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Azizieh Y, Westhaver LP, Badrudin D, Boudreau JE, Gala-Lopez BL. Changing liver utilization and discard rates in clinical transplantation in the ex-vivo machine preservation era. FRONTIERS IN MEDICAL TECHNOLOGY 2023; 5:1079003. [PMID: 36908294 PMCID: PMC9996101 DOI: 10.3389/fmedt.2023.1079003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 01/30/2023] [Indexed: 02/25/2023] Open
Abstract
Liver transplantation is a well-established treatment for many with end-stage liver disease. Unfortunately, the increasing organ demand has surpassed the donor supply, and approximately 30% of patients die while waiting for a suitable liver. Clinicians are often forced to consider livers of inferior quality to increase organ donation rates, but ultimately, many of those organs end up being discarded. Extensive testing in experimental animals and humans has shown that ex-vivo machine preservation allows for a more objective characterization of the graft outside the body, with particular benefit for suboptimal organs. This review focuses on the history of the implementation of ex-vivo liver machine preservation and how its enactment may modify our current concept of organ acceptability. We provide a brief overview of the major drivers of organ discard (age, ischemia time, steatosis, etc.) and how this technology may ultimately revert such a trend. We also discuss future directions for this technology, including the identification of new markers of injury and repair and the opportunity for other ex-vivo regenerative therapies. Finally, we discuss the value of this technology, considering current and future donor characteristics in the North American population that may result in a significant organ discard.
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Affiliation(s)
- Yara Azizieh
- Department of Pathology, Dalhousie University, Halifax, NS, Canada
| | | | - David Badrudin
- Department of Surgery, Université de Montréal, Montréal, QC, Canada
| | - Jeanette E Boudreau
- Department of Pathology, Dalhousie University, Halifax, NS, Canada.,Department of Microbiology and Immunology, Dalhousie University, Halifax, NS, Canada.,Beatrice Hunter Cancer Research Institute, Halifax, NS, Canada
| | - Boris L Gala-Lopez
- Department of Pathology, Dalhousie University, Halifax, NS, Canada.,Department of Microbiology and Immunology, Dalhousie University, Halifax, NS, Canada.,Beatrice Hunter Cancer Research Institute, Halifax, NS, Canada.,Department of Surgery, Dalhousie University, Halifax, NS, Canada
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Portillo DJ, Bayliss L, Rivas S, Pineda G, Kaur S, Bunegin L, Hood RL. Characterizing and Tuning Perfusion Parameters Within an Innovative, Versatile Oxygenating Perfusion System. Ann Biomed Eng 2021; 49:3154-3164. [PMID: 34414529 DOI: 10.1007/s10439-021-02843-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 07/25/2021] [Indexed: 12/20/2022]
Abstract
The advantages of oxygenated perfusion are continuing to be demonstrated by many groups focused on improving the efficacy of tissue preservation for transplant, bioreactors for studies of basic tissue physiology, and closed-loop resuscitation. This work presents a novel and portable device that supplies oxygenated and pulsatile perfusion, both of which are regulated by a single pump-oxygenator component comprised of silicone tubes that are cyclically inflated/deflated with compressed oxygen. In this study, pump variables (oxygen supply pressure and length of a silicone tube) were evaluated against hydraulic elements that mimicked the vascular resistance of kidneys, livers, and hearts. The perfusion pressures, flow rates, and oxygenation rates produced by the device were characterized for all configurations of pump variables, and the pulse rates were tuned to improve performance. The device supplied perfusion pressures ranging from 3.5 to 109 mmHg, flow rates ranging from 1.4 to 71.8 mL min-1, and oxygenation rates up to 316.6 µmol min-1. From those results, it was determined that the device was capable of achieving perfusion parameters used in previous kidney, liver, and heart preservation studies. Ultimately, this research demonstrated the efficacy of a novel device that is designed to supply oxygenated perfusion across a range of applications.
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Affiliation(s)
- Daniel J Portillo
- Department of Mechanical Engineering, The University of Texas at San Antonio, 1 UTSA Circle, San Antonio, TX, 78249, USA
| | - Lauren Bayliss
- Department of Emergency Medicine, McGovern Medical School at The University of Texas Health Science Center at Houston, 6431 Fannin, JJL 260G, Houston, TX, 77030, USA.,Department of Internal Medicine, The University of Texas-Rio Grande Valley School of Medicine, 1201 W University Dr., Edinburg, TX, 78539, USA
| | - Stephen Rivas
- Department of Mechanical Engineering, The University of Texas at San Antonio, 1 UTSA Circle, San Antonio, TX, 78249, USA
| | - Gabriela Pineda
- Department of Mechanical Engineering, The University of Texas at San Antonio, 1 UTSA Circle, San Antonio, TX, 78249, USA
| | - Sukhwinder Kaur
- Department of Biomedical Engineering, The University of Texas at San Antonio, 1 UTSA Circle, San Antonio, TX, 78249, USA
| | - Leonid Bunegin
- Vascular Perfusion Solutions, Inc., San Antonio, TX, USA
| | - R Lyle Hood
- Department of Mechanical Engineering, The University of Texas at San Antonio, 1 UTSA Circle, San Antonio, TX, 78249, USA. .,Department of Biomedical Engineering, The University of Texas at San Antonio, 1 UTSA Circle, San Antonio, TX, 78249, USA. .,Department of Emergency Medicine, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX, 78229, USA.
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3
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Current review of machine perfusion in liver transplantation from the Japanese perspective. Surg Today 2021; 52:359-368. [PMID: 33754175 DOI: 10.1007/s00595-021-02265-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 02/21/2021] [Indexed: 12/11/2022]
Abstract
In light of the present evidence, machine perfusion is opening up new horizons in the field of liver transplantation. Although many advances have been made in liver transplantation, organ preservation methods have so far changed very little. Static cold storage is universally used for graft preservation in liver transplantation; however, there is a need for better preservation methods, such as ex vivo machine perfusion, to improve the outcomes by decreasing warm ischemic damage. Based on the findings of basic and clinical trials, hypothermic and normothermic machine perfusion techniques are now commercially available and include the OrganOx metra, Liver Assist, Cleveland NMP device, Organ Care System, and LifePort Liver. Recent clinical trials have provided further evidence for the potential role of normothermic machine perfusion to resuscitate and subsequently improve utilization of marginal or currently discarded livers. Further studies are required to explore the longer-term outcomes, late biliary complications, outcomes in specific high-risk groups, viability biomarkers, optimum and maximum perfusion duration, perfusate composition, and liver-directed therapeutic interventions during normothermic machine perfusion. The use of organs from marginal donors after brain death, such as fatty livers and the livers from elderly donors with multiple comorbidities, may be accepted for machine perfusion in Japan in the near future.
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Kvietkauskas M, Zitkute V, Leber B, Strupas K, Stiegler P, Schemmer P. The Role of Metabolomics in Current Concepts of Organ Preservation. Int J Mol Sci 2020; 21:ijms21186607. [PMID: 32927605 PMCID: PMC7555311 DOI: 10.3390/ijms21186607] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 09/06/2020] [Accepted: 09/08/2020] [Indexed: 12/16/2022] Open
Abstract
In solid organ transplantation (Tx), both survival rates and quality of life have improved dramatically over the last few decades. Each year, the number of people on the wait list continues to increase, widening the gap between organ supply and demand. Therefore, the use of extended criteria donor grafts is growing, despite higher susceptibility to ischemia-reperfusion injury (IRI) and consecutive inferior Tx outcomes. Thus, tools to characterize organ quality prior to Tx are crucial components for Tx success. Innovative techniques of metabolic profiling revealed key pathways and mechanisms involved in IRI occurring during organ preservation. Although large-scale trials are needed, metabolomics appears to be a promising tool to characterize potential biomarkers, for the assessment of graft quality before Tx and evaluate graft-related outcomes. In this comprehensive review, we summarize the currently available literature on the use of metabolomics in solid organ Tx, with a special focus on metabolic profiling during graft preservation to assess organ quality prior to Tx.
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Affiliation(s)
- Mindaugas Kvietkauskas
- General, Visceral and Transplant Surgery, Department of Surgery, Medical University of Graz, Auenbruggerpl. 2, Graz 8036, Austria; (M.K.); (V.Z.); (B.L.); (P.S.)
- Faculty of Medicine, Vilnius University, M. K. Ciurlionio 21, 03101 Vilnius, Lithuania;
| | - Viktorija Zitkute
- General, Visceral and Transplant Surgery, Department of Surgery, Medical University of Graz, Auenbruggerpl. 2, Graz 8036, Austria; (M.K.); (V.Z.); (B.L.); (P.S.)
- Faculty of Medicine, Vilnius University, M. K. Ciurlionio 21, 03101 Vilnius, Lithuania;
| | - Bettina Leber
- General, Visceral and Transplant Surgery, Department of Surgery, Medical University of Graz, Auenbruggerpl. 2, Graz 8036, Austria; (M.K.); (V.Z.); (B.L.); (P.S.)
| | - Kestutis Strupas
- Faculty of Medicine, Vilnius University, M. K. Ciurlionio 21, 03101 Vilnius, Lithuania;
| | - Philipp Stiegler
- General, Visceral and Transplant Surgery, Department of Surgery, Medical University of Graz, Auenbruggerpl. 2, Graz 8036, Austria; (M.K.); (V.Z.); (B.L.); (P.S.)
- Correspondence: ; Tel.: +43-316-385-84094
| | - Peter Schemmer
- General, Visceral and Transplant Surgery, Department of Surgery, Medical University of Graz, Auenbruggerpl. 2, Graz 8036, Austria; (M.K.); (V.Z.); (B.L.); (P.S.)
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Bhogal RH, Mirza DF, Afford SC, Mergental H. Biomarkers of Liver Injury during Transplantation in an Era of Machine Perfusion. Int J Mol Sci 2020; 21:ijms21051578. [PMID: 32106626 PMCID: PMC7084877 DOI: 10.3390/ijms21051578] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 02/06/2020] [Accepted: 02/13/2020] [Indexed: 02/06/2023] Open
Abstract
Liver ischaemia–reperfusion injury (IRI) is an intrinsic part of the transplantation process and damages the parenchymal cells of the liver including hepatocytes, endothelial cells and cholangiocytes. Many biomarkers of IRI have been described over the past two decades that have attempted to quantify the extent of IRI involving different hepatic cellular compartments, with the aim to allow clinicians to predict the suitability of donor livers for transplantation. The advent of machine perfusion has added an additional layer of complexity to this field and has forced researchers to re-evaluate the utility of IRI biomarkers in different machine preservation techniques. In this review, we summarise the current understanding of liver IRI biomarkers and discuss them in the context of machine perfusion.
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Affiliation(s)
- Ricky H. Bhogal
- National Institute for Health Research, Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TT, UK; (D.F.M.); (S.C.A.)
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham B15 2TT, UK
- The Royal Marsden Hospital NHS Foundation Trust, London SW3 6JJ, UK
- Correspondence: (R.H.B.); (H.M.); Tel.: +44-20-7468-3000 (R.H.B.); +44-121-371-4638 (H.M.)
| | - Darius F. Mirza
- National Institute for Health Research, Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TT, UK; (D.F.M.); (S.C.A.)
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham B15 2TT, UK
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UK
| | - Simon C. Afford
- National Institute for Health Research, Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TT, UK; (D.F.M.); (S.C.A.)
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham B15 2TT, UK
| | - Hynek Mergental
- National Institute for Health Research, Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TT, UK; (D.F.M.); (S.C.A.)
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham B15 2TT, UK
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UK
- Correspondence: (R.H.B.); (H.M.); Tel.: +44-20-7468-3000 (R.H.B.); +44-121-371-4638 (H.M.)
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