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Yu J, Zhang N, Zhang Z, Li Y, Gao J, Chen C, Wen Z. Exploring predisposing factors and pathogenesis contributing to injuries of donor lungs. Expert Rev Respir Med 2022; 16:1191-1203. [PMID: 36480922 DOI: 10.1080/17476348.2022.2157264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Lung transplantation (LTx) remains the only therapeutic strategy for patients with incurable lung diseases. However, its use has been severely limited by the narrow donor pool and potential concerns of inferior quality of donor lungs, which are more susceptible to external influence than other transplant organs. Multiple insults, including various causes of death and a series of perimortem events, may act together on donor lungs and eventually culminate in primary graft dysfunction (PGD) after transplantation as well as other poor short-term outcomes. AREAS COVERED This review focuses on the predisposing factors contributing to injuries to the donor lungs, specifically focusing on the pathogenesis of these injuries and their impact on post-transplant outcomes. Additionally, various maneuvers to mitigate donor lung injuries have been proposed. EXPERT OPINION The selection criteria for eligible donors vary and may be poor discriminators of lung injury. Not all transplanted lungs are in ideal condition. With the rapidly increasing waiting list for LTx, the trend of using marginal donors has become more apparent, underscoring the need to gain a deeper understanding of donor lung injuries and discover more donor resources.
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Affiliation(s)
- Jing Yu
- Department of Anesthesiology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, 200433, Shanghai, Zhejiang, China
| | - Nan Zhang
- Department of Anesthesiology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, 200433, Shanghai, Zhejiang, China
| | - Zhiyuan Zhang
- Department of Anesthesiology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, 200433, Shanghai, Zhejiang, China
| | - Yuping Li
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, 200433, Shanghai, Zhejiang, China
| | - Jiameng Gao
- Department of Anesthesiology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, 200433, Shanghai, Zhejiang, China
| | - Chang Chen
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, 200433, Shanghai, Zhejiang, China
| | - Zongmei Wen
- Department of Anesthesiology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, 200433, Shanghai, Zhejiang, China
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Outcome After Lung Transplantation From a Donor With Bacterial Pneumonia Under the Japanese Donor Evaluation System. Transplant Proc 2022; 54:782-788. [DOI: 10.1016/j.transproceed.2021.12.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 12/27/2021] [Indexed: 01/20/2023]
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3
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Lung Transplantation, Pulmonary Endothelial Inflammation, and Ex-Situ Lung Perfusion: A Review. Cells 2021; 10:cells10061417. [PMID: 34200413 PMCID: PMC8229792 DOI: 10.3390/cells10061417] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 06/01/2021] [Accepted: 06/02/2021] [Indexed: 12/31/2022] Open
Abstract
Lung transplantation (LTx) is the gold standard treatment for end-stage lung disease; however, waitlist mortality remains high due to a shortage of suitable donor lungs. Organ quality can be compromised by lung ischemic reperfusion injury (LIRI). LIRI causes pulmonary endothelial inflammation and may lead to primary graft dysfunction (PGD). PGD is a significant cause of morbidity and mortality post-LTx. Research into preservation strategies that decrease the risk of LIRI and PGD is needed, and ex-situ lung perfusion (ESLP) is the foremost technological advancement in this field. This review addresses three major topics in the field of LTx: first, we review the clinical manifestation of LIRI post-LTx; second, we discuss the pathophysiology of LIRI that leads to pulmonary endothelial inflammation and PGD; and third, we present the role of ESLP as a therapeutic vehicle to mitigate this physiologic insult, increase the rates of donor organ utilization, and improve patient outcomes.
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4
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Prediction of donor related lung injury in clinical lung transplantation using a validated ex vivo lung perfusion inflammation score. J Heart Lung Transplant 2021; 40:687-695. [PMID: 33781664 DOI: 10.1016/j.healun.2021.03.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 02/24/2021] [Accepted: 03/01/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Ex vivo lung perfusion (EVLP) is an isolated organ assessment technique that has revolutionized the field of lung transplantation and enabled a safe increase in the number of organs transplanted. The objective of this study was to develop a protein-based assay that would provide a precision medicine approach to lung injury assessment during EVLP. METHODS Perfusate samples collected from clinical EVLP cases performed from 2009 to 2019 were separated into development (n = 281) and validation (n = 57) sets to derive and validate an inflammation score based on IL-6 and IL-8 protein levels in perfusate. The ability of an inflammation score to predict lungs suitable for transplantation and likely to produce excellent recipient outcomes (time on ventilator ≤ 3 days) was assessed. Inflammation scores were compared to conventional clinical EVLP assessment parameters and associated with outcomes, including primary graft dysfunction and patient care in the ICU. RESULTS An inflammation score accurately predicted the decision to transplant (AUROC 68% [95% CI 62-74]) at the end of EVLP and those transplants associated with short ventilator times (AUROC 73% [95% CI 66-80]). The score identified lungs more likely to develop primary graft dysfunction at 72-hours post-transplant (OR 4.0, p = 0.03). A model comprised of the inflammation score and ∆PO2 was able to determine EVLP transplants that were likely to have excellent recipient outcomes, with an accuracy of 87% [95% CI 83-92]. CONCLUSIONS The adoption of an inflammation score will improve accuracy of EVLP decision-making and increase confidence of surgical teams to determine lungs that are suitable for transplantation, thereby improving organ utilization rates and patient outcomes.
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Chakos A, Ferret P, Muston B, Yan TD, Tian DH. Ex-vivo lung perfusion versus standard protocol lung transplantation-mid-term survival and meta-analysis. Ann Cardiothorac Surg 2020; 9:1-9. [PMID: 32175234 PMCID: PMC7049550 DOI: 10.21037/acs.2020.01.02] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Accepted: 01/06/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND While extended criteria lung donation has helped expand the lung donor pool, utilization of lungs from donors of at least one other solid organ is still limited to around 15-30%. Ex-vivo lung perfusion (EVLP) offers the ability to expand the number of useable lung grafts through assessment and reconditioning of explanted lungs, particularly those not initially meeting criteria for transplantation. This meta-analysis aimed to examine the mid- to long-term survival and other short-term outcomes of patients transplanted with EVLP-treated lungs versus standard/cold-storage protocol lungs. METHODS Literature search of ten medical databases was conducted for original studies involving "ex-vivo lung perfusion" and "EVLP". Included articles were assessed by two independent researchers, survival data from Kaplan-Meier curves digitized, and individual patient data imputed to conduct aggregated survival analysis. Meta-analyses of suitably reported outcomes were conducted using a random-effects model. RESULTS Thirteen studies met inclusion criteria, with a total of 407 EVLP lung transplants and 1,765 as per standard/cold storage protocol. One study was a randomized controlled trial while the remainder were single-institution cohort series of varying design. The majority of donor lungs were from brain death donors, with EVLP lungs having significantly worse PaO2/FiO2 ratio and significantly greater rate of abnormal chest X-ray. Aggregated survival analysis of all included studies revealed no significant survival difference for EVLP or standard protocol lungs (hazard ratio 1.00; 95% confidence interval: 0.79-1.27, P=0.981). Survival at 12, 24, and 36 months for the EVLP cohort was 84%, 79%, and 74%, respectively. Survival at 12, 24, and 36 months for the standard protocol cohort was 85%, 79%, and 73%, respectively. Meta-analysis did not find a significant difference in risk of 30-day mortality or primary graft dysfunction grade 3 at 72 hours between cohorts. CONCLUSIONS There was no significant difference in mid- to long-term survival of EVLP lung transplant patients when compared to standard protocol donor lungs. The incidence of 30-day mortality and primary graft dysfunction grade 3 at 72 hours did not differ significantly between groups. EVLP offers the potential to increase lung donor utilization while providing similar short-term outcomes and mid- to long-term survival.
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Affiliation(s)
- Adam Chakos
- The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - Paule Ferret
- The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia
| | - Benjamin Muston
- The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia
| | - Tristan D. Yan
- The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
- Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, Sydney, Australia
| | - David H. Tian
- The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia
- Department of Anaesthesia and Perioperative Medicine, Westmead Hospital, Sydney, Australia
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Endothelial Glycocalyx Shedding Predicts Donor Organ Acceptability and Is Associated With Primary Graft Dysfunction in Lung Transplant Recipients. Transplantation 2019; 103:1277-1285. [DOI: 10.1097/tp.0000000000002539] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Steinmeyer J, Becker S, Avsar M, Salman J, Höffler K, Haverich A, Warnecke G, Mühlfeld C, Ochs M, Schnapper-Isl A. Cellular and acellular ex vivo lung perfusion preserve functional lung ultrastructure in a large animal model: a stereological study. Respir Res 2018; 19:238. [PMID: 30509256 PMCID: PMC6278069 DOI: 10.1186/s12931-018-0942-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Accepted: 11/19/2018] [Indexed: 01/07/2023] Open
Abstract
Background Ex vivo lung perfusion (EVLP) is used by an increasing number of transplant centres. It is still controversial whether an acellular or cellular (erythrocyte enriched) perfusate is preferable. The aim of this paper was to evaluate whether acellular (aEVLP) or cellular EVLP (cEVLP) preserves functional lung ultrastructure better and to generate a hypothesis regarding possible underlying mechanisms. Methods Lungs of 20 pigs were assigned to 4 groups: control, ischaemia (24 h), aEVLP and cEVLP (both EVLP groups: 24 h ischaemia + 12 h EVLP). After experimental procedures, whole lungs were perfusion fixed, samples for light and electron microscopic stereology were taken, and ventilation, diffusion and perfusion related parameters were estimated. Results Lung structure was well preserved in all groups. Lungs had less atelectasis and higher air content after EVLP. No significant group differences were found in alveolar septum composition or blood-air barrier thickness. Small amounts of intraalveolar oedema were detected in both EVLP groups but significantly more in aEVLP than in cEVLP. Conclusions Both EVLP protocols supported lungs well for up to 12 h and could largely prevent ischaemia ex vivo reperfusion associated lung injury. In both EVLP groups, oedema volume remained below the level of functional relevance. The group difference in oedema formation was possibly due to inferior septal perfusion in aEVLP. Electronic supplementary material The online version of this article (10.1186/s12931-018-0942-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jasmin Steinmeyer
- Institute of Functional and Applied Anatomy, Hannover Medical School, Hannover, Germany
| | - Simon Becker
- Institute of Functional and Applied Anatomy, Hannover Medical School, Hannover, Germany.,REBIRTH Cluster of Excellence, Hannover, Germany.,Department of Anesthesiology, Intensive Care, Palliative Care and Pain Medicine, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, Germany
| | - Murat Avsar
- Department of Cardiothoracic, Transplantation and Vascular Surgery (HTTG), Hannover Medical School, Hannover, Germany
| | - Jawad Salman
- Department of Cardiothoracic, Transplantation and Vascular Surgery (HTTG), Hannover Medical School, Hannover, Germany
| | - Klaus Höffler
- Department of Cardiothoracic, Transplantation and Vascular Surgery (HTTG), Hannover Medical School, Hannover, Germany
| | - Axel Haverich
- REBIRTH Cluster of Excellence, Hannover, Germany.,Department of Cardiothoracic, Transplantation and Vascular Surgery (HTTG), Hannover Medical School, Hannover, Germany.,Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Member of the German Center for Lung Research (DZL), Hannover, Germany
| | - Gregor Warnecke
- REBIRTH Cluster of Excellence, Hannover, Germany.,Department of Cardiothoracic, Transplantation and Vascular Surgery (HTTG), Hannover Medical School, Hannover, Germany.,Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Member of the German Center for Lung Research (DZL), Hannover, Germany
| | - Christian Mühlfeld
- Institute of Functional and Applied Anatomy, Hannover Medical School, Hannover, Germany.,REBIRTH Cluster of Excellence, Hannover, Germany.,Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Member of the German Center for Lung Research (DZL), Hannover, Germany
| | - Matthias Ochs
- Institute of Functional and Applied Anatomy, Hannover Medical School, Hannover, Germany.,REBIRTH Cluster of Excellence, Hannover, Germany.,Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Member of the German Center for Lung Research (DZL), Hannover, Germany
| | - Anke Schnapper-Isl
- Institute of Functional and Applied Anatomy, Hannover Medical School, Hannover, Germany. .,REBIRTH Cluster of Excellence, Hannover, Germany.
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Jing L, Yao L, Zhao M, Peng LP, Liu M. Organ preservation: from the past to the future. Acta Pharmacol Sin 2018; 39:845-857. [PMID: 29565040 DOI: 10.1038/aps.2017.182] [Citation(s) in RCA: 86] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2017] [Accepted: 12/31/2017] [Indexed: 12/13/2022] Open
Abstract
Organ transplantation is the most effective therapy for patients with end-stage disease. Preservation solutions and techniques are crucial for donor organ quality, which is directly related to morbidity and survival after transplantation. Currently, static cold storage (SCS) is the standard method for organ preservation. However, preservation time with SCS is limited as prolonged cold storage increases the risk of early graft dysfunction that contributes to chronic complications. Furthermore, the growing demand for the use of marginal donor organs requires methods for organ assessment and repair. Machine perfusion has resurfaced and dominates current research on organ preservation. It is credited to its dynamic nature and physiological-like environment. The development of more sophisticated machine perfusion techniques and better perfusates may lead to organ repair/reconditioning. This review describes the history of organ preservation, summarizes the progresses that has been made to date, and discusses future directions for organ preservation.
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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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10
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Aboelnazar NS, Himmat S, Hatami S, White CW, Burhani MS, Dromparis P, Matsumura N, Tian G, Dyck JR, Mengel M, Freed DH, Nagendran J. Negative pressure ventilation decreases inflammation and lung edema during normothermic ex-vivo lung perfusion. J Heart Lung Transplant 2018; 37:520-530. [DOI: 10.1016/j.healun.2017.09.007] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 09/04/2017] [Accepted: 09/11/2017] [Indexed: 11/29/2022] Open
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Stone ML, Zhao Y, Robert Smith J, Weiss ML, Kron IL, Laubach VE, Sharma AK. Mesenchymal stromal cell-derived extracellular vesicles attenuate lung ischemia-reperfusion injury and enhance reconditioning of donor lungs after circulatory death. Respir Res 2017; 18:212. [PMID: 29268735 PMCID: PMC5740880 DOI: 10.1186/s12931-017-0704-9] [Citation(s) in RCA: 88] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Accepted: 12/13/2017] [Indexed: 02/07/2023] Open
Abstract
Background Lung ischemia-reperfusion (IR) injury after transplantation as well as acute shortage of suitable donor lungs are two critical issues impacting lung transplant patients. This study investigates the anti-inflammatory and immunomodulatory role of human mesenchymal stromal cells (MSCs) and MSC-derived extracellular vesicles (EVs) to attenuate lung IR injury and improve of ex-vivo lung perfusion (EVLP)-mediated rehabilitation in donation after circulatory death (DCD) lungs. Methods C57BL/6 wild-type (WT) mice underwent sham surgery or lung IR using an in vivo hilar-ligation model with or without MSCs or EVs. In vitro studies used primary iNKT cells and macrophages (MH-S cells) were exposed to hypoxia/reoxygenation with/without co-cultures with MSCs or EVs. Also, separate groups of WT mice underwent euthanasia and 1 h of warm ischemia and stored at 4 °C for 1 h followed by 1 h of normothermic EVLP using Steen solution or Steen solution containing MSCs or EVs. Results Lungs from MSCs or EV-treated mice had significant attenuation of lung dysfunction and injury (decreased edema, neutrophil infiltration and myeloperoxidase levels) compared to IR alone. A significant decrease in proinflammatory cytokines (IL-17, TNF-α, CXCL1 and HMGB1) and upregulation of keratinocyte growth factor, prostaglandin E2 and IL-10 occurred in the BAL fluid from MSC or EV-treated mice after IR compared to IR alone. Furthermore, MSCs or EVs significantly downregulated iNKT cell-produced IL-17 and macrophage-produced HMGB1 and TNF-α after hypoxia/reoxygenation. Finally, EVLP of DCD lungs with Steen solution including MSCs or EVs provided significantly enhanced protection versus Steen solution alone. Co-cultures of MSCs or EVs with lung endothelial cells prevents neutrophil transendothelial migration after exposure to hypoxia/reoxygenation and TNF-α/HMGB1 cytomix. Conclusions These results suggest that MSC-derived EVs can attenuate lung inflammation and injury after IR as well as enhance EVLP-mediated reconditioning of donor lungs. The therapeutic benefits of EVs are in part mediated through anti-inflammatory promoting mechanisms via attenuation of immune cell activation as well as prevention of endothelial barrier integrity to prevent lung edema. Therefore, MSC-derived EVs offer a potential therapeutic strategy to treat post-transplant IR injury as well as rehabilitation of DCD lungs.
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Affiliation(s)
- Matthew L Stone
- Department of Surgery, University of Virginia, P.O. Box 801359, Charlottesville, VA, 22908, USA
| | - Yunge Zhao
- Department of Surgery, University of Virginia, P.O. Box 801359, Charlottesville, VA, 22908, USA
| | - J Robert Smith
- Department of Anatomy and Physiology, Kansas State University, Manhattan, KS, USA
| | - Mark L Weiss
- Department of Anatomy and Physiology, Kansas State University, Manhattan, KS, USA
| | - Irving L Kron
- Department of Surgery, University of Virginia, P.O. Box 801359, Charlottesville, VA, 22908, USA
| | - Victor E Laubach
- Department of Surgery, University of Virginia, P.O. Box 801359, Charlottesville, VA, 22908, USA
| | - Ashish K Sharma
- Department of Surgery, University of Virginia, P.O. Box 801359, Charlottesville, VA, 22908, USA.
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12
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Himmat S, Alzamil A, Aboelnazar N, Hatami S, White C, Dromparis P, Mengel M, Freed D, Nagendran J. A Decrease in Hypoxic Pulmonary Vasoconstriction Correlates With Increased Inflammation During Extended Normothermic Ex Vivo Lung Perfusion. Artif Organs 2017; 42:271-279. [PMID: 29266272 DOI: 10.1111/aor.13017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 07/12/2017] [Accepted: 08/04/2017] [Indexed: 02/06/2023]
Abstract
Normothermic ex vivo lung perfusion (EVLP) is an evolving technology to evaluate function of donor lungs to determine suitability for transplantation. We hypothesize that hypoxic pulmonary vasoconstriction (HPV) during EVLP will provide a more sensitive parameter of lung function to determine donor lung quality for lung transplantation. Eight porcine lungs were procured, and subsequently underwent EVLP with autologous blood and STEEN solution for 10 h. Standard physiologic parameters including dynamic compliance, peak airway pressure, and pulmonary vascular resistance (PVR) remained stable (P = 0.055), mean oxygenation (PO2 /FiO2 ) was 400 ± 18 mm Hg on average throughout perfusion. Response to hypoxia resulted in a robust increase in PVR (ΔPVR) up to 4 h of perfusion, however the HPV response then blunted beyond T6 (P < 0.01). The decrease in HPV response inversely correlated to cytokine concentrations of Interleukin-6 and tumor necrosis factor-α (P < 0.01). Despite acceptable lung oxygenation and standard physiologic parameters during 10 h of EVLP, there is a subclinical deterioration of lung function. HPV challenges can be performed during EVLP as a simple and more sensitive index of pulmonary vascular reactivity.
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Affiliation(s)
- Sayed Himmat
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada.,Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Almothana Alzamil
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada.,Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Nader Aboelnazar
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada.,Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Sanaz Hatami
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada.,Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Christopher White
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada.,Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Peter Dromparis
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - Michael Mengel
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - Darren Freed
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada.,Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada.,Division of Cardiac Surgery, Department of Surgery, Alberta Transplant Institute, Edmonton, Alberta, Canada.,Canadian National Transplant Research Program, Canadian Institute for Health Research, Edmonton, Alberta, Canada
| | - Jayan Nagendran
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada.,Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada.,Division of Cardiac Surgery, Department of Surgery, Alberta Transplant Institute, Edmonton, Alberta, Canada.,Canadian National Transplant Research Program, Canadian Institute for Health Research, Edmonton, Alberta, Canada
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Giwa S, Lewis JK, Alvarez L, Langer R, Roth AE, Church GM, Markmann JF, Sachs DH, Chandraker A, Wertheim JA, Rothblatt M, Boyden ES, Eidbo E, Lee WPA, Pomahac B, Brandacher G, Weinstock DM, Elliott G, Nelson D, Acker JP, Uygun K, Schmalz B, Weegman BP, Tocchio A, Fahy GM, Storey KB, Rubinsky B, Bischof J, Elliott JAW, Woodruff TK, Morris GJ, Demirci U, Brockbank KGM, Woods EJ, Ben RN, Baust JG, Gao D, Fuller B, Rabin Y, Kravitz DC, Taylor MJ, Toner M. The promise of organ and tissue preservation to transform medicine. Nat Biotechnol 2017; 35:530-542. [PMID: 28591112 PMCID: PMC5724041 DOI: 10.1038/nbt.3889] [Citation(s) in RCA: 298] [Impact Index Per Article: 42.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Accepted: 04/28/2017] [Indexed: 02/06/2023]
Abstract
The ability to replace organs and tissues on demand could save or improve millions of lives each year globally and create public health benefits on par with curing cancer. Unmet needs for organ and tissue preservation place enormous logistical limitations on transplantation, regenerative medicine, drug discovery, and a variety of rapidly advancing areas spanning biomedicine. A growing coalition of researchers, clinicians, advocacy organizations, academic institutions, and other stakeholders has assembled to address the unmet need for preservation advances, outlining remaining challenges and identifying areas of underinvestment and untapped opportunities. Meanwhile, recent discoveries provide proofs of principle for breakthroughs in a family of research areas surrounding biopreservation. These developments indicate that a new paradigm, integrating multiple existing preservation approaches and new technologies that have flourished in the past 10 years, could transform preservation research. Capitalizing on these opportunities will require engagement across many research areas and stakeholder groups. A coordinated effort is needed to expedite preservation advances that can transform several areas of medicine and medical science.
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Affiliation(s)
- Sebastian Giwa
- Organ Preservation Alliance, NASA Research Park, Moffett Field, California, USA
- Sylvatica Biotech, Inc., Charleston, South Carolina, USA
- Ossium Health, San Francisco, California, USA
| | - Jedediah K Lewis
- Organ Preservation Alliance, NASA Research Park, Moffett Field, California, USA
| | - Luis Alvarez
- Regenerative Biology Research Group, Cancer and Developmental Biology Laboratory, National Cancer Institute, Bethesda, Maryland, USA
- Walter Reed National Military Medical Center, Bethesda, Maryland, USA
- Department of Chemistry and Life Science, United States Military Academy, West Point, New York, USA
| | - Robert Langer
- Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | - Alvin E Roth
- Department of Economics, Stanford University, Stanford, California, USA
| | - George M Church
- Department of Genetics, Harvard Medical School, Boston, Massachusetts, USA
| | - James F Markmann
- Division of Transplant Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - David H Sachs
- Columbia Center for Translational Immunology, Columbia University Medical Center, New York, New York, USA
| | - Anil Chandraker
- American Society of Transplantation, Mt. Laurel, New Jersey, USA
- Transplantation Research Center, Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jason A Wertheim
- American Society of Transplant Surgeons, Arlington Virginia, USA
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | | | - Edward S Boyden
- MIT Media Lab and McGovern Institute, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | - Elling Eidbo
- Association of Organ Procurement Organizations, Vienna, Virginia, USA
| | - W P Andrew Lee
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Bohdan Pomahac
- Department of Surgery, Division of Plastic Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Gerald Brandacher
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - David M Weinstock
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Gloria Elliott
- Department of Mechanical Engineering and Engineering Science, University of North Carolina at Charlotte, Charlotte, North Carolina, USA
| | - David Nelson
- Department of Transplant Medicine, Nazih Zuhdi Transplant Institute, Integris Baptist Medical Center, Oklahoma City, Oklahoma, USA
| | - Jason P Acker
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
- Society for Cryobiology, Baltimore, Maryland, USA
| | - Korkut Uygun
- Department of Surgery, Center for Engineering in Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Boris Schmalz
- Organ Preservation Alliance, NASA Research Park, Moffett Field, California, USA
- Max Planck Institute of Psychiatry, Munich, Germany
| | - Brad P Weegman
- Organ Preservation Alliance, NASA Research Park, Moffett Field, California, USA
- Sylvatica Biotech, Inc., Charleston, South Carolina, USA
| | - Alessandro Tocchio
- Organ Preservation Alliance, NASA Research Park, Moffett Field, California, USA
- Department of Radiology, Stanford School of Medicine, Stanford, California, USA
| | - Greg M Fahy
- 21st Century Medicine, Fontana, California, USA
| | - Kenneth B Storey
- Institute of Biochemistry, Carleton University, Ottawa, Ontario, Canada
| | - Boris Rubinsky
- Department of Mechanical Engineering, University of California Berkeley, Berkeley, California, USA
| | - John Bischof
- Department of Mechanical Engineering, University of Minnesota, Minneapolis, Minnesota, USA
| | - Janet A W Elliott
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
- Department of Chemical and Materials Engineering, University of Alberta, Edmonton, Alberta, Canada
| | - Teresa K Woodruff
- Division of Obstetrics and Gynecology-Reproductive Science in Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | | | - Utkan Demirci
- Department of Radiology, Stanford School of Medicine, Stanford, California, USA
- Department of Electrical Engineering (by courtesy), Stanford, California, USA
| | | | - Erik J Woods
- Ossium Health, San Francisco, California, USA
- Society for Cryobiology, Baltimore, Maryland, USA
- Department of Microbiology and Immunology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Robert N Ben
- Department of Chemistry and Biomolecular Sciences, University of Ottawa, Ottawa, Ontario, Canada
| | - John G Baust
- Department of Biological Sciences, Binghamton University, State University of New York, Binghamton, New York, USA
| | - Dayong Gao
- Society for Cryobiology, Baltimore, Maryland, USA
- Department of Mechanical Engineering, University of Washington, Seattle, Washington, USA
| | - Barry Fuller
- Division of Surgery &Interventional Science, University College Medical School, Royal Free Hospital Campus, London, UK
| | - Yoed Rabin
- Department of Mechanical Engineering, Carnegie Mellon University, Pittsburgh, Pennsylvania, USA
| | | | - Michael J Taylor
- Sylvatica Biotech, Inc., Charleston, South Carolina, USA
- Department of Mechanical Engineering, Carnegie Mellon University, Pittsburgh, Pennsylvania, USA
- Department of Surgery, University of Arizona, Tucson, Arizona, USA
| | - Mehmet Toner
- Department of Surgery, Center for Engineering in Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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14
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Intratracheal Administration of Small Interfering RNA Targeting Fas Reduces Lung Ischemia-Reperfusion Injury. Crit Care Med 2017; 44:e604-13. [PMID: 26963318 DOI: 10.1097/ccm.0000000000001601] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Lung ischemia-reperfusion injury is the main cause of primary graft dysfunction after lung transplantation and results in increased morbidity and mortality. Fas-mediated apoptosis is one of the pathologic mechanisms involved in the development of ischemia-reperfusion injury. We hypothesized that the inhibition of Fas gene expression in lungs by intratracheal administration of small interfering RNA could reduce lung ischemia-reperfusion injury in an ex vivo model reproducing the procedural sequence of lung transplantation. DESIGN Prospective, randomized, controlled experimental study. SETTING University research laboratory. SUBJECTS C57/BL6 mice weighing 28-30 g. INTERVENTIONS Ischemia-reperfusion injury was induced in lungs isolated from mice, 48 hours after treatment with intratracheal small interfering RNA targeting Fas, control small interfering RNA, or vehicle. Isolated lungs were exposed to 6 hours of cold ischemia (4°C), followed by 2 hours of warm (37°C) reperfusion with a solution containing 10% of fresh whole blood and mechanical ventilation with constant low driving pressure. MEASUREMENTS AND MAIN RESULTS Fas gene expression was significantly silenced at the level of messenger RNA and protein after ischemia-reperfusion in lungs treated with small interfering RNA targeting Fas compared with lungs treated with control small interfering RNA or vehicle. Silencing of Fas gene expression resulted in reduced edema formation (bronchoalveolar lavage protein concentration and lung histology) and improvement in lung compliance. These effects were associated with a significant reduction of pulmonary cell apoptosis of lungs treated with small interfering RNA targeting Fas, which did not affect cytokine release and neutrophil infiltration. CONCLUSIONS Fas expression silencing in the lung by small interfering RNA is effective against ischemia-reperfusion injury. This approach represents a potential innovative strategy of organ preservation before lung transplantation.
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15
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Gennai S, Monsel A, Hao Q, Park J, Matthay MA, Lee JW. Microvesicles Derived From Human Mesenchymal Stem Cells Restore Alveolar Fluid Clearance in Human Lungs Rejected for Transplantation. Am J Transplant 2015; 15:2404-12. [PMID: 25847030 PMCID: PMC4792255 DOI: 10.1111/ajt.13271] [Citation(s) in RCA: 117] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Revised: 02/09/2015] [Accepted: 02/15/2015] [Indexed: 01/25/2023]
Abstract
The need to increase the donor pool for lung transplantation is a major public health issue. We previously found that administration of mesenchymal stem cells "rehabilitated" marginal donor lungs rejected for transplantation using ex vivo lung perfusion. However, the use of stem cells has some inherent limitation such as the potential for tumor formation. In the current study, we hypothesized that microvesicles, small anuclear membrane fragments constitutively released from mesenchymal stem cells, may be a good alternative to using stem cells. Using our well established ex vivo lung perfusion model, microvesicles derived from human mesenchymal stem cells increased alveolar fluid clearance (i.e. ability to absorb pulmonary edema fluid) in a dose-dependent manner, decreased lung weight gain following perfusion and ventilation, and improved airway and hemodynamic parameters compared to perfusion alone. Microvesicles derived from normal human lung fibroblasts as a control had no effect. Co-administration of microvesicles with anti-CD44 antibody attenuated these effects, suggesting a key role of the CD44 receptor in the internalization of the microvesicles into the injured host cell and its effect. In summary, microvesicles derived from human mesenchymal stem cells were as effective as the parent mesenchymal stem cells in rehabilitating marginal donor human lungs.
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Affiliation(s)
- S. Gennai
- Department of Emergency Medicine, Grenoble University Hospital, La Tronche, France
| | - A. Monsel
- Multidisciplinary Intensive Care Unit, Department of Anesthesiology and Critical Care, La Pitié-Salpêtrière Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Q. Hao
- Department of Anesthesiology, University of California San Francisco, San Francisco, CA
| | - J. Park
- Department of Anesthesiology, University of California San Francisco, San Francisco, CA
| | - M. A. Matthay
- Department of Anesthesiology, University of California San Francisco, San Francisco, CA
,Departments of Medicine, Anesthesiology and Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA
| | - J. W. Lee
- Department of Anesthesiology, University of California San Francisco, San Francisco, CA
,Corresponding author: Jae-Woo Lee,
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16
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Bennett SC, Beal EW, Dumond CA, Preston T, Ralston J, Pope-Harman A, Black S, Hayes Jr D, Whitson BA. Mechanical circulatory support in lung transplantation: Cardiopulmonary bypass, extracorporeal life support, and ex-vivo lung perfusion. World J Respirol 2015; 5:78-92. [DOI: 10.5320/wjr.v5.i2.78] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2014] [Revised: 03/15/2015] [Accepted: 04/20/2015] [Indexed: 02/06/2023] Open
Abstract
Lung transplant is the standard of care for patients with end-stage lung disease refractory to medical management. There is currently a critical organ shortage for lung transplantation with only 17% of offered organs being transplanted. Of those patients receiving a lung transplant, up to 25% will develop primary graft dysfunction, which is associated with an 8-fold increase in 30-d mortality. There are numerous mechanical lung assistance modalities that may be employed to help combat these challenges. We will discuss the use of mechanical lung assistance during lung transplantation, as a bridge to transplant, as a treatment for primary graft dysfunction, and finally as a means to remodel and evaluate organs deemed unsuitable for transplant, thus increasing the donor pool, improving survival to transplant, and improving overall patient survival.
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17
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Abrahimi P, Liu R, Pober JS. Blood Vessels in Allotransplantation. Am J Transplant 2015; 15:1748-54. [PMID: 25807965 DOI: 10.1111/ajt.13242] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Revised: 12/23/2014] [Accepted: 01/23/2015] [Indexed: 01/25/2023]
Abstract
Human vascularized allografts are perfused through blood vessels composed of cells (endothelium, pericytes, and smooth muscle cells) that remain largely of graft origin and are thus subject to host alloimmune responses. Graft vessels must be healthy to maintain homeostatic functions including control of perfusion, maintenance of permselectivity, prevention of thrombosis, and participation in immune surveillance. Vascular cell injury can cause dysfunction that interferes with these processes. Graft vascular cells can be activated by mediators of innate and adaptive immunity to participate in graft inflammation contributing to both ischemia/reperfusion injury and allograft rejection. Different forms of rejection may affect graft vessels in different ways, ranging from thrombosis and neutrophilic inflammation in hyperacute rejection, to endothelialitis/intimal arteritis and fibrinoid necrosis in acute cell-mediated or antibody-mediated rejection, respectively, and to diffuse luminal stenosis in chronic rejection. While some current therapies targeting the host immune system do affect graft vascular cells, direct targeting of the graft vasculature may create new opportunities for preventing allograft injury and loss.
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Affiliation(s)
- P Abrahimi
- Department of Immunobiology, Yale School of Medicine, New Haven, CT
| | - R Liu
- Department of Immunobiology, Yale School of Medicine, New Haven, CT
| | - J S Pober
- Department of Immunobiology, Yale School of Medicine, New Haven, CT
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18
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Schumer EM, Zoeller KA, Linsky PL, Monreal G, Choi Y, Giridharan GA, Sobieski MA, Slaughter MS, van Berkel VH. Feasibility Study of Pulsatile Left Ventricular Assist Device for Prolonged Ex Vivo Lung Perfusion. Ann Thorac Surg 2015; 99:1961-7; discussion 1967-8. [DOI: 10.1016/j.athoracsur.2015.02.087] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Revised: 02/10/2015] [Accepted: 02/18/2015] [Indexed: 11/17/2022]
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19
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Nakagiri T, Inoue M, Minami M, Hoshikawa Y, Chida M, Bando T, Oto T, Shiraishi T, Yamasaki N, Ashikari J, Sawa Y, Okumura M. Interim report of the Japanese original donor evaluation and management system: the medical consultant system. Surg Today 2015; 44:1227-31. [PMID: 24077998 DOI: 10.1007/s00595-013-0731-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Accepted: 06/04/2013] [Indexed: 11/29/2022]
Abstract
PURPOSE Lung transplantation (LTx) is an established therapy for end-stage lung failure. However, in Japan, the donor organ shortage is extremely severe compared with other developed countries, because of the strict Japanese Organ Transplantation Law. To maximize LTx opportunities in Japan, we have established a special donor evaluation and management system termed the medical consultant (MC) system. METHODS Data from 171 lung donor candidates registered in Japan from May 1998 to May 2012 were obtained and investigated in a retrospective manner. The candidates were separated into the non-MC-intervened and MC-intervened groups, and then data regarding the PaO2/FiO2 ratio, donation rate and organ survival rate were analyzed and compared between the groups. RESULTS The PaO2/FiO2 ratio of the MC-intervened group was ameliorated from the time of first brain death diagnosis to organ harvest. Although the base condition of the MC-intervened group was significantly worse than that of the non-MC-intervened group, the donation rates showed no significant difference (0.64 and 0.66, respectively; p = 0.89). There was a difference in the organ survival rate between the non-MC and MC-intervened groups (5-year survival rates of 67.2 and 88.3 %, respectively; p = 0.16). CONCLUSION The MC system used for organ donor evaluation and management in Japan has achieved acceptable interim results.
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20
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Tatham KC, O'Dea KP, Wakabayashi K, Marczin N, Takata M. The role of ex vivo lung perfusion in lung transplantation. J Intensive Care Soc 2014; 16:58-63. [PMID: 28979376 DOI: 10.1177/1751143714554062] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Whilst lung transplantation is a viable solution for end-stage lung disease, donor shortages, donor lung inflammation and perioperative lung injury remain major limitations. Ex vivo lung perfusion has emerged as the next frontier in lung transplantation to address and overcome these limitations, with multicentre clinical trials ongoing in the UK, rest of Europe and North America. Our research seeks to identify the poorly understood cellular and molecular mechanisms of primary graft dysfunction through the development of an isolated perfused lung model of transplantation and investigation of the role of pulmonary inflammation in this paradigm.
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Affiliation(s)
- Kate Colette Tatham
- Section of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Chelsea and Westminster Hospital NHS Foundation Trust, Imperial College, London, UK
| | - Kieran Patrick O'Dea
- Section of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Chelsea and Westminster Hospital NHS Foundation Trust, Imperial College, London, UK
| | - Kenji Wakabayashi
- Section of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Chelsea and Westminster Hospital NHS Foundation Trust, Imperial College, London, UK.,Office for Global Education and Career Development, International Exchange Centre, Tokyo Medical and Dental University, Tokyo, Japan
| | - Nandor Marczin
- Section of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Chelsea and Westminster Hospital NHS Foundation Trust, Imperial College, London, UK.,Department of Anaesthetics, The Royal Brompton and Harefield NHS Foundation Trust, Imperial College, London, UK
| | - Masao Takata
- Section of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Chelsea and Westminster Hospital NHS Foundation Trust, Imperial College, London, UK
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21
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Ciubotaru A, Haverich A. Ex vivo approach to treat failing organs: expanding the limits. Eur Surg Res 2014; 54:64-74. [PMID: 25358862 DOI: 10.1159/000367942] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2014] [Accepted: 08/26/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND Advanced organ failure is often classified as an end-stage disease where the treatment options are limited only to transplantation. As an alternative, different attempts have been undertaken to improve the outcome of the treatment of failing organs by using targeted ex vivo approaches. This may solve the issue of organ shortage by treating the donor organs before transplantation and the number of patients requiring transplantation may also be reduced by applying extensive ex vivo treatment followed by autotransplantation. METHODS We performed a literature review of PubMed and included articles published between 1962 and 2013. The following keywords were used (and; or): ex vivo, therapy, surgery, organ perfusion and autotransplantation. This review includes specific methods and attempts related to ex vivo organ perfusion and preservation, temporary life support systems, surgical and other therapeutic approaches, and diagnostic methods applied ex vivo to an isolated organ. RESULTS For the practical clinical use of ex vivo therapies, we could identify three major directions: (1) ex vivo pretransplant organ reconditioning, (2) ex vivo surgery and (3) ex vivo medical treatment. Different attempts have been made worldwide in the above-mentioned areas focusing on ex vivo organ preservation and treatment. We summarize in the present review the developments in the field of ex vivo organ recovery and evaluate the possibilities of combining and applying different technologies such as organ perfusion and storage, ex vivo exact topographical diagnosis, ex vivo locoregional medical treatment and ex vivo surgical correction. CONCLUSION Ex vivo therapies open new horizons in the treatment of end-stage organ pathologies.
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Affiliation(s)
- Anatol Ciubotaru
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
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22
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Chatterjee S, Nieman GF, Christie JD, Fisher AB. Shear stress-related mechanosignaling with lung ischemia: lessons from basic research can inform lung transplantation. Am J Physiol Lung Cell Mol Physiol 2014; 307:L668-80. [PMID: 25239915 DOI: 10.1152/ajplung.00198.2014] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Cessation of blood flow represents a physical event that is sensed by the pulmonary endothelium leading to a signaling cascade that has been termed "mechanotransduction." This paradigm has clinical relevance for conditions such as pulmonary embolism, lung bypass surgery, and organ procurement and storage during lung transplantation. On the basis of our findings with stop of flow, we postulate that normal blood flow is "sensed" by the endothelium by virtue of its location at the interface of the blood and vessel wall and that this signal is necessary to maintain the endothelial cell membrane potential. Stop of flow is sensed by a "mechanosome" consisting of PECAM-VEGF receptor-VE cadherin that is located in the endothelial cell caveolae. Activation of the mechanosome results in endothelial cell membrane depolarization that in turn leads to activation of NADPH oxidase (NOX2) to generate reactive oxygen species (ROS). Endothelial depolarization additionally results in opening of T-type voltage-gated Ca(2+) channels, increased intracellular Ca(2+), and activation of nitric oxide (NO) synthase with resultant generation of NO. Increased NO causes vasodilatation whereas ROS provide a signal for neovascularization; however, with lung transplantation overproduction of ROS and NO can cause oxidative injury and/or activation of proteins that drive inflammation and cell death. Understanding the key events in the mechanosignaling cascade has important lessons for the design of strategies or interventions that may reduce injury during storage of donor lungs with the goal to increase the availability of lungs suitable for donation and thus improving access to lung transplantation.
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Affiliation(s)
- Shampa Chatterjee
- Institute for Environmental Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennyslvania;
| | - Gary F Nieman
- Department of Surgery, SUNY Upstate Medical University, Syracuse, New York; and
| | - Jason D Christie
- Pulmonary Allergy and Critical Care Division, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Aron B Fisher
- Institute for Environmental Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennyslvania
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23
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Stanzi A, Neyrinck A, Somers J, Cauwenberghs H, Verbeken E, Santambrogio L, Van Raemdonck D. Do we need to cool the lung graft after ex vivo lung perfusion? A preliminary study. J Surg Res 2014; 192:647-55. [PMID: 25201574 DOI: 10.1016/j.jss.2014.07.068] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Revised: 07/26/2014] [Accepted: 07/31/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND After normothermic ex vivo lung perfusion (EVLP), pulmonary grafts are usually flush-cooled and stored on ice until implantation although evidence for this practice lacks. We compared outcomes between 2 post-EVLP preservation strategies in a porcine left single-lung transplantation model. MATERIAL AND METHODS After cold flush and 2-h EVLP, donor lungs were prepared and split. In [C], (n = 5) lungs cooled on device to 15°C were preserved in ice-water; in [W] (n = 5), lungs were disconnected from EVLP at 37°C and kept at room temperature. The left lung was transplanted in a recipient animal. Posttransplant, 6 h-monitoring included hourly assessment of pulmonary vascular resistance, pulmonary artery pressure, plateau airway pressure, compliance, and oxygenation before and after exclusion of the right lung. Lung biopsies and bronchoscopy with bronchoalveolar lavage (BAL) were performed at retrieval, at the end of EVLP (R lung), and 1 and 6 h after reperfusion (L lung). RESULTS Lungs in [W] showed the highest compliance (P < 0.05) and the lowest plateau airway pressure (not statistically significant) throughout the whole reperfusion period. Oxygenation and pulmonary artery pressure were similar between groups. Pulmonary vascular resistance was stable in [C], but rose after reperfusion in [W]. Histologic signs of lung injury and BAL neutrophilia were more pronounced in [C] at 1 h (not statistically significant and P < 0.05, respectively). BAL cytokine levels and lung tissue expression of intercellular adhesion molecule 1 did not differ between groups. CONCLUSIONS Normothermic preparation after EVLP results in similar graft performances compared with lung cooling after EVLP.
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Affiliation(s)
- Alessia Stanzi
- Laboratory for Experimental Thoracic Surgery, Department of Clinical and Experimental Medicine, KU Leuven University, Leuven, Belgium; Department of Thoracic Surgery, Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Arne Neyrinck
- Laboratory for Experimental Thoracic Surgery, Department of Clinical and Experimental Medicine, KU Leuven University, Leuven, Belgium; Department of Anesthesia, University Hospitals Leuven, Leuven, Belgium
| | - Jana Somers
- Laboratory for Experimental Thoracic Surgery, Department of Clinical and Experimental Medicine, KU Leuven University, Leuven, Belgium
| | - Hans Cauwenberghs
- Department of Anesthesia, University Hospitals Leuven, Leuven, Belgium
| | - Eric Verbeken
- Department of Pathology, University Hospitals Leuven, Leuven, Belgium
| | - Luigi Santambrogio
- Department of Thoracic Surgery, Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Dirk Van Raemdonck
- Laboratory for Experimental Thoracic Surgery, Department of Clinical and Experimental Medicine, KU Leuven University, Leuven, Belgium; Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium.
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24
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Machine perfusion in solid organ transplantation: where is the benefit? Langenbecks Arch Surg 2014; 399:421-7. [PMID: 24429900 DOI: 10.1007/s00423-014-1161-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Accepted: 01/01/2014] [Indexed: 12/26/2022]
Abstract
BACKGROUND Machine perfusion (MP) in solid organ transplantation has been a topic of variable importance for decades. At the dawn of organ transplantation, MP was one of the standard techniques for preservation; today's gold standard for organ preservation for transplantation is cold storage (CS). The outcome after transplantation of solid organs has tremendously improved over the last five decades. MP has been continuously under investigation and may be an option for organ preservation in selected cases; however, there is only little evidence from clinical trials that can be used to advocate for MP as a routine organ preservation method. METHODS This article reviews the current knowledge on MP in the field of solid organ transplantation with special focus on findings from clinical trials. CONCLUSION Especially in heart and lung transplantation, MP seems to be a promising tool to improve postoperative outcome, but a general evidence-based recommendation for or against an application of MP cannot be given due to the lack of the highest level of clinical evidence. Gold standards such as CS should not be left behind without good reason. Randomized clinical trials are desperately needed to further improve outcome and for better understanding of the underlying pathophysiological mechanisms.
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25
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Abstract
Setting up an extracorporeal life support program requires motivated experts, institutional commitment, and an interprofessional team of healthcare providers with dedicated time, space, and resources. This article provides guidance on the key steps involved in the process of developing a sustainable extracorporeal membrane oxygenation program, based on guidelines from the Extracorporeal Life Support Organization and from an international perspective.
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26
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Abstract
Lung transplantation may be the only intervention that can prolong survival and improve quality of life for those individuals with advanced lung disease who are acceptable candidates for the procedure. However, these candidates may be extremely ill and require ventilator and/or circulatory support as a bridge to transplantation, and lung transplantation recipients are at risk of numerous post-transplant complications that include surgical complications, primary graft dysfunction, acute rejection, opportunistic infection, and chronic lung allograft dysfunction (CLAD), which may be caused by chronic rejection. Many advances in pre- and post-transplant management have led to improved outcomes over the past decade. These include the creation of sound guidelines for candidate selection, improved surgical techniques, advances in donor lung preservation, an improving ability to suppress and treat allograft rejection, the development of prophylaxis protocols to decrease the incidence of opportunistic infection, more effective therapies for treating infectious complications, and the development of novel therapies to treat and manage CLAD. A major obstacle to prolonged survival beyond the early post-operative time period is the development of bronchiolitis obliterans syndrome (BOS), which is the most common form of CLAD. This manuscript discusses recent and evolving advances in the field of lung transplantation.
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27
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Van De Wauwer C, Munneke AJ, Engels GE, Berga FM, Rakhorst G, Nijsten MW, Mariani MA, Erasmus ME. In situ lung perfusion is a valuable tool to assess lungs from donation after circulatory death donors category I-II. Transpl Int 2013; 26:485-92. [DOI: 10.1111/tri.12068] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2012] [Revised: 11/01/2012] [Accepted: 01/06/2013] [Indexed: 01/15/2023]
Affiliation(s)
- Caroline Van De Wauwer
- Department of Cardiothoracic Surgery; University Medical Center Groningen; Groningen; The Netherlands
| | - Anita J. Munneke
- Department of Biomedical Engineering; University Medical Center Groningen; Groningen; The Netherlands
| | - Gerwin E. Engels
- Department of Biomedical Engineering; University Medical Center Groningen; Groningen; The Netherlands
| | - Foke M. Berga
- Department of Cardiothoracic Surgery; University Medical Center Groningen; Groningen; The Netherlands
| | - Gerhard Rakhorst
- Department of Biomedical Engineering; University Medical Center Groningen; Groningen; The Netherlands
| | - Maarten W. Nijsten
- Department of Critical Care; University Medical Center Groningen; Groningen; The Netherlands
| | - Massimo A. Mariani
- Department of Cardiothoracic Surgery; University Medical Center Groningen; Groningen; The Netherlands
| | - Michiel E. Erasmus
- Department of Cardiothoracic Surgery; University Medical Center Groningen; Groningen; The Netherlands
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