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Mahboub P, Aburawi M, Ozgur OS, Pendexter C, Cronin S, Lin FM, Jain R, Karabacak MN, Karimian N, Tessier SN, Markmann JF, Yeh H, Uygun K. Gradual rewarming with a hemoglobin-based oxygen carrier improves viability of donation after circulatory death in rat livers. FRONTIERS IN TRANSPLANTATION 2024; 3:1353124. [PMID: 38993754 PMCID: PMC11235298 DOI: 10.3389/frtra.2024.1353124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Accepted: 06/10/2024] [Indexed: 07/13/2024]
Abstract
Background Donation after circulatory death (DCD) grafts are vital for increasing available donor organs. Gradual rewarming during machine perfusion has proven effective in mitigating reperfusion injury and enhancing graft quality. Limited data exist on artificial oxygen carriers as an effective solution to meet the increasing metabolic demand with temperature changes. The aim of the present study was to assess the efficacy and safety of utilizing a hemoglobin-based oxygen carrier (HBOC) during the gradual rewarming of DCD rat livers. Methods Liver grafts were procured after 30 min of warm ischemia. The effect of 90 min of oxygenated rewarming perfusion from ice cold temperatures (4 °C) to 37 °C with HBOC after cold storage was evaluated and the results were compared with cold storage alone. Reperfusion at 37 °C was performed to assess the post-preservation recovery. Results Gradual rewarming with HBOC significantly enhanced recovery, demonstrated by markedly lower lactate levels and reduced vascular resistance compared to cold-stored liver grafts. Increased bile production in the HBOC group was noted, indicating improved liver function and bile synthesis capacity. Histological examination showed reduced cellular damage and better tissue preservation in the HBOC-treated livers compared to those subjected to cold storage alone. Conclusion This study suggests the safety of using HBOC during rewarming perfusion of rat livers as no harmful effect was detected. Furthermore, the viability assessment indicated improvement in graft function.
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Affiliation(s)
- Paria Mahboub
- Department of Surgery, University Medical Center Groningen, Groningen, Netherlands
- Center for Engineering in Medicine and Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
- Department of Research, Shriners Hospitals for Children, Boston, MA, United States
| | - Mohamed Aburawi
- Department of Research, Shriners Hospitals for Children, Boston, MA, United States
- Transplant Center, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - O Sila Ozgur
- Center for Engineering in Medicine and Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
- Department of Research, Shriners Hospitals for Children, Boston, MA, United States
| | - Casie Pendexter
- Center for Engineering in Medicine and Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
- Department of Research, Shriners Hospitals for Children, Boston, MA, United States
| | - Stephanie Cronin
- Center for Engineering in Medicine and Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
- Department of Research, Shriners Hospitals for Children, Boston, MA, United States
| | - Florence Min Lin
- Department of Research, Shriners Hospitals for Children, Boston, MA, United States
| | - Rohil Jain
- Center for Engineering in Medicine and Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
- Department of Research, Shriners Hospitals for Children, Boston, MA, United States
| | - Murat N Karabacak
- Center for Engineering in Medicine and Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
- Department of Research, Shriners Hospitals for Children, Boston, MA, United States
| | - Negin Karimian
- Center for Engineering in Medicine and Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
- Department of Research, Shriners Hospitals for Children, Boston, MA, United States
| | - Shannon N Tessier
- Center for Engineering in Medicine and Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
- Department of Research, Shriners Hospitals for Children, Boston, MA, United States
| | - James F Markmann
- Transplant Center, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Heidi Yeh
- Transplant Center, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Korkut Uygun
- Center for Engineering in Medicine and Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
- Department of Research, Shriners Hospitals for Children, Boston, MA, United States
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Stoess C, Choi YK, Onyuru J, Friess H, Hoffman HM, Hartmann D, Feldstein AE. Cell Death in Liver Disease and Liver Surgery. Biomedicines 2024; 12:559. [PMID: 38540172 PMCID: PMC10968531 DOI: 10.3390/biomedicines12030559] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 02/15/2024] [Accepted: 02/17/2024] [Indexed: 01/03/2025] Open
Abstract
Cell death is crucial for maintaining tissue balance and responding to diseases. However, under pathological conditions, the surge in dying cells results in an overwhelming presence of cell debris and the release of danger signals. In the liver, this gives rise to hepatic inflammation and hepatocellular cell death, which are key factors in various liver diseases caused by viruses, toxins, metabolic issues, or autoimmune factors. Both clinical and in vivo studies strongly affirm that hepatocyte death serves as a catalyst in the progression of liver disease. This advancement is characterized by successive stages of inflammation, fibrosis, and cirrhosis, culminating in a higher risk of tumor development. In this review, we explore pivotal forms of cell death, including apoptosis, pyroptosis, and necroptosis, examining their roles in both acute and chronic liver conditions, including liver cancer. Furthermore, we discuss the significance of cell death in liver surgery and ischemia-reperfusion injury. Our objective is to illuminate the molecular mechanisms governing cell death in liver diseases, as this understanding is crucial for identifying therapeutic opportunities aimed at modulating cell death pathways.
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Affiliation(s)
- Christian Stoess
- Department of Pediatric Gastroenterology, University of California San Diego, 9500 Gilman Dr, La Jolla, CA 92093, USA; (C.S.)
- Department of Surgery, TUM School of Medicine, Klinikum rechts der Isar, Technical University of Munich, 81675 Munich, Germany
| | - Yeon-Kyung Choi
- Department of Pediatric Gastroenterology, University of California San Diego, 9500 Gilman Dr, La Jolla, CA 92093, USA; (C.S.)
- Department of Internal Medicine, School of Medicine, Kyungpook National University Chilgok Hospital, Kyungpook National University, Daegu 41404, Republic of Korea
| | - Janset Onyuru
- Department of Pediatric Allergy, Immunology and Rheumatology, University of California San Diego, La Jolla, CA 92093, USA
| | - Helmut Friess
- Department of Surgery, TUM School of Medicine, Klinikum rechts der Isar, Technical University of Munich, 81675 Munich, Germany
| | - Hal M. Hoffman
- Department of Pediatric Allergy, Immunology and Rheumatology, University of California San Diego, La Jolla, CA 92093, USA
| | - Daniel Hartmann
- Department of Surgery, TUM School of Medicine, Klinikum rechts der Isar, Technical University of Munich, 81675 Munich, Germany
| | - Ariel E. Feldstein
- Department of Pediatric Gastroenterology, University of California San Diego, 9500 Gilman Dr, La Jolla, CA 92093, USA; (C.S.)
- Novo Nordisk, Global Drug Discovery, Ørestads Boulevard 108, 2300 Copenhagen, Denmark
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Lucas-Ruiz F, Peñín-Franch A, Pons JA, Ramírez P, Pelegrín P, Cuevas S, Baroja-Mazo A. Emerging Role of NLRP3 Inflammasome and Pyroptosis in Liver Transplantation. Int J Mol Sci 2022; 23:ijms232214396. [PMID: 36430874 PMCID: PMC9698208 DOI: 10.3390/ijms232214396] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 11/11/2022] [Accepted: 11/17/2022] [Indexed: 11/22/2022] Open
Abstract
The nucleotide-binding domain leucine-rich repeat-receptor, pyrin domain-containing-3 (NLRP3) inflammasome contributes to the inflammatory response by activating caspase-1, which in turn participates in the maturation of interleukin (IL)-1β and IL-18, which are mainly secreted via pyroptosis. Pyroptosis is a lytic type of cell death that is controlled by caspase-1 processing gasdermin D. The amino-terminal fragment of gasdermin D inserts into the plasma membrane, creating stable pores and enabling the release of several proinflammatory factors. The activation of NLRP3 inflammasome and pyroptosis has been involved in the progression of liver fibrosis and its end-stage cirrhosis, which is among the main etiologies for liver transplantation (LT). Moreover, the NLRP3 inflammasome is involved in ischemia-reperfusion injury and early inflammation and rejection after LT. In this review, we summarize the recent literature addressing the role of the NLRP3 inflammasome and pyroptosis in all stages involved in LT and argue the potential targeting of this pathway as a future therapeutic strategy to improve LT outcomes. Likewise, we also discuss the impact of graft quality influenced by donation after circulatory death and the expected role of machine perfusion technology to modify the injury response related to inflammasome activation.
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Affiliation(s)
- Fernando Lucas-Ruiz
- Molecular Inflammation Group, Biomedical Research Institute of Murcia (IMIB-Pascual Parrilla), University Clinical Hospital Virgen de la Arrixaca, 30120 Murcia, Spain
| | - Alejandro Peñín-Franch
- Molecular Inflammation Group, Biomedical Research Institute of Murcia (IMIB-Pascual Parrilla), University Clinical Hospital Virgen de la Arrixaca, 30120 Murcia, Spain
| | - José Antonio Pons
- Hepatology and Liver Transplant Unit, Biomedical Research Institute of Murcia (IMIB-Pascual Parrilla), University Clinical Hospital Virgen de la Arrixaca, 30120 Murcia, Spain
| | - Pablo Ramírez
- General Surgery and Abdominal Solid Organ Transplantation Unit, Biomedical Research Institute of Murcia (IMIB-Pascual Parrilla), University Clinical Hospital Virgen de la Arrixaca, 30120 Murcia, Spain
| | - Pablo Pelegrín
- Molecular Inflammation Group, Biomedical Research Institute of Murcia (IMIB-Pascual Parrilla), University Clinical Hospital Virgen de la Arrixaca, 30120 Murcia, Spain
- Department of Biochemistry and Molecular Biology B and Immunology, Faculty of Medicine, University of Murcia, 30120 Murcia, Spain
- Correspondence: (P.P.); (A.B.-M.); Tel.: +34-86-8885-031 (P.P.); Tel.: +34-86-8885-039 (A.B.-M.)
| | - Santiago Cuevas
- Molecular Inflammation Group, Biomedical Research Institute of Murcia (IMIB-Pascual Parrilla), University Clinical Hospital Virgen de la Arrixaca, 30120 Murcia, Spain
| | - Alberto Baroja-Mazo
- Molecular Inflammation Group, Biomedical Research Institute of Murcia (IMIB-Pascual Parrilla), University Clinical Hospital Virgen de la Arrixaca, 30120 Murcia, Spain
- Correspondence: (P.P.); (A.B.-M.); Tel.: +34-86-8885-031 (P.P.); Tel.: +34-86-8885-039 (A.B.-M.)
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Roushansarai NS, Pascher A, Becker F. Innate Immune Cells during Machine Perfusion of Liver Grafts-The Janus Face of Hepatic Macrophages. J Clin Med 2022; 11:jcm11226669. [PMID: 36431146 PMCID: PMC9696117 DOI: 10.3390/jcm11226669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 11/08/2022] [Accepted: 11/09/2022] [Indexed: 11/13/2022] Open
Abstract
Machine perfusion is an emerging technology in the field of liver transplantation. While machine perfusion has now been implemented in clinical routine throughout transplant centers around the world, a debate has arisen regarding its concurrent effect on the complex hepatic immune system during perfusion. Currently, our understanding of the perfusion-elicited processes involving innate immune cells remains incomplete. Hepatic macrophages (Kupffer cells) represent a special subset of hepatic immune cells with a dual pro-inflammatory, as well as a pro-resolving and anti-inflammatory, role in the sequence of ischemia-reperfusion injury. The purpose of this review is to provide an overview of the current data regarding the immunomodulatory role of machine perfusion and to emphasize the importance of macrophages for hepatic ischemia-reperfusion injury.
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Oxygen Transport during Ex Situ Machine Perfusion of Donor Livers Using Red Blood Cells or Artificial Oxygen Carriers. Int J Mol Sci 2020; 22:ijms22010235. [PMID: 33379394 PMCID: PMC7795786 DOI: 10.3390/ijms22010235] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 12/14/2020] [Accepted: 12/24/2020] [Indexed: 12/21/2022] Open
Abstract
Oxygenated ex situ machine perfusion of donor livers is an alternative for static cold preservation that can be performed at temperatures from 0 °C to 37 °C. Organ metabolism depends on oxygen to produce adenosine triphosphate and temperatures below 37 °C reduce the metabolic rate and oxygen requirements. The transport and delivery of oxygen in machine perfusion are key determinants in preserving organ viability and cellular function. Oxygen delivery is more challenging than carbon dioxide removal, and oxygenation of the perfusion fluid is temperature dependent. The maximal oxygen content of water-based solutions is inversely related to the temperature, while cellular oxygen demand correlates positively with temperature. Machine perfusion above 20 °C will therefore require an oxygen carrier to enable sufficient oxygen delivery to the liver. Human red blood cells are the most physiological oxygen carriers. Alternative artificial oxygen transporters are hemoglobin-based oxygen carriers, perfluorocarbons, and an extracellular oxygen carrier derived from a marine invertebrate. We describe the principles of oxygen transport, delivery, and consumption in machine perfusion for donor livers using different oxygen carrier-based perfusion solutions and we discuss the properties, advantages, and disadvantages of these carriers and their use.
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Jiménez-Castro MB, Cornide-Petronio ME, Gracia-Sancho J, Peralta C. Inflammasome-Mediated Inflammation in Liver Ischemia-Reperfusion Injury. Cells 2019; 8:1131. [PMID: 31547621 PMCID: PMC6829519 DOI: 10.3390/cells8101131] [Citation(s) in RCA: 166] [Impact Index Per Article: 27.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 09/19/2019] [Accepted: 09/21/2019] [Indexed: 12/16/2022] Open
Abstract
Ischemia-reperfusion injury is an important cause of liver damage occurring during surgical procedures including hepatic resection and liver transplantation, and represents the main underlying cause of graft dysfunction and liver failure post-transplantation. To date, ischemia-reperfusion injury is an unsolved problem in clinical practice. In this context, inflammasome activation, recently described during ischemia-reperfusion injury, might be a potential therapeutic target to mitigate the clinical problems associated with liver transplantation and hepatic resections. The present review aims to summarize the current knowledge in inflammasome-mediated inflammation, describing the experimental models used to understand the molecular mechanisms of inflammasome in liver ischemia-reperfusion injury. In addition, a clear distinction between steatotic and non-steatotic livers and between warm and cold ischemia-reperfusion injury will be discussed. Finally, the most updated therapeutic strategies, as well as some of the scientific controversies in the field will be described. Such information may be useful to guide the design of better experimental models, as well as the effective therapeutic strategies in liver surgery and transplantation that can succeed in achieving its clinical application.
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Affiliation(s)
| | | | - Jordi Gracia-Sancho
- Liver Vascular Biology Research Group, Barcelona Hepatic Hemodynamic Laboratory IDIBAPS, 08036 Barcelona, Spain.
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), 08036 Barcelona, Spain.
| | - Carmen Peralta
- Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), 08036 Barcelona, Spain.
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), 08036 Barcelona, Spain.
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Vodovotz Y, Simmons RL, Barclay D, Yin J, Jefferson BS, Zamora R. Decoding the secreted inflammatory response of primary human hepatocytes to hypoxic stress in vitro. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:371. [PMID: 31555685 DOI: 10.21037/atm.2019.07.09] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background The cellular and molecular response of liver cells to hypoxic stress is not fully understood. We used computational modeling to gain insights into the inflammatory response of primary human hepatocytes (HC) to hypoxic stress in vitro. Methods Primary HC from cancer patients were exposed to hypoxia (1% O2) or normoxia (21% O2) for 1-48 h, and the cell supernatants were assayed for 21 inflammatory mediators. Data were analyzed by Two-Way ANOVA, Dynamic Bayesian Network (DBN) inference, Dynamic Network Analysis (DyNA), and Time-interval Principal Component Analysis (TI-PCA). Results The chemokines MCP-1/CCL2 and IP-10/CXCL10, along with the cytokines interleukin (IL)-2 and IL-15 were altered significantly over time in hypoxic vs. normoxic HC. DBN inference suggested central, coordinating roles for MCP-1 and IL-8 in regulating a largely conserved inflammatory program in both hypoxic and normoxic HC. DyNA likewise suggested similar network trajectories of decreasing complexity over time in both hypoxic and normoxic HC, though with differential connectivity of MCP-1, IP-10, IL-8, and Eotaxin. TI-PCA pointed to IL-1β as a central characteristic of inflammation in hypoxic HC across all time intervals, along with IL-15 and IL-10, vs. Eotaxin, IL-7, IL-10, IL-15, and IL-17A in normoxic HC. Conclusions Thus, diverse human HC appear to respond in a largely conserved fashion to cell culture stress, with distinct characteristics based on the presence or absence of hypoxia.
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Affiliation(s)
- Yoram Vodovotz
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA.,Center for Inflammation and Regenerative Modeling, McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, USA.,Pittsburgh Liver Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Richard L Simmons
- Center for Inflammation and Regenerative Modeling, McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Derek Barclay
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jinling Yin
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Ruben Zamora
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA.,Center for Inflammation and Regenerative Modeling, McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, USA.,Pittsburgh Liver Research Center, University of Pittsburgh, Pittsburgh, PA, USA
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Akateh C, Beal EW, Whitson BA, Black SM. Normothermic Ex-vivo Liver Perfusion and the Clinical Implications for Liver Transplantation. J Clin Transl Hepatol 2018; 6:276-282. [PMID: 30271739 PMCID: PMC6160298 DOI: 10.14218/jcth.2017.00048] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Revised: 02/07/2018] [Accepted: 03/01/2018] [Indexed: 12/13/2022] Open
Abstract
Despite significant improvements in outcomes after liver transplantation, many patients continue to die on the waiting list, while awaiting an available organ for transplantation. Organ shortage is not only due to an inadequate number of available organs, but also the inability to adequately assess and evaluate these organs prior to transplantation. Over the last few decades, ex-vivo perfusion of the liver has emerged as a useful technique for both improved organ preservation and assessment of organs prior to transplantation. Large animal studies have shown the superiority of ex-vivo perfusion over cold static storage. However, these studies have not, necessarily, been translatable to human livers. Small animal studies have been essential in understanding and improving this technology. Similarly, these results have yet to be translated into clinical use. A few Phase 1 clinical trials have shown promise and confirmed the viability of this technology. However, more robust studies are needed before ex-vivo liver perfusion can be widely accepted as the new clinical standard of organ preservation. Here, we aimed to review all relevant large and small animal research, as well as human liver studies on normothermic ex-vivo perfusion, and to identify areas of deficiency and opportunities for future research endeavors.
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Affiliation(s)
- Clifford Akateh
- General and Gastrointestinal Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
- *Correspondence to: Clifford Akateh, General and Gastrointestinal Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, 395 W 12th Ave, Room 654, Columbus, OH-43210-1267, USA. Tel: +1-614-293-8704, Fax: +1-614-293-4063, E-mail:
| | - Eliza W. Beal
- General and Gastrointestinal Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Bryan A. Whitson
- Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Sylvester M. Black
- Division of Transplant Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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Optimizing Livers for Transplantation Using Machine Perfusion versus Cold Storage in Large Animal Studies and Human Studies: A Systematic Review and Meta-Analysis. BIOMED RESEARCH INTERNATIONAL 2018; 2018:9180757. [PMID: 30255101 PMCID: PMC6145150 DOI: 10.1155/2018/9180757] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 08/01/2018] [Accepted: 08/16/2018] [Indexed: 12/25/2022]
Abstract
Background Liver allograft preservation frequently involves static cold storage (CS) and machine perfusion (MP). With its increasing popularity, we investigated whether MP was superior to CS in terms of beneficial outcomes. Methods Human studies and large animal studies that optimized livers for transplantation using MP versus CS were assessed (PubMed/Medline/EMBASE). Meta-analyses were conducted for comparisons. Study quality was assessed according to the Newcastle-Ottawa quality assessment scale and SYRCLE's risk of bias tool. Results Nineteen studies were included. Among the large animal studies, lower levels of lactate dehydrogenase (SMD -3.16, 95% CI -5.14 to -1.18), alanine transferase (SMD -2.46, 95% CI -4.03 to -0.90), and hyaluronic acid (SMD -2.48, 95% CI -4.21 to -0.74) were observed in SNMP-preserved compared to CS-preserved livers. NMP-preserved livers showing lower level of hyaluronic acid (SMD -3.97, 95% CI -5.46 to -2.47) compared to CS-preserved livers. Biliary complications (RR 0.45, 95% CI 0.28 to 0.73) and early graft dysfunction (RR 0.56, 95% CI 0.34 to 0.92) also significantly reduced with HMP preservation in human studies. No evidence of publication bias was found. Conclusions MP preservation could improve short-term outcomes after transplantation compared to CS preservation. Additional randomized controlled trials (RCTs) are needed to develop clinical applications of MP preservation.
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