1
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Salehi S, Lippert Lozano E, Zhang Y, Guo Y, Liu R, Tran K, Messner F, Brandacher G, Grayson WL. Design of a Multiparametric Perfusion Bioreactor System for Evaluating Sub-Normothermic Preservation of Rat Abdominal Wall Vascularized Composite Allografts. Bioengineering (Basel) 2024; 11:307. [PMID: 38671729 PMCID: PMC11047557 DOI: 10.3390/bioengineering11040307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 03/04/2024] [Accepted: 03/07/2024] [Indexed: 04/28/2024] Open
Abstract
Static cold storage (SCS), the current clinical gold standard for organ preservation, provides surgeons with a limited window of time between procurement and transplantation. In vascularized composite allotransplantation (VCA), this time limitation prevents many viable allografts from being designated to the best-matched recipients. Machine perfusion (MP) systems hold significant promise for extending and improving organ preservation. Most of the prior MP systems for VCA have been built and tested for large animal models. However, small animal models are beneficial for high-throughput biomolecular investigations. This study describes the design and development of a multiparametric bioreactor with a circuit customized to perfuse rat abdominal wall VCAs. To demonstrate its concept and functionality, this bioreactor system was employed in a small-scale demonstrative study in which biomolecular metrics pertaining to graft viability were evaluated non-invasively and in real time. We additionally report a low incidence of cell death from ischemic necrosis as well as minimal interstitial edema in machine perfused grafts. After up to 12 h of continuous perfusion, grafts were shown to survive transplantation and reperfusion, successfully integrating with recipient tissues and vasculature. Our multiparametric bioreactor system for rat abdominal wall VCA provides an advanced framework to test novel techniques to enhance normothermic and sub-normothermic VCA preservations in small animal models.
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Affiliation(s)
- Sara Salehi
- Translational Tissue Engineering Center, Johns Hopkins University School of Medicine, 400 N. Broadway, Smith 5023, Baltimore, MD 21231, USA; (S.S.); (E.L.L.); (R.L.); (K.T.)
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD 21218, USA;
| | - Ernesto Lippert Lozano
- Translational Tissue Engineering Center, Johns Hopkins University School of Medicine, 400 N. Broadway, Smith 5023, Baltimore, MD 21231, USA; (S.S.); (E.L.L.); (R.L.); (K.T.)
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD 21218, USA;
| | - Yichuan Zhang
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD 21218, USA;
- Vascularized Composite Allotransplantation Laboratory, Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (Y.G.); (F.M.); (G.B.)
| | - Yinan Guo
- Vascularized Composite Allotransplantation Laboratory, Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (Y.G.); (F.M.); (G.B.)
| | - Renee Liu
- Translational Tissue Engineering Center, Johns Hopkins University School of Medicine, 400 N. Broadway, Smith 5023, Baltimore, MD 21231, USA; (S.S.); (E.L.L.); (R.L.); (K.T.)
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD 21218, USA;
| | - Kenny Tran
- Translational Tissue Engineering Center, Johns Hopkins University School of Medicine, 400 N. Broadway, Smith 5023, Baltimore, MD 21231, USA; (S.S.); (E.L.L.); (R.L.); (K.T.)
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD 21218, USA;
| | - Franka Messner
- Vascularized Composite Allotransplantation Laboratory, Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (Y.G.); (F.M.); (G.B.)
- Department of Visceral, Transplant and Thoracic Surgery, Innsbruck Medical University, 6020 Innsbruck, Austria
| | - Gerald Brandacher
- Vascularized Composite Allotransplantation Laboratory, Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (Y.G.); (F.M.); (G.B.)
- Department of Visceral, Transplant and Thoracic Surgery, Innsbruck Medical University, 6020 Innsbruck, Austria
| | - Warren L. Grayson
- Translational Tissue Engineering Center, Johns Hopkins University School of Medicine, 400 N. Broadway, Smith 5023, Baltimore, MD 21231, USA; (S.S.); (E.L.L.); (R.L.); (K.T.)
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD 21218, USA;
- Department of Materials Science and Engineering, Johns Hopkins University, Baltimore, MD 21218, USA
- Institute for Nanobiotechnology, Johns Hopkins University, Baltimore, MD 21218, USA
- Department of Chemical and Biomolecular Engineering, Johns Hopkins University, Baltimore, MD 2121, USA
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2
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Westhaver LP, Nersesian S, Arseneau RJ, Hefler J, Hargreaves BK, Edgar A, Azizieh Y, Cuesta-Gomez N, Izquierdo DL, Shapiro AJ, Gala-Lopez BL, Boudreau JE. Mitochondrial DNA levels in perfusate and bile during ex vivo normothermic machine correspond with donor liver quality. Heliyon 2024; 10:e27122. [PMID: 38463874 PMCID: PMC10920371 DOI: 10.1016/j.heliyon.2024.e27122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Accepted: 02/23/2024] [Indexed: 03/12/2024] Open
Abstract
Ex vivo normothermic machine perfusion (NMP) preserves donor organs and permits real-time assessment of allograft health, but the most effective indicators of graft viability are uncertain. Mitochondrial DNA (mtDNA), released consequent to traumatic cell injury and death, including the ischemia-reperfusion injury inherent in transplantation, may meet the need for a biomarker in this context. We describe a real time PCR-based approach to assess cell-free mtDNA during NMP as a universal biomarker of allograft quality. Measured in the perfusate fluid of 29 livers, the quantity of mtDNA correlated with metrics of donor liver health including International Normalized Ratio (INR), lactate, and warm ischemia time, and inversely correlated with inferior vena cava (IVC) flow during perfusion. Our findings endorse mtDNA as a simple and rapidly measured feature that can inform donor liver health, opening the possibility to better assess livers acquired from extended criteria donors to improve organ supply.
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Affiliation(s)
| | - Sarah Nersesian
- Department of Microbiology and Immunology, Dalhousie University, Halifax, NS, Canada
- Beatrice Hunter Cancer Research Institute, Halifax, NS, Canada
| | | | - Joshua Hefler
- Department of Surgery, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada
| | | | - Alexander Edgar
- Department of Microbiology and Immunology, Dalhousie University, Halifax, NS, Canada
| | - Yara Azizieh
- Department of Pathology, Dalhousie University, Halifax, NS, Canada
| | - Nerea Cuesta-Gomez
- Department of Surgery, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada
- Alberta Diabetes Institute, University of Alberta, Edmonton, AB, Canada
| | - Dayne L. Izquierdo
- Department of Surgery, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada
| | - A.M. James Shapiro
- Department of Surgery, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada
- Alberta Diabetes Institute, University of Alberta, Edmonton, AB, Canada
| | - Boris L. Gala-Lopez
- Department of Pathology, Dalhousie University, Halifax, NS, Canada
- Department of Microbiology and Immunology, Dalhousie University, Halifax, NS, Canada
- Beatrice Hunter Cancer Research Institute, Halifax, NS, Canada
- Department of Surgery, Dalhousie University, Halifax, NS, Canada
| | - Jeanette E. Boudreau
- Department of Pathology, Dalhousie University, Halifax, NS, Canada
- Department of Microbiology and Immunology, Dalhousie University, Halifax, NS, Canada
- Beatrice Hunter Cancer Research Institute, Halifax, NS, Canada
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3
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Zdyrski C, Gabriel V, Gessler TB, Ralston A, Sifuentes-Romero I, Kundu D, Honold S, Wickham H, Topping NE, Sahoo DK, Bista B, Tamplin J, Ospina O, Piñeyro P, Arriaga M, Galan JA, Meyerholz DK, Allenspach K, Mochel JP, Valenzuela N. Establishment and characterization of turtle liver organoids provides a potential model to decode their unique adaptations. Commun Biol 2024; 7:218. [PMID: 38388772 PMCID: PMC10883927 DOI: 10.1038/s42003-024-05818-1] [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: 09/27/2023] [Accepted: 01/15/2024] [Indexed: 02/24/2024] Open
Abstract
Painted turtles are remarkable for their freeze tolerance and supercooling ability along with their associated resilience to hypoxia/anoxia and oxidative stress, rendering them an ideal biomedical model for hypoxia-induced injuries (including strokes), tissue cooling during surgeries, and organ cryopreservation. Yet, such research is hindered by their seasonal reproduction and slow maturation. Here we developed and characterized adult stem cell-derived turtle liver organoids (3D self-assembled in vitro structures) from painted, snapping, and spiny softshell turtles spanning ~175My of evolution, with a subset cryopreserved. This development is, to the best of our knowledge, a first for this vertebrate Order, and complements the only other non-avian reptile organoids from snake venom glands. Preliminary characterization, including morphological, transcriptomic, and proteomic analyses, revealed organoids enriched in cholangiocytes. Deriving organoids from distant turtles and life stages demonstrates that our techniques are broadly applicable to chelonians, permitting the development of functional genomic tools currently lacking in herpetological research. Such platform could potentially support studies including genome-to-phenome mapping, gene function, genome architecture, and adaptive responses to climate change, with implications for ecological, evolutionary, and biomedical research.
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Affiliation(s)
- Christopher Zdyrski
- SMART Pharmacology, Department of Biomedical Sciences, Iowa State University, Ames, IA, USA.
- 3D Health Solutions Inc., Ames, IA, USA.
- SMART Pharmacology, Precision One Health Initiative, University of Georgia, Athens, GA, USA.
| | - Vojtech Gabriel
- SMART Pharmacology, Department of Biomedical Sciences, Iowa State University, Ames, IA, USA
| | - Thea B Gessler
- Department of Ecology, Evolution, and Organismal Biology, Iowa State University, Ames, IA, USA
| | | | - Itzel Sifuentes-Romero
- Department of Ecology, Evolution, and Organismal Biology, Iowa State University, Ames, IA, USA
| | - Debosmita Kundu
- Department of Statistics, Iowa State University, Ames, IA, USA
| | - Sydney Honold
- SMART Pharmacology, Department of Biomedical Sciences, Iowa State University, Ames, IA, USA
| | - Hannah Wickham
- SMART Pharmacology, Department of Biomedical Sciences, Iowa State University, Ames, IA, USA
| | - Nicholas E Topping
- Department of Ecology, Evolution, and Organismal Biology, Iowa State University, Ames, IA, USA
| | - Dipak Kumar Sahoo
- Department of Veterinary Clinical Sciences, Iowa State University, Ames, IA, USA
| | - Basanta Bista
- Department of Ecology, Evolution, and Organismal Biology, Iowa State University, Ames, IA, USA
| | - Jeffrey Tamplin
- Department of Biology, University of Northern Iowa, Cedar Falls, IA, USA
| | - Oscar Ospina
- Department of Biostatistics and Bioinformatics, Moffitt Cancer Center, Tampa, FL, USA
| | - Pablo Piñeyro
- Veterinary Diagnostic Laboratory, Iowa State University, Ames, IA, USA
| | - Marco Arriaga
- Department of Human Genetics, University of Texas Rio Grande Valley, Brownsville, TX, USA
| | - Jacob A Galan
- Department of Human Genetics, University of Texas Rio Grande Valley, Brownsville, TX, USA
| | | | - Karin Allenspach
- SMART Pharmacology, Department of Biomedical Sciences, Iowa State University, Ames, IA, USA
- 3D Health Solutions Inc., Ames, IA, USA
- Department of Veterinary Clinical Sciences, Iowa State University, Ames, IA, USA
- SMART Pharmacology, Precision One Health Initiative, University of Georgia, Athens, GA, USA
| | - Jonathan P Mochel
- SMART Pharmacology, Department of Biomedical Sciences, Iowa State University, Ames, IA, USA
- 3D Health Solutions Inc., Ames, IA, USA
- SMART Pharmacology, Precision One Health Initiative, University of Georgia, Athens, GA, USA
| | - Nicole Valenzuela
- Department of Ecology, Evolution, and Organismal Biology, Iowa State University, Ames, IA, USA.
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4
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Tang G, Zhang L, Xia L, Zhang J, Wei Z, Zhou R. Hypothermic oxygenated perfusion in liver transplantation: a meta-analysis of randomized controlled trials and matched studies. Int J Surg 2024; 110:464-477. [PMID: 37738017 PMCID: PMC10793758 DOI: 10.1097/js9.0000000000000784] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 09/10/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND Hypothermic oxygenated machine perfusion (HOPE) is a novel organ-preservation technology designed to optimize organ quality. However, the effects of HOPE on morbidity and mortality after liver transplantation remain unclear. This meta-analysis evaluated the potential benefits of HOPE in liver transplantation. MATERIALS AND METHODS The Embase, Web of Science, PubMed, Cochrane Library, and Scopus databases were searched for articles published up to 15 June 2023 (updated on 12 August 2023). Mean differences (MDs), risk ratios (RRs), and 95% confidence intervals were calculated. RESULTS Eleven studies encompassing five randomized controlled trials and six matched studies were included, with a total of 1000 patients. HOPE did not reduce the incidence of major postoperative complications (RR 0.80), primary non-function (PNF) (RR 0.54), reperfusion syndrome (RR 0.92), hepatic artery thrombosis (RR 0.92), renal replacement therapy (RR 0.98), length of hospital stay (MD, -1.38 days), 1-year recipient death (RR 0.67), or intensive care unit stay (MD, 0.19 days) after liver transplantation. HOPE reduced the incidence of biliary complications (RR 0.74), non-anastomotic biliary strictures (NAS) (RR 0.34), early allograft dysfunction (EAD) (RR 0.54), and acute rejection (RR 0.54). In addition, HOPE improved the retransplantation (RR 0.42) and 1-year graft loss rates (RR 0.38). CONCLUSIONS Compared with static cold storage (SCS), HOPE can reduce the incidence of biliary complications, NAS, EAD, and acute rejection and retransplantation rate after liver transplantation and improve the 1-year graft loss rate. These findings suggest that HOPE, when compared to SCS, can contribute to minimizing complications and enhancing graft survival in liver transplantation. Further research is needed to investigate long-term outcomes and confirm the promising advantages of HOPE in liver transplantation settings.
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Affiliation(s)
- Gang Tang
- Biliary Surgical Department of West China Hospital
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, People’s Republic of China
| | | | - Lingying Xia
- Biliary Surgical Department of West China Hospital
- Center for Translational Medicine, West China Second University Hospital, Sichuan University, Chengdu, Sichuan
| | - Jie Zhang
- Biliary Surgical Department of West China Hospital
| | - Zhengqiang Wei
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, People’s Republic of China
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Tingle SJ, Dobbins JJ, Thompson ER, Figueiredo RS, Mahendran B, Pandanaboyana S, Wilson C. Machine perfusion in liver transplantation. Cochrane Database Syst Rev 2023; 9:CD014685. [PMID: 37698189 PMCID: PMC10496129 DOI: 10.1002/14651858.cd014685.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/13/2023]
Abstract
BACKGROUND Liver transplantation is the only chance of cure for people with end-stage liver disease and some people with advanced liver cancers or acute liver failure. The increasing prevalence of these conditions drives demand and necessitates the increasing use of donated livers which have traditionally been considered suboptimal. Several novel machine perfusion preservation technologies have been developed, which attempt to ameliorate some of the deleterious effects of ischaemia reperfusion injury. Machine perfusion technology aims to improve organ quality, thereby improving outcomes in recipients of suboptimal livers when compared to traditional static cold storage (SCS; ice box). OBJECTIVES To evaluate the effects of different methods of machine perfusion (including hypothermic oxygenated machine perfusion (HOPE), normothermic machine perfusion (NMP), controlled oxygenated rewarming, and normothermic regional perfusion) versus each other or versus static cold storage (SCS) in people undergoing liver transplantation. SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search date was 10 January 2023. SELECTION CRITERIA We included randomised clinical trials which compared different methods of machine perfusion, either with each other or with SCS. Studies comparing HOPE via both hepatic artery and portal vein, or via portal vein only, were grouped. The protocol detailed that we also planned to include quasi-randomised studies to assess treatment harms. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcomes were 1. overall participant survival, 2. quality of life, and 3. serious adverse events. Secondary outcomes were 4. graft survival, 5. ischaemic biliary complications, 6. primary non-function of the graft, 7. early allograft function, 8. non-serious adverse events, 9. transplant utilisation, and 10. transaminase release during the first week post-transplant. We assessed bias using Cochrane's RoB 2 tool and used GRADE to assess certainty of evidence. MAIN RESULTS We included seven randomised trials (1024 transplant recipients from 1301 randomised/included livers). All trials were parallel two-group trials; four compared HOPE versus SCS, and three compared NMP versus SCS. No trials used normothermic regional perfusion. When compared with SCS, it was uncertain whether overall participant survival was improved with either HOPE (hazard ratio (HR) 0.91, 95% confidence interval (CI) 0.42 to 1.98; P = 0.81, I2 = 0%; 4 trials, 482 recipients; low-certainty evidence due to imprecision because of low number of events) or NMP (HR 1.08, 95% CI 0.31 to 3.80; P = 0.90; 1 trial, 222 recipients; very low-certainty evidence due to imprecision and risk of bias). No trials reported quality of life. When compared with SCS alone, HOPE was associated with improvement in the following clinically relevant outcomes: graft survival (HR 0.45, 95% CI 0.23 to 0.87; P = 0.02, I2 = 0%; 4 trials, 482 recipients; high-certainty evidence), serious adverse events in extended criteria DBD liver transplants (OR 0.45, 95% CI 0.22 to 0.91; P = 0.03, I2 = 0%; 2 trials, 156 participants; moderate-certainty evidence) and clinically significant ischaemic cholangiopathy in recipients of DCD livers (OR 0.31, 95% CI 0.11 to 0.92; P = 0.03; 1 trial, 156 recipients; high-certainty evidence). In contrast, NMP was not associated with improvement in any of these clinically relevant outcomes. NMP was associated with improved utilisation compared with SCS (one trial found a 50% lower rate of organ discard; P = 0.008), but the reasons underlying this effect are unknown. We identified 11 ongoing studies investigating machine perfusion technologies. AUTHORS' CONCLUSIONS In situations where the decision has been made to transplant a liver donated after circulatory death or donated following brain death, end-ischaemic HOPE will provide superior clinically relevant outcomes compared with SCS alone. Specifically, graft survival is improved (high-certainty evidence), serious adverse events are reduced (moderate-certainty evidence), and in donors after circulatory death, clinically relevant ischaemic biliary complications are reduced (high-certainty evidence). There is no good evidence that NMP has the same benefits over SCS in terms of these clinically relevant outcomes. NMP does appear to improve utilisation of grafts that would otherwise be discarded with SCS; however, the reasons for this, and whether this effect is specific to NMP, is not clear. Further studies into NMP viability criteria and utilisation, as well as head-to-head trials with other perfusion technologies are needed. In the setting of donation following circulatory death transplantation, further trials are needed to assess the effect of these ex situ machine perfusion methods against, or in combination with, normothermic regional perfusion.
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Affiliation(s)
- Samuel J Tingle
- NIHR Blood and Transplant Research Unit, Newcastle University and Cambridge University, Newcastle upon Tyne, UK
| | | | - Emily R Thompson
- Institute of Transplantation, The Freeman Hospital, Newcastle upon Tyne, UK
| | | | | | - Sanjay Pandanaboyana
- HPB and Liver Transplant Surgery, Freeman Hospital, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Colin Wilson
- Institute of Transplantation, The Freeman Hospital, Newcastle upon Tyne, UK
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Biliary Complications After Liver Transplantation in the United States: Changing Trends and Economic Implications. Transplantation 2023; 107:e127-e138. [PMID: 36928182 DOI: 10.1097/tp.0000000000004528] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
BACKGROUND Biliary complications (BCs) continue to impact patient and graft survival after liver transplant (LT), despite improvements in organ preservation, surgical technique, and posttransplant care. Real-world evidence provides a national estimate of the incidence of BC after LT, implications for patient and graft outcomes, and attributable cost not available in transplant registry data. METHODS An administrative health claims-based BC identification algorithm was validated using electronic health records (N = 128) and then applied to nationally linked Medicare and transplant registry claims. RESULTS The real-world evidence algorithm identified 97% of BCs in the electronic health record review. Nationally, the incidence of BCs within 1 y of LT appears to have improved from 22.2% in 2002 to 20.8% in 2018. Factors associated with BCs include donor type (living versus deceased), recipient age, diagnosis, prior transplant, donor age, and donor cause of death. BCs increased the risk-adjusted hazard ratio (aHR) for posttransplant death (aHR, 1.43; P < 0.0001) and graft loss (aHR, 1.48; P < 0.0001). Nationally, BCs requiring intervention increased risk-adjusted first-year Medicare spending by $39 710 (P < 0.0001). CONCLUSIONS BCs remain an important cause of morbidity and expense after LT and would benefit from a systematic quality-improvement program.
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Banker A, Bhatt N, Rao PS, Agrawal P, Shah M, Nayak M, Mohanka R. A Review of Machine Perfusion Strategies in Liver Transplantation. J Clin Exp Hepatol 2023; 13:335-349. [PMID: 36950485 PMCID: PMC10025749 DOI: 10.1016/j.jceh.2022.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 07/26/2022] [Accepted: 08/02/2022] [Indexed: 02/17/2023] Open
Abstract
The acceptance of liver transplantation as the standard of care for end-stage liver diseases has led to a critical shortage of donor allografts. To expand the donor organ pool, many countries have liberalized the donor criteria including extended criteria donors and donation after circulatory death. These marginal livers are at a higher risk of injury when they are preserved using the standard static cold storage (SCS) preservation techniques. In recent years, research has focused on optimizing organ preservation techniques to protect these marginal livers. Machine perfusion (MP) of the expanded donor liver has witnessed considerable advancements in the last decade. Research has showed MP strategies to confer significant advantages over the SCS techniques, such as longer preservation times, viability assessment and the potential to recondition high risk allografts prior to implantation. In this review article, we address the topic of MP in liver allograft preservation, with emphasis on current trends in clinical application. We discuss the relevant clinical trials related to the techniques of hypothermic MP, normothermic MP, hypothermic oxygenated MP, and controlled oxygenated rewarming. We also discuss the potential applications of ex vivo therapeutics which may be relevant in the future to further optimize the allograft prior to transplantation.
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Key Words
- ALP, Alkaline phosphatase
- ALT, Alanine transaminase
- ASO, Antisense oligonucleotides
- AST, Aspartate transaminase
- CIT, Cold ischemia times
- COPE, Consortium for Organ Preservation in Europe
- COR, Controlled oxygenated rewarming
- DBD, Donation after brain death
- DCD, Donation after circulatory death
- DHOPE, dual hypothermic oxygenated machine perfusion
- EAD, Early allograft dysfunction
- ECD, Extended criteria donors
- ETC, Electron transport chain
- GGT, Gamma glutamyl transferase
- HCV, Hepatitis C virus
- HMP, Hypothermic machine perfusion
- HOPE, Hypothermic oxygenated machine perfusion
- ICU, Intensive care unit
- IGL, Institute George Lopez-1
- INR, International normalized ratio
- IRI, ischemia reperfusion injury
- LDH, Lactate dehydrogenase
- MELD, Model for end-stage liver disease
- MP, Machine perfusion
- NAS, Non-anastomotic biliary strictures
- NMP, Normothermic machine perfusion
- NO, Nitric oxide
- PNF, Primary nonfunction
- ROS, Reactive oxygen species
- RT-PCR, Reverse transcription polymerase chain reaction
- SNMP, Sub-normothermic machine perfusion
- UW, University of Wisconsin
- WIT, Warm ischemia times
- hypothermic machine perfusion
- hypothermic oxygenated machine perfusion
- machine perfusion
- normothermic machine perfusion
- static cold storage
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Affiliation(s)
- Amay Banker
- Department of Liver Transplant and HPB Surgery, Sir HN Reliance Foundation Hospital, Mumbai, India
| | - Neha Bhatt
- Department of Liver Transplant and HPB Surgery, Sir HN Reliance Foundation Hospital, Mumbai, India
| | - Prashantha S. Rao
- Department of Liver Transplant and HPB Surgery, Sir HN Reliance Foundation Hospital, Mumbai, India
| | - Pravin Agrawal
- Department of Liver Transplant and HPB Surgery, Sir HN Reliance Foundation Hospital, Mumbai, India
| | - Mitul Shah
- Department of Liver Transplant and HPB Surgery, Sir HN Reliance Foundation Hospital, Mumbai, India
| | - Madhavi Nayak
- Department of Liver Transplant and HPB Surgery, Sir HN Reliance Foundation Hospital, Mumbai, India
| | - Ravi Mohanka
- Department of Liver Transplant and HPB Surgery, Sir HN Reliance Foundation Hospital, Mumbai, India
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8
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Azizieh Y, Westhaver LP, Badrudin D, Boudreau JE, Gala-Lopez BL. Changing liver utilization and discard rates in clinical transplantation in the ex-vivo machine preservation era. FRONTIERS IN MEDICAL TECHNOLOGY 2023; 5:1079003. [PMID: 36908294 PMCID: PMC9996101 DOI: 10.3389/fmedt.2023.1079003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 01/30/2023] [Indexed: 02/25/2023] Open
Abstract
Liver transplantation is a well-established treatment for many with end-stage liver disease. Unfortunately, the increasing organ demand has surpassed the donor supply, and approximately 30% of patients die while waiting for a suitable liver. Clinicians are often forced to consider livers of inferior quality to increase organ donation rates, but ultimately, many of those organs end up being discarded. Extensive testing in experimental animals and humans has shown that ex-vivo machine preservation allows for a more objective characterization of the graft outside the body, with particular benefit for suboptimal organs. This review focuses on the history of the implementation of ex-vivo liver machine preservation and how its enactment may modify our current concept of organ acceptability. We provide a brief overview of the major drivers of organ discard (age, ischemia time, steatosis, etc.) and how this technology may ultimately revert such a trend. We also discuss future directions for this technology, including the identification of new markers of injury and repair and the opportunity for other ex-vivo regenerative therapies. Finally, we discuss the value of this technology, considering current and future donor characteristics in the North American population that may result in a significant organ discard.
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Affiliation(s)
- Yara Azizieh
- Department of Pathology, Dalhousie University, Halifax, NS, Canada
| | | | - David Badrudin
- Department of Surgery, Université de Montréal, Montréal, QC, Canada
| | - Jeanette E Boudreau
- Department of Pathology, Dalhousie University, Halifax, NS, Canada.,Department of Microbiology and Immunology, Dalhousie University, Halifax, NS, Canada.,Beatrice Hunter Cancer Research Institute, Halifax, NS, Canada
| | - Boris L Gala-Lopez
- Department of Pathology, Dalhousie University, Halifax, NS, Canada.,Department of Microbiology and Immunology, Dalhousie University, Halifax, NS, Canada.,Beatrice Hunter Cancer Research Institute, Halifax, NS, Canada.,Department of Surgery, Dalhousie University, Halifax, NS, Canada
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9
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Muller X, Rossignol G, Mohkam K, Mabrut JY. Novel strategies in liver graft preservation - The French perspective. J Visc Surg 2022; 159:389-398. [PMID: 36109331 DOI: 10.1016/j.jviscsurg.2022.06.006] [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: 10/14/2022]
Abstract
Given the increasing graft shortage, the transplant community is forced to use so called marginal liver grafts with a higher susceptibility to ischemia-reperfusion injury. This exposes the recipient to a higher risk of graft failure and post-transplant complications. While static cold storage remains the gold standard in low-risk transplant scenarios, dynamic preservation strategies may allow to improve outcomes after transplantation of marginal liver grafts. Two dynamic preservation strategies, end-ischemic hypothermic oxygenated perfusion (HOPE) and continuous normothermic machine perfusion (cNMP), have been evaluated in randomized clinical trials. The results show improved preservation of liver grafts after cNMP and reduction of post-transplant biliary complications after HOPE. In comparison to cNMP, HOPE has the advantage of requiring less logistics and expertise with the possibility to return to default static cold storage. Both strategies allow to assess graft viability prior to transplantation and may thus contribute to optimizing graft selection and reducing discard rates. The use of dynamic preservation is rapidly increasing in France and results from a national randomized trial on the use of HOPE in marginal grafts will soon be available. Future applications should focus on controlled donation after circulatory death liver grafts, split grafts and graft treatment during perfusion. The final aim of dynamic liver graft preservation is to improve post-transplant outcomes, increase the number of transplanted grafts and allow expansion of transplant indications.
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Affiliation(s)
- X Muller
- Department of General Surgery and Liver Transplantation, Croix-Rousse University Hospital, Hospices Civils de Lyon, Lyon, France; The Lyon Cancer Research Centre, Inserm U1052 UMR 5286, Lyon, France; ED 340 BMIC, Claude-Bernard Lyon 1 University, 69622 Villeurbanne, France.
| | - G Rossignol
- Department of General Surgery and Liver Transplantation, Croix-Rousse University Hospital, Hospices Civils de Lyon, Lyon, France; The Lyon Cancer Research Centre, Inserm U1052 UMR 5286, Lyon, France; ED 340 BMIC, Claude-Bernard Lyon 1 University, 69622 Villeurbanne, France; Department of Pediatric Surgery and Liver Transplantation, Femme-Mère-Enfant University Hospital, Hospices Civils de Lyon, Lyon, France
| | - K Mohkam
- Department of General Surgery and Liver Transplantation, Croix-Rousse University Hospital, Hospices Civils de Lyon, Lyon, France; The Lyon Cancer Research Centre, Inserm U1052 UMR 5286, Lyon, France; Department of Pediatric Surgery and Liver Transplantation, Femme-Mère-Enfant University Hospital, Hospices Civils de Lyon, Lyon, France
| | - J Y Mabrut
- Department of General Surgery and Liver Transplantation, Croix-Rousse University Hospital, Hospices Civils de Lyon, Lyon, France; The Lyon Cancer Research Centre, Inserm U1052 UMR 5286, Lyon, France
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Schlegel A, Porte R, Dutkowski P. Protective mechanisms and current clinical evidence of hypothermic oxygenated machine perfusion (HOPE) in preventing post-transplant cholangiopathy. J Hepatol 2022; 76:1330-1347. [PMID: 35589254 DOI: 10.1016/j.jhep.2022.01.024] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 01/10/2022] [Accepted: 01/31/2022] [Indexed: 12/12/2022]
Abstract
The development of cholangiopathies after liver transplantation impacts on the quality and duration of graft and patient survival, contributing to higher costs as numerous interventions are required to treat strictures and infections at the biliary tree. Prolonged donor warm ischaemia time in combination with additional cold storage are key risk factors for the development of biliary strictures. Based on this, the clinical implementation of dynamic preservation strategies is a current hot topic in the field of donation after circulatory death (DCD) liver transplantation. Despite various retrospective studies reporting promising results, also regarding biliary complications, there are only a few randomised-controlled trials on machine perfusion. Recently, the group from Groningen has published the first randomised-controlled trial on hypothermic oxygenated perfusion (HOPE), demonstrating a significant reduction of symptomatic ischaemic cholangiopathies with the use of a short period of HOPE before DCD liver implantation. The most likely mechanism for this important effect, also shown in several experimental studies, is based on mitochondrial reprogramming under hypothermic aerobic conditions, e.g. exposure to oxygen in the cold, with a controlled and slow metabolism of ischaemically accumulated succinate and simultaneous ATP replenishment. This unique feature prevents mitochondrial oxidative injury and further downstream tissue inflammation. HOPE treatment therefore supports livers by protecting them from ischaemia-reperfusion injury (IRI), and thereby also prevents the development of post-transplant biliary injury. With reduced IRI-associated inflammation, recipients are also protected from activation of the innate immune system, with less acute rejections seen after HOPE.
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Affiliation(s)
- Andrea Schlegel
- Department of Visceral Surgery and Transplantation, University Hospital Zurich, Swiss HPB and Transplant Center, Zurich, Switzerland; General and Liver Transplant Surgery Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20100 Milan, Italy
| | - Robert Porte
- Department of Surgery, Surgical Research Laboratory, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Philipp Dutkowski
- Department of Visceral Surgery and Transplantation, University Hospital Zurich, Swiss HPB and Transplant Center, Zurich, Switzerland.
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De Simone P, Ghinolfi D. Hospital-Based Health Technology Assessment of Machine Perfusion Systems for Human Liver Transplantation. Transpl Int 2022; 35:10405. [PMID: 35692735 PMCID: PMC9184439 DOI: 10.3389/ti.2022.10405] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 05/05/2022] [Indexed: 01/14/2023]
Abstract
Based on published data, we have carried out a hospital-based health technology assessment of machine perfusion in adult liver transplantation using cold storage as a comparator, and within the perspective of a national health system-based hospital practice and disease-related group reimbursement policy. A systematic literature review on machine perfusion for adult liver transplantation was conducted exploring the Pubmed, CINAHL, Scopus, Embase, and Cochrane databases. The literature was analyzed with the intent to provide information on 6 dimensions and 19 items of the hospital-based health technology assessment framework derived from previous studies. Out of 705 references, 47 (6.7%) were retained for current analysis. Use of machine perfusion was associated with advantages over cold storage, i.e., a 10%–50% reduced risk for early allograft dysfunction, 7%–15% less ischemia reperfusion injury; 7%–50% fewer ischemic biliary complications, comparable or improved 1-year graft and patient survival, and up to a 50% lower graft discard rate. Hospital stay was not longer, and technical failures were anecdotal. Information on costs of machine perfusion is limited, but this technology is projected to increase hospital costs while cost-effectiveness analysis requires data over the transplant patient lifetime. No hospital-based health technology assessment study on machine perfusion in liver transplantation was previously conducted. From the hospital perspective, there is evidence of the clinical advantages of this novel technology, but strategies to counterbalance the increased costs of liver transplantation are urgently needed. Further studies should focus on the ethical, social, and organizational issues related to machine perfusion.
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Affiliation(s)
- Paolo De Simone
- Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
- Department of Surgical, Medical, Biomolecular Pathology and Intensive Care Unit, University of Pisa, Pisa, Italy
- *Correspondence: Paolo De Simone,
| | - Davide Ghinolfi
- Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
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12
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Predictors of Long-Term Outcomes After Liver Transplantation Depending on the Length of Cold Ischemia Time. Transplant Proc 2022; 54:1025-1028. [PMID: 35644686 DOI: 10.1016/j.transproceed.2022.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Revised: 02/19/2022] [Accepted: 03/14/2022] [Indexed: 11/22/2022]
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13
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Knijff LWD, van Kooten C, Ploeg RJ. The Effect of Hypothermic Machine Perfusion to Ameliorate Ischemia-Reperfusion Injury in Donor Organs. Front Immunol 2022; 13:848352. [PMID: 35572574 PMCID: PMC9099247 DOI: 10.3389/fimmu.2022.848352] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 04/04/2022] [Indexed: 12/23/2022] Open
Abstract
Hypothermic machine perfusion (HMP) has become the new gold standard in clinical donor kidney preservation and a promising novel strategy in higher risk donor livers in several countries. As shown by meta-analysis for the kidney, HMP decreases the risk of delayed graft function (DGF) and improves graft survival. For the liver, HMP immediately prior to transplantation may reduce the chance of early allograft dysfunction (EAD) and reduce ischemic sequelae in the biliary tract. Ischemia-reperfusion injury (IRI), unavoidable during transplantation, can lead to massive cell death and is one of the main causes for DGF, EAD or longer term impact. Molecular mechanisms that are affected in IRI include levels of hypoxia inducible factor (HIF), induction of cell death, endothelial dysfunction and immune responses. In this review we have summarized and discussed mechanisms on how HMP can ameliorate IRI. Better insight into how HMP influences IRI in kidney and liver transplantation may lead to new therapies and improved transplant outcomes.
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Affiliation(s)
- Laura W. D. Knijff
- Nephrology, Department of Internal Medicine, Leiden University Medical Centre, Leiden, Netherlands
- Transplant Centre of the Leiden University Medical Centre, Leiden University Medical Centre, Leiden, Netherlands
| | - Cees van Kooten
- Nephrology, Department of Internal Medicine, Leiden University Medical Centre, Leiden, Netherlands
- Transplant Centre of the Leiden University Medical Centre, Leiden University Medical Centre, Leiden, Netherlands
| | - Rutger J. Ploeg
- Transplant Centre of the Leiden University Medical Centre, Leiden University Medical Centre, Leiden, Netherlands
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
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14
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Early Postoperative Transaminase Activities Affecting Early and Late Liver Graft Survival. Transplant Proc 2022; 54:1021-1024. [PMID: 35461712 DOI: 10.1016/j.transproceed.2022.02.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 02/09/2022] [Indexed: 11/20/2022]
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15
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Necroptosis in Solid Organ Transplantation: A Literature Overview. Int J Mol Sci 2022; 23:ijms23073677. [PMID: 35409037 PMCID: PMC8998671 DOI: 10.3390/ijms23073677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 03/21/2022] [Accepted: 03/25/2022] [Indexed: 12/04/2022] Open
Abstract
Ischemia-reperfusion injury (IRI) is encountered in various stages during solid organ transplantation (SOT). IRI is known to be a multifactorial inflammatory condition involving hypoxia, metabolic stress, leukocyte extravasation, cellular death (including apoptosis, necrosis and necroptosis) and an activation of immune response. Although the cycle of sterile inflammation during IRI is consistent among different organs, the underlying mechanisms are poorly understood. Receptor-interacting protein kinase 3 (RIPK3) and mixed-lineage kinase domain-like pseudokinase (MLKL) are thought to be crucial in the implementation of necroptosis. Moreover, apart from “silent” apoptotic death, necrosis also causes sterile inflammation—necroinflammation, which is triggered by various damage-associated molecular patterns (DAMPs). Those DAMPs activate the innate immune system, causing local and systemic inflammatory responses, which can result in graft failure. In this overview we summarize knowledge on mechanisms of sterile inflammation processes during SOT with special focus on necroptosis and IRI and discuss protective strategies.
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Mao XL, Cai Y, Chen YH, Wang Y, Jiang XX, Ye LP, Li SW. Novel Targets and Therapeutic Strategies to Protect Against Hepatic Ischemia Reperfusion Injury. Front Med (Lausanne) 2022; 8:757336. [PMID: 35059411 PMCID: PMC8764312 DOI: 10.3389/fmed.2021.757336] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 12/08/2021] [Indexed: 12/16/2022] Open
Abstract
Hepatic ischemia reperfusion injury (IRI), a fascinating topic that has drawn a lot of interest in the last few years, is a major complication caused by a variety of clinical situations, such as liver transplantation, severe trauma, vascular surgery, and hemorrhagic shock. The IRI process involves a series of complex events, including mitochondrial deenergization, metabolic acidosis, adenosine-5'-triphosphate depletion, Kupffer cell activation, calcium overload, oxidative stress, and the upregulation of pro-inflammatory cytokine signal transduction. A number of protective strategies have been reported to ameliorate IRI, including pharmacological therapy, ischemic pre-conditioning, ischemic post-conditioning, and machine reperfusion. However, most of these strategies are only at the stage of animal model research at present, and the potential mechanisms and exact therapeutic targets have yet to be clarified. IRI remains a main cause of postoperative liver dysfunction, often leading to postoperative morbidity or even mortality. Very recently, it was reported that the activation of peroxisome proliferator-activated receptor γ (PPARγ), a member of a superfamily of nuclear transcription factors activated by agonists, can attenuate IRI in the liver, and FAM3A has been confirmed to mediate the protective effect of PPARγ in hepatic IRI. In addition, non-coding RNAs, like LncRNAs and miRNAs, have also been reported to play a pivotal role in the liver IRI process. In this review, we presented an overview of the latest advances of treatment strategies and proposed potential mechanisms behind liver IRI. We also highlighted the role of several important molecules (PPARγ, FAM3A, and non-coding RNAs) in protecting against hepatic IRI. Only after achieving a comprehensive understanding of potential mechanisms and targets behind IRI can we effectively ameliorate IRI in the liver and achieve better therapeutic effects.
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Affiliation(s)
- Xin-Li Mao
- Key Laboratory of Minimally Invasive Techniques and Rapid Rehabilitation of Digestive System Tumor of Zhejiang Province, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Linhai, China.,Department of Gastroenterology, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Linhai, China.,Institute of Digestive Disease, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Linhai, China
| | - Yue Cai
- Key Laboratory of Minimally Invasive Techniques and Rapid Rehabilitation of Digestive System Tumor of Zhejiang Province, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Linhai, China.,Department of Gastroenterology, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Linhai, China.,Institute of Digestive Disease, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Linhai, China
| | - Ya-Hong Chen
- Health Management Center, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Linhai, China
| | - Yi Wang
- Key Laboratory of Minimally Invasive Techniques and Rapid Rehabilitation of Digestive System Tumor of Zhejiang Province, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Linhai, China.,Department of Gastroenterology, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Linhai, China.,Institute of Digestive Disease, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Linhai, China
| | - Xiu-Xiu Jiang
- Department of Urology, The Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Li-Ping Ye
- Key Laboratory of Minimally Invasive Techniques and Rapid Rehabilitation of Digestive System Tumor of Zhejiang Province, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Linhai, China.,Department of Gastroenterology, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Linhai, China.,Institute of Digestive Disease, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Linhai, China
| | - Shao-Wei Li
- Key Laboratory of Minimally Invasive Techniques and Rapid Rehabilitation of Digestive System Tumor of Zhejiang Province, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Linhai, China.,Department of Gastroenterology, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Linhai, China.,Institute of Digestive Disease, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Linhai, China
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Hussain B, Kasinath V, Madsen JC, Bromberg J, Tullius SG, Abdi R. Intra-Organ Delivery of Nanotherapeutics for Organ Transplantation. ACS NANO 2021; 15:17124-17136. [PMID: 34714050 PMCID: PMC9050969 DOI: 10.1021/acsnano.1c04707] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Targeted delivery of therapeutics through the use of nanoparticles (NPs) has emerged as a promising method that increases their efficacy and reduces their side effects. NPs can be tailored to localize to selective tissues through conjugation to ligands that bind cell-specific receptors. Although the vast majority of nanodelivery platforms have focused on cancer therapy, efforts have begun to introduce nanotherapeutics to the fields of immunology as well as transplantation. In this review, we provide an overview from a clinician's perspective of current nanotherapeutic strategies to treat solid organ transplants with NPs during the time interval between organ harvest from the donor and placement into the recipient, an innovative technology that can provide major benefits to transplant patients. The use of ex vivo normothermic machine perfusion (NMP), which is associated with preserving the function of the organ following transplantation, also provides an ideal opportunity for a localized, sustained, and controlled delivery of nanotherapeutics to the organ during this critical time period. Here, we summarize previous endeavors to improve transplantation outcomes by treating the organ with NPs prior to placement in the recipient. Investigations in this burgeoning field of research are promising, but more extensive studies are needed to overcome the physiological challenges to achieving effective nanotherapeutic delivery to transplanted organs discussed in this review.
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Affiliation(s)
- Bilal Hussain
- Transplantation Research Center and Division of Renal Medicine, Brigham and Women’s Hospital, Boston, MA 02115, USA
| | - Vivek Kasinath
- Transplantation Research Center and Division of Renal Medicine, Brigham and Women’s Hospital, Boston, MA 02115, USA
| | - Joren C. Madsen
- Department of Surgery and Center for Transplantation Sciences, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Jonathan Bromberg
- Departments of Surgery and Microbiology and Immunology, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Stefan G. Tullius
- Transplant Surgery Research Laboratory and Division of Transplant Surgery, Brigham and Women’s Hospital, Boston, MA 02115, USA
| | - Reza Abdi
- Transplantation Research Center and Division of Renal Medicine, Brigham and Women’s Hospital, Boston, MA 02115, USA
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Jakubauskas M, Jakubauskiene L, Leber B, Strupas K, Stiegler P, Schemmer P. Machine Perfusion in Liver Transplantation: A Systematic Review and Meta-Analysis. Visc Med 2021; 38:243-254. [PMID: 36160822 PMCID: PMC9421699 DOI: 10.1159/000519788] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 09/12/2021] [Indexed: 11/27/2022] Open
Abstract
Background Liver transplantation (LTx) is the only treatment option for patients with end-stage liver disease. Novel organ preservation techniques such as hypothermic machine perfusion (HMP) or normothermic machine perfusion (NMP) are under investigation in order to improve organ quality from extended criteria donors and donors after circulatory death. The aim of this study was to systematically review the literature reporting LTx outcomes using NMP or HMP compared to static cold storage (SCS). Methods The following data were retrieved: graft primary nonfunction rate, early allograft dysfunction (EAD) rate, biliary complication rate, and 12-month graft and patient survival. A total of 15 studies were included (6 NMP and 9 HMP studies), and meta-analysis was performed only for HMP studies because NMP had considerable differences. Results The systematic review showed the potential of NMP to reduce graft injury and lower the liver graft discard rate. The performed quantitative analyses showed that the use of HMP reduces the rate of EAD (odds ratio [OR] 0.51; 95% confidence interval [CI] 0.34–0.76; p = 0.001; I2 = 0%) and non-anastomotic biliary strictures (OR 0.34; 95% CI 0.17–0.67; p = 0.002; I2 = 0%) compared to SCS. Conclusion Our systematic review and meta-analysis revealed that the use of HMP reduces the rate of EAD and non-anastomotic biliary strictures compared to SCS.
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Affiliation(s)
- Matas Jakubauskas
- General, Visceral and Transplant Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
- Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Lina Jakubauskiene
- General, Visceral and Transplant Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
- Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Bettina Leber
- General, Visceral and Transplant Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | | | - Philipp Stiegler
- General, Visceral and Transplant Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
- *Philipp Stiegler,
| | - Peter Schemmer
- General, Visceral and Transplant Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
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Transplantation of discarded livers: the complementary role of normothermic regional perfusion. Nat Commun 2021; 12:4471. [PMID: 34294697 PMCID: PMC8298635 DOI: 10.1038/s41467-021-24595-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Accepted: 06/23/2021] [Indexed: 11/18/2022] Open
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20
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William N, Acker JP. High Sub-Zero Organ Preservation: A Paradigm of Nature-Inspired Strategies. Cryobiology 2021; 102:15-26. [PMID: 33905707 DOI: 10.1016/j.cryobiol.2021.04.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 03/18/2021] [Accepted: 04/11/2021] [Indexed: 01/03/2023]
Abstract
The field of organ preservation is filled with advancements that have yet to see widespread clinical translation, with some of the more notable strategies deriving their inspiration from nature. While static cold storage (SCS) at 2 °C to 4 °C is the current state-of-the-art, it contributes to the current shortage of transplantable organs due to the limited preservation times it affords combined with the limited ability of marginal grafts (i.e. those at risk for post-transplant dysfunction or primary non-function) to tolerate SCS. The era of storage solution optimization to minimize SCS-induced hypothermic injury has plateaued in its improvements, resulting in a shift towards the use of machine perfusion systems to oxygenate organs at normothermic, sub-normothermic, or hypothermic temperatures, as well as the use of sub-zero storage temperatures to leverage the protection brought forth by a reduction in metabolic demand. Many of the rigors that organs are subjected to at low sub-zero temperatures (-80 °C to -196 °C) commonly used for mammalian cell preservation have yet to be surmounted. Therefore, this article focuses on an intermediate temperature range (0 °C to -20 °C), where much success has been seen in the past two decades. The mechanisms leveraged by organisms capable of withstanding prolonged periods at these temperatures through either avoiding or tolerating the formation of ice has provided a foundation for some of the more promising efforts. This article therefore aims to contextualize the translation of these strategies into the realm of mammalian organ preservation.
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Affiliation(s)
- Nishaka William
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, AB, T6G 2R3, Canada.
| | - Jason P Acker
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, AB, T6G 2R3, Canada; Centre for Innovation, Canadian Blood Services, 8249 114th Street, Edmonton, AB, T6G 2R8, Canada.
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21
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Wang RF, Fagelman EJ, Smith NK, Sakai T. Abdominal Organ Transplantation: Noteworthy Literature in 2020. Semin Cardiothorac Vasc Anesth 2021; 25:138-150. [PMID: 33845699 DOI: 10.1177/10892532211007256] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
In 2020, we identified and screened over 490 peer-reviewed publications on pancreatic transplantation, over 500 on intestinal transplantation, and over 5000 on kidney transplantation. The liver transplantation section specially focused on clinical trials and systematic reviews published in 2020 and featured selected articles. This review highlights noteworthy literature pertinent to anesthesiologists and critical care physicians caring for patients undergoing abdominal organ transplantation. We explore a wide range of topics, including COVID-19 and organ transplantation, risk factors and outcomes, pain management, artificial intelligence, robotic donor surgery, and machine perfusion.
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Affiliation(s)
- Ryan F Wang
- The Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA
| | - Erica J Fagelman
- The Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA
| | - Natalie K Smith
- The Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA
| | - Tetsuro Sakai
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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22
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Mitochondrial Consequences of Organ Preservation Techniques during Liver Transplantation. Int J Mol Sci 2021; 22:ijms22062816. [PMID: 33802177 PMCID: PMC7998211 DOI: 10.3390/ijms22062816] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 02/26/2021] [Accepted: 03/03/2021] [Indexed: 02/08/2023] Open
Abstract
Allograft ischemia during liver transplantation (LT) adversely affects the function of mitochondria, resulting in impairment of oxidative phosphorylation and compromised post-transplant recovery of the affected organ. Several preservation methods have been developed to improve donor organ quality; however, their effects on mitochondrial functions have not yet been compared. This study aimed to summarize the available data on mitochondrial effects of graft preservation methods in preclinical models of LT. Furthermore, a network meta-analysis was conducted to determine if any of these treatments provide a superior benefit, suggesting that they might be used on humans. A systematic search was conducted using electronic databases (EMBASE, MEDLINE (via PubMed), the Cochrane Central Register of Controlled Trials (CENTRAL) and Web of Science) for controlled animal studies using preservation methods for LT. The ATP content of the graft was the primary outcome, as this is an indicator overall mitochondrial function. Secondary outcomes were the respiratory activity of mitochondrial complexes, cytochrome c and aspartate aminotransferase (ALT) release. Both a random-effects model and the SYRCLE risk of bias analysis for animal studies were used. After a comprehensive search of the databases, 25 studies were enrolled in the analysis. Treatments that had the most significant protective effect on ATP content included hypothermic and subnormothermic machine perfusion (HMP and SNMP) (MD = −1.0, 95% CI: (−2.3, 0.3) and MD = −1.1, 95% CI: (−3.2, 1.02)), while the effects of warm ischemia (WI) without cold storage (WI) and normothermic machine perfusion (NMP) were less pronounced (MD = −1.8, 95% CI: (−2.9, −0.7) and MD = −2.1 MD; CI: (−4.6; 0.4)). The subgroup of static cold storage (SCS) with shorter preservation time (< 12 h) yielded better results than SCS ≥ 12 h, NMP and WI, in terms of ATP preservation and the respiratory capacity of complexes. HMP and SNMP stand out in terms of mitochondrial protection when compared to other treatments for LT in animals. The shorter storage time at lower temperatures, together with the dynamic preservation, provided superior protection for the grafts in terms of mitochondrial function. Additional clinical studies on human patients including marginal donors and longer ischemia times are needed to confirm any superiority of preservation methods with respect to mitochondrial function.
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Tingle SJ, Ibrahim I, Thompson ER, Bates L, Sivaharan A, Bury Y, Figuereido R, Wilson C. Methaemoglobinaemia Can Complicate Normothermic Machine Perfusion of Human Livers. Front Surg 2021; 8:634777. [PMID: 33598479 PMCID: PMC7882904 DOI: 10.3389/fsurg.2021.634777] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Accepted: 01/04/2021] [Indexed: 01/14/2023] Open
Abstract
Background: Although liver normothermic machine perfusion is increasingly used clinically, there are few reports of complications or adverse events. Many centers perform liver NMP to viability test suboptimal grafts, often for prolonged periods. In addition, several researchers are investigating NMP as a drug delivery platform, which usually necessitates prolonged perfusion of otherwise non-viable liver grafts. We describe two instances of methaemoglobinaemia during NMP of suboptimal livers. Methods: The NMP of eight human livers rejected for transplantation is described. Methaemoglobinaeima developed in two; one perfused using generic Medtronic™ perfusion equipment and one using the OrganOx Metra®. Results: The first liver (53 years DBD) developed methaemoglobinaemia (metHb = 2.4%) after 13 h of NMP, increasing to metHb = 19% at 16 h. Another liver (45 years DBD) developed methaemoglobinaemia at 25 h (metHb = 2.8%), which increased to metHb = 28.2% at 38 h. Development of methaemoglobinaemia was associated with large reductions in oxygen delivery and oxygen extraction. Both livers were steatotic and showed several suboptimal features on viability testing. Delivery of methylene blue failed to reverse the methaemoglobinaemia. Compared to a matched cohort of steatotic organs, livers which developed methaemoglobinaemia showed significantly higher levels of hemolysis at 12 h (prior to development of methaemoglobinaemia). Conclusions: Methaemglobinaemia is a complication of NMP of suboptimal liver grafts, not limited to a single machine or perfusion protocol. It can occur within 13 h (a timepoint frequently surpassed when NMP is used clinically) and renders further perfusion futile. Therefore, metHb should be monitored during NMP visually and using blood gas analysis.
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Affiliation(s)
- Samuel J Tingle
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, United Kingdom.,Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Ibrahim Ibrahim
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, United Kingdom.,Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Emily R Thompson
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, United Kingdom.,Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Lucy Bates
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, United Kingdom.,Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Ashwin Sivaharan
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Yvonne Bury
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom.,Department of Cellular Pathology, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
| | - Rodrigo Figuereido
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, United Kingdom.,Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Colin Wilson
- Institute of Transplantation, Freeman Hospital, Newcastle upon Tyne, United Kingdom
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24
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Kvietkauskas M, Zitkute V, Leber B, Strupas K, Stiegler P, Schemmer P. The Role of Metabolomics in Current Concepts of Organ Preservation. Int J Mol Sci 2020; 21:ijms21186607. [PMID: 32927605 PMCID: PMC7555311 DOI: 10.3390/ijms21186607] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 09/06/2020] [Accepted: 09/08/2020] [Indexed: 12/16/2022] Open
Abstract
In solid organ transplantation (Tx), both survival rates and quality of life have improved dramatically over the last few decades. Each year, the number of people on the wait list continues to increase, widening the gap between organ supply and demand. Therefore, the use of extended criteria donor grafts is growing, despite higher susceptibility to ischemia-reperfusion injury (IRI) and consecutive inferior Tx outcomes. Thus, tools to characterize organ quality prior to Tx are crucial components for Tx success. Innovative techniques of metabolic profiling revealed key pathways and mechanisms involved in IRI occurring during organ preservation. Although large-scale trials are needed, metabolomics appears to be a promising tool to characterize potential biomarkers, for the assessment of graft quality before Tx and evaluate graft-related outcomes. In this comprehensive review, we summarize the currently available literature on the use of metabolomics in solid organ Tx, with a special focus on metabolic profiling during graft preservation to assess organ quality prior to Tx.
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Affiliation(s)
- Mindaugas Kvietkauskas
- General, Visceral and Transplant Surgery, Department of Surgery, Medical University of Graz, Auenbruggerpl. 2, Graz 8036, Austria; (M.K.); (V.Z.); (B.L.); (P.S.)
- Faculty of Medicine, Vilnius University, M. K. Ciurlionio 21, 03101 Vilnius, Lithuania;
| | - Viktorija Zitkute
- General, Visceral and Transplant Surgery, Department of Surgery, Medical University of Graz, Auenbruggerpl. 2, Graz 8036, Austria; (M.K.); (V.Z.); (B.L.); (P.S.)
- Faculty of Medicine, Vilnius University, M. K. Ciurlionio 21, 03101 Vilnius, Lithuania;
| | - Bettina Leber
- General, Visceral and Transplant Surgery, Department of Surgery, Medical University of Graz, Auenbruggerpl. 2, Graz 8036, Austria; (M.K.); (V.Z.); (B.L.); (P.S.)
| | - Kestutis Strupas
- Faculty of Medicine, Vilnius University, M. K. Ciurlionio 21, 03101 Vilnius, Lithuania;
| | - Philipp Stiegler
- General, Visceral and Transplant Surgery, Department of Surgery, Medical University of Graz, Auenbruggerpl. 2, Graz 8036, Austria; (M.K.); (V.Z.); (B.L.); (P.S.)
- Correspondence: ; Tel.: +43-316-385-84094
| | - Peter Schemmer
- General, Visceral and Transplant Surgery, Department of Surgery, Medical University of Graz, Auenbruggerpl. 2, Graz 8036, Austria; (M.K.); (V.Z.); (B.L.); (P.S.)
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25
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Baidya R, Crawford DHG, Gautheron J, Wang H, Bridle KR. Necroptosis in Hepatosteatotic Ischaemia-Reperfusion Injury. Int J Mol Sci 2020; 21:ijms21165931. [PMID: 32824744 PMCID: PMC7460692 DOI: 10.3390/ijms21165931] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 08/12/2020] [Accepted: 08/12/2020] [Indexed: 02/07/2023] Open
Abstract
While liver transplantation remains the sole treatment option for patients with end-stage liver disease, there are numerous limitations to liver transplantation including the scarcity of donor livers and a rise in livers that are unsuitable to transplant such as those with excess steatosis. Fatty livers are susceptible to ischaemia-reperfusion (IR) injury during transplantation and IR injury results in primary graft non-function, graft failure and mortality. Recent studies have described new cell death pathways which differ from the traditional apoptotic pathway. Necroptosis, a regulated form of cell death, has been associated with hepatic IR injury. Receptor-interacting protein kinase 3 (RIPK3) and mixed-lineage kinase domain-like pseudokinase (MLKL) are thought to be instrumental in the execution of necroptosis. The study of hepatic necroptosis and potential therapeutic approaches to attenuate IR injury will be a key factor in improving our knowledge regarding liver transplantation with fatty donor livers. In this review, we focus on the effect of hepatic steatosis during liver transplantation as well as molecular mechanisms of necroptosis and its involvement during liver IR injury. We also discuss the immune responses triggered during necroptosis and examine the utility of necroptosis inhibitors as potential therapeutic approaches to alleviate IR injury.
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Affiliation(s)
- Raji Baidya
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland QLD 4006, Australia; (R.B.); (D.H.G.C.)
- Gallipoli Medical Research Institute, Brisbane, Queensland QLD 4120, Australia;
| | - Darrell H. G. Crawford
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland QLD 4006, Australia; (R.B.); (D.H.G.C.)
- Gallipoli Medical Research Institute, Brisbane, Queensland QLD 4120, Australia;
| | - Jérémie Gautheron
- Sorbonne University, Inserm, Centre de Recherche Saint-Antoine (CRSA), 75012 Paris, France;
- Institute of Cardiometabolism and Nutrition (ICAN), 75013 Paris, France
| | - Haolu Wang
- Gallipoli Medical Research Institute, Brisbane, Queensland QLD 4120, Australia;
- Diamantina Institute, The University of Queensland, Brisbane, Queensland QLD 4102, Australia
| | - Kim R. Bridle
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland QLD 4006, Australia; (R.B.); (D.H.G.C.)
- Gallipoli Medical Research Institute, Brisbane, Queensland QLD 4120, Australia;
- Correspondence: ; Tel.: +61-7-3346-0698
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