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Nykänen AI, Keshavjee S, Liu M. Creating superior lungs for transplantation with next-generation gene therapy during ex vivo lung perfusion. J Heart Lung Transplant 2024; 43:838-848. [PMID: 38310996 DOI: 10.1016/j.healun.2024.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Revised: 12/23/2023] [Accepted: 01/29/2024] [Indexed: 02/06/2024] Open
Abstract
Engineering donor organs to better tolerate the harmful non-immunological and immunological responses inherently related to solid organ transplantation would improve transplant outcomes. Our enhanced knowledge of ischemia-reperfusion injury, alloimmune responses and pathological fibroproliferation after organ transplantation, and the advanced toolkit available for gene therapies, have brought this goal closer to clinical reality. Ex vivo organ perfusion has evolved rapidly especially in the field of lung transplantation, where clinicians routinely use ex vivo lung perfusion (EVLP) to confirm the quality of marginal donor lungs before transplantation, enabling safe transplantation of organs originally considered unusable. EVLP would also be an attractive platform to deliver gene therapies, as treatments could be administered to an isolated organ before transplantation, thereby providing a window for sophisticated organ engineering while minimizing off-target effects to the recipient. Here, we review the status of lung transplant first-generation gene therapies that focus on inducing transgene expression in the target cells. We also highlight recent advances in next-generation gene therapies, that enable gene editing and epigenetic engineering, that could be used to permanently change the donor organ genome and to induce widespread transcriptional gene expression modulation in the donor lung. In a future vision, dedicated organ repair and engineering centers will use gene editing and epigenetic engineering, to not only increase the donor organ pool, but to create superior organs that will function better and longer in the recipient.
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Affiliation(s)
- Antti I Nykänen
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada; Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Cardiothoracic Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Shaf Keshavjee
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada; Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Division of Thoracic Surgery, Department of Surgery, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Mingyao Liu
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada; Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
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García-Villegas R, Arni S. Hemoadsorption in Organ Preservation and Transplantation: A Narrative Review. Life (Basel) 2023; 14:65. [PMID: 38255680 PMCID: PMC10817660 DOI: 10.3390/life14010065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 12/19/2023] [Accepted: 12/27/2023] [Indexed: 01/24/2024] Open
Abstract
Cytokine adsorption can resolve different complications characteristic of transplantation medicine, such as cytokine storm activation and blood ABO and immune incompatibilities. Cytokine adsorption is also performed for the treatment of various life-threatening conditions, such as endotoxic septic shock, acute respiratory distress syndrome, and cardiogenic shock, all potentially leading to adverse clinical outcomes during transplantation. After surgery, dysmetabolism and stress response limit successful graft survival and can lead to primary or secondary graft dysfunction. In this clinical context, and given that a major problem in transplant medicine is that the demand for organs far exceeds the supply, a technological innovation such as a hemoadsorption system could greatly contribute to increasing the number of usable organ donors. The objectives of this review are to describe the specific advantages and disadvantages of the application of cytokine adsorption in the context of transplantation and examine, before and/or after organ transplantation, the benefits of the addition of a cytokine adsorption therapy protocol.
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Affiliation(s)
- Refugio García-Villegas
- Departamento de Fisiología, Biofísica y Neurociencias, Centro de Investigación y de Estudios Avanzados del Instituto Politécnico Nacional, D.F., Mexico City 07360, Mexico;
| | - Stephan Arni
- Department of Thoracic Surgery, University Hospital Zürich, 8091 Zürich, Switzerland
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Niroomand A, Hirdman G, Pierre L, Ghaidan H, Kjellström S, Stenlo M, Hyllén S, Olm F, Lindstedt S. Proteomic changes to immune and inflammatory processes underlie lung preservation using ex vivo cytokine adsorption. Front Cardiovasc Med 2023; 10:1274444. [PMID: 37849943 PMCID: PMC10577429 DOI: 10.3389/fcvm.2023.1274444] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 09/13/2023] [Indexed: 10/19/2023] Open
Abstract
Introduction In recent years, the field of graft preservation has made considerable strides in improving outcomes related to solid organ restoration and regeneration. Ex vivo lung perfusion (EVLP) in line with the related devices and treatments has yielded promising results within preclinical and clinical studies, with the potential to improve graft quality. Its main benefit is to render marginal and declined donor lungs suitable for transplantation, ultimately increasing the donor pool available for transplantation. In addition, using such therapies in machine perfusion could also increase preservation time, facilitating logistical planning. Cytokine adsorption has been demonstrated as a potentially safe and effective therapy when applied to the EVLP circuit and post-transplantation. However, the mechanism by which this therapy improves the donor lung on a molecular basis is not yet fully understood. Methods We hypothesized that there were characteristic inflammatory and immunomodulatory differences between the lungs treated with and without cytokine adsorption, reflecting proteomic changes in the gene ontology pathways and across inflammation-related proteins. In this study, we investigate the molecular mechanisms and signaling pathways of how cytokine adsorption impacts lung function when used during EVLP and post-transplantation as hemoperfusion in a porcine model. Lung tissues during EVLP and post-lung transplantation were analyzed for their proteomic profiles using mass spectrometry. Results We found through gene set enrichment analysis that the inflammatory and immune processes and coagulation pathways were significantly affected by the cytokine treatment after EVLP and transplantation. Conclusion In conclusion, we showed that the molecular mechanisms are using a proteomic approach behind the previously reported effects of cytokine adsorption when compared to the non-treated transplant recipients undergoing EVLP.
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Affiliation(s)
- Anna Niroomand
- Department of Clinical Sciences, Lund University, Lund, Sweden
- Lund Stem Cell Center, Lund University, Lund, Sweden
- School of Medicine, Rutgers Robert Wood Johnson University, New Brunswick, NJ, United States
| | - Gabriel Hirdman
- Department of Clinical Sciences, Lund University, Lund, Sweden
- Lund Stem Cell Center, Lund University, Lund, Sweden
- Wallenberg Center for Molecular Medicine, Lund University, Lund, Sweden
| | - Leif Pierre
- Department of Clinical Sciences, Lund University, Lund, Sweden
- Lund Stem Cell Center, Lund University, Lund, Sweden
- Wallenberg Center for Molecular Medicine, Lund University, Lund, Sweden
- Department of Cardiothoracic Surgery and Transplantation, Skåne University Hospital, Lund, Sweden
| | - Haider Ghaidan
- Department of Clinical Sciences, Lund University, Lund, Sweden
- Lund Stem Cell Center, Lund University, Lund, Sweden
- Wallenberg Center for Molecular Medicine, Lund University, Lund, Sweden
- Department of Cardiothoracic Surgery and Transplantation, Skåne University Hospital, Lund, Sweden
| | - Sven Kjellström
- Department of Clinical Sciences, BioMS, Lund University, Lund, Sweden
| | - Martin Stenlo
- Department of Clinical Sciences, Lund University, Lund, Sweden
- Lund Stem Cell Center, Lund University, Lund, Sweden
- Wallenberg Center for Molecular Medicine, Lund University, Lund, Sweden
- Department of Cardiothoracic Surgery and Transplantation, Skåne University Hospital, Lund, Sweden
- Department of Cardiothoracic Anesthesia and Intensive Care, Skåne University Hospital, Lund, Sweden
| | - Snejana Hyllén
- Department of Clinical Sciences, Lund University, Lund, Sweden
- Lund Stem Cell Center, Lund University, Lund, Sweden
- Wallenberg Center for Molecular Medicine, Lund University, Lund, Sweden
- Department of Cardiothoracic Anesthesia and Intensive Care, Skåne University Hospital, Lund, Sweden
| | - Franziska Olm
- Department of Clinical Sciences, Lund University, Lund, Sweden
- Lund Stem Cell Center, Lund University, Lund, Sweden
- Wallenberg Center for Molecular Medicine, Lund University, Lund, Sweden
| | - Sandra Lindstedt
- Department of Clinical Sciences, Lund University, Lund, Sweden
- Lund Stem Cell Center, Lund University, Lund, Sweden
- Wallenberg Center for Molecular Medicine, Lund University, Lund, Sweden
- Department of Cardiothoracic Surgery and Transplantation, Skåne University Hospital, Lund, Sweden
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Nykänen AI, Liu M, Keshavjee S. Mesenchymal Stromal Cell Therapy in Lung Transplantation. Bioengineering (Basel) 2023; 10:728. [PMID: 37370659 DOI: 10.3390/bioengineering10060728] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Revised: 06/14/2023] [Accepted: 06/15/2023] [Indexed: 06/29/2023] Open
Abstract
Lung transplantation is often the only viable treatment option for a patient with end-stage lung disease. Lung transplant results have improved substantially over time, but ischemia-reperfusion injury, primary graft dysfunction, acute rejection, and chronic lung allograft dysfunction (CLAD) continue to be significant problems. Mesenchymal stromal cells (MSC) are pluripotent cells that have anti-inflammatory and protective paracrine effects and may be beneficial in solid organ transplantation. Here, we review the experimental studies where MSCs have been used to protect the donor lung against ischemia-reperfusion injury and alloimmune responses, as well as the experimental and clinical studies using MSCs to prevent or treat CLAD. In addition, we outline ex vivo lung perfusion (EVLP) as an optimal platform for donor lung MSC delivery, as well as how the therapeutic potential of MSCs could be further leveraged with genetic engineering.
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Affiliation(s)
- Antti I Nykänen
- Latner Thoracic Surgery Research Laboratories, Toronto General Research Hospital Institute, University Health Network, Toronto, ON M5G 1L7, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada
- Department of Cardiothoracic Surgery, Helsinki University Hospital and University of Helsinki, FI-00029 Helsinki, Finland
| | - Mingyao Liu
- Latner Thoracic Surgery Research Laboratories, Toronto General Research Hospital Institute, University Health Network, Toronto, ON M5G 1L7, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada
| | - Shaf Keshavjee
- Latner Thoracic Surgery Research Laboratories, Toronto General Research Hospital Institute, University Health Network, Toronto, ON M5G 1L7, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada
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Advances in Lung Transplantation. Cells 2023; 12:cells12060923. [PMID: 36980264 PMCID: PMC10047853 DOI: 10.3390/cells12060923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 03/13/2023] [Accepted: 03/15/2023] [Indexed: 03/19/2023] Open
Abstract
Nowadays, lung transplantation is a clinical reality for the treatment of benign end-stage respiratory diseases [...]
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Niroomand A, Lindstedt S. All for one and one for all: A commentary on centralized ex vivo lung perfusion centers. J Heart Lung Transplant 2023; 42:289-290. [PMID: 36503728 DOI: 10.1016/j.healun.2022.08.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 08/26/2022] [Accepted: 08/29/2022] [Indexed: 01/18/2023] Open
Affiliation(s)
- Anna Niroomand
- Department of Clinical Sciences, Lund University, Sweden; Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Sandra Lindstedt
- Department of Clinical Sciences, Lund University, Sweden; Department of Cardiothoracic Surgery and Transplantation, Skåne University Hospital, Lund, Sweden; Wallenberg Center for Molecular Medicine, Lund University, Sweden; Lund Stem Cell Center, Lund University, Sweden.
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Miller CL, O JM, Allan JS, Madsen JC. Novel approaches for long-term lung transplant survival. Front Immunol 2022; 13:931251. [PMID: 35967365 PMCID: PMC9363671 DOI: 10.3389/fimmu.2022.931251] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 07/04/2022] [Indexed: 11/16/2022] Open
Abstract
Allograft failure remains a major barrier in the field of lung transplantation and results primarily from acute and chronic rejection. To date, standard-of-care immunosuppressive regimens have proven unsuccessful in achieving acceptable long-term graft and patient survival. Recent insights into the unique immunologic properties of lung allografts provide an opportunity to develop more effective immunosuppressive strategies. Here we describe advances in our understanding of the mechanisms driving lung allograft rejection and highlight recent progress in the development of novel, lung-specific strategies aimed at promoting long-term allograft survival, including tolerance.
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Affiliation(s)
- Cynthia L. Miller
- Center for Transplantation Sciences, Massachusetts General Hospital, Boston, MA, United States
| | - Jane M. O
- Center for Transplantation Sciences, Massachusetts General Hospital, Boston, MA, United States
| | - James S. Allan
- Center for Transplantation Sciences, Massachusetts General Hospital, Boston, MA, United States
- Division of Thoracic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA, United States
| | - Joren C. Madsen
- Center for Transplantation Sciences, Massachusetts General Hospital, Boston, MA, United States
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA, United States
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Hirdman G, Niroomand A, Olm F, Lindstedt S. Taking a Deep Breath: an Examination of Current Controversies in Surgical Procedures in Lung Transplantation. CURRENT TRANSPLANTATION REPORTS 2022; 9:160-172. [PMID: 35601346 PMCID: PMC9108015 DOI: 10.1007/s40472-022-00367-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/2022] [Indexed: 11/30/2022]
Abstract
Abstract
Purpose of Review
This article reviews controversial questions within the field of lung transplantation, with a focus on data generated within the last 3 years. We aim to summarize differing opinions on a selection of topics, including bridge-to-transplantation, intraoperative machine circulatory support, bronchial anastomosis, size mismatch, delayed chest closure, and ex vivo lung perfusion.
Recent Findings
With the growing rate of lung transplantations worldwide and increasing numbers of patients placed on waiting lists, the importance of determining best practices has only increased in recent years. Factors which promote successful outcomes have been identified across all the topics, with certain approaches promoted, such as ambulation in bridge-to-transplant and widespread intraoperative ECMO as machine support.
Summary
While great strides have been made in the operative procedures involved in lung transplantation, there are still key questions to be answered. The consensus which can be reached will be instrumental in further improving outcomes in recipients.
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Affiliation(s)
- Gabriel Hirdman
- Department of Cardiothoracic Surgery and Transplantation, Skåne University Hospital, Lund University, Lund, Sweden
- Wallenberg Center for Molecular Medicine, Lund University, Lund, Sweden
- Department of Clinical Sciences, Lund University, Lund, Sweden
- Lund Stem Cell Center, Lund University, Lund, Sweden
| | - Anna Niroomand
- Wallenberg Center for Molecular Medicine, Lund University, Lund, Sweden
- Department of Clinical Sciences, Lund University, Lund, Sweden
- Lund Stem Cell Center, Lund University, Lund, Sweden
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ USA
| | - Franziska Olm
- Department of Cardiothoracic Surgery and Transplantation, Skåne University Hospital, Lund University, Lund, Sweden
- Wallenberg Center for Molecular Medicine, Lund University, Lund, Sweden
- Department of Clinical Sciences, Lund University, Lund, Sweden
- Lund Stem Cell Center, Lund University, Lund, Sweden
| | - Sandra Lindstedt
- Department of Cardiothoracic Surgery and Transplantation, Skåne University Hospital, Lund University, Lund, Sweden
- Wallenberg Center for Molecular Medicine, Lund University, Lund, Sweden
- Department of Clinical Sciences, Lund University, Lund, Sweden
- Lund Stem Cell Center, Lund University, Lund, Sweden
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