to acute cellular rejection is much higher in xenotransplantation (46% vs. 7%) than in allotransplantation (3% vs. 63%) in NHPs. Although AMR in an allograft can often be reversed, to our knowledge there is no report of its successful reversal in a pig xenograft. As there is less experience in preventing or reversing AMR in models of xenotransplantation, the results of studies in patients with allografts provide more information. These include (i) depletion or neutralization of serum anti-donor antibodies, (ii) inhibition of complement activation, (iii) therapies targeting B or plasma cells, and (iv) anti-inflammatory therapy. Depletion or neutralization of anti-pig antibody, for example, by plasmapheresis, is effective in depleting antibodies, but they recover within days. IgG-degrading enzymes do not deplete IgM. Despite the expression of human complement-regulatory proteins on the pig graft, inhibition of systemic complement activation may be necessary, particularly if AMR is to be reversed. Potential therapies include (i) inhibition of complement activation (e.g., by IVIg, C1 INH, or an anti-C5 antibody), but some complement inhibitors are not effective in NHPs, for example, eculizumab. Possible B cell-targeted therapies include (i) B cell depletion, (ii) plasma cell depletion, (iii) modulation of B cell activation, and (iv) enhancing the generation of regulatory B and/or T cells. Among anti-inflammatory agents, anti-IL6R mAb and TNF blockers are increasingly being tested in xenotransplantation models, but with no definitive evidence that they reverse AMR. Increasing attention should be directed toward testing combinations of the above therapies. We suggest that treatment with a systemic complement inhibitor is likely to be most effective, possibly combined with anti-inflammatory agents (if these are not already being administered). Ultimately, it may require further genetic engineering of the organ-source pig to resolve the problem entirely, for example, knockout or knockdown of SLA, and/or expression of PD-L1, HLA E, and/or HLA-G.
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Affiliation(s)
- Zahra Habibabady
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Gannon McGrath
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Kohei Kinoshita
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Akihiro Maenaka
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Ileka Ikechukwu
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Gabriela F. Elias
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Tjasa Zaletel
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Ivy Rosales
- Department of Pathology, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Hidetaka Hara
- Yunnan Xenotransplantation Engineering Research Center, Yunnan Agricultural University, Kunming, Yunnan, China
| | - Richard N. Pierson
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - David K. C. Cooper
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
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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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Choe YH, Sorensen J, Garry DJ, Garry MG. Blastocyst complementation and interspecies chimeras in gene edited pigs. Front Cell Dev Biol 2022; 10:1065536. [PMID: 36568986 PMCID: PMC9773398 DOI: 10.3389/fcell.2022.1065536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Accepted: 11/17/2022] [Indexed: 12/13/2022] Open
Abstract
The only curative therapy for many endstage diseases is allograft organ transplantation. Due to the limited supply of donor organs, relatively few patients are recipients of a transplanted organ. Therefore, new strategies are warranted to address this unmet need. Using gene editing technologies, somatic cell nuclear transfer and human induced pluripotent stem cell technologies, interspecies chimeric organs have been pursued with promising results. In this review, we highlight the overall technical strategy, the successful early results and the hurdles that need to be addressed in order for these approaches to produce a successful organ that could be transplanted in patients with endstage diseases.
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Affiliation(s)
- Yong-ho Choe
- Lillehei Heart Institute, University of Minnesota, Minneapolis, MN, United States
- Cardiovascular Division, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Jacob Sorensen
- Lillehei Heart Institute, University of Minnesota, Minneapolis, MN, United States
- Cardiovascular Division, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Daniel J. Garry
- Lillehei Heart Institute, University of Minnesota, Minneapolis, MN, United States
- Cardiovascular Division, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
- Stem Cell Institute, University of Minnesota, Minneapolis, MN, United States
- Paul and Sheila Wellstone Muscular Dystrophy Center, University of Minnesota, Minneapolis, MN, United States
| | - Mary G. Garry
- Lillehei Heart Institute, University of Minnesota, Minneapolis, MN, United States
- Cardiovascular Division, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
- Stem Cell Institute, University of Minnesota, Minneapolis, MN, United States
- Paul and Sheila Wellstone Muscular Dystrophy Center, University of Minnesota, Minneapolis, MN, United States
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