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Wehrle CJ, Jiao C, Sun K, Zhang M, Fairchild RL, Miller C, Hashimoto K, Schlegel A. Machine perfusion in liver transplantation: recent advances and coming challenges. Curr Opin Organ Transplant 2024; 29:228-238. [PMID: 38726745 DOI: 10.1097/mot.0000000000001150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/03/2024]
Abstract
PURPOSE OF REVIEW Machine perfusion has been adopted into clinical practice in Europe since the mid-2010s and, more recently, in the United States (US) following approval of normothermic machine perfusion (NMP). We aim to review recent advances, provide discussion of potential future directions, and summarize challenges currently facing the field. RECENT FINDINGS Both NMP and hypothermic-oxygenated perfusion (HOPE) improve overall outcomes after liver transplantation versus traditional static cold storage (SCS) and offer improved logistical flexibility. HOPE offers additional protection to the biliary system stemming from its' protection of mitochondria and lessening of ischemia-reperfusion injury. Normothermic regional perfusion (NRP) is touted to offer similar protective effects on the biliary system, though this has not been studied prospectively.The most critical question remaining is the optimal use cases for each of the three techniques (NMP, HOPE, and NRP), particularly as HOPE and NRP become more available in the US. There are additional questions regarding the most effective criteria for viability assessment and the true economic impact of these techniques. Finally, with each technique purported to allow well tolerated use of riskier grafts, there is an urgent need to define terminology for graft risk, as baseline population differences make comparison of current data challenging. SUMMARY Machine perfusion is now widely available in all western countries and has become an essential tool in liver transplantation. Identification of the ideal technique for each graft, optimization of viability assessment, cost-effectiveness analyses, and proper definition of graft risk are the next steps to maximizing the utility of these powerful tools.
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Affiliation(s)
| | - Chunbao Jiao
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland, Ohio, USA
| | - Keyue Sun
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland, Ohio, USA
| | - Mingyi Zhang
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland, Ohio, USA
| | - Robert L Fairchild
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland, Ohio, USA
| | | | - Koji Hashimoto
- Transplantation Center, Cleveland Clinic
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland, Ohio, USA
| | - Andrea Schlegel
- Transplantation Center, Cleveland Clinic
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland, Ohio, USA
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Brubaker AL, Sellers MT, Abt PL, Croome KP, Merani S, Wall A, Abreu P, Alebrahim M, Baskin R, Bohorquez H, Cannon RM, Cederquist K, Edwards J, Huerter BG, Hobeika MJ, Kautzman L, Langnas AN, Lee DD, Manzi J, Nassar A, Neidlinger N, Nydam TL, Schnickel GT, Siddiqui F, Suah A, Taj R, Taner CB, Testa G, Vianna R, Vyas F, Montenovo MI. US Liver Transplant Outcomes After Normothermic Regional Perfusion vs Standard Super Rapid Recovery. JAMA Surg 2024; 159:677-685. [PMID: 38568597 PMCID: PMC10993160 DOI: 10.1001/jamasurg.2024.0520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 01/06/2024] [Indexed: 04/06/2024]
Abstract
Importance Normothermic regional perfusion (NRP) is an emerging recovery modality for transplantable allografts from controlled donation after circulatory death (cDCD) donors. In the US, only 11.4% of liver recipients who are transplanted from a deceased donor receive a cDCD liver. NRP has the potential to safely expand the US donor pool with improved transplant outcomes as compared with standard super rapid recovery (SRR). Objective To assess outcomes of US liver transplants using controlled donation after circulatory death livers recovered with normothermic regional perfusion vs standard super rapid recovery. Design, Setting, and Participants This was a retrospective, observational cohort study comparing liver transplant outcomes from cDCD donors recovered by NRP vs SRR. Outcomes of cDCD liver transplant from January 2017 to May 2023 were collated from 17 US transplant centers and included livers recovered by SRR and NRP (thoracoabdominal NRP [TA-NRP] and abdominal NRP [A-NRP]). Seven transplant centers used NRP, allowing for liver allografts to be transplanted at 17 centers; 10 centers imported livers recovered via NRP from other centers. Exposures cDCD livers were recovered by either NRP or SRR. Main Outcomes and Measures The primary outcome was ischemic cholangiopathy (IC). Secondary end points included primary nonfunction (PNF), early allograft dysfunction (EAD), biliary anastomotic strictures, posttransplant length of stay (LOS), and patient and graft survival. Results A total of 242 cDCD livers were included in this study: 136 recovered by SRR and 106 recovered by NRP (TA-NRP, 79 and A-NRP, 27). Median (IQR) NRP and SRR donor age was 30.5 (22-44) years and 36 (27-49) years, respectively. Median (IQR) posttransplant LOS was significantly shorter in the NRP cohort (7 [5-11] days vs 10 [7-16] days; P < .001). PNF occurred only in the SRR allografts group (n = 2). EAD was more common in the SRR cohort (123 of 136 [56.1%] vs 77 of 106 [36.4%]; P = .007). Biliary anastomotic strictures were increased 2.8-fold in SRR recipients (7 of 105 [6.7%] vs 30 of 134 [22.4%]; P = .001). Only SRR recipients had IC (0 vs 12 of 133 [9.0%]; P = .002); IC-free survival by Kaplan-Meier was significantly improved in NRP recipients. Patient and graft survival were comparable between cohorts. Conclusion and Relevance There was comparable patient and graft survival in liver transplant recipients of cDCD donors recovered by NRP vs SRR, with reduced rates of IC, biliary complications, and EAD in NRP recipients. The feasibility of A-NRP and TA-NRP implementation across multiple US transplant centers supports increasing adoption of NRP to improve organ use, access to transplant, and risk of wait-list mortality.
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Affiliation(s)
- Aleah L. Brubaker
- Department of Surgery, Division of Transplant and Hepatobiliary Surgery, University of California San Diego, La Jolla, California
- CONCORD: Consortium for Donation after Circulatory Death and Normothermic Regional Perfusion Outcomes Research and Development
| | - Marty T. Sellers
- CONCORD: Consortium for Donation after Circulatory Death and Normothermic Regional Perfusion Outcomes Research and Development
- Tennessee Donor Services, Nashville
| | - Peter L. Abt
- CONCORD: Consortium for Donation after Circulatory Death and Normothermic Regional Perfusion Outcomes Research and Development
- Department of Surgery, Transplant Division, University of Pennsylvania, Philadelphia
| | - Kristopher P. Croome
- CONCORD: Consortium for Donation after Circulatory Death and Normothermic Regional Perfusion Outcomes Research and Development
- Department of Transplant, Mayo Clinic Florida, Jacksonville
| | - Shaheed Merani
- CONCORD: Consortium for Donation after Circulatory Death and Normothermic Regional Perfusion Outcomes Research and Development
- Department of Surgery, University of Nebraska Medical Center, Omaha
| | - Anji Wall
- CONCORD: Consortium for Donation after Circulatory Death and Normothermic Regional Perfusion Outcomes Research and Development
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas
| | - Phillipe Abreu
- Miami Transplant Institute, Jackson Memorial Hospital, University of Miami, Miami, Florida
| | | | - Roy Baskin
- Methodist Transplant Specialists, Dallas, Texas
| | - Humberto Bohorquez
- Department of Surgery, Ochsner School of Medicine, New Orleans, Louisiana
| | - Robert M. Cannon
- Department of Surgery, University of Alabama at Birmingham, Birmingham
| | - Kelly Cederquist
- Department of Surgery, Transplant Division, University of Pennsylvania, Philadelphia
| | - John Edwards
- Gift of Life Donor Program, Philadelphia, Pennsylvania
| | | | - Mark J. Hobeika
- J.C. Walter Jr Transplant Center, Houston Methodist Hospital, Houston, Texas
| | | | - Alan N. Langnas
- Department of Surgery, University of Nebraska Medical Center, Omaha
| | - David D. Lee
- Department of Surgery, Loyola University, Chicago, Illinois
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Joao Manzi
- Miami Transplant Institute, Jackson Memorial Hospital, University of Miami, Miami, Florida
| | - Ahmed Nassar
- Department of Surgery, Emory University, Atlanta, Georgia
- Department of Surgery, Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, Michigan
| | | | - Trevor L. Nydam
- CONCORD: Consortium for Donation after Circulatory Death and Normothermic Regional Perfusion Outcomes Research and Development
- Department of Surgery, Division of Transplant Surgery, University of Colorado, Aurora
| | - Gabriel T. Schnickel
- Department of Surgery, Division of Transplant and Hepatobiliary Surgery, University of California San Diego, La Jolla, California
| | - Farjad Siddiqui
- Department of Surgery, The Ohio State University, Columbus
- Department of Surgery, Emory University, Atlanta, Georgia
| | - Ashley Suah
- Department of Surgery, Emory University, Atlanta, Georgia
- Department of Surgery, University of Chicago, Chicago, Illinois
| | - Raeda Taj
- Department of Surgery, Division of Transplant and Hepatobiliary Surgery, University of California San Diego, La Jolla, California
- Department of Surgery, Transplant Division, University of Pennsylvania, Philadelphia
| | | | - Giuliano Testa
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas
| | - Rodrigo Vianna
- Miami Transplant Institute, Jackson Memorial Hospital, University of Miami, Miami, Florida
| | - Frederick Vyas
- Department of Surgery, Transplant Division, University of Pennsylvania, Philadelphia
| | - Martin I. Montenovo
- CONCORD: Consortium for Donation after Circulatory Death and Normothermic Regional Perfusion Outcomes Research and Development
- Department of Surgery, Vanderbilt University, Nashville, Tennessee
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Longchamp A, Nakamura T, Uygun K, Markmann JF. Role of Machine Perfusion in Liver Transplantation. Surg Clin North Am 2024; 104:45-65. [PMID: 37953040 DOI: 10.1016/j.suc.2023.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Abstract
Given the current severe shortage of available livers for transplantation, there is an urgent need to maximize the utilization of donor organs. One of the strategies to increase the number of available livers for transplantation is to improve organ utilization through the use of elderly, overweight, or organs donated after circulatory death. However, the utilization of these "marginal" organs was associated with an increased risk of early allograft dysfunction, primary nonfunction, ischemic biliary complications, or even re-transplantation. Ischemia-reperfusion injury is a key mechanism in the pathogenesis of these complications.
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Affiliation(s)
- Alban Longchamp
- Division of Transplant Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Department of Surgery, Center for Engineering in Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Tsukasa Nakamura
- Division of Transplant Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Korkut Uygun
- Division of Transplant Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Department of Surgery, Center for Engineering in Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - James F Markmann
- Division of Transplant Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Department of Surgery, Center for Engineering in Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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Ghinolfi D, Patrono D, De Carlis R, Melandro F, Buscemi V, Farnesi F, Torri F, Lauterio A, Di Salvo M, Cerchione R, Zanierato M, Morganti R, Romagnoli R, De Simone P, De Carlis L. Liver transplantation with uncontrolled versus controlled DCD donors using normothermic regional perfusion and ex-situ machine perfusion. Liver Transpl 2024; 30:46-60. [PMID: 37450659 DOI: 10.1097/lvt.0000000000000219] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 06/30/2023] [Indexed: 07/18/2023]
Abstract
In Italy, 20 minutes of continuous, flat-line electrocardiogram are required for death declaration, which significantly increases the risks of donation after circulatory death (DCD) LT. Despite prolonged warm ischemia time, Italian centers reported good outcomes in controlled donation after circulatory death LT by combining normothermic regional and end-ischemic machine perfusion. However, data on uncontrolled DCD (uDCD) LT performed by this approach are lacking. This was a multicenter, retrospective study performed at 3 large-volume centers comparing clinical outcomes of uncontrolled versus controlled DCD LT. The aim of the study was to assess outcomes of sequential normothermic regional perfusion and end-ischemic machine perfusion in uncontrolled DCD liver transplantation (LT). Of 153 DCD donors evaluated during the study period, 40 uDCD and 59 donation after circulatory death grafts were transplanted (utilization rate 52% vs. 78%, p = 0.004). Recipients of uDCD grafts had higher MEAF (4.9 vs. 3.5, p < 0.001) and CCI scores at discharge (24.4 vs. 8.7, p = 0.026), longer ICU stay (5 vs. 4 d, p = 0.047), and a trend toward more severe AKI. At multivariate analysis, 90-day graft loss was associated with recipient BMI and lactate downtrend during normothermic regional perfusion. One-year graft survival was lower in uDCD (75% vs. 90%, p = 0.007) but became comparable when non-liver-related graft losses were treated as censors (77% vs. 90%, p = 0.100). The incidence of ischemic cholangiopathy was 10% in uDCD versus 3% in donation after circulatory death, p = 0.356. uDCD LT with prolonged warm ischemia is feasible by the sequential use of normothermic regional perfusion and end-ischemic machine perfusion. Proper donor and recipient selection are key to achieving good outcomes in this setting.
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Affiliation(s)
- Davide Ghinolfi
- Division of Hepatic Surgery and Liver Transplantation, University of Pisa Hospital, Pisa, Italy
| | - Damiano Patrono
- General Surgery 2U-Liver Transplant Unit, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Università di Torino, Corso Bramante, Turin, Italy
| | - Riccardo De Carlis
- Department of General Surgery and Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
- PhD Course in Clinical and Experimental Sciences, University of Padua, Padua, Italy
| | - Fabio Melandro
- Division of Hepatic Surgery and Liver Transplantation, University of Pisa Hospital, Pisa, Italy
| | - Vincenzo Buscemi
- Department of General Surgery and Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Francesca Farnesi
- General Surgery 2U-Liver Transplant Unit, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Università di Torino, Corso Bramante, Turin, Italy
| | - Francesco Torri
- Division of Hepatic Surgery and Liver Transplantation, University of Pisa Hospital, Pisa, Italy
| | - Andrea Lauterio
- Department of General Surgery and Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Maria Di Salvo
- General Surgery 2U-Liver Transplant Unit, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Università di Torino, Corso Bramante, Turin, Italy
| | - Raffaele Cerchione
- Department of General Surgery and Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Marinella Zanierato
- Anesthesia and Critical Care, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Università di Torino, Corso Bramante, Turin, Italy
| | | | - Renato Romagnoli
- General Surgery 2U-Liver Transplant Unit, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Università di Torino, Corso Bramante, Turin, Italy
| | - Paolo De Simone
- Division of Hepatic Surgery and Liver Transplantation, University of Pisa Hospital, Pisa, Italy
| | - Luciano De Carlis
- Department of General Surgery and Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
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Nwaduru C, Baker E, Buff M, Selim M, Ovalle LA, Baker TB, Zimmerman MA. Assessing Liver Viability: Insights From Mitochondrial Bioenergetics in Ischemia-Reperfusion Injury. Transplant Proc 2024; 56:228-235. [PMID: 38171992 DOI: 10.1016/j.transproceed.2023.11.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 11/30/2023] [Indexed: 01/05/2024]
Abstract
Orthotopic liver transplantation remains the definitive treatment for patients with end-stage liver disease. Unfortunately, the increasing demand for donor livers and the limited supply of viable organs have both led to a critical need for innovative strategies to expand the pool of transplantable organs. The mitochondrion, central to hepatic cellular function, plays a pivotal role in hepatic ischemic injury, with impaired mitochondrial function and oxidative stress leading to cell death. Mitochondrial protection strategies have shown promise in mitigating IRI and resuscitating marginal organs for transplant. Machine perfusion (MP) has been proven a valuable tool for reviving marginal organs with very promising results. Evaluation of liver viability during perfusion traditionally relies on parameters including lactate clearance, bile production, and transaminase levels. Nevertheless, the quest for more comprehensive and universally applicable viability markers persists. Normothermic regional perfusion has gained robust attention, offering extended recovery time for organs from donation after cardiac death donors. This approach has shown remarkable success in improving organ quality and reducing ischemic injury using the body's physiological conditions. The current challenge lies in the absence of a reliable assessment tool for predicting graft viability and post-transplant outcomes. To address this, exploring insights from mitochondrial function in the context of ischemia-reperfusion injury could offer a promising path toward better patient outcomes and graft longevity. Indeed, hypoxia-induced mitochondrial injury may serve as a surrogate marker of organ viability following oxygenated resuscitation techniques in the future.
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Affiliation(s)
- Chinedu Nwaduru
- Department of Surgery, Division of Transplantation and Advanced Hepatobiliary Surgery, University of Utah School of Medicine, Salt Lake City, Utah.
| | - Emma Baker
- Department of Surgery, Division of Transplantation and Advanced Hepatobiliary Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Michelle Buff
- Department of Surgery, Division of Transplantation and Advanced Hepatobiliary Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Motaz Selim
- Department of Surgery, Division of Transplantation and Advanced Hepatobiliary Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Leo Aviles Ovalle
- Department of Surgery, Division of Transplantation and Advanced Hepatobiliary Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Talia B Baker
- Department of Surgery, Division of Transplantation and Advanced Hepatobiliary Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Michael A Zimmerman
- Department of Surgery, Division of Transplantation and Advanced Hepatobiliary Surgery, University of Utah School of Medicine, Salt Lake City, Utah
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Panconesi R, Carvalho MF, Eden J, Fazi M, Ansari F, Mancina L, Navari N, Sousa Da Silva RX, Dondossola D, Borrego LB, Pietzke M, Peris A, Meierhofer D, Muiesan P, Galkin A, Marra F, Dutkowski P, Schlegel A. Mitochondrial injury during normothermic regional perfusion (NRP) and hypothermic oxygenated perfusion (HOPE) in a rodent model of DCD liver transplantation. EBioMedicine 2023; 98:104861. [PMID: 37924707 PMCID: PMC10660010 DOI: 10.1016/j.ebiom.2023.104861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 10/15/2023] [Accepted: 10/16/2023] [Indexed: 11/06/2023] Open
Abstract
BACKGROUND Normothermic regional perfusion (NRP) and hypothermic-oxygenated-perfusion (HOPE), were both shown to improve outcomes after liver transplantation from donors after circulatory death (DCD). Comparative clinical and mechanistical studies are however lacking. METHODS A rodent model of NRP and HOPE, both in the donor, was developed. Following asystolic donor warm ischemia time (DWIT), the abdominal compartment was perfused either with a donor-blood-based-perfusate at 37 °C (NRP) or with oxygenated Belzer-MPS at 10 °C (donor-HOPE) for 2 h. Livers were then procured and underwent 5 h static cold storage (CS), followed by transplantation. Un-perfused and HOPE-treated DCD-livers (after CS) and healthy livers (DBD) with direct implantation after NRP served as controls. Endpoints included the entire spectrum of ischemia-reperfusion-injury. FINDINGS Healthy control livers (DBD) showed minimal signs of inflammation during 2 h NRP and achieved 100% posttransplant recipient survival. In contrast, DCD livers with 30 and 60 min DWIT suffered from greater mitochondrial injury and inflammation as measured by increased perfusate Lactate, FMN- and HMGB-1-levels with subsequent Toll-like-receptor activation during NRP. In contrast, donor-HOPE (instead of NRP) led to significantly less mitochondrial-complex-I-injury and inflammation. Results after donor-HOPE were comparable to ex-situ HOPE after CS. Most DCD-liver recipients survived when treated with one HOPE-technique (86%), compared to only 40% after NRP (p = 0.0053). Following a reduction of DWIT (15 min), DCD liver recipients achieved comparable survivals with NRP (80%). INTERPRETATION High-risk DCD livers benefit more from HOPE-treatment, either immediately in the donor or after cold storage. Comparative prospective clinical studies are required to translate the results. FUNDING Funding was provided by the Swiss National Science Foundation (grant no: 32003B-140776/1, 3200B-153012/1, 320030-189055/1, and 31IC30-166909) and supported by University Careggi (grant no 32003B-140776/1) and the OTT (grant No.: DRGT641/2019, cod.prog. 19CT03) and the Max Planck Society. Work in the A.G. laboratory was partially supported by the NIH R01NS112381 and R21NS125466 grants.
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Affiliation(s)
- Rebecca Panconesi
- Hepatobiliary Unit, Careggi University Hospital, University of Florence, Florence, Italy; Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy; Department of Surgery, A.O.U. Città della Salute e della Scienza di Torino, University of Turin, 10124, Turin, Italy; Department of Visceral Surgery and Transplantation, University Hospital Zurich, Swiss HPB and Transplant Center, Zurich, Switzerland
| | | | - Janina Eden
- Department of Visceral Surgery and Transplantation, University Hospital Zurich, Swiss HPB and Transplant Center, Zurich, Switzerland
| | - Marilena Fazi
- Hepatobiliary Unit, Careggi University Hospital, University of Florence, Florence, Italy; Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Fariha Ansari
- Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, 407 East 61st Street, New York, NY, 10065, USA
| | - Leandro Mancina
- Department of Visceral Surgery and Transplantation, University Hospital Zurich, Swiss HPB and Transplant Center, Zurich, Switzerland
| | - Nadia Navari
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Richard Xavier Sousa Da Silva
- Department of Visceral Surgery and Transplantation, University Hospital Zurich, Swiss HPB and Transplant Center, Zurich, Switzerland
| | - Daniele Dondossola
- General and Liver Transplant Surgery Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico and University of Milan, Centre of Preclinical Research, 20122, Italy
| | - Lucia Bautista Borrego
- Department of Visceral Surgery and Transplantation, University Hospital Zurich, Swiss HPB and Transplant Center, Zurich, Switzerland
| | - Matthias Pietzke
- Max Planck Institute for Molecular Genetics, Mass Spectrometry Facility, 14195, Berlin, Germany
| | - Adriano Peris
- Tuscany Regional Transplant Authority, Centro Regionale Allocazione Organi e Tessuti (CRAOT), Florence, Italy
| | - David Meierhofer
- Max Planck Institute for Molecular Genetics, Mass Spectrometry Facility, 14195, Berlin, Germany
| | - Paolo Muiesan
- Hepatobiliary Unit, Careggi University Hospital, University of Florence, Florence, Italy; Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy; Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, 407 East 61st Street, New York, NY, 10065, USA
| | - Alexander Galkin
- Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, 407 East 61st Street, New York, NY, 10065, USA
| | - Fabio Marra
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy; Center for Research, High Education and Transfer DENOThe, University of Florence, Florence, Italy
| | - Philipp Dutkowski
- Department of Visceral Surgery and Transplantation, University Hospital Zurich, Swiss HPB and Transplant Center, Zurich, Switzerland
| | - Andrea Schlegel
- Hepatobiliary Unit, Careggi University Hospital, University of Florence, Florence, Italy; Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy; 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 and University of Milan, Centre of Preclinical Research, 20122, Italy; Transplantation Center, Digestive Disease and Surgery Institute and Department of Immunology, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA.
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7
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Liang A, Cheng W, Cao P, Cai S, Zhang L, Zhong K, Nie Y. Effects of machine perfusion strategies on different donor types in liver transplantation: a systematic review and meta-analysis. Int J Surg 2023; 109:3617-3630. [PMID: 37578436 PMCID: PMC10651255 DOI: 10.1097/js9.0000000000000661] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 07/24/2023] [Indexed: 08/15/2023]
Abstract
BACKGROUND The increasing use of extended criteria donors (ECD) sets higher requirements for graft preservation. Machine perfusion (MP) improves orthotopic liver transplantation (OLT) outcomes, but its effects on different donor types remains unclear. The authors' aim was to assess the effects of hypothermic machine perfusion (HMP), normothermic machine perfusion (NMP), or normothermic regional perfusion (NRP) versus static cold storage (SCS) on different donor types. MATERIALS AND METHODS A literature search comparing the efficacy of MP versus SCS in PubMed, Cochrane, and EMBASE database was conducted. A meta-analysis was performed to obtain pooled effects of MP on ECD, donation after circulatory death (DCD), and donor after brainstem death. RESULTS Thirty nine studies were included (nine randomized controlled trials and 30 cohort studies). Compared with SCS, HMP significantly reduced the risk of non-anastomotic biliary stricture (NAS) [odds ratio (OR) 0.43, 95% confidence interval (CI) 0.26-0.72], major complications (OR 0.55, 95% CI 0.39-0.78), and early allograft dysfunction (EAD) (OR 0.46, 95% CI 0.32-0.65) and improved 1-year graft survival (OR 2.36, 95% CI 1.55-3.62) in ECD-OLT. HMP also reduced primary non-function (PNF) (OR 0.40, 95% CI 0.18-0.92) and acute rejection (OR 0.62, 95% CI 0.40-0.97). NMP only reduced major complications in ECD-OLT (OR 0.56, 95% CI 0.34-0.94), without favorable effects on other complications and survival. NRP lowered the overall risk of NAS (OR 0.27, 95% CI 0.11-0.68), PNF (OR 0.43, 95% CI 0.22-0.85), and EAD (OR 0.58, 95% CI 0.42-0.80) and meanwhile improved 1-year graft survival (OR 2.40, 95% CI 1.65-3.49) in control DCD-OLT. CONCLUSIONS HMP might currently be considered for marginal livers as it comprehensively improves ECD-OLT outcomes. NMP assists some outcomes in ECD-OLT, but more evidence regarding NMP-ECD is warranted. NRP significantly improves DCD-OLT outcomes and is recommended where longer non-touch periods exist.
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Affiliation(s)
- Aijun Liang
- General Surgery Center, Department of Hepatobiliary Surgery II, Guangdong Provincial Research Center for Artificial Organ and Tissue Engineering, Guangzhou Clinical Research and Transformation Center for Artificial Liver, Institute of Regenerative Medicine, Zhujiang Hospital, Southern Medical University,Guangzhou, Guangdong Province, China
| | - Weiye Cheng
- General Surgery Center, Department of Hepatobiliary Surgery II, Guangdong Provincial Research Center for Artificial Organ and Tissue Engineering, Guangzhou Clinical Research and Transformation Center for Artificial Liver, Institute of Regenerative Medicine, Zhujiang Hospital, Southern Medical University,Guangzhou, Guangdong Province, China
| | - Peihua Cao
- Clinical Research Center, Zhujiang Hospital
- Department of Biostatistics, School of Public Health, Southern Medical University, Guangzhou, Guangdong, People’s Republic of China
| | - Shaoru Cai
- General Surgery Center, Department of Hepatobiliary Surgery II, Guangdong Provincial Research Center for Artificial Organ and Tissue Engineering, Guangzhou Clinical Research and Transformation Center for Artificial Liver, Institute of Regenerative Medicine, Zhujiang Hospital, Southern Medical University,Guangzhou, Guangdong Province, China
| | - Linya Zhang
- General Surgery Center, Department of Hepatobiliary Surgery II, Guangdong Provincial Research Center for Artificial Organ and Tissue Engineering, Guangzhou Clinical Research and Transformation Center for Artificial Liver, Institute of Regenerative Medicine, Zhujiang Hospital, Southern Medical University,Guangzhou, Guangdong Province, China
| | - Kebo Zhong
- General Surgery Center, Department of Hepatobiliary Surgery II, Guangdong Provincial Research Center for Artificial Organ and Tissue Engineering, Guangzhou Clinical Research and Transformation Center for Artificial Liver, Institute of Regenerative Medicine, Zhujiang Hospital, Southern Medical University,Guangzhou, Guangdong Province, China
| | - Yu Nie
- General Surgery Center, Department of Hepatobiliary Surgery II, Guangdong Provincial Research Center for Artificial Organ and Tissue Engineering, Guangzhou Clinical Research and Transformation Center for Artificial Liver, Institute of Regenerative Medicine, Zhujiang Hospital, Southern Medical University,Guangzhou, Guangdong Province, China
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8
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Steinberg I, Patrono D, De Cesaris E, Lucà M, Catalano G, Marro M, Rizza G, Simonato E, Brazzi L, Romagnoli R, Zanierato M. Viability assessment of livers donated after circulatory determination of death during normothermic regional perfusion. Artif Organs 2023; 47:1592-1603. [PMID: 37548353 DOI: 10.1111/aor.14622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 06/14/2023] [Accepted: 07/25/2023] [Indexed: 08/08/2023]
Abstract
BACKGROUND Abdominal normothermic regional perfusion (A-NRP) allows in-situ reperfusion and recovery of abdominal organs metabolism in donors after circulatory death (DCD). Besides improving liver transplantation outcomes, liver injury and function can be assessed during A-NRP. METHODS To refine liver viability assessment during A-NRP, prospectively collected data of controlled DCD donors managed at our Institution between October 2019 and May 2022 were retrospectively analyzed. Baseline characteristics, procedural variables and A-NRP parameters of donors whose liver was successfully transplanted were compared to those of donors whose liver was discarded. RESULTS Twenty-seven donors were included and in 20 (74%) the liver was accepted (positive outcome). No differences between study groups were observed concerning baseline characteristics and warm ischemia times (WIT). Initial lactate levels were positively correlated with functional WIT (r2 = 0.4, p = 0.04), whereas transaminase levels were not. Blood flow during A-NRP was comparable, whereas oxygen consumption (VO2 ) was significantly higher in the positive outcome group after 1 h. Time courses of lactate, AST and ALT were significantly different between study groups (p < 0.001). Donors whose liver was accepted showed faster lactate clearance, a difference which was amplified by normalizing lactate clearance to oxygen delivery (DO2 ) and VO2 . Lactate clearance was correlated to transaminase levels and DO2 -normalized lactate clearance was the parameter best discriminating between study groups. CONCLUSIONS DO2 -normalized lactate clearance may represent an element of liver viability assessment during A-NRP.
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Affiliation(s)
- Irene Steinberg
- Department of Anesthesia and Critical Care, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
- Department of Surgical Sciences, University of Turin, Turin, Italy
- Department of Mechanical and Aerospace Engineering, Polytechnic University of Turin, Turin, Italy
| | - Damiano Patrono
- General Surgery 2U - Liver Transplant Center, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Enrico De Cesaris
- Department of Anesthesia and Critical Care, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Michele Lucà
- Department of Anesthesia and Critical Care, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Giorgia Catalano
- General Surgery 2U - Liver Transplant Center, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Matteo Marro
- Cardiovascular Surgery, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Giorgia Rizza
- General Surgery 2U - Liver Transplant Center, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Erika Simonato
- Cardiovascular Surgery, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Luca Brazzi
- Department of Anesthesia and Critical Care, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
- Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Renato Romagnoli
- Department of Surgical Sciences, University of Turin, Turin, Italy
- General Surgery 2U - Liver Transplant Center, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Marinella Zanierato
- Department of Anesthesia and Critical Care, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
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9
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Liang A, Zhang L, Jia J, Zhong K, Nie Y. The conclusion of reducing acute rejection after liver transplantation by machine perfusion should be extrapolated with caution. Hepatobiliary Surg Nutr 2023; 12:785-789. [PMID: 37886195 PMCID: PMC10598305 DOI: 10.21037/hbsn-23-180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 06/21/2023] [Indexed: 10/28/2023]
Affiliation(s)
- Aijun Liang
- General Surgery Center, Department of Hepatobiliary Surgery II, Guangdong Provincial Research Center for Artificial Organ and Tissue Engineering, Guangzhou Clinical Research and Transformation Center for Artificial Liver, Institute of Regenerative Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Linya Zhang
- General Surgery Center, Department of Hepatobiliary Surgery II, Guangdong Provincial Research Center for Artificial Organ and Tissue Engineering, Guangzhou Clinical Research and Transformation Center for Artificial Liver, Institute of Regenerative Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Junjun Jia
- Key Laboratory of Combined Multi-Organ Transplantation, Ministry of Public Health, Hangzhou, China
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Hangzhou, China
| | - Kebo Zhong
- General Surgery Center, Department of Hepatobiliary Surgery II, Guangdong Provincial Research Center for Artificial Organ and Tissue Engineering, Guangzhou Clinical Research and Transformation Center for Artificial Liver, Institute of Regenerative Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Yu Nie
- General Surgery Center, Department of Hepatobiliary Surgery II, Guangdong Provincial Research Center for Artificial Organ and Tissue Engineering, Guangzhou Clinical Research and Transformation Center for Artificial Liver, Institute of Regenerative Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, China
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10
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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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11
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Patrono D, De Stefano N, Vissio E, Apostu AL, Petronio N, Vitelli G, Catalano G, Rizza G, Catalano S, Colli F, Chiusa L, Romagnoli R. How to Preserve Steatotic Liver Grafts for Transplantation. J Clin Med 2023; 12:3982. [PMID: 37373676 DOI: 10.3390/jcm12123982] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 06/05/2023] [Accepted: 06/08/2023] [Indexed: 06/29/2023] Open
Abstract
Liver allograft steatosis is a significant risk factor for postoperative graft dysfunction and has been associated with inferior patient and graft survival, particularly in the case of moderate or severe macrovesicular steatosis. In recent years, the increasing incidence of obesity and fatty liver disease in the population has led to a higher proportion of steatotic liver grafts being used for transplantation, making the optimization of their preservation an urgent necessity. This review discusses the mechanisms behind the increased susceptibility of fatty livers to ischemia-reperfusion injury and provides an overview of the available strategies to improve their utilization for transplantation, with a focus on preclinical and clinical evidence supporting donor interventions, novel preservation solutions, and machine perfusion techniques.
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Affiliation(s)
- Damiano Patrono
- General Surgery 2U-Liver Transplant Unit, Department of Surgical Sciences, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Università di Torino, Corso Bramante 88-90, 10126 Turin, Italy
| | - Nicola De Stefano
- General Surgery 2U-Liver Transplant Unit, Department of Surgical Sciences, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Università di Torino, Corso Bramante 88-90, 10126 Turin, Italy
| | - Elena Vissio
- Department of Pathology, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Università di Torino, Corso Bramante 88-90, 10126 Turin, Italy
| | - Ana Lavinia Apostu
- General Surgery 2U-Liver Transplant Unit, Department of Surgical Sciences, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Università di Torino, Corso Bramante 88-90, 10126 Turin, Italy
| | - Nicoletta Petronio
- General Surgery 2U-Liver Transplant Unit, Department of Surgical Sciences, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Università di Torino, Corso Bramante 88-90, 10126 Turin, Italy
| | - Giovanni Vitelli
- General Surgery 2U-Liver Transplant Unit, Department of Surgical Sciences, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Università di Torino, Corso Bramante 88-90, 10126 Turin, Italy
| | - Giorgia Catalano
- General Surgery 2U-Liver Transplant Unit, Department of Surgical Sciences, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Università di Torino, Corso Bramante 88-90, 10126 Turin, Italy
| | - Giorgia Rizza
- General Surgery 2U-Liver Transplant Unit, Department of Surgical Sciences, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Università di Torino, Corso Bramante 88-90, 10126 Turin, Italy
| | - Silvia Catalano
- General Surgery 2U-Liver Transplant Unit, Department of Surgical Sciences, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Università di Torino, Corso Bramante 88-90, 10126 Turin, Italy
| | - Fabio Colli
- General Surgery 2U-Liver Transplant Unit, Department of Surgical Sciences, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Università di Torino, Corso Bramante 88-90, 10126 Turin, Italy
| | - Luigi Chiusa
- Department of Pathology, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Università di Torino, Corso Bramante 88-90, 10126 Turin, Italy
| | - Renato Romagnoli
- General Surgery 2U-Liver Transplant Unit, Department of Surgical Sciences, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Università di Torino, Corso Bramante 88-90, 10126 Turin, Italy
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12
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De Carlis R, Paolo Muiesan, Taner B. Donation after circulatory death: Novel strategies to improve the liver transplant outcome. J Hepatol 2023; 78:1169-1180. [PMID: 37208104 DOI: 10.1016/j.jhep.2023.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 04/07/2023] [Accepted: 04/11/2023] [Indexed: 05/21/2023]
Abstract
In many countries, donation after circulatory death (DCD) liver grafts are used to overcome organ shortages; however, DCD grafts have been associated with an increased risk of complications and even graft loss after liver transplantation. The increased risk of complications is thought to correlate with prolonged functional donor warm ischaemia time. Stringent donor selection criteria and utilisation of in situ and ex situ organ perfusion technologies have led to improved outcomes. Additionally, the increased use of novel organ perfusion strategies has led to the possibility of reconditioning marginal DCD liver grafts. Moreover, these technologies enable the assessment of liver function before implantation, thus providing valuable data that can guide more precise graft-recipient selection. In this review, we first describe the different definitions of functional warm donor ischaemia time and its role as a determinant of outcomes after DCD liver transplantation, with a focus on the thresholds proposed for graft acceptance. Next, organ perfusion strategies, namely normothermic regional perfusion, hypothermic oxygenated perfusion, and normothermic machine perfusion are discussed. For each technique, clinical studies reporting on the transplant outcome are described, together with a discussion on the possible protective mechanisms involved and the functional criteria adopted for graft selection. Finally, we review multimodal preservation protocols involving a combination of more than one perfusion technique and potential future directions in the field.
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Affiliation(s)
- Riccardo De Carlis
- Division of General Surgery and Transplantation, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy; Ph.D. Course in Clinical and Experimental Sciences, University of Padua, Padua, Italy
| | - Paolo Muiesan
- General and Liver Transplant Surgery Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico and University of Milan, Centre of Preclinical Research, 20122, Italy
| | - Burcin Taner
- Department of Transplant, Mayo Clinic Florida, Jacksonville, United States.
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13
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Vargas PA, Yu C, Goldaracena N. Comprehensive review of the application of MP and the potential for graft modification. FRONTIERS IN TRANSPLANTATION 2023; 2:1163539. [PMID: 38993846 PMCID: PMC11235300 DOI: 10.3389/frtra.2023.1163539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 04/20/2023] [Indexed: 07/13/2024]
Abstract
Introduction Following procurement, the liver graft is exposed to an ischemic period that triggers several pathophysiologic changes in response to oxygen deprivation. Therefore, the goal during organ preservation is to attenuate such response and provide an adequate environment that prepares the graft for its metabolic reactivation following implantation. This has been widely achieved via static cold storage preservation, where the maintenance of the graft using cold preservation solutions reduce its metabolic activity and confer cytoprotection until transplantation. However, despite being the gold standard for organ preservation, static cold storage holds several disadvantages. In addition, the ongoing organ shortage has led to the use of unconventional grafts that could benefit from therapies pre-transplant. Organ preservation via machine perfusion systems appears as a promising solution to address both. Methods Here, we aim to present a state-of-the-art narrative review regarding liver graft modification options using machine perfusion systems in combination with adjuvant strategies including immunomodulation, gene therapy and pharmacotherapy. Results Available reports are scarce and mostly on experimental animal models. Most of the literature reflects the use of normothermic or subnormothermic machine perfusion devices given that these particular type of machine allows for a metabolically active organ, and therefore facilitates its modification. Although limited, promising findings in available reports suggest that organ preservation using machine perfusion system when combined with alternative therapies can be feasible and safe strategies for graft modification. Discussion Further research on clinical settings are needed to better elucidate the true effect of graft modification pre-transplant on short- and long-term graft and patient survival. There is a long way ahead to develop guidelines and approve these novel therapies for clinical practice. However, the path looks promising.
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Affiliation(s)
- Paola A. Vargas
- Division of Transplant Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, VA, United States
| | - Christine Yu
- Department of Public Health Sciences, University of Virginia, Charlottesville, VA, United States
| | - Nicolas Goldaracena
- Division of Transplant Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, VA, United States
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14
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Rigo F, De Stefano N, Patrono D, De Donato V, Campi L, Turturica D, Doria T, Sciannameo V, Berchialla P, Tandoi F, Romagnoli R. Impact of Hypothermic Oxygenated Machine Perfusion on Hepatocellular Carcinoma Recurrence after Liver Transplantation. J Pers Med 2023; 13:jpm13050703. [PMID: 37240873 DOI: 10.3390/jpm13050703] [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: 03/31/2023] [Revised: 04/16/2023] [Accepted: 04/21/2023] [Indexed: 05/28/2023] Open
Abstract
BACKGROUND Machine perfusion may be able to mitigate ischemia-reperfusion injury (IRI), which increases hepatocellular carcinoma (HCC) recurrence after liver transplantation (LT). This study aimed to investigate the impact of dual-hypothermic oxygenated machine perfusion (D-HOPE) on HCC recurrence in LT. METHODS A single-center retrospective study was conducted from 2016 to 2020. Pre- and postoperative data of HCC patients undergoing LT were analyzed. Recipients of a D-HOPE-treated graft were compared to those of livers preserved using static cold storage (SCS). The primary endpoint was recurrence-free survival (RFS). RESULTS Of 326 patients, 246 received an SCS-preserved liver and 80 received a D-HOPE-treated graft (donation after brain death (DBD), n = 66; donation after circulatory death (DCD), n = 14). Donors of D-HOPE-treated grafts were older and had higher BMI. All DCD donors were treated by normothermic regional perfusion and D-HOPE. The groups were comparable in terms of HCC features and estimated 5-year RFS according to the Metroticket 2.0 model. D-HOPE did not reduce HCC recurrence (D-HOPE 10%; SCS 8.9%; p = 0.95), which was confirmed using Bayesian model averaging and inverse probability of treatment weighting-adjusted RFS analysis. Postoperative outcomes were comparable between groups, except for lower AST and ALT peak in the D-HOPE group. CONCLUSIONS In this single-center study, D-HOPE did not reduce HCC recurrence but allowed utilizing livers from extended criteria donors with comparable outcomes, improving access to LT for patients suffering from HCC.
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Affiliation(s)
- Federica Rigo
- General Surgery 2U-Liver Transplant Unit, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, 10126 Turin, Italy
| | - Nicola De Stefano
- General Surgery 2U-Liver Transplant Unit, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, 10126 Turin, Italy
| | - Damiano Patrono
- General Surgery 2U-Liver Transplant Unit, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, 10126 Turin, Italy
| | - Victor De Donato
- General Surgery 2U-Liver Transplant Unit, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, 10126 Turin, Italy
| | - Ludovico Campi
- General Surgery 2U-Liver Transplant Unit, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, 10126 Turin, Italy
| | - Diana Turturica
- General Surgery 2U-Liver Transplant Unit, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, 10126 Turin, Italy
| | - Teresa Doria
- General Surgery 2U-Liver Transplant Unit, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, 10126 Turin, Italy
| | - Veronica Sciannameo
- Centre for Biostatistics, Epidemiology and Public Health (C-BEPH), Department of Clinical and Biological Sciences, University of Torino, 10126 Turin, Italy
| | - Paola Berchialla
- Centre for Biostatistics, Epidemiology and Public Health (C-BEPH), Department of Clinical and Biological Sciences, University of Torino, 10126 Turin, Italy
| | - Francesco Tandoi
- General Surgery 2U-Liver Transplant Unit, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, 10126 Turin, Italy
- HPB and Liver Transplant Unit, Azienda Ospedaliero Universitaria Consorziale Policlinico, 70124 Bari, Italy
| | - Renato Romagnoli
- General Surgery 2U-Liver Transplant Unit, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, 10126 Turin, Italy
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15
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Patrono D, Colli F, Colangelo M, De Stefano N, Apostu AL, Mazza E, Catalano S, Rizza G, Mirabella S, Romagnoli R. How Can Machine Perfusion Change the Paradigm of Liver Transplantation for Patients with Perihilar Cholangiocarcinoma? J Clin Med 2023; 12:jcm12052026. [PMID: 36902813 PMCID: PMC10004136 DOI: 10.3390/jcm12052026] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 02/24/2023] [Accepted: 03/01/2023] [Indexed: 03/08/2023] Open
Abstract
Perihilar cholangiocarcinomas (pCCA) are rare yet aggressive tumors originating from the bile ducts. While surgery remains the mainstay of treatment, only a minority of patients are amenable to curative resection, and the prognosis of unresectable patients is dismal. The introduction of liver transplantation (LT) after neoadjuvant chemoradiation for unresectable pCCA in 1993 represented a major breakthrough, and it has been associated with 5-year survival rates consistently >50%. Despite these encouraging results, pCCA has remained a niche indication for LT, which is most likely due to the need for stringent candidate selection and the challenges in preoperative and surgical management. Machine perfusion (MP) has recently been reintroduced as an alternative to static cold storage to improve liver preservation from extended criteria donors. Aside from being associated with superior graft preservation, MP technology allows for the safe extension of preservation time and the testing of liver viability prior to implantation, which are characteristics that may be especially useful in the setting of LT for pCCA. This review summarizes current surgical strategies for pCCA treatment, with a focus on unmet needs that have contributed to the limited spread of LT for pCCA and how MP could be used in this setting, with a particular emphasis on the possibility of expanding the donor pool and improving transplant logistics.
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16
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De Stefano N, Calleri A, Navarro-Tableros V, Rigo F, Patrono D, Romagnoli R. State-of-the-Art and Future Directions in Organ Regeneration with Mesenchymal Stem Cells and Derived Products during Dynamic Liver Preservation. Medicina (B Aires) 2022; 58:medicina58121826. [PMID: 36557029 PMCID: PMC9785426 DOI: 10.3390/medicina58121826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 11/29/2022] [Accepted: 12/09/2022] [Indexed: 12/14/2022] Open
Abstract
Transplantation is currently the treatment of choice for end-stage liver diseases but is burdened by the shortage of donor organs. Livers from so-called extended-criteria donors represent a valid option to overcome organ shortage, but they are at risk for severe post-operative complications, especially when preserved with conventional static cold storage. Machine perfusion technology reduces ischemia-reperfusion injury and allows viability assessment of these organs, limiting their discard rate and improving short- and long-term outcomes after transplantation. Moreover, by keeping the graft metabolically active, the normothermic preservation technique guarantees a unique platform to administer regenerative therapies ex vivo. With their anti-inflammatory and immunomodulatory properties, mesenchymal stem cells are among the most promising sources of therapies for acute and chronic liver failure, but their routine clinical application is limited by several biosafety concerns. It is emerging that dynamic preservation and stem cell therapy may supplement each other if combined, as machine perfusion can be used to deliver stem cells to highly injured grafts, avoiding potential systemic side effects. The aim of this narrative review is to provide a comprehensive overview on liver preservation techniques and mesenchymal stem cell-based therapies, focusing on their application in liver graft reconditioning.
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Affiliation(s)
- Nicola De Stefano
- General Surgery 2U—Liver Transplant Unit, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, University of Torino, 10126 Turin, Italy
| | - Alberto Calleri
- Gastrohepatology Unit, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, University of Torino, 10126 Turin, Italy
| | - Victor Navarro-Tableros
- 2i3T, Società per la Gestione dell’incubatore di Imprese e per il Trasferimento Tecnologico, University of Torino, 10126 Turin, Italy
| | - Federica Rigo
- General Surgery 2U—Liver Transplant Unit, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, University of Torino, 10126 Turin, Italy
| | - Damiano Patrono
- General Surgery 2U—Liver Transplant Unit, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, University of Torino, 10126 Turin, Italy
| | - Renato Romagnoli
- General Surgery 2U—Liver Transplant Unit, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, University of Torino, 10126 Turin, Italy
- Correspondence: ; Tel.: +39-011-6334364
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17
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Meier RPH, Kelly Y, Braun H, Maluf D, Freise C, Ascher N, Roberts J, Roll G. Comparison of Biliary Complications Rates After Brain Death, Donation After Circulatory Death, and Living-Donor Liver Transplantation: A Single-Center Cohort Study. Transpl Int 2022; 35:10855. [PMID: 36568142 PMCID: PMC9780276 DOI: 10.3389/ti.2022.10855] [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: 08/22/2022] [Accepted: 11/23/2022] [Indexed: 12/14/2022]
Abstract
Donation-after-circulatory-death (DCD), donation-after-brain-death (DBD), and living-donation (LD) are the three possible options for liver transplantation (LT), each with unique benefits and complication rates. We aimed to compare DCD-, DBD-, and LD-LT-specific graft survival and biliary complications (BC). We collected data on 138 DCD-, 3,027 DBD- and 318 LD-LTs adult recipients from a single center and analyzed patient/graft survival. BC (leak and anastomotic/non-anastomotic stricture (AS/NAS)) were analyzed in a subset of 414 patients. One-/five-year graft survival were 88.6%/70.0% for DCD-LT, 92.6%/79.9% for DBD-LT, and, 91.7%/82.9% for LD-LT. DCD-LTs had a 1.7-/1.3-fold adjusted risk of losing their graft compared to DBD-LT and LD-LT, respectively (p < 0.010/0.403). Bile leaks were present in 10.1% (DCD-LTs), 7.2% (DBD-LTs), and 36.2% (LD-LTs) (ORs, DBD/LD vs. DCD: 0.7/4.2, p = 0.402/<0.001). AS developed in 28.3% DCD-LTs, 18.1% DBD-LTs, and 43.5% LD-LTs (ORs, DBD/LD vs. DCD: 0.5/1.8, p = 0.018/0.006). NAS was present in 15.2% DCD-LTs, 1.4% DBDs-LT, and 4.3% LD-LTs (ORs, DBD/LD vs. DCD: 0.1/0.3, p = 0.001/0.005). LTs w/o BC had better liver graft survival compared to any other groups with BC. DCD-LT and LD-LT had excellent graft survival despite significantly higher BC rates compared to DBD-LT. DCD-LT represents a valid alternative whose importance should increase further with machine/perfusion systems.
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Affiliation(s)
- Raphael Pascal Henri Meier
- University of California, San Francisco, San Francisco, CA, United States,University of Maryland, Baltimore, Baltimore, MD, United States,*Correspondence: Raphael Pascal Henri Meier,
| | - Yvonne Kelly
- University of California, San Francisco, San Francisco, CA, United States
| | - Hillary Braun
- University of California, San Francisco, San Francisco, CA, United States
| | - Daniel Maluf
- University of Maryland, Baltimore, Baltimore, MD, United States
| | - Chris Freise
- University of California, San Francisco, San Francisco, CA, United States
| | - Nancy Ascher
- University of California, San Francisco, San Francisco, CA, United States
| | - John Roberts
- University of California, San Francisco, San Francisco, CA, United States
| | - Garrett Roll
- University of California, San Francisco, San Francisco, CA, United States
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18
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Widmer J, Eden J, Carvalho MF, Dutkowski P, Schlegel A. Machine Perfusion for Extended Criteria Donor Livers: What Challenges Remain? J Clin Med 2022; 11:jcm11175218. [PMID: 36079148 PMCID: PMC9457017 DOI: 10.3390/jcm11175218] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 08/30/2022] [Indexed: 11/28/2022] Open
Abstract
Based on the renaissance of dynamic preservation techniques, extended criteria donor (ECD) livers reclaimed a valuable eligibility in the transplantable organ pool. Being more vulnerable to ischemia, ECD livers carry an increased risk of early allograft dysfunction, primary non-function and biliary complications and, hence, unveiled the limitations of static cold storage (SCS). There is growing evidence that dynamic preservation techniques—dissimilar to SCS—mitigate reperfusion injury by reconditioning organs prior transplantation and therefore represent a useful platform to assess viability. Yet, a debate is ongoing about the advantages and disadvantages of different perfusion strategies and their best possible applications for specific categories of marginal livers, including organs from donors after circulatory death (DCD) and brain death (DBD) with extended criteria, split livers and steatotic grafts. This review critically discusses the current clinical spectrum of livers from ECD donors together with the various challenges and posttransplant outcomes in the context of standard cold storage preservation. Based on this, the potential role of machine perfusion techniques is highlighted next. Finally, future perspectives focusing on how to achieve higher utilization rates of the available donor pool are highlighted.
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Affiliation(s)
- Jeannette Widmer
- Department of Surgery and Transplantation, Swiss HPB Centre, University Hospital Zurich, 8091 Zürich, Switzerland
| | - Janina Eden
- Department of Surgery and Transplantation, Swiss HPB Centre, University Hospital Zurich, 8091 Zürich, Switzerland
| | - Mauricio Flores Carvalho
- Hepatobiliary Unit, Department of Clinical and Experimental Medicine, University of Florence, AOU Careggi, 50139 Florence, Italy
| | - Philipp Dutkowski
- Department of Surgery and Transplantation, Swiss HPB Centre, University Hospital Zurich, 8091 Zürich, Switzerland
| | - Andrea Schlegel
- Department of Surgery and Transplantation, Swiss HPB Centre, University Hospital Zurich, 8091 Zürich, Switzerland
- Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Centre of Preclinical Research, 20122 Milan, Italy
- Correspondence:
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