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Mergental H, Laing RW, Kirkham AJ, Clarke G, Boteon YL, Barton D, Neil DAH, Isaac JR, Roberts KJ, Abradelo M, Schlegel A, Dasari BVM, Ferguson JW, Cilliers H, Morris C, Friend PJ, Yap C, Afford SC, Perera MTPR, Mirza DF. Discarded livers tested by normothermic machine perfusion in the VITTAL trial: Secondary end points and 5-year outcomes. Liver Transpl 2024; 30:30-45. [PMID: 38109282 DOI: 10.1097/lvt.0000000000000270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 08/27/2023] [Indexed: 12/20/2023]
Abstract
Normothermic machine perfusion (NMP) enables pretransplant assessment of high-risk donor livers. The VITTAL trial demonstrated that 71% of the currently discarded organs could be transplanted with 100% 90-day patient and graft survivals. Here, we report secondary end points and 5-year outcomes of this prospective, open-label, phase 2 adaptive single-arm study. The patient and graft survivals at 60 months were 82% and 72%, respectively. Four patients lost their graft due to nonanastomotic biliary strictures, one caused by hepatic artery thrombosis in a liver donated following brain death, and 3 in elderly livers donated after circulatory death (DCD), which all clinically manifested within 6 months after transplantation. There were no late graft losses for other reasons. All the 4 patients who died during the study follow-up had functioning grafts. Nonanastomotic biliary strictures developed in donated after circulatory death livers that failed to produce bile with pH >7.65 and bicarbonate levels >25 mmol/L. Histological assessment in these livers revealed high bile duct injury scores characterized by arterial medial necrosis. The quality of life at 6 months significantly improved in all but 4 patients suffering from nonanastomotic biliary strictures. This first report of long-term outcomes of high-risk livers assessed by normothermic machine perfusion demonstrated excellent 5-year survival without adverse effects in all organs functioning beyond 1 year (ClinicalTrials.gov number NCT02740608).
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Affiliation(s)
- Hynek Mergental
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust (UHBFT), Birmingham, UK
- National Institute for Health Research (NIHR), Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, UK
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, UK
| | - Richard W Laing
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust (UHBFT), Birmingham, UK
- Hepato-pancreato Biliary Unit, Royal Stoke University Hospital, Stoke on Trent, UK
| | - Amanda J Kirkham
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - George Clarke
- National Institute for Health Research (NIHR), Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, UK
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, UK
| | - Yuri L Boteon
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust (UHBFT), Birmingham, UK
- Liver Unit, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Darren Barton
- D3B team, Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Desley A H Neil
- National Institute for Health Research (NIHR), Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, UK
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, UK
- Department of Cellular Pathology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust (UHBFT), Birmingham, UK
| | - John R Isaac
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust (UHBFT), Birmingham, UK
| | - Keith J Roberts
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust (UHBFT), Birmingham, UK
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, UK
| | - Manuel Abradelo
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust (UHBFT), Birmingham, UK
- HPB and Abdominal Organ Transplantation Department, 12 de Octubre University Hospital, Madrid, Spain
| | - Andrea Schlegel
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust (UHBFT), Birmingham, UK
- National Institute for Health Research (NIHR), Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, UK
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Centre of Preclinical Research, Milan, Italy
| | - Bobby V M Dasari
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust (UHBFT), Birmingham, UK
| | - James W Ferguson
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust (UHBFT), Birmingham, UK
- National Institute for Health Research (NIHR), Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, UK
| | - Hentie Cilliers
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust (UHBFT), Birmingham, UK
| | | | - Peter J Friend
- OrganOx Limited, Oxford, UK
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Christina Yap
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
- Clinical Trials and Statistics Unit, The Institute for Cancer Research, London
| | - Simon C Afford
- National Institute for Health Research (NIHR), Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, UK
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, UK
| | - M Thamara P R Perera
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust (UHBFT), Birmingham, UK
- National Institute for Health Research (NIHR), Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, UK
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, UK
| | - Darius F Mirza
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust (UHBFT), Birmingham, UK
- National Institute for Health Research (NIHR), Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, UK
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, UK
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De Goeij FHC, De Meijer V, Mergental H, Guarrera JV, Asthana S, Ghinolfi D, Boteon YL, Selzner N, Kalisvaart M, Pulitano C, Sonnenday C, Martins PN, Berlakovich G, Schlegel A. Challenges With the Implementation of Machine Perfusion in Clinical Liver Transplantation. Transplantation 2023:00007890-990000000-00614. [PMID: 38057969 DOI: 10.1097/tp.0000000000004872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/08/2023]
Abstract
Dynamic organ preservation is a relatively old technique which has regained significant interest in the last decade. Machine perfusion (MP) techniques are applied in various fields of solid organ transplantation today. The first clinical series of ex situ MP in liver transplantation was presented in 2010. Since then, the number of research and clinical applications has substantially increased. Despite the notable beneficial effect on organ quality and recipient outcome, MP is still not routinely used in liver transplantation. Based on the enormous need to better preserve organs and the subsequent demand to continuously innovate and develop perfusion equipment further, this technology is also beneficial to test and deliver future therapeutic strategies to livers before implantation. This article summarizes the various challenges observed during the current shift from static to dynamic liver preservation in the clinical setting. The different organ perfusion strategies are discussed first, together with ongoing clinical trials and future study design. The current status of research and the impact of costs and regulations is highlighted next. Factors contributing to costs and other required resources for a worldwide successful implementation and reimbursement are presented third. The impact of research on cost-utility and effectivity to guide the tailored decision-making regarding the optimal perfusion strategy is discussed next. Finally, this article provides potential solutions to the challenging field of innovation in healthcare considering the various social and economic factors and the role of clinical, regulatory, and financial stakeholders worldwide.
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Affiliation(s)
- Femke H C De Goeij
- Department of Surgery, Division of Hepatopancreatobiliary and Transplant Surgery, Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Vincent De Meijer
- Department of Surgery, Section of Hepatobiliary Surgery and Liver Transplantation, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
- Department of Surgery, Surgical Research Laboratory, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Hynek Mergental
- The Liver Unit, Queen Elizabeth University Hospital, Birmingham, United Kingdom
- The Liver Unit, Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - James V Guarrera
- Division of Abdominal Transplant Surgery, Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ
| | | | - Davide Ghinolfi
- Hepatobiliary Surgery and Liver Transplantation, University of Pisa Medical School Hospital, Pisa, Italy
| | - Yuri L Boteon
- Instituto Israelita de Ensino e Pesquisa Albert Einstein, Faculdade Israelita de Ciências da Saúde Albert Einstein, São Paulo, Brazil
| | - Nazia Selzner
- Ajmera Transplant Center, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Marit Kalisvaart
- Department of Surgery and Transplantation, Swiss HPB Centre, University Hospital Zurich, Zurich, Switzerland
| | - Carlo Pulitano
- Australian National Liver Transplantation Unit, Royal Prince Alfred Hospital and Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | | | - Paulo N Martins
- Division of Organ Transplantation, Department of Surgery, University of Massachusetts Memorial Hospital, University of Massachusetts, Worcester, MA
| | - Gabriela Berlakovich
- Division of Transplantation, Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - Andrea Schlegel
- Transplantation Center, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
- Department of Immunology, Lerner Research Institute, Cleveland Clinic, Cleveland, OH
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3
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Clarke G, Mao J, Fan Y, Hann A, Gupta A, Nutu A, Buckel E, Kayani K, Murphy N, Bangash MN, Casey AL, Wootton I, Lawson AJ, Dasari BVM, Perera MTPR, Mergental H, Afford SC. N-acetylcysteine: a novel approach to methaemoglobinaemia in normothermic liver machine perfusion. Sci Rep 2023; 13:19022. [PMID: 37923778 PMCID: PMC10624848 DOI: 10.1038/s41598-023-45206-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Accepted: 10/17/2023] [Indexed: 11/06/2023] Open
Abstract
Extended duration of normothermic machine perfusion (NMP) provides opportunities to resuscitate suboptimal donor livers. This intervention requires adequate oxygen delivery typically provided by a blood-based perfusion solution. Methaemoglobin (MetHb) results from the oxidation of iron within haemoglobin and represents a serious problem in perfusions lasting > 24 h. We explored the effects of anti-oxidant, N-acetylcysteine (NAC) on the accumulation of methaemoglobin. NMP was performed on nine human donor livers declined for transplantation: three were perfused without NAC (no-NAC group), and six organs perfused with an initial NAC bolus, followed by continuous infusion (NAC group), with hourly methaemoglobin perfusate measurements. In-vitro experiments examined the impact of NAC (3 mg) on red cells (30 ml) in the absence of liver tissue. The no-NAC group sustained perfusions for an average of 96 (range 87-102) h, universally developing methaemoglobinaemia (≥ 2%) observed after an average of 45 h, with subsequent steep rise. The NAC group was perfused for an average of 148 (range 90-184) h. Only 2 livers developed methaemoglobinaemia (peak MetHb of 6%), with an average onset of 116.5 h. Addition of NAC efficiently limits formation and accumulation of methaemoglobin during NMP, and allows the significant extension of perfusion duration.
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Affiliation(s)
- George Clarke
- Liver Unit, Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Birmingham, B15 2TH, UK.
- Birmingham Biomedical Research Centre, National Institute for Health Research (NIHR), University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH, UK.
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, B15 2TH, UK.
| | - Jingwen Mao
- Birmingham Biomedical Research Centre, National Institute for Health Research (NIHR), University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH, UK
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, B15 2TH, UK
| | - Yiyu Fan
- Birmingham Biomedical Research Centre, National Institute for Health Research (NIHR), University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH, UK
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, B15 2TH, UK
| | - Angus Hann
- Liver Unit, Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Birmingham, B15 2TH, UK
- Birmingham Biomedical Research Centre, National Institute for Health Research (NIHR), University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH, UK
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, B15 2TH, UK
| | | | - Anisa Nutu
- Liver Unit, Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Birmingham, B15 2TH, UK
| | - Erwin Buckel
- Liver Unit, Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Birmingham, B15 2TH, UK
| | - Kayani Kayani
- Birmingham Biomedical Research Centre, National Institute for Health Research (NIHR), University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH, UK
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, B15 2TH, UK
- Queen Elizabeth Hospital Birmingham, Birmingham, B15 2TH, UK
| | - Nicholas Murphy
- Intensive Care Unit, Queen Elizabeth Hospital Birmingham, Birmingham, B15 2TH, UK
- Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, B15 2TH, UK
| | - Mansoor N Bangash
- Intensive Care Unit, Queen Elizabeth Hospital Birmingham, Birmingham, B15 2TH, UK
- Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, B15 2TH, UK
| | - Anna L Casey
- Microbiology Department, Queen Elizabeth Hospital Birmingham, Birmingham, B15 2TH, UK
| | - Isla Wootton
- Clinical Biochemistry, Queen Elizabeth Hospital Birmingham, Birmingham, B15 2TH, UK
| | - Alexander J Lawson
- Clinical Biochemistry, Queen Elizabeth Hospital Birmingham, Birmingham, B15 2TH, UK
| | - Bobby V M Dasari
- Liver Unit, Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Birmingham, B15 2TH, UK
| | - M Thamara P R Perera
- Liver Unit, Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Birmingham, B15 2TH, UK
- Birmingham Biomedical Research Centre, National Institute for Health Research (NIHR), University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH, UK
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, B15 2TH, UK
| | - Hynek Mergental
- Liver Unit, Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Birmingham, B15 2TH, UK
- Birmingham Biomedical Research Centre, National Institute for Health Research (NIHR), University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH, UK
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, B15 2TH, UK
| | - Simon C Afford
- Birmingham Biomedical Research Centre, National Institute for Health Research (NIHR), University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH, UK
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, B15 2TH, UK
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Schlegel A, Mergental H, Fondevila C, Porte RJ, Friend PJ, Dutkowski P. Machine perfusion of the liver and bioengineering. J Hepatol 2023; 78:1181-1198. [PMID: 37208105 DOI: 10.1016/j.jhep.2023.02.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 02/03/2023] [Accepted: 02/09/2023] [Indexed: 05/21/2023]
Abstract
With the increasing number of accepted candidates on waiting lists worldwide, there is an urgent need to expand the number and the quality of donor livers. Dynamic preservation approaches have demonstrated various benefits, including improving liver function and graft survival, and reducing liver injury and post-transplant complications. Consequently, organ perfusion techniques are being used in clinical practice in many countries. Despite this success, a proportion of livers do not meet current viability tests required for transplantation, even with the use of modern perfusion techniques. Therefore, devices are needed to further optimise machine liver perfusion - one promising option is to prolong machine liver perfusion for several days, with ex situ treatment of perfused livers. For example, stem cells, senolytics, or molecules targeting mitochondria or downstream signalling can be administered during long-term liver perfusion to modulate repair mechanisms and regeneration. Besides, today's perfusion equipment is also designed to enable the use of various liver bioengineering techniques, to develop scaffolds or for their re-cellularisation. Cells or entire livers can also undergo gene modulation to modify animal livers for xenotransplantation, to directly treat injured organs or to repopulate such scaffolds with "repaired" autologous cells. This review first discusses current strategies to improve the quality of donor livers, and secondly reports on bioengineering techniques to design optimised organs during machine perfusion. Current practice, as well as the benefits and challenges associated with these different perfusion strategies are discussed.
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Affiliation(s)
- Andrea Schlegel
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Centre of Preclinical Research, Milan, 20122, Italy; Department of Surgery and Transplantation, Swiss HPB Center, University Hospital Zurich, Switzerland
| | - Hynek Mergental
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, United Kingdom
| | - Constantino Fondevila
- Hepatopancreatobiliary Surgery & Transplantation, General & Digestive Surgery Service, Hospital Universitario La Paz, IdiPAZ, CIBERehd, Madrid, Spain
| | - Robert J Porte
- Erasmus MC Transplant Institute, Department of Surgery, Division of HPB & Transplant Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Peter J Friend
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Philipp Dutkowski
- Department of Surgery and Transplantation, Swiss HPB Center, University Hospital Zurich, Switzerland.
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Durán M, Calleja R, Hann A, Clarke G, Ciria R, Nutu A, Sanabria-Mateos R, Ayllón MD, López-Cillero P, Mergental H, Briceño J, Perera MTPR. Machine perfusion and the prevention of ischemic type biliary lesions following liver transplant: What is the evidence? World J Gastroenterol 2023; 29:3066-3083. [PMID: 37346149 PMCID: PMC10280793 DOI: 10.3748/wjg.v29.i20.3066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 03/01/2023] [Accepted: 04/28/2023] [Indexed: 05/26/2023] Open
Abstract
The widespread uptake of different machine perfusion (MP) strategies for liver transplant has been driven by an effort to minimize graft injury. Damage to the cholangiocytes during the liver donation, preservation, or early posttransplant period may result in stricturing of the biliary tree and inadequate biliary drainage. This problem continues to trouble clinicians, and may have catastrophic consequences for the graft and patient. Ischemic injury, as a result of compromised hepatic artery flow, is a well-known cause of biliary strictures, sepsis, and graft failure. However, very similar lesions can appear with a patent hepatic artery and these are known as ischemic type biliary lesions (ITBL) that are attributed to microcirculatory dysfunction rather than main hepatic arterial compromise. Both the warm and cold ischemic period duration appear to influence the onset of ITBL. All of the commonly used MP techniques deliver oxygen to the graft cells, and therefore may minimize the cholangiocyte injury and subsequently reduce the incidence of ITBL. As clinical experience and published evidence grows for these modalities, the impact they have on ITBL rates is important to consider. In this review, the evidence for the three commonly used MP strategies (abdominal normothermic regional perfusion [A-NRP], hypothermic oxygenated perfusion [HOPE], and normothermic machine perfusion [NMP] for ITBL prevention has been critically reviewed. Inconsistencies with ITBL definitions used in trials, coupled with variations in techniques of MP, make interpretation challenging. Overall, the evidence suggests that both HOPE and A-NRP prevent ITBL in donated after circulatory death grafts compared to cold storage. The evidence for ITBL prevention in donor after brain death grafts with any MP technique is weak.
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Affiliation(s)
- Manuel Durán
- Department of Liver Transplantation, Reina Sofía University Hospital, Córdoba 14004, Spain
| | - Rafael Calleja
- Department of Liver Transplantation, Reina Sofía University Hospital, Córdoba 14004, Spain
| | - Angus Hann
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham B15 2TH, United Kingdom
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham B15 2TH, United Kingdom
| | - George Clarke
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham B15 2TH, United Kingdom
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham B15 2TH, United Kingdom
| | - Ruben Ciria
- Department of Liver Transplantation, Reina Sofía University Hospital, Córdoba 14004, Spain
| | - Anisa Nutu
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham B15 2TH, United Kingdom
| | | | - María Dolores Ayllón
- Department of Liver Transplantation, Reina Sofía University Hospital, Córdoba 14004, Spain
| | - Pedro López-Cillero
- Department of Liver Transplantation, Reina Sofía University Hospital, Córdoba 14004, Spain
| | - Hynek Mergental
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham B15 2TH, United Kingdom
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham B15 2TH, United Kingdom
| | - Javier Briceño
- Department of Liver Transplantation, Reina Sofía University Hospital, Córdoba 14004, Spain
| | - M Thamara P R Perera
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham B15 2TH, United Kingdom
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham B15 2TH, United Kingdom
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7
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Mohkam K, Nasralla D, Mergental H, Muller X, Butler A, Jassem W, Imber C, Monbaliu D, Perera MTPR, Laing RW, García‐Valdecasas JC, Paul A, Dondero F, Cauchy F, Savier E, Scatton O, Robin F, Sulpice L, Bucur P, Salamé E, Pittau G, Allard M, Pradat P, Rossignol G, Mabrut J, Ploeg RJ, Friend PJ, Mirza DF, Lesurtel M. In situ normothermic regional perfusion versus ex situ normothermic machine perfusion in liver transplantation from donation after circulatory death. Liver Transpl 2022; 28:1716-1725. [PMID: 35662403 PMCID: PMC9796010 DOI: 10.1002/lt.26522] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Revised: 03/14/2022] [Accepted: 03/19/2022] [Indexed: 12/30/2022]
Abstract
In situ normothermic regional perfusion (NRP) and ex situ normothermic machine perfusion (NMP) aim to improve the outcomes of liver transplantation (LT) using controlled donation after circulatory death (cDCD). NRP and NMP have not yet been compared directly. In this international observational study, outcomes of LT performed between 2015 and 2019 for organs procured from cDCD donors subjected to NRP or NMP commenced at the donor center were compared using propensity score matching (PSM). Of the 224 cDCD donations in the NRP cohort that proceeded to asystole, 193 livers were procured, resulting in 157 transplants. In the NMP cohort, perfusion was commenced in all 40 cases and resulted in 34 transplants (use rates: 70% vs. 85% [p = 0.052], respectively). After PSM, 34 NMP liver recipients were matched with 68 NRP liver recipients. The two cohorts were similar for donor functional warm ischemia time (21 min after NRP vs. 20 min after NMP; p = 0.17), UK-Donation After Circulatory Death risk score (5 vs. 5 points; p = 0.38), and laboratory Model for End-Stage Liver Disease scores (12 vs. 12 points; p = 0.83). The incidence of nonanastomotic biliary strictures (1.5% vs. 2.9%; p > 0.99), early allograft dysfunction (20.6% vs. 8.8%; p = 0.13), and 30-day graft loss (4.4% vs. 8.8%; p = 0.40) were similar, although peak posttransplant aspartate aminotransferase levels were higher in the NRP cohort (872 vs. 344 IU/L; p < 0.001). NRP livers were more frequently allocated to recipients suffering from hepatocellular carcinoma (HCC; 60.3% vs. 20.6%; p < 0.001). HCC-censored 2-year graft and patient survival rates were 91.5% versus 88.2% (p = 0.52) and 97.9% versus 94.1% (p = 0.25) after NRP and NMP, respectively. Both perfusion techniques achieved similar outcomes and appeared to match benchmarks expected for donation after brain death livers. This study may inform the design of a definitive trial.
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Affiliation(s)
- Kayvan Mohkam
- Department of Digestive Surgery & Liver Transplantation, Croix‐Rousse Hospital, Hospices Civils de LyonClaude Bernard Lyon 1 UniversityLyonFrance
| | - David Nasralla
- Department of Hepatopancreatobiliary and Liver Transplant SurgeryRoyal Free HospitalLondonUK
| | - Hynek Mergental
- Liver Unit, Queen Elizabeth HospitalUniversity Hospitals BirminghamBirminghamUK
| | - Xavier Muller
- Department of Digestive Surgery & Liver Transplantation, Croix‐Rousse Hospital, Hospices Civils de LyonClaude Bernard Lyon 1 UniversityLyonFrance
| | - Andrew Butler
- Department of Surgery, Addenbrooke's HospitalUniversity of CambridgeCambridgeUK
| | - Wayel Jassem
- Institute of Liver StudiesKing's College HospitalLondonUK
| | - Charles Imber
- Department of Hepatopancreatobiliary and Liver Transplant SurgeryRoyal Free HospitalLondonUK
| | - Diethard Monbaliu
- Abdominal Transplant Surgery Unit, Department of SurgeryUniversity Hospitals LeuvenLeuvenBelgium
| | | | - Richard W. Laing
- Liver Unit, Queen Elizabeth HospitalUniversity Hospitals BirminghamBirminghamUK
| | | | - Andreas Paul
- Department of General, Visceral and Transplantation SurgeryUniversity Hospital EssenEssenGermany
| | - Federica Dondero
- Department of Hepatobiliopancreatic SurgeryDepartment of Hepatopancreatobiliary Surgery and Liver TransplantationBeaujon Hospital, Assitance Publique‐Hôpitaux de Paris (AP‐HP), University Paris CitéClichyFrance
| | - François Cauchy
- Department of Hepatobiliopancreatic SurgeryDepartment of Hepatopancreatobiliary Surgery and Liver TransplantationBeaujon Hospital, Assitance Publique‐Hôpitaux de Paris (AP‐HP), University Paris CitéClichyFrance
| | - Eric Savier
- Department of Hepatobiliary Surgery and Liver Transplantation, Pitié‐Salpêtrière HospitalSorbonne UniversityParisFrance
| | - Olivier Scatton
- Department of Hepatobiliary Surgery and Liver Transplantation, Pitié‐Salpêtrière HospitalSorbonne UniversityParisFrance
| | - Fabien Robin
- Department of Hepatobiliary and Digestive SurgeryPontchaillou University HospitalRennesFrance
| | - Laurent Sulpice
- Department of Hepatobiliary and Digestive SurgeryPontchaillou University HospitalRennesFrance
| | - Petru Bucur
- Department of Digestive, Oncological, Endocrine, Hepato‐Biliary, Pancreatic and Liver Transplant SurgeryTrousseau HospitalToursFrance
| | - Ephrem Salamé
- Department of Digestive, Oncological, Endocrine, Hepato‐Biliary, Pancreatic and Liver Transplant SurgeryTrousseau HospitalToursFrance
| | - Gabriella Pittau
- Centre Hépato‐Biliaire, Hôpital Paul Brousse, Assistance Publique‐Hôpitaux de Paris (AP‐HP)Université Paris SudVillejuifFrance
| | - Marc‐Antoine Allard
- Centre Hépato‐Biliaire, Hôpital Paul Brousse, Assistance Publique‐Hôpitaux de Paris (AP‐HP)Université Paris SudVillejuifFrance
| | - Pierre Pradat
- Clinical Research Centre, Hospices Civils de LyonClaude Bernard Lyon 1 UniversityLyonFrance
| | - Guillaume Rossignol
- Department of Digestive Surgery & Liver Transplantation, Croix‐Rousse Hospital, Hospices Civils de LyonClaude Bernard Lyon 1 UniversityLyonFrance
| | - Jean‐Yves Mabrut
- Department of Digestive Surgery & Liver Transplantation, Croix‐Rousse Hospital, Hospices Civils de LyonClaude Bernard Lyon 1 UniversityLyonFrance
| | - Rutger J. Ploeg
- Nuffield Department of Surgical SciencesUniversity of OxfordOxfordUK
| | - Peter J. Friend
- Nuffield Department of Surgical SciencesUniversity of OxfordOxfordUK
| | - Darius F. Mirza
- Liver Unit, Queen Elizabeth HospitalUniversity Hospitals BirminghamBirminghamUK
| | - Mickaël Lesurtel
- Department of Digestive Surgery & Liver Transplantation, Croix‐Rousse Hospital, Hospices Civils de LyonClaude Bernard Lyon 1 UniversityLyonFrance
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8
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Mergental H, Laing RW, Hodson J, Boteon YL, Attard JA, Walace LL, Neil DAH, Barton D, Schlegel A, Muiesan P, Abradelo M, Isaac JR, Roberts K, Perera MTPR, Afford SC, Mirza DF. Introduction of the Concept of Diagnostic Sensitivity and Specificity of Normothermic Perfusion Protocols to Assess High-Risk Donor Livers. Liver Transpl 2022; 28:794-806. [PMID: 34619014 DOI: 10.1002/lt.26326] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 08/23/2021] [Accepted: 09/10/2021] [Indexed: 12/14/2022]
Abstract
Normothermic machine perfusion (NMP) allows objective assessment of donor liver transplantability. Several viability evaluation protocols have been established, consisting of parameters such as perfusate lactate clearance, pH, transaminase levels, and the production and composition of bile. The aims of this study were to assess 3 such protocols, namely, those introduced by the teams from Birmingham (BP), Cambridge (CP), and Groningen (GP), using a cohort of high-risk marginal livers that had initially been deemed unsuitable for transplantation and to introduce the concept of the viability assessment sensitivity and specificity. To demonstrate and quantify the diagnostic accuracy of these protocols, we used a composite outcome of organ use and 24-month graft survival as a surrogate endpoint. The effects of assessment modifications, including the removal of the most stringent components of the protocols, were also assessed. Of the 31 organs, 22 were transplanted after a period of NMP, of which 18 achieved the outcome of 24-month graft survival. The BP yielded 94% sensitivity and 50% specificity when predicting this outcome. The GP and CP both seemed overly conservative, with 1 and 0 organs, respectively, meeting these protocols. Modification of the GP and CP to exclude their most stringent components increased this to 11 and 8 organs, respectively, and resulted in moderate sensitivity (56% and 44%) but high specificity (92% and 100%, respectively) with respect to the composite outcome. This study shows that the normothermic assessment protocols can be useful in identifying potentially viable organs but that the balance of risk of underuse and overuse varies by protocol.
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Affiliation(s)
- Hynek Mergental
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom.,National Institute for Health Research, Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom.,Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - Richard W Laing
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom.,National Institute for Health Research, Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom.,Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - James Hodson
- Department of Statistics, Institute for Translational Medicine, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Yuri L Boteon
- National Institute for Health Research, Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom.,Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - Joseph A Attard
- National Institute for Health Research, Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom.,Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - Laine L Walace
- National Institute for Health Research, Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom.,Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - Desley A H Neil
- Department of Cellular Pathology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Darren Barton
- D3B Team, Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom
| | - Andrea Schlegel
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom.,Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - Paolo Muiesan
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Manuel Abradelo
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - John R Isaac
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Keith Roberts
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - M Thamara P R Perera
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Simon C Afford
- National Institute for Health Research, Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom.,Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - Darius F Mirza
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom.,National Institute for Health Research, Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom.,Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
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9
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Mergental H, Stephenson BTF, Laing RW, Muiesan P, Perera MTPR, Afford SC, Mirza DF. Comment on Long-Term Normothermic Machine Preservation of Partial Livers. Annals of Surgery Open 2022; 3. [DOI: 10.1097/as9.0000000000000124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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10
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Hann A, Lembach H, Nutu A, Mergental H, Isaac JL, Isaac JR, Oo YH, Armstrong MJ, Rajoriya N, Afford S, Bartlett D, Mirza DF, Hartog H, Perera MTPR. Assessment of Deceased Brain Dead Donor Liver Grafts via Normothermic Machine Perfusion: Lactate Clearance Time Threshold Can Be Safely Extended to 6 Hours. Liver Transpl 2022; 28:493-496. [PMID: 34606663 DOI: 10.1002/lt.26317] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 09/04/2021] [Accepted: 09/14/2021] [Indexed: 01/01/2023]
Affiliation(s)
- Angus Hann
- Liver Unit, Queen Elizabeth Hospital, Birmingham, UK.,Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Hanns Lembach
- Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
| | - Anisa Nutu
- Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
| | - Hynek Mergental
- Liver Unit, Queen Elizabeth Hospital, Birmingham, UK.,Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - John L Isaac
- Liver Unit, Queen Elizabeth Hospital, Birmingham, UK.,Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - John R Isaac
- Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
| | - Ye H Oo
- Liver Unit, Queen Elizabeth Hospital, Birmingham, UK.,Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Matthew J Armstrong
- Liver Unit, Queen Elizabeth Hospital, Birmingham, UK.,Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Neil Rajoriya
- Liver Unit, Queen Elizabeth Hospital, Birmingham, UK.,Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Simon Afford
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
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11
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Attard J, Sneiders D, Laing R, Boteon Y, Mergental H, Isaac J, Mirza DF, Afford S, Hartog H, Neil DAH, Perera MTPR. The effect of end-ischaemic normothermic machine perfusion on donor hepatic artery endothelial integrity. Langenbecks Arch Surg 2022; 407:717-726. [PMID: 34999966 DOI: 10.1007/s00423-021-02394-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 11/30/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Ex vivo normothermic machine liver perfusion (NMLP) involves artificial cannulation of vessels and generation of flow pressures. This could lead to shear stress-induced endothelial damage, predisposing to vascular complications, or improved preservation of donor artery quality. This study aims to assess the spatial donor hepatic artery (HA) endothelial quality downstream of the cannulation site after end-ischaemic NMLP. METHODS Remnant HA segments from the coeliac trunk up to the gastroduodenal artery branching were obtained after NMLP (n = 15) and after static cold storage (SCS) preservation (n = 15). Specimens were fixed in 10% neutral buffered formalin and sectioned at pre-determined anatomical sites downstream of the coeliac trunk. CD31 immunohistostaining was used to assess endothelial integrity by a 5-point ordinal scale (grade 0: intact endothelial lining, grade 5: complete denudation). Endothelial integrity after SCS was used as a control for the state of the endothelium at commencement of NMP. RESULTS In the SCS specimens, regardless of the anatomical site, near complete endothelial denudation was present throughout the HA (median scores 4.5-5). After NMLP, significantly less endothelial loss in the distal HA was present compared to SCS grafts (NMLP vs. SCS: median grade 3 vs. 4.5; p = 0.042). In NMLP specimens, near complete endothelial denudation was present at the cannulation site in all cases (median grade: 5), with significantly less loss of the endothelial lining the further from the cannulation site (proximal vs. distal, median grade 5 vs. 3; p = 0.005). CONCLUSION Loss of endothelial lining throughout the HA after SCS and at the cannulation site after NMLP suggests extensive damage related to surgical handling and preservation injury. Gradual improved endothelial lining along more distal sites of the HA after NMLP indicates potential for re-endothelialisation. The regenerative effect of NMLP on artery quality seems to occur to a greater extent further from the cannulation site. Therefore, arterial cannulation for machine perfusion of liver grafts should ideally be as proximal as possible on the coeliac trunk or aortic patch, while the site of anastomosis should preferentially be attempted distal on the common HA.
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Affiliation(s)
- J Attard
- Centre for Liver Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - D Sneiders
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Erasmus MC Transplant Institute, Department of Surgery, Division of HPB and Transplant Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - R Laing
- Centre for Liver Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Y Boteon
- Centre for Liver Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - H Mergental
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - J Isaac
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - D F Mirza
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - S Afford
- Centre for Liver Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - H Hartog
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - D A H Neil
- Centre for Liver Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Department of Cellular Pathology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - M T P R Perera
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
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12
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Hann A, Raza SS, Sneiders D, Nutu A, Mergental H, Mirza DF, Hartog H, Perera MTP. Comment on: Static cold storage compared with normothermic machine perfusion of the liver and effect on ischaemic-type biliary lesions after transplantation: a propensity-score matched study. Br J Surg 2021; 109:e12-e13. [PMID: 34672319 DOI: 10.1093/bjs/znab349] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 09/08/2021] [Indexed: 11/13/2022]
Affiliation(s)
- Angus Hann
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham, UK.,University of Birmingham, Edgbaston, UK
| | - Syed Soulat Raza
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Dimitri Sneiders
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Anisa Nutu
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Hynek Mergental
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham, UK.,University of Birmingham, Edgbaston, UK
| | - Darius F Mirza
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham, UK.,University of Birmingham, Edgbaston, UK
| | - Hermien Hartog
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham, UK
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13
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Neil DAH, Mergental H, Hann A, Laing RW, Hartog H, Mirza DF, Perera MTPR. Is Hepatocyte Necrosis a Good Marker of Donor Liver Viability During Machine Perfusion? Hepatol Commun 2021; 6:435-436. [PMID: 34558864 PMCID: PMC8793988 DOI: 10.1002/hep4.1816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Affiliation(s)
- Desley A H Neil
- Department of Cellular Pathology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom.,Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - Hynek Mergental
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom.,Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom.,National Institute for Health Research, Birmingham Biomedical Research Centre, University of Birmingham and UHBFT, Birmingham, United Kingdom
| | - Angus Hann
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom.,Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Richard W Laing
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom.,Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Hermien Hartog
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Darius F Mirza
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom.,Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom.,National Institute for Health Research, Birmingham Biomedical Research Centre, University of Birmingham and UHBFT, Birmingham, United Kingdom
| | - M Thamara P R Perera
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
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14
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Mergental H, Perera MTPR, Nasralla D. Hypothermic Machine Perfusion in Liver Transplantation. N Engl J Med 2021; 385:766-767. [PMID: 34407356 DOI: 10.1056/nejmc2108879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Hynek Mergental
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - M Thamara P R Perera
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - David Nasralla
- Royal Free London NHS Foundation Trust, London, United Kingdom
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15
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Abstract
PURPOSE OF REVIEW To summarize key studies in liver preservation published over the last 3 years and evaluate benefits and limitations of the different perfusion techniques. Selected experimental applications that may be translated to the clinical use will be also discussed. RECENT FINDINGS Normothermic machine perfusion (NMP) has transitioned into clinical practice. Viability assessment is a reliable tool for clinical decision-making, and safety of the back-to-base approach has facilitated adoption of the technology. Data supporting well tolerated use of declined livers after NMP and new protocols selecting complex recipients aim to improve access to suitable organs. Hypothermic machine perfusion (HMP) is showing promising clinical results by decreasing biliary complications in recipients' receiving organs donated after circulatory death (DCD) and improving early graft function in extended criteria organs. Long-term data of HMP on DCD livers shows improved graft survival over standard SCS. Novel approaches utilizing sequential HMP--NMP or ischaemia-free preservation aim to improve outcomes of extended criteria organs. SUMMARY Machine perfusion for organ transplantation has become an established technique but the field is rapidly evolving. Ongoing research focuses on evaluation of the intervention efficacy and finding optimal indications to use each perfusion strategy according to graft type and clinical scenario.
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Affiliation(s)
- Hanns Lembach Jahnsen
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust (UHBFT), Birmingham
| | - Hynek Mergental
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust (UHBFT), Birmingham
- National Institute for Health Research (NIHR), Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, United Kingdom
| | - M Thamara P R Perera
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust (UHBFT), Birmingham
| | - Darius F Mirza
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust (UHBFT), Birmingham
- National Institute for Health Research (NIHR), Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, United Kingdom
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16
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Attard JA, Osei-Bordom DC, Boteon Y, Wallace L, Ronca V, Reynolds G, Perera MTPR, Oo YH, Mergental H, Mirza DF, Afford SC. Ex situ Normothermic Split Liver Machine Perfusion: Protocol for Robust Comparative Controls in Liver Function Assessment Suitable for Evaluation of Novel Therapeutic Interventions in the Pre-clinical Setting. Front Surg 2021; 8:627332. [PMID: 33681282 PMCID: PMC7925992 DOI: 10.3389/fsurg.2021.627332] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 01/06/2021] [Indexed: 01/14/2023] Open
Abstract
Background:Ex situ donor liver machine perfusion is a promising tool to assess organ viability prior to transplantation and platform to investigate novel therapeutic interventions. However, the wide variability in donor and graft characteristics between individual donor livers limits the comparability of results. We investigated the hypothesis that the development of a split liver ex situ machine perfusion protocol provides the ideal comparative controls in the investigation of machine perfusion techniques and therapeutic interventions, thus leading to more comparable results. Methods: Four discarded human donor livers were surgically split following identification and separation of right and left inflow and outflow vessels. Each lobe, on separate perfusion machines, was subjected to normothermic perfusion using an artificial hemoglobin-based oxygen carrier solution for 6 h. Metabolic parameters as well as hepatic artery and portal vein perfusion parameters monitored. Results: Trends in hepatic artery and portal vein flows showed a general increase in both lobes throughout each perfusion experiment, even when normalized for tissue weight. Progressive decreases in perfusate lactate and glucose levels exhibited comparable trends in between lobes. Conclusion: Our results demonstrate comparability between right and left lobes when simultaneously subjected to normothermic machine perfusion. In the pre-clinical setting, this model provides the ideal comparative controls in the investigation of therapeutic interventions.
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Affiliation(s)
- Joseph A Attard
- National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, University Hospitals Birmingham National Health Service (NHS) Foundation Trust, University of Birmingham, Birmingham, United Kingdom.,Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom.,Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham National Health Service (NHS) Foundation Trust, Birmingham, United Kingdom
| | - Daniel-Clement Osei-Bordom
- National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, University Hospitals Birmingham National Health Service (NHS) Foundation Trust, University of Birmingham, Birmingham, United Kingdom.,Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - Yuri Boteon
- National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, University Hospitals Birmingham National Health Service (NHS) Foundation Trust, University of Birmingham, Birmingham, United Kingdom.,Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom.,Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham National Health Service (NHS) Foundation Trust, Birmingham, United Kingdom
| | - Lorraine Wallace
- National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, University Hospitals Birmingham National Health Service (NHS) Foundation Trust, University of Birmingham, Birmingham, United Kingdom.,Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - Vincenzo Ronca
- National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, University Hospitals Birmingham National Health Service (NHS) Foundation Trust, University of Birmingham, Birmingham, United Kingdom.,Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - Gary Reynolds
- National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, University Hospitals Birmingham National Health Service (NHS) Foundation Trust, University of Birmingham, Birmingham, United Kingdom.,Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - M T P R Perera
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham National Health Service (NHS) Foundation Trust, Birmingham, United Kingdom
| | - Ye Htun Oo
- National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, University Hospitals Birmingham National Health Service (NHS) Foundation Trust, University of Birmingham, Birmingham, United Kingdom.,Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom.,Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham National Health Service (NHS) Foundation Trust, Birmingham, United Kingdom.,Centre for Rare Disease, European Reference Network Centre (ERN RARE-LIVER), Hamburg, Germany
| | - Hynek Mergental
- National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, University Hospitals Birmingham National Health Service (NHS) Foundation Trust, University of Birmingham, Birmingham, United Kingdom.,Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom.,Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham National Health Service (NHS) Foundation Trust, Birmingham, United Kingdom
| | - Darius F Mirza
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham National Health Service (NHS) Foundation Trust, Birmingham, United Kingdom
| | - Simon C Afford
- National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, University Hospitals Birmingham National Health Service (NHS) Foundation Trust, University of Birmingham, Birmingham, United Kingdom.,Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
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17
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Mergental H, Laing RW, Afford SC, Mirza DF. Reply to 'Hypothermic machine perfusion before viability testing of previously discarded human livers'. Nat Commun 2021; 12:1015. [PMID: 33579911 PMCID: PMC7881196 DOI: 10.1038/s41467-021-21183-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 01/18/2021] [Indexed: 12/16/2022] Open
Affiliation(s)
- Hynek Mergental
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
- National Institute for Health Research (NIHR), Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK.
| | - Richard W Laing
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- National Institute for Health Research (NIHR), Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Simon C Afford
- National Institute for Health Research (NIHR), Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Darius F Mirza
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- National Institute for Health Research (NIHR), Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
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18
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Laing RW, Stubblefield S, Wallace L, Roobrouck VD, Bhogal RH, Schlegel A, Boteon YL, Reynolds GM, Ting AE, Mirza DF, Newsome PN, Mergental H, Afford SC. The Delivery of Multipotent Adult Progenitor Cells to Extended Criteria Human Donor Livers Using Normothermic Machine Perfusion. Front Immunol 2020; 11:1226. [PMID: 32714318 PMCID: PMC7344318 DOI: 10.3389/fimmu.2020.01226] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 05/15/2020] [Indexed: 12/30/2022] Open
Abstract
Background: Pre-clinical research with multi-potent adult progenitor cells (MAPC® cells, Multistem, Athersys Inc., Cleveland, Ohio) suggests their potential as an anti-inflammatory and immunomodulatory therapy in organ transplantation. Normothermic machine perfusion of the liver (NMP-L) has been proposed as a way of introducing therapeutic agents into the donor organ. Delivery of cellular therapy to human donor livers using this technique has not yet been described in the literature. The primary objectives of this study were to develop a technique for delivering cellular therapy to human donor livers using NMP-L and demonstrate engraftment. Methods: Six discarded human livers were perfused for 6 h at 37°C using the Liver Assist (Organ Assist, Groningen). 50 × 106 CMPTX-labeled MAPC cells were infused directly into the right lobe via the hepatic artery (HA, n = 3) or portal vein (PV, n = 3) over 20 min at different time points during the perfusion. Perfusion parameters were recorded and central and peripheral biopsies were taken at multiple time-points from both lobes and subjected to standard histological stains and confocal microscopy. Perfusate was analyzed using a 35-plex multiplex assay and proteomic analysis. Results: There was no detrimental effect on perfusion flow parameters on infusion of MAPC cells by either route. Three out of six livers met established criteria for organ viability. Confocal microscopy demonstrated engraftment of MAPC cells across vascular endothelium when perfused via the artery. 35-plex multiplex analysis of perfusate yielded 13 positive targets, 9 of which appeared to be related to the infusion of MAPC cells (including Interleukin's 1b, 4, 5, 6, 8, 10, MCP-1, GM-CSF, SDF-1a). Proteomic analysis revealed 295 unique proteins in the perfusate from time-points following the infusion of cellular therapy, many of which have strong links to MAPC cells and mesenchymal stem cells in the literature. Functional enrichment analysis demonstrated their immunomodulatory potential. Conclusion: We have demonstrated that cells can be delivered directly to the target organ, prior to host immune cell population exposure and without compromising the perfusion. Transendothelial migration occurs following arterial infusion. MAPC cells appear to secrete a host of soluble factors that would have anti-inflammatory and immunomodulatory benefits in a human model of liver transplantation.
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Affiliation(s)
- Richard W Laing
- NIHR Liver Biomedical Research Unit, Centre for Liver Research, College of Medical and Dental Sciences, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom.,Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | | | - Lorraine Wallace
- NIHR Liver Biomedical Research Unit, Centre for Liver Research, College of Medical and Dental Sciences, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | | | - Ricky H Bhogal
- NIHR Liver Biomedical Research Unit, Centre for Liver Research, College of Medical and Dental Sciences, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom.,Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Andrea Schlegel
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Yuri L Boteon
- NIHR Liver Biomedical Research Unit, Centre for Liver Research, College of Medical and Dental Sciences, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom.,Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Gary M Reynolds
- NIHR Liver Biomedical Research Unit, Centre for Liver Research, College of Medical and Dental Sciences, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | | | - Darius F Mirza
- NIHR Liver Biomedical Research Unit, Centre for Liver Research, College of Medical and Dental Sciences, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom.,Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Philip N Newsome
- NIHR Liver Biomedical Research Unit, Centre for Liver Research, College of Medical and Dental Sciences, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom.,Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Hynek Mergental
- NIHR Liver Biomedical Research Unit, Centre for Liver Research, College of Medical and Dental Sciences, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom.,Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Simon C Afford
- NIHR Liver Biomedical Research Unit, Centre for Liver Research, College of Medical and Dental Sciences, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom.,Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
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19
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Mergental H, Laing RW, Kirkham AJ, Perera MTPR, Boteon YL, Attard J, Barton D, Curbishley S, Wilkhu M, Neil DAH, Hübscher SG, Muiesan P, Isaac JR, Roberts KJ, Abradelo M, Schlegel A, Ferguson J, Cilliers H, Bion J, Adams DH, Morris C, Friend PJ, Yap C, Afford SC, Mirza DF. Transplantation of discarded livers following viability testing with normothermic machine perfusion. Nat Commun 2020; 11:2939. [PMID: 32546694 PMCID: PMC7298000 DOI: 10.1038/s41467-020-16251-3] [Citation(s) in RCA: 232] [Impact Index Per Article: 58.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 04/17/2020] [Indexed: 12/26/2022] Open
Abstract
There is a limited access to liver transplantation, however, many organs are discarded based on subjective assessment only. Here we report the VITTAL clinical trial (ClinicalTrials.gov number NCT02740608) outcomes, using normothermic machine perfusion (NMP) to objectively assess livers discarded by all UK centres meeting specific high-risk criteria. Thirty-one livers were enroled and assessed by viability criteria based on the lactate clearance to levels ≤2.5 mmol/L within 4 h. The viability was achieved by 22 (71%) organs, that were transplanted after a median preservation time of 18 h, with 100% 90-day survival. During the median follow up of 542 days, 4 (18%) patients developed biliary strictures requiring re-transplantation. This trial demonstrates that viability testing with NMP is feasible and in this study enabled successful transplantation of 71% of discarded livers, with 100% 90-day patient and graft survival; it does not seem to prevent non-anastomotic biliary strictures in livers donated after circulatory death with prolonged warm ischaemia. The shortage of viable donated livers limits patient access to liver transplantation. Here the authors report the use of normothermic machine perfusion to help identify viable organs from livers discarded based on current clinical criteria, which are then transplanted to recipients in a single-arm clinical trial.
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Affiliation(s)
- Hynek Mergental
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust (UHBFT), Birmingham, UK. .,National Institute for Health Research (NIHR), Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK. .,Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK.
| | - Richard W Laing
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust (UHBFT), Birmingham, UK.,National Institute for Health Research (NIHR), Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Amanda J Kirkham
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - M Thamara P R Perera
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust (UHBFT), Birmingham, UK
| | - Yuri L Boteon
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust (UHBFT), Birmingham, UK.,National Institute for Health Research (NIHR), Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Joseph Attard
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust (UHBFT), Birmingham, UK.,National Institute for Health Research (NIHR), Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Darren Barton
- D3B team, Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Stuart Curbishley
- National Institute for Health Research (NIHR), Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Manpreet Wilkhu
- D3B team, Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Desley A H Neil
- National Institute for Health Research (NIHR), Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK.,Department of Cellular Pathology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust (UHBFT), Birmingham, UK
| | - Stefan G Hübscher
- National Institute for Health Research (NIHR), Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK.,Department of Cellular Pathology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust (UHBFT), Birmingham, UK
| | - Paolo Muiesan
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust (UHBFT), Birmingham, UK
| | - John R Isaac
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust (UHBFT), Birmingham, UK
| | - Keith J Roberts
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust (UHBFT), Birmingham, UK.,Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Manuel Abradelo
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust (UHBFT), Birmingham, UK
| | - Andrea Schlegel
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust (UHBFT), Birmingham, UK.,Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - James Ferguson
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust (UHBFT), Birmingham, UK.,National Institute for Health Research (NIHR), Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Hentie Cilliers
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust (UHBFT), Birmingham, UK
| | - Julian Bion
- Department of Intensive Care Medicine, University of Birmingham, Birmingham, UK
| | - David H Adams
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust (UHBFT), Birmingham, UK.,National Institute for Health Research (NIHR), Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | | | - Peter J Friend
- OrganOx Limited, Oxford, UK.,Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Christina Yap
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK.,Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | - Simon C Afford
- National Institute for Health Research (NIHR), Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK. .,Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK.
| | - Darius F Mirza
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust (UHBFT), Birmingham, UK. .,National Institute for Health Research (NIHR), Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK. .,Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK.
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20
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Martins PN, Buchwald JE, Mergental H, Vargas L, Quintini C. The role of normothermic machine perfusion in liver transplantation. Int J Surg 2020; 82S:52-60. [PMID: 32417462 DOI: 10.1016/j.ijsu.2020.05.026] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 04/14/2020] [Accepted: 05/11/2020] [Indexed: 02/07/2023]
Abstract
To expand the donor pool of suitable organs for transplantation, there is an increased interest in utilizing extended criteria donor grafts (ECD). Ex-situ machine perfusion has shown to be a promising new modality in the organ preservation field to reduce injury and recover ECD liver grafts. Machine perfusion (MP) is considered a significant improvement in the field of transplantation over the past 20 years. Normothermic machine perfusion has entered the clinical arena in the last decade and has shown promising results to improve the quality of marginal organs and to increase the pool of liver grafts. It allows assessment of viability and function of grafts prior to transplantation. In addition, it has the potential to serve as a platform for pharmacologic organ treatment and graft optimization. Machine perfusion moved from the experimental phase to a more mature phase after safety was confirmed by initial clinical trials. Now, it is time to confirm its superiority and cost-effectiveness before a broader clinical use. In this paper we review the history, current status including outcomes of all clinical trials, limitations, and future trends of normothermic machine preservation.
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Affiliation(s)
- Paulo N Martins
- University of Massachusetts, Dept of Surgery, Transplant Division, Worcester, MA, USA.
| | - Julianna E Buchwald
- University of Massachusetts, Dept of Surgery, Transplant Division, Worcester, MA, USA
| | - Hynek Mergental
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Luciano Vargas
- Dept of Surgery, Transplant Division, University of Nebraska Medical Center, USA
| | - Cristiano Quintini
- Dept of Surgery, Transplant Division, Cleveland Clinic, Cleveland, OH, USA
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21
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Boteon YL, Laing RW, Schlegel A, Wallace L, Smith A, Attard J, Bhogal RH, Reynolds G, Thamara Pr Perera M, Muiesan P, Mirza DF, Mergental H, Afford SC. Correction: The impact on the bioenergetic status and oxidative-mediated tissue injury of a combined protocol of hypothermic and normothermic machine perfusion using an acellular haemoglobin-based oxygen carrier: The cold-to-warm machine perfusion of the liver. PLoS One 2020; 15:e0230062. [PMID: 32106259 PMCID: PMC7046300 DOI: 10.1371/journal.pone.0230062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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22
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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23
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Boteon YL, Laing RW, Schlegel A, Wallace L, Smith A, Attard J, Bhogal RH, Reynolds G, PR Perera MT, Muiesan P, Mirza DF, Mergental H, Afford SC. The impact on the bioenergetic status and oxidative-mediated tissue injury of a combined protocol of hypothermic and normothermic machine perfusion using an acellular haemoglobin-based oxygen carrier: The cold-to-warm machine perfusion of the liver. PLoS One 2019; 14:e0224066. [PMID: 31644544 PMCID: PMC6808429 DOI: 10.1371/journal.pone.0224066] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 10/04/2019] [Indexed: 01/12/2023] Open
Abstract
Introduction The combination of hypothermic and normothermic machine perfusion (HMP+NMP) of the liver provides individual benefits of both techniques, improving the rescue of marginal organs. The aim of this study was to investigate the effect on the bioenergetic status and the oxidative-mediated tissue injury of an uninterrupted combined protocol of HMP+NMP using a single haemoglobin-based oxygen carrier (HBOC)-based perfusate. Methods Ten discarded human donor livers had either 2 hours of dual hypothermic oxygenated perfusion (D-HOPE) with sequential controlled rewarming (COR) and then NMP using the HBOC-based perfusate uninterruptedly (cold-to-warm group); or 2 hours of hypothermic oxygenated perfusion (HOPE) with an oxygen carrier-free perfusate, followed by perfusate exchange and then NMP with an HBOC-based perfusate. Markers of liver function, tissue adenosine triphosphate (ATP) levels and tissue injury were systematically assessed. Results The hypothermic phase downregulated mitochondrial respiration and increased ATP levels in both groups. The cold-to-warm group presented higher arterial vascular resistance during rewarming/NMP (p = 0.03) with a trend of lower arterial flow (p = 0.09). At the end of NMP tissue expression of markers of reactive oxygen species production, oxidative injury and inflammation were comparable between the groups. Conclusion The uninterrupted combined protocol of HMP+NMP using an HBOC-based perfusate—cold-to-warm MP—mitigated the oxidative-mediated tissue injury and enhanced hepatic energy stores, similarly to an interrupted combined protocol; however, it simplified the logistics of this combination and may favour its clinical applicability.
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Affiliation(s)
- Yuri L. Boteon
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
- National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Richard W. Laing
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
- National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Andrea Schlegel
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Lorraine Wallace
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
- National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Amanda Smith
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Joseph Attard
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
- National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Ricky H. Bhogal
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
- National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Gary Reynolds
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
- National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - M. Thamara PR Perera
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Paolo Muiesan
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Darius F. Mirza
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
- National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Hynek Mergental
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
- National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Simon C. Afford
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
- National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
- * E-mail:
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24
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Ceresa CDL, Nasralla D, Watson CJE, Butler AJ, Coussios CC, Crick K, Hodson L, Imber C, Jassem W, Knight SR, Mergental H, Ploeg RJ, Pollok JM, Quaglia A, Shapiro AMJ, Weissenbacher A, Friend PJ. Transient Cold Storage Prior to Normothermic Liver Perfusion May Facilitate Adoption of a Novel Technology. Liver Transpl 2019; 25:1503-1513. [PMID: 31206217 DOI: 10.1002/lt.25584] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 05/16/2019] [Indexed: 12/12/2022]
Abstract
Clinical adoption of normothermic machine perfusion (NMP) may be facilitated by simplifying logistics and reducing costs. This can be achieved by cold storage of livers for transportation to recipient centers before commencing NMP. The purpose of this study was to assess the safety and feasibility of post-static cold storage normothermic machine perfusion (pSCS-NMP) in liver transplantation. In this multicenter prospective study, 31 livers were transplanted. The primary endpoint was 30-day graft survival. Secondary endpoints included the following: peak posttransplant aspartate aminotransferase (AST), early allograft dysfunction (EAD), postreperfusion syndrome (PRS), adverse events, critical care and hospital stay, biliary complications, and 12-month graft survival. The 30-day graft survival rate was 94%. Livers were preserved for a total of 14 hours 10 minutes ± 4 hours 46 minutes, which included 6 hours 1 minute ± 1 hour 19 minutes of static cold storage before 8 hours 24 minutes ± 4 hours 4 minutes of NMP. Median peak serum AST in the first 7 days postoperatively was 457 U/L (92-8669 U/L), and 4 (13%) patients developed EAD. PRS was observed in 3 (10%) livers. The median duration of initial critical care stay was 3 days (1-20 days), and median hospital stay was 13 days (7-31 days). There were 7 (23%) patients who developed complications of grade 3b severity or above, and 2 (6%) patients developed biliary complications: 1 bile leak and 1 anastomotic stricture with no cases of ischemic cholangiopathy. The 12-month overall graft survival rate (including death with a functioning graft) was 84%. In conclusion, this study demonstrates that pSCS-NMP was feasible and safe, which may facilitate clinical adoption.
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Affiliation(s)
- Carlo D L Ceresa
- Nuffield Department of Surgical Sciences, Oxford Transplant Centre, Churchill Hospital, University of Oxford, Oxford, United Kingdom
| | - David Nasralla
- Nuffield Department of Surgical Sciences, Oxford Transplant Centre, Churchill Hospital, University of Oxford, Oxford, United Kingdom
| | - Christopher J E Watson
- Department of Surgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Andrew J Butler
- Department of Surgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Constantin C Coussios
- Institute of Biomedical Engineering, Department of Engineering Science, University of Oxford, Oxford, United Kingdom
| | - Keziah Crick
- Department of Surgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Leanne Hodson
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, United Kingdom
| | - Charles Imber
- Department of Hepatopancreatobiliary and Liver Transplant Surgery, Royal Free Hospital, London, United Kingdom
| | - Wayel Jassem
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - Simon R Knight
- Nuffield Department of Surgical Sciences, Oxford Transplant Centre, Churchill Hospital, University of Oxford, Oxford, United Kingdom
| | - Hynek Mergental
- Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Rutger J Ploeg
- Nuffield Department of Surgical Sciences, Oxford Transplant Centre, Churchill Hospital, University of Oxford, Oxford, United Kingdom
| | - Joerg M Pollok
- Department of Hepatopancreatobiliary and Liver Transplant Surgery, Royal Free Hospital, London, United Kingdom
| | - Alberto Quaglia
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - A M James Shapiro
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Annemarie Weissenbacher
- Nuffield Department of Surgical Sciences, Oxford Transplant Centre, Churchill Hospital, University of Oxford, Oxford, United Kingdom
| | - Peter J Friend
- Nuffield Department of Surgical Sciences, Oxford Transplant Centre, Churchill Hospital, University of Oxford, Oxford, United Kingdom
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25
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Attard JA, Dunn WB, Mergental H, Mirza DF, Afford SC, Perera MTPR. Systematic Review: Clinical Metabolomics to Forecast Outcomes in Liver Transplantation Surgery. OMICS 2019; 23:463-476. [PMID: 31513460 DOI: 10.1089/omi.2019.0086] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Liver transplantation is an effective intervention for end-stage liver disease, fulminant hepatic failure, and early hepatocellular carcinoma. Yet, there is marked patient-to-patient variation in liver transplantation outcomes. This calls for novel diagnostics to enable rational deployment of donor livers. Metabolomics is a postgenomic high-throughput systems biology approach to diagnostic innovation in clinical medicine. We report here an original systematic review of the metabolomic studies that have identified putative biomarkers in the context of liver transplantation. Eighteen studies met the inclusion criteria that involved sampling of blood (n = 4), dialysate fluid (n = 4), bile (n = 5), and liver tissue (n = 5). Metabolites of amino acid and nitrogen metabolism, anaerobic glycolysis, lipid breakdown products, and bile acid metabolism were significantly different in transplanted livers with and without graft dysfunction. However, criteria for defining the graft dysfunction varied across studies. This systematic review demonstrates that metabolomics can be deployed in identification of metabolic indicators of graft dysfunction with a view to implicated molecular mechanisms. We conclude the article with a horizon scanning of metabolomics technology in liver transplantation and its future prospects and challenges in research and clinical practice.
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Affiliation(s)
- Joseph A Attard
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, United Kingdom.,Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom.,Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - Warwick B Dunn
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom.,Phenome Centre Birmingham, University of Birmingham, Birmingham, United Kingdom.,School of Biosciences, University of Birmingham, Birmingham, United Kingdom
| | - Hynek Mergental
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Darius F Mirza
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Simon C Afford
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, United Kingdom.,Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - M Thamara P R Perera
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
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26
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Boteon YL, Attard J, Boteon APCS, Wallace L, Reynolds G, Hubscher S, Mirza DF, Mergental H, Bhogal RH, Afford SC. Manipulation of Lipid Metabolism During Normothermic Machine Perfusion: Effect of Defatting Therapies on Donor Liver Functional Recovery. Liver Transpl 2019; 25:1007-1022. [PMID: 30821045 PMCID: PMC6618030 DOI: 10.1002/lt.25439] [Citation(s) in RCA: 82] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 02/12/2019] [Indexed: 12/20/2022]
Abstract
Strategies to increase the use of steatotic donor livers are required to tackle the mortality on the transplant waiting list. We aimed to test the efficacy of pharmacological enhancement of the lipid metabolism of human livers during ex situ normothermic machine perfusion to promote defatting and improve the functional recovery of the organs. Because of steatosis, 10 livers were discarded and were allocated either to a defatting group that had the perfusate supplemented with a combination of drugs to enhance lipid metabolism or to a control group that received perfusion fluid with vehicle only. Steatosis was assessed using tissue homogenate and histological analyses. Markers for lipid oxidation and solubilization, oxidative injury, inflammation, and biliary function were evaluated by enzyme-linked immunosorbent assay, immunohistochemistry, and in-gel protein detection. Treatment reduced tissue triglycerides by 38% and macrovesicular steatosis by 40% over 6 hours. This effect was driven by increased solubility of the triglycerides (P = 0.04), and mitochondrial oxidation as assessed by increased ketogenesis (P = 0.008) and adenosine triphosphate synthesis (P = 0.01) were associated with increased levels of the enzymes acyl-coenzyme A oxidase 1, carnitine palmitoyltransferase 1A, and acetyl-coenzyme A synthetase. Concomitantly, defatted livers exhibited enhanced metabolic functional parameters such as urea production (P = 0.03), lower vascular resistance, lower release of alanine aminotransferase (P = 0.049), and higher bile production (P = 0.008) with a higher bile pH (P = 0.03). The treatment down-regulated the expression of markers for oxidative injury as well as activation of immune cells (CD14; CD11b) and reduced the release of inflammatory cytokines in the perfusate (tumor necrosis factor α; interleukin 1β). In conclusion, pharmacological enhancement of intracellular lipid metabolism during normothermic machine perfusion decreased the lipid content of human livers within 6 hours. It also improved the intracellular metabolic support to the organs, leading to successful functional recovery and decreased expression of markers of reperfusion injury.
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Affiliation(s)
- Yuri L. Boteon
- Liver UnitQueen Elizabeth Hospital, University Hospitals Birmingham National Health Service Foundation TrustBirminghamUnited Kingdom,National Institute for Health Research Birmingham Biomedical Research CentreUniversity Hospitals Birmingham National Health Service Foundation TrustBirminghamUnited Kingdom,Centre for Liver and Gastrointestinal ResearchInstitute of Immunology and Immunotherapy, College of Medical and Dental Sciences, University of BirminghamBirminghamUnited Kingdom
| | - Joseph Attard
- Liver UnitQueen Elizabeth Hospital, University Hospitals Birmingham National Health Service Foundation TrustBirminghamUnited Kingdom,National Institute for Health Research Birmingham Biomedical Research CentreUniversity Hospitals Birmingham National Health Service Foundation TrustBirminghamUnited Kingdom,Centre for Liver and Gastrointestinal ResearchInstitute of Immunology and Immunotherapy, College of Medical and Dental Sciences, University of BirminghamBirminghamUnited Kingdom
| | - Amanda P. C. S. Boteon
- Liver UnitQueen Elizabeth Hospital, University Hospitals Birmingham National Health Service Foundation TrustBirminghamUnited Kingdom
| | - Lorraine Wallace
- National Institute for Health Research Birmingham Biomedical Research CentreUniversity Hospitals Birmingham National Health Service Foundation TrustBirminghamUnited Kingdom,Centre for Liver and Gastrointestinal ResearchInstitute of Immunology and Immunotherapy, College of Medical and Dental Sciences, University of BirminghamBirminghamUnited Kingdom
| | - Gary Reynolds
- National Institute for Health Research Birmingham Biomedical Research CentreUniversity Hospitals Birmingham National Health Service Foundation TrustBirminghamUnited Kingdom,Centre for Liver and Gastrointestinal ResearchInstitute of Immunology and Immunotherapy, College of Medical and Dental Sciences, University of BirminghamBirminghamUnited Kingdom
| | - Stefan Hubscher
- Liver UnitQueen Elizabeth Hospital, University Hospitals Birmingham National Health Service Foundation TrustBirminghamUnited Kingdom,Department of Cellular PathologyQueen Elizabeth Hospital, University Hospitals Birmingham National Health Service Foundation TrustBirminghamUnited Kingdom
| | - Darius F. Mirza
- Liver UnitQueen Elizabeth Hospital, University Hospitals Birmingham National Health Service Foundation TrustBirminghamUnited Kingdom,National Institute for Health Research Birmingham Biomedical Research CentreUniversity Hospitals Birmingham National Health Service Foundation TrustBirminghamUnited Kingdom,Centre for Liver and Gastrointestinal ResearchInstitute of Immunology and Immunotherapy, College of Medical and Dental Sciences, University of BirminghamBirminghamUnited Kingdom
| | - Hynek Mergental
- Liver UnitQueen Elizabeth Hospital, University Hospitals Birmingham National Health Service Foundation TrustBirminghamUnited Kingdom,National Institute for Health Research Birmingham Biomedical Research CentreUniversity Hospitals Birmingham National Health Service Foundation TrustBirminghamUnited Kingdom,Centre for Liver and Gastrointestinal ResearchInstitute of Immunology and Immunotherapy, College of Medical and Dental Sciences, University of BirminghamBirminghamUnited Kingdom
| | - Ricky H. Bhogal
- The Royal Marsden, Department of Academic SurgeryFulham RoadChelseaLondon
| | - Simon C. Afford
- National Institute for Health Research Birmingham Biomedical Research CentreUniversity Hospitals Birmingham National Health Service Foundation TrustBirminghamUnited Kingdom,Centre for Liver and Gastrointestinal ResearchInstitute of Immunology and Immunotherapy, College of Medical and Dental Sciences, University of BirminghamBirminghamUnited Kingdom
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King D, Neil D, Forde C, Mirza D, Mergental H, Elsharkawy AM. Aortic conduit aneurysm and enteric fistula formation in a post-liver transplant patient: A potential causative role for cytomegalovirus? Transpl Infect Dis 2019; 21:e13092. [PMID: 30972849 DOI: 10.1111/tid.13092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Revised: 03/27/2019] [Accepted: 04/03/2019] [Indexed: 11/28/2022]
Abstract
Hepatic arterial aortic conduits can be used as an alternative means of revascularizing the donor liver when the native recipient hepatic artery (HA) cannot be used. Cytomegalovirus (CMV) is a common Herpesviridae infection in patients who have undergone solid organ transplants. It can be asymptomatic but may cause fever and invasive disease affecting any organ system. Here we describe the first case in the literature of an aortic conduit aneurysm and concurrent CMV viremia following liver transplantation. We speculate on a causative role for CMV in the development of the aneurysm.
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Affiliation(s)
- Dominic King
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, England
| | - Desley Neil
- Histopathology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, England
| | - Colm Forde
- Radiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, England
| | - Darius Mirza
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, England
| | - Hynek Mergental
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, England
| | - Ahmed M Elsharkawy
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, England
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28
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Boteon APCS, Schlegel A, Kalisvaart M, Boteon YL, Abradelo M, Mergental H, Roberts JK, Mirza DF, Perera MTPR, Isaac JR, Muiesan P. Retrieval Practice or Overall Donor and Recipient Risk: What Impacts on Outcomes After Donation After Circulatory Death Liver Transplantation in the United Kingdom? Liver Transpl 2019; 25:545-558. [PMID: 30919560 DOI: 10.1002/lt.25410] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 12/02/2018] [Indexed: 02/07/2023]
Abstract
Parameters of retrieval surgery are meticulously documented in the United Kingdom, where up to 40% of livers are donation after circulatory death (DCD) donations. This retrospective analysis focuses on outcomes after transplantation of DCD livers, retrieved by different UK centers between 2011 and 2016. Donor and recipient risk factors and the donor retrieval technique were assessed. A total of 236 DCD livers from 9 retrieval centers with a median UK DCD risk score of 5 (low risk) to 7 points (high risk) were compared. The majority used University of Wisconsin solution for aortic flush with a median hepatectomy time of 27-44 minutes. The overall liver injury rate appeared relatively high (27.1%) with an observed tendency toward more retrieval injuries from centers performing a quicker hepatectomy. Among all included risk factors, the UK DCD risk score remained the best predictor for overall graft loss in the multivariate analysis (P < 0.001). In high-risk and futile donor-recipient combinations, the occurrence of liver retrieval injuries had negative impact on graft survival (P = 0.023). Expectedly, more ischemic cholangiopathies (P = 0.003) were found in livers transplanted with a higher cumulative donor-recipient risk. Although more biliary complications with subsequent graft loss were found in high-risk donor-recipient combinations, the impact of the standardized national retrieval practice on outcomes after DCD liver transplantation was minimal.
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Affiliation(s)
- Amanda P C S Boteon
- The Liver Unit, University Hospitals Birmingham National Health Service Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Andrea Schlegel
- The Liver Unit, University Hospitals Birmingham National Health Service Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
- National Institute for Health Research Birmingham Biomedical Research Centre and Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - Marit Kalisvaart
- The Liver Unit, University Hospitals Birmingham National Health Service Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Yuri L Boteon
- The Liver Unit, University Hospitals Birmingham National Health Service Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
- National Institute for Health Research Birmingham Biomedical Research Centre and Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - Manuel Abradelo
- The Liver Unit, University Hospitals Birmingham National Health Service Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Hynek Mergental
- The Liver Unit, University Hospitals Birmingham National Health Service Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
- National Institute for Health Research Birmingham Biomedical Research Centre and Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - J Keith Roberts
- The Liver Unit, University Hospitals Birmingham National Health Service Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
- National Institute for Health Research Birmingham Biomedical Research Centre and Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - Darius F Mirza
- The Liver Unit, University Hospitals Birmingham National Health Service Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
- National Institute for Health Research Birmingham Biomedical Research Centre and Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
- Department of Liver Surgery, Birmingham Children's Hospital National Health Service Foundation Trust, Birmingham, United Kingdom
| | - M Thamara P R Perera
- The Liver Unit, University Hospitals Birmingham National Health Service Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
- Department of Liver Surgery, Birmingham Children's Hospital National Health Service Foundation Trust, Birmingham, United Kingdom
| | - John R Isaac
- The Liver Unit, University Hospitals Birmingham National Health Service Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
- Department of Liver Surgery, Birmingham Children's Hospital National Health Service Foundation Trust, Birmingham, United Kingdom
| | - Paolo Muiesan
- The Liver Unit, University Hospitals Birmingham National Health Service Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
- National Institute for Health Research Birmingham Biomedical Research Centre and Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
- Department of Liver Surgery, Birmingham Children's Hospital National Health Service Foundation Trust, Birmingham, United Kingdom
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29
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Boteon YL, Laing RW, Schlegel A, Wallace L, Smith A, Attard J, Bhogal RH, Neil DAH, Hübscher S, Perera MTPR, Mirza DF, Afford SC, Mergental H. Combined Hypothermic and Normothermic Machine Perfusion Improves Functional Recovery of Extended Criteria Donor Livers. Liver Transpl 2018; 24:1699-1715. [PMID: 30058119 PMCID: PMC6588092 DOI: 10.1002/lt.25315] [Citation(s) in RCA: 73] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 07/03/2018] [Indexed: 12/23/2022]
Abstract
Hypothermic oxygenated perfusion (HOPE) and normothermic perfusion are seen as distinct techniques of ex situ machine perfusion of the liver. We aimed to demonstrate the feasibility of combining both techniques and whether it would improve functional parameters of donor livers into transplant standards. Ten discarded human donor livers had either 6 hours of normothermic perfusion (n = 5) or 2 hours of HOPE followed by 4 hours of normothermic perfusion (n = 5). Liver function was assessed according to our viability criteria; markers of tissue injury and hepatic metabolic activity were compared between groups. Donor characteristics were comparable. During the hypothermic perfusion phase, livers down-regulated mitochondrial respiration (oxygen uptake, P = 0.04; partial pressure of carbon dioxide perfusate, P = 0.04) and increased adenosine triphosphate levels 1.8-fold. Following normothermic perfusion, those organs achieved lower tissue expression of markers of oxidative injury (4-hydroxynonenal, P = 0.008; CD14 expression, P = 0.008) and inflammation (CD11b, P = 0.02; vascular cell adhesion molecule 1, P = 0.05) compared with livers that had normothermic perfusion alone. All livers in the combined group achieved viability criteria, whereas 40% (2/5) in the normothermic group failed (P = 0.22). In conclusion, this study suggests that a combined protocol of hypothermic oxygenated and normothermic perfusions might attenuate oxidative stress, tissue inflammation, and improve metabolic recovery of the highest-risk donor livers compared with normothermic perfusion alone.
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Affiliation(s)
- Yuri L. Boteon
- Liver Unit,National Institute for Health Research, Birmingham Biomedical Research Centre, Institute of Immunology and Immunotherapy, College of Medical and Dental SciencesUniversity of BirminghamBirminghamUnited Kingdom
| | - Richard W. Laing
- Liver Unit,National Institute for Health Research, Birmingham Biomedical Research Centre, Institute of Immunology and Immunotherapy, College of Medical and Dental SciencesUniversity of BirminghamBirminghamUnited Kingdom
| | | | - Lorraine Wallace
- National Institute for Health Research, Birmingham Biomedical Research Centre, Institute of Immunology and Immunotherapy, College of Medical and Dental SciencesUniversity of BirminghamBirminghamUnited Kingdom
| | | | | | - Ricky H. Bhogal
- Liver Unit,National Institute for Health Research, Birmingham Biomedical Research Centre, Institute of Immunology and Immunotherapy, College of Medical and Dental SciencesUniversity of BirminghamBirminghamUnited Kingdom
| | - Desley A. H. Neil
- Department of PathologyQueen Elizabeth Hospital, University Hospitals Birmingham National Health Service Foundation TrustBirminghamUnited Kingdom
| | - Stefan Hübscher
- Department of PathologyQueen Elizabeth Hospital, University Hospitals Birmingham National Health Service Foundation TrustBirminghamUnited Kingdom
| | | | - Darius F. Mirza
- Liver Unit,National Institute for Health Research, Birmingham Biomedical Research Centre, Institute of Immunology and Immunotherapy, College of Medical and Dental SciencesUniversity of BirminghamBirminghamUnited Kingdom
| | - Simon C. Afford
- National Institute for Health Research, Birmingham Biomedical Research Centre, Institute of Immunology and Immunotherapy, College of Medical and Dental SciencesUniversity of BirminghamBirminghamUnited Kingdom
| | - Hynek Mergental
- Liver Unit,National Institute for Health Research, Birmingham Biomedical Research Centre, Institute of Immunology and Immunotherapy, College of Medical and Dental SciencesUniversity of BirminghamBirminghamUnited Kingdom
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30
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Boteon YL, Boteon APCS, Attard J, Mergental H, Mirza DF, Bhogal RH, Afford SC. Ex situ machine perfusion as a tool to recondition steatotic donor livers: Troublesome features of fatty livers and the role of defatting therapies. A systematic review. Am J Transplant 2018; 18:2384-2399. [PMID: 29947472 DOI: 10.1111/ajt.14992] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 06/13/2018] [Accepted: 06/18/2018] [Indexed: 02/06/2023]
Abstract
Long-standing research has shown that increased lipid content in donor livers is associated with inferior graft outcomes posttransplant. The global epidemic that is obesity has increased the prevalence of steatosis in organ donors, to the extent that it has become one of the main reasons for declining livers for transplantation. Consequently, it is one of the major culprits behind the discrepancy between the number of donor livers offered for transplantation and those that go on to be transplanted. Steatotic livers are characterized by poor microcirculation, depleted energy stores because of an impaired capacity for mitochondrial recovery, and a propensity for an exaggerated inflammatory response following reperfusion injury culminating in poorer graft function postoperatively. Ex situ machine perfusion, currently a novel method in graft preservation, is showing great promise in providing a tool for the recovery and reconditioning of marginal livers. Hence, reconditioning these steatotic livers using machine perfusion has the potential to increase the number of liver transplants performed. In this review, we consider the problematic issues associated with fatty livers in the realm of transplantation and discuss pharmacological and nonpharmacological options that are being developed to enhance recovery of these organs using machine perfusion and defatting strategies.
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Affiliation(s)
- Yuri L Boteon
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, Institute of Immunology and Immunotherapy, College of Medical and Dental Sciences, University of Birmingham, UK
| | - Amanda P C S Boteon
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Joseph Attard
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Hynek Mergental
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Darius F Mirza
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Ricky H Bhogal
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Simon C Afford
- National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, Institute of Immunology and Immunotherapy, College of Medical and Dental Sciences, University of Birmingham, UK
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31
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Mergental H, Stephenson BTF, Laing RW, Kirkham AJ, Neil DAH, Wallace LL, Boteon YL, Widmer J, Bhogal RH, Perera MTPR, Smith A, Reynolds GM, Yap C, Hübscher SG, Mirza DF, Afford SC. Development of Clinical Criteria for Functional Assessment to Predict Primary Nonfunction of High-Risk Livers Using Normothermic Machine Perfusion. Liver Transpl 2018; 24:1453-1469. [PMID: 30359490 PMCID: PMC6659387 DOI: 10.1002/lt.25291] [Citation(s) in RCA: 74] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 04/06/2018] [Accepted: 05/03/2018] [Indexed: 12/12/2022]
Abstract
Increased use of high-risk allografts is critical to meet the demand for liver transplantation. We aimed to identify criteria predicting viability of organs, currently declined for clinical transplantation, using functional assessment during normothermic machine perfusion (NMP). Twelve discarded human livers were subjected to NMP following static cold storage. Livers were perfused with a packed red cell-based fluid at 37°C for 6 hours. Multilevel statistical models for repeated measures were employed to investigate the trend of perfusate blood gas profiles and vascular flow characteristics over time and the effect of lactate-clearing (LC) and non-lactate-clearing (non-LC) ability of the livers. The relationship of lactate clearance capability with bile production and histological and molecular findings were also examined. After 2 hours of perfusion, median lactate concentrations were 3.0 and 14.6 mmol/L in the LC and non-LC groups, respectively. LC livers produced more bile and maintained a stable perfusate pH and vascular flow >150 and 500 mL/minute through the hepatic artery and portal vein, respectively. Histology revealed discrepancies between subjectively discarded livers compared with objective findings. There were minimal morphological changes in the LC group, whereas non-LC livers often showed hepatocellular injury and reduced glycogen deposition. Adenosine triphosphate levels in the LC group increased compared with the non-LC livers. We propose composite viability criteria consisting of lactate clearance, pH maintenance, bile production, vascular flow patterns, and liver macroscopic appearance. These have been tested successfully in clinical transplantation. In conclusion, NMP allows an objective assessment of liver function that may reduce the risk and permit use of currently unused high-risk livers.
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Affiliation(s)
- Hynek Mergental
- National Institute for Health Research Birmingham, Liver Biomedical Research Centre, College of Medical and Dental SciencesUniversity of Birmingham,Liver UnitQueen Elizabeth Hospital Birmingham, University Hospitals Birmingham National Health Service Foundation Trust
| | - Barnaby T. F. Stephenson
- National Institute for Health Research Birmingham, Liver Biomedical Research Centre, College of Medical and Dental SciencesUniversity of Birmingham
| | - Richard W. Laing
- National Institute for Health Research Birmingham, Liver Biomedical Research Centre, College of Medical and Dental SciencesUniversity of Birmingham,Liver UnitQueen Elizabeth Hospital Birmingham, University Hospitals Birmingham National Health Service Foundation Trust
| | - Amanda J. Kirkham
- Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomics SciencesUniversity of BirminghamBirminghamUnited Kingdom
| | - Desley A. H. Neil
- Liver UnitQueen Elizabeth Hospital Birmingham, University Hospitals Birmingham National Health Service Foundation Trust
| | - Lorraine L. Wallace
- National Institute for Health Research Birmingham, Liver Biomedical Research Centre, College of Medical and Dental SciencesUniversity of Birmingham
| | - Yuri L. Boteon
- National Institute for Health Research Birmingham, Liver Biomedical Research Centre, College of Medical and Dental SciencesUniversity of Birmingham,Liver UnitQueen Elizabeth Hospital Birmingham, University Hospitals Birmingham National Health Service Foundation Trust
| | - Jeannette Widmer
- National Institute for Health Research Birmingham, Liver Biomedical Research Centre, College of Medical and Dental SciencesUniversity of Birmingham
| | - Ricky H. Bhogal
- National Institute for Health Research Birmingham, Liver Biomedical Research Centre, College of Medical and Dental SciencesUniversity of Birmingham,Liver UnitQueen Elizabeth Hospital Birmingham, University Hospitals Birmingham National Health Service Foundation Trust
| | - M. Thamara P. R. Perera
- Liver UnitQueen Elizabeth Hospital Birmingham, University Hospitals Birmingham National Health Service Foundation Trust
| | - Amanda Smith
- Liver UnitQueen Elizabeth Hospital Birmingham, University Hospitals Birmingham National Health Service Foundation Trust
| | - Gary M. Reynolds
- National Institute for Health Research Birmingham, Liver Biomedical Research Centre, College of Medical and Dental SciencesUniversity of Birmingham
| | - Christina Yap
- Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomics SciencesUniversity of BirminghamBirminghamUnited Kingdom
| | - Stefan G. Hübscher
- National Institute for Health Research Birmingham, Liver Biomedical Research Centre, College of Medical and Dental SciencesUniversity of Birmingham
| | - Darius F. Mirza
- National Institute for Health Research Birmingham, Liver Biomedical Research Centre, College of Medical and Dental SciencesUniversity of Birmingham,Liver UnitQueen Elizabeth Hospital Birmingham, University Hospitals Birmingham National Health Service Foundation Trust
| | - Simon C. Afford
- National Institute for Health Research Birmingham, Liver Biomedical Research Centre, College of Medical and Dental SciencesUniversity of Birmingham
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32
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Bhogal RH, Weston CJ, Velduis S, G D Leuvenink H, Reynolds GM, Davies S, Nyguet-Thin L, Alfaifi M, Shepard EL, Boteon Y, Wallace L, Oo YH, Adams DH, Mirza DF, Mergental H, Muirhead G, Stephenson BTF, Afford SC. The Reactive Oxygen Species-Mitophagy Signaling Pathway Regulates Liver Endothelial Cell Survival During Ischemia/Reperfusion Injury. Liver Transpl 2018; 24:1437-1452. [PMID: 30040176 DOI: 10.1002/lt.25313] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 04/29/2018] [Accepted: 06/04/2018] [Indexed: 12/12/2022]
Abstract
Ischemia/reperfusion injury (IRI) is the main cause of complications following liver transplantation. Reactive oxygen species (ROS) were thought to be the main regulators of IRI. However, recent studies demonstrate that ROS activate the cytoprotective mechanism of autophagy promoting cell survival. Liver IRI initially damages the liver endothelial cells (LEC), but whether ROS-autophagy promotes cell survival in LEC during IRI is not known. Primary human LEC were isolated from human liver tissue and exposed to an in vitro model of IRI to assess the role of autophagy in LEC. The role of autophagy during liver IRI in vivo was assessed using a murine model of partial liver IRI. During IRI, ROS specifically activate autophagy-related protein (ATG) 7 promoting autophagic flux and the formation of LC3B-positive puncta around mitochondria in primary human LEC. Inhibition of ROS reduces autophagic flux in LEC during IRI inducing necrosis. In addition, small interfering RNA knockdown of ATG7 sensitized LEC to necrosis during IRI. In vivo murine livers in uninjured liver lobes demonstrate autophagy within LEC that is reduced following IRI with concomitant reduction in autophagic flux and increased cell death. In conclusion, these findings demonstrate that during liver IRI ROS-dependent autophagy promotes the survival of LEC, and therapeutic targeting of this signaling pathway may reduce liver IRI following transplantation.
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Affiliation(s)
- Ricky H Bhogal
- Centre for Liver Research, School of Infection and Immunity, Institute for Biomedical Research, The Medical School, Birmingham, United Kingdom
- The Liver Unit, University Hospitals of Birmingham, New Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Christopher J Weston
- Centre for Liver Research, School of Infection and Immunity, Institute for Biomedical Research, The Medical School, Birmingham, United Kingdom
| | - Susanne Velduis
- University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | - Henri G D Leuvenink
- University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | - Gary M Reynolds
- Centre for Liver Research, School of Infection and Immunity, Institute for Biomedical Research, The Medical School, Birmingham, United Kingdom
| | - Scott Davies
- Centre for Liver Research, School of Infection and Immunity, Institute for Biomedical Research, The Medical School, Birmingham, United Kingdom
| | - Luu Nyguet-Thin
- Centre for Liver Research, School of Infection and Immunity, Institute for Biomedical Research, The Medical School, Birmingham, United Kingdom
| | - Mohammed Alfaifi
- Centre for Liver Research, School of Infection and Immunity, Institute for Biomedical Research, The Medical School, Birmingham, United Kingdom
| | - Emma L Shepard
- Centre for Liver Research, School of Infection and Immunity, Institute for Biomedical Research, The Medical School, Birmingham, United Kingdom
| | - Yuri Boteon
- Centre for Liver Research, School of Infection and Immunity, Institute for Biomedical Research, The Medical School, Birmingham, United Kingdom
| | - Lorraine Wallace
- Centre for Liver Research, School of Infection and Immunity, Institute for Biomedical Research, The Medical School, Birmingham, United Kingdom
| | - Ye H Oo
- Centre for Liver Research, School of Infection and Immunity, Institute for Biomedical Research, The Medical School, Birmingham, United Kingdom
| | - David H Adams
- Centre for Liver Research, School of Infection and Immunity, Institute for Biomedical Research, The Medical School, Birmingham, United Kingdom
| | - Darius F Mirza
- Centre for Liver Research, School of Infection and Immunity, Institute for Biomedical Research, The Medical School, Birmingham, United Kingdom
- The Liver Unit, University Hospitals of Birmingham, New Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Hynek Mergental
- Centre for Liver Research, School of Infection and Immunity, Institute for Biomedical Research, The Medical School, Birmingham, United Kingdom
- The Liver Unit, University Hospitals of Birmingham, New Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Gillian Muirhead
- Centre for Liver Research, School of Infection and Immunity, Institute for Biomedical Research, The Medical School, Birmingham, United Kingdom
| | - Barnaby T F Stephenson
- Centre for Liver Research, School of Infection and Immunity, Institute for Biomedical Research, The Medical School, Birmingham, United Kingdom
| | - Simon C Afford
- Centre for Liver Research, School of Infection and Immunity, Institute for Biomedical Research, The Medical School, Birmingham, United Kingdom
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33
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Bhogal RH, Mergental H, Mirza DF, Afford SC. The Emerging Importance of Liver Sinusoidal Endothelial Cells in Regulating Injury during Machine Perfusion of Deceased Liver Donors. Semin Liver Dis 2018; 38:252-259. [PMID: 30041277 DOI: 10.1055/s-0038-1661371] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
While majority of liver transplants worldwide continue to be performed using deceased donor organs, the demands for donor livers continues to exceed the current supply. In an attempt to maximize the number of potentially usable donor livers and expand the current donor pool, there is intense global research by various groups exploring the role of machine perfusion in the liver transplantation, particularly with respect to the machine perfusion of extended-criteria liver donors. In this review, the authors summarize the current field of machine perfusion strategies as applied to deceased donor liver transplantation and how therapeutic targeting of the liver sinusoidal endothelial cell may improve the quality of donor livers.
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Affiliation(s)
- Ricky H Bhogal
- Centre for Liver Research, Institute for Biomedical Research, University of Birmingham College of Medical and Dental Sciences, The Medical School, Birmingham, United Kingdom
| | - Hynek Mergental
- Centre for Liver Research, Institute for Biomedical Research, University of Birmingham College of Medical and Dental Sciences, The Medical School, Birmingham, United Kingdom
| | - Darius F Mirza
- Centre for Liver Research, Institute for Biomedical Research, University of Birmingham College of Medical and Dental Sciences, The Medical School, Birmingham, United Kingdom
| | - Simon C Afford
- Centre for Liver Research, Institute for Biomedical Research, University of Birmingham College of Medical and Dental Sciences, The Medical School, Birmingham, United Kingdom
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Boteon YL, Wallace L, Boteon APCS, Mirza DF, Mergental H, Bhogal RH, Afford S. An effective protocol for pharmacological defatting of primary human hepatocytes which is non-toxic to cholangiocytes or intrahepatic endothelial cells. PLoS One 2018; 13:e0201419. [PMID: 30044872 PMCID: PMC6059478 DOI: 10.1371/journal.pone.0201419] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 07/14/2018] [Indexed: 12/14/2022] Open
Abstract
Introduction Pharmacological defatting of rat hepatocytes and hepatoma cell lines suggests that the same method could be used to ameliorate macrovesicular steatosis in moderate to severely fatty livers. However there is no data assessing the effects of those drugs on primary human liver cells. We aimed to determine the effectiveness of a pharmacological cocktail in reducing the in vitro lipid content of primary human hepatocytes (PHH). In addition we sought to determine the cytotoxicity of the cocktail towards non-parenchymal liver cells. Methods Steatosis was induced in PHH by supplementation with a combination of saturated and unsaturated free fatty acids. This was followed by addition of a defatting drug cocktail for up to 48 hours. The same experimental method was used with human intra-hepatic endothelial cells (HIEC) and human cholangiocytes. MTT assay was used to assess cell viability, triglyceride quantification and oil red O staining were used to determine intracellular lipids content whilst ketone bodies were measured in the supernatants following experimentation. Results Incubation of fat loaded PHH with the drugs over 48 hours reduced the intracellular lipid area by 54%, from 12.85% to 5.99% (p = 0.002) (percentage of total oil red O area), and intracellular triglyceride by 35%, from 28.24 to 18.30 nmol/million of cells (p<0.001). Total supernatant ketone bodies increased 1.4-fold over 48 hours in the defatted PHH compared with vehicle controls (p = 0.002). Moreover incubation with the drugs for 48 hours increased the viability of PHH by 11%, cholangiocytes by 25% whilst having no cytotoxic effects on HIEC. Conclusion These data demonstrate that pharmacological intervention can significantly decrease intracellular lipid content of PHH, increase fatty acids β-oxidation whilst being non-toxic to PHH, HIEC or cholangiocytes.
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Affiliation(s)
- Yuri L. Boteon
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
- National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, Institute of Immunology and Immunotherapy, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Lorraine Wallace
- National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, Institute of Immunology and Immunotherapy, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Amanda P. C. S. Boteon
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Darius F. Mirza
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Hynek Mergental
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Ricky H. Bhogal
- National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, Institute of Immunology and Immunotherapy, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Simon Afford
- National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, Institute of Immunology and Immunotherapy, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
- * E-mail:
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Boteon YL, Stephenson BTF, Neil DAH, Mirza DF, Afford SC, Mergental H. Lipid metabolism and functional assessment of discarded human livers with steatosis undergoing 24 hours of normothermic machine perfusion. Liver Transpl 2018; 24:708-709. [PMID: 29415347 DOI: 10.1002/lt.25029] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 12/18/2017] [Indexed: 02/07/2023]
Affiliation(s)
- Yuri L Boteon
- Liver Unit Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham National Health Service Foundation Trust, Birmingham, UK.,National Institute for Health Research Birmingham Liver Biomedical Research Centre Institute of Immunology and Immunotherapy College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Barney T F Stephenson
- National Institute for Health Research Birmingham Liver Biomedical Research Centre Institute of Immunology and Immunotherapy College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Desley A H Neil
- Liver Unit Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham National Health Service Foundation Trust, Birmingham, UK
| | - Darius F Mirza
- Liver Unit Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham National Health Service Foundation Trust, Birmingham, UK.,National Institute for Health Research Birmingham Liver Biomedical Research Centre Institute of Immunology and Immunotherapy College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Simon C Afford
- National Institute for Health Research Birmingham Liver Biomedical Research Centre Institute of Immunology and Immunotherapy College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Hynek Mergental
- Liver Unit Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham National Health Service Foundation Trust, Birmingham, UK.,National Institute for Health Research Birmingham Liver Biomedical Research Centre Institute of Immunology and Immunotherapy College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
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Boteon APCDS, Boteon YL, Vinuela EF, Derosas C, Mergental H, Isaac JR, Muiesan P, Mehzard H, Ma YT, Shah T, Mirza DF, Perera MTPR. The impact of transarterial chemoembolization induced complications on outcomes after liver transplantation: A propensity-matched study. Clin Transplant 2018; 32:e13255. [PMID: 29637619 DOI: 10.1111/ctr.13255] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/02/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Loco-regional complications of transarterial chemoembolization (TACE) may adversely affect technical aspects of the liver transplantation (LT). This study reviewed the impact of those complications on postoperative outcomes encompassing implications on graft selection. METHODS A retrospective, propensity score matching (1:1) analysis accounting for donor and recipient confounders was performed on a dataset of patients undergoing LT for hepatocellular carcinoma. Outcomes of patients who had TACE (TACE-group) were compared with those who did not (NoTACE-group). RESULTS A total of 57 matched pairs were analyzed. TACE achieved effective tumor control (Pre-TACE vs Post-TACE; Median: 44 mm [interquartile range: 43-50] vs 17 mm [0-36]; P = .002) on imaging follow-up. TACE group had, at the hepatectomy, higher incidence of ischemia-related complications (adhesions of the necrotic tumor, cholecystitis, and/or bile duct necrosis) (40.4% vs 10.5%; P = .001). Overall major post-LT complications rate (Dindo-Clavien ≥3) were similar (P = .134). Those in the TACE group with donors after circulatory death (DCD) had 4.6% 90-day mortality and 54.3% major complication rate compared to 6.9% and 77.3% (P = .380 and P = .112, respectively). CONCLUSION TACE was an effective bridging procedure that may complicate LT inducing ischemic-related complications; nevertheless, it has not shown repercussions on mortality or morbidity after the procedure, even using donors after circulatory death.
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Affiliation(s)
| | | | | | - Carlos Derosas
- Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Hynek Mergental
- Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - John R Isaac
- Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Paolo Muiesan
- Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Homoyoon Mehzard
- Department of Radiology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Yuk Ting Ma
- The Cancer Centre, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Tahir Shah
- Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Darius F Mirza
- Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham, UK
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Stephenson BTF, Bonney GK, Laing RW, Bhogal RH, Marcon F, Neil DAH, Perera MTPR, Afford SC, Mergental H, Mirza DF. Proof of concept: liver splitting during normothermic machine perfusion. J Surg Case Rep 2018; 2018:rjx218. [PMID: 29644030 PMCID: PMC5887957 DOI: 10.1093/jscr/rjx218] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2017] [Accepted: 03/14/2018] [Indexed: 12/21/2022] Open
Abstract
Introduction Despite utilizing extended criteria donors, there remains a shortage of livers for transplantation. No data exists on splitting donor livers with concurrent NMP-L. Methods A liver recovered from a donor after circulatory death was subjected to NMP-L using a red cell based fluid. During NMP-L, a ‘classical’ left lateral + right trisegmentectomy split was performed using an integrated bipolar/ultrasonic device. After splitting, blood flow was confirmed using Doppler ultrasound in each lobe. Results Prior to splitting, flow rates were maintained physiologically. Lactate decreased from 13.9 to 3.0 mmol/L. Lactate before and after splitting were similar in the hepatic arteries, portal veins and IVC. Doppler ultrasound demonstrated arterial and venous waveforms in both lobes after splitting. Conclusions ‘Classical’ liver splitting during NMP-L is feasible, maintaining viability of both lobes. Establishing this procedure may attenuate cold ischaemic injury, allow pre-implantation monitoring of both grafts and facilitate logistics of transplanting two grafts.
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Affiliation(s)
- Barney T F Stephenson
- NIHR Birmingham Liver Biomedical Research Unit and Centre for Liver Research, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
| | - Glenn K Bonney
- The Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, UK
| | - Richard W Laing
- NIHR Birmingham Liver Biomedical Research Unit and Centre for Liver Research, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
| | - Ricky H Bhogal
- NIHR Birmingham Liver Biomedical Research Unit and Centre for Liver Research, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
| | - Francesca Marcon
- NIHR Birmingham Liver Biomedical Research Unit and Centre for Liver Research, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
| | - Desley A H Neil
- NIHR Birmingham Liver Biomedical Research Unit and Centre for Liver Research, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
| | - M Thamara P R Perera
- The Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, UK
| | - Simon C Afford
- NIHR Birmingham Liver Biomedical Research Unit and Centre for Liver Research, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
| | - Hynek Mergental
- The Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, UK
| | - Darius F Mirza
- The Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, UK
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Schlegel A, Scalera I, Perera MTPR, Kalisvaart M, Mergental H, Mirza DF, Isaac J, Muiesan P. Impact of donor age in donation after circulatory death liver transplantation: Is the cutoff "60" still of relevance? Liver Transpl 2018; 24:352-362. [PMID: 28885771 DOI: 10.1002/lt.24865] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 06/19/2017] [Accepted: 08/24/2017] [Indexed: 02/07/2023]
Abstract
Advanced donor age has been identified as a risk factor when combined with donor warm ischemia time (WIT), eg, in donation after circulatory death (DCD). In several countries, DCD livers older than 60 years are not considered suitable due to concerns related to poor graft function and development of ischemic cholangiopathy. In this study, we evaluate outcomes after DCD liver transplantation using grafts from donors older than 60 years. We analyzed outcomes after DCD liver transplantation (n = 315), comparing donors > 60 years (n = 93) and donors ≤ 60 years (n = 222) from our center between 2005 and 2015. End points included graft function and complications and patient and graft survival. Multivariate risk analysis was performed to define further key factors that predicted inferior outcome. Donor age at the cutoff 60 years failed to stratify patient and graft survival. The rate of vascular, biliary, and overall complications was comparably low in both cohorts, and the median comprehensive complication index was 42.7 points, independent from the donor age. Second, donor body mass index (BMI) above a threshold of 25 kg/m2 significantly impacted on graft and patient survival at any donor age, whereas donor WIT and cold ischemia times were not predictive for graft loss. In conclusion, older DCD donors can be successfully used for liver transplantation with good longterm outcomes when further risk factors are limited. Additional risk is transmitted by an increased donor BMI regardless of donor age. Liver Transplantation 24 352-362 2018 AASLD.
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Affiliation(s)
- Andrea Schlegel
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, UK.,National Institute for Health Research Liver Biomedical Research Unit, University Hospitals Birmingham, Birmingham, UK
| | - Irene Scalera
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, UK
| | - M Thamara P R Perera
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, UK.,National Institute for Health Research Liver Biomedical Research Unit, University Hospitals Birmingham, Birmingham, UK.,Department of Liver Surgery, Birmingham Children's Hospital National Health Service Foundation Trust, Birmingham, UK
| | - Marit Kalisvaart
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, UK
| | - Hynek Mergental
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, UK.,National Institute for Health Research Liver Biomedical Research Unit, University Hospitals Birmingham, Birmingham, UK
| | - Darius F Mirza
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, UK.,National Institute for Health Research Liver Biomedical Research Unit, University Hospitals Birmingham, Birmingham, UK.,Department of Liver Surgery, Birmingham Children's Hospital National Health Service Foundation Trust, Birmingham, UK
| | - John Isaac
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, UK.,Department of Liver Surgery, Birmingham Children's Hospital National Health Service Foundation Trust, Birmingham, UK
| | - Paolo Muiesan
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, UK.,Department of Liver Surgery, Birmingham Children's Hospital National Health Service Foundation Trust, Birmingham, UK
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Schlegel A, Kalisvaart M, Scalera I, Laing RW, Mergental H, Mirza DF, Perera T, Isaac J, Dutkowski P, Muiesan P. The UK DCD Risk Score: A new proposal to define futility in donation-after-circulatory-death liver transplantation. J Hepatol 2018; 68:456-464. [PMID: 29155020 DOI: 10.1016/j.jhep.2017.10.034] [Citation(s) in RCA: 151] [Impact Index Per Article: 25.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Revised: 10/17/2017] [Accepted: 10/25/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND & AIMS Primary non-function and ischaemic cholangiopathy are the most feared complications following donation-after-circulatory-death (DCD) liver transplantation. The aim of this study was to design a new score on risk assessment in liver-transplantation DCD based on donor-and-recipient parameters. METHODS Using the UK national DCD database, a risk analysis was performed in adult recipients of DCD liver grafts in the UK between 2000 and 2015 (n = 1,153). A new risk score was calculated (UK DCD Risk Score) on the basis of a regression analysis. This is validated using the United Network for Organ Sharing database (n = 1,617) and our own DCD liver-transplant database (n = 315). Finally, the new score was compared with two other available prediction systems: the DCD risk scores from the University of California, Los Angeles and King's College Hospital, London. RESULTS The following seven strongest predictors of DCD graft survival were identified: functional donor warm ischaemia, cold ischaemia, recipient model for end-stage liver disease, recipient age, donor age, previous orthotopic liver transplantation, and donor body mass index. A combination of these risk factors (UK DCD risk model) stratified the best recipients in terms of graft survival in the entire UK DCD database, as well as in the United Network for Organ Sharing and in our own DCD population. Importantly, the UK DCD Risk Score significantly predicted graft loss caused by primary non-function or ischaemic cholangiopathy in the futile group (>10 score points). The new prediction model demonstrated a better C statistic of 0.79 compared to the two other available systems (0.71 and 0.64, respectively). CONCLUSIONS The UK DCD Risk Score is a reliable tool to detect high-risk and futile combinations of donor-and-recipient factors in DCD liver transplantation. It is simple to use and offers a great potential for making better decisions on which DCD graft should be rejected or may benefit from functional assessment and further optimization by machine perfusion. LAY SUMMARY In this study, we provide a new prediction model for graft loss in donation-after-circulatory-death (DCD) liver transplantation. Based on UK national data, the new UK DCD Risk Score involves the following seven clinically relevant risk factors: donor age, donor body mass index, functional donor warm ischaemia, cold storage, recipient age, recipient laboratory model for end-stage liver disease, and retransplantation. Three risk classes were defined: low risk (0-5 points), high risk (6-10 points), and futile (>10 points). This new model stratified best in terms of graft survival compared to other available models. Futile combinations (>10 points) achieved an only very limited 1- and 5-year graft survival of 37% and less than 20%, respectively. In contrast, an excellent graft survival has been shown in low-risk combinations (≤5 points). The new model is easy to calculate at the time of liver acceptance. It may help to decide which risk combination will benefit from additional graft treatment, or which DCD liver should be declined for a certain recipient.
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Affiliation(s)
- Andrea Schlegel
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, UK
| | - Marit Kalisvaart
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, UK
| | - Irene Scalera
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, UK
| | - Richard W Laing
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, UK
| | - Hynek Mergental
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, UK
| | - Darius F Mirza
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, UK
| | - Thamara Perera
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, UK
| | - John Isaac
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, UK
| | - Philipp Dutkowski
- Department of Surgery and Transplantation, Swiss HPB Centre, University Hospital Zurich, Zurich, Switzerland
| | - Paolo Muiesan
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, UK.
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Boteon YL, Laing R, Mergental H, Reynolds GM, Mirza DF, Afford SC, Bhogal RH. Mechanisms of autophagy activation in endothelial cell and their targeting during normothermic machine liver perfusion. World J Gastroenterol 2017; 23:8443-8451. [PMID: 29358854 PMCID: PMC5752706 DOI: 10.3748/wjg.v23.i48.8443] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Revised: 06/19/2017] [Accepted: 07/12/2017] [Indexed: 02/06/2023] Open
Abstract
Ischaemia-reperfusion injury (IRI) is the leading cause of injury seen in the liver following transplantation. IRI also causes injury following liver surgery and haemodynamic shock. The first cells within the liver to be injured by IRI are the liver sinusoidal endothelial cells (LSEC). Recent evidence suggests that LSEC co-ordinate and regulates the livers response to a variety of injuries. It is becoming increasingly apparent that the cyto-protective cellular process of autophagy is a key regulator of IRI. In particular LSEC autophagy may be an essential gatekeeper to the development of IRI. The recent availability of liver perfusion devices has allowed for the therapeutic targeting of autophagy to reduce IRI. In particular normothermic machine liver perfusion (NMP-L) allow the delivery of pharmacological agents to donor livers whilst maintaining physiological temperature and hepatic flow rates. In this review we summarise the current understanding of endothelial autophagy and how this may be manipulated during NMP-L to reduce liver IRI.
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Affiliation(s)
- Yuri L Boteon
- The Liver Unit, University Hospitals of Birmingham, Mindelsohn Way, Edgbaston, Birmingham B15 2TT, United Kingdom
- The Centre for Liver Research, Centre for Liver Research, National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, Institute for Biomedical Research, University of Birmingham, Birmingham B15 2TT, United Kingdom
| | - Richard Laing
- The Liver Unit, University Hospitals of Birmingham, Mindelsohn Way, Edgbaston, Birmingham B15 2TT, United Kingdom
- The Centre for Liver Research, Centre for Liver Research, National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, Institute for Biomedical Research, University of Birmingham, Birmingham B15 2TT, United Kingdom
| | - Hynek Mergental
- The Liver Unit, University Hospitals of Birmingham, Mindelsohn Way, Edgbaston, Birmingham B15 2TT, United Kingdom
- The Centre for Liver Research, Centre for Liver Research, National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, Institute for Biomedical Research, University of Birmingham, Birmingham B15 2TT, United Kingdom
| | - Gary M Reynolds
- The Centre for Liver Research, Centre for Liver Research, National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, Institute for Biomedical Research, University of Birmingham, Birmingham B15 2TT, United Kingdom
| | - Darius F Mirza
- The Liver Unit, University Hospitals of Birmingham, Mindelsohn Way, Edgbaston, Birmingham B15 2TT, United Kingdom
- The Centre for Liver Research, Centre for Liver Research, National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, Institute for Biomedical Research, University of Birmingham, Birmingham B15 2TT, United Kingdom
| | - Simon C Afford
- The Centre for Liver Research, Centre for Liver Research, National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, Institute for Biomedical Research, University of Birmingham, Birmingham B15 2TT, United Kingdom
| | - Ricky H Bhogal
- The Liver Unit, University Hospitals of Birmingham, Mindelsohn Way, Edgbaston, Birmingham B15 2TT, United Kingdom
- The Centre for Liver Research, Centre for Liver Research, National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, Institute for Biomedical Research, University of Birmingham, Birmingham B15 2TT, United Kingdom
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Laing RW, Mergental H, Yap C, Kirkham A, Whilku M, Barton D, Curbishley S, Boteon YL, Neil DA, Hübscher SG, Perera MTPR, Muiesan P, Isaac J, Roberts KJ, Cilliers H, Afford SC, Mirza DF. Viability testing and transplantation of marginal livers (VITTAL) using normothermic machine perfusion: study protocol for an open-label, non-randomised, prospective, single-arm trial. BMJ Open 2017; 7:e017733. [PMID: 29183928 PMCID: PMC5719273 DOI: 10.1136/bmjopen-2017-017733] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION The use of marginal or extended criteria donor livers is increasing. These organs carry a greater risk of initial dysfunction and early failure, as well as inferior long-term outcomes. As such, many are rejected due to a perceived risk of use and use varies widely between centres. Ex situ normothermic machine perfusion of the liver (NMP-L) may enable the safe transplantation of organs that meet defined objective criteria denoting their high-risk status and are currently being declined for use by all the UK transplant centres. METHODS AND ANALYSIS Viability testing and transplantation of marginal livers is an open-label, non-randomised, prospective, single-arm trial designed to determine whether currently unused donor livers can be salvaged and safely transplanted with equivalent outcomes in terms of patient survival. The procured rejected livers must meet predefined criteria that objectively denote their marginal condition. The liver is subjected to NMP-L following a period of static cold storage. Organs metabolising lactate to ≤2.5 mmol/L within 4 hours of the perfusion commencing in combination with two or more of the following parameters-bile production, metabolism of glucose, a hepatic arterial flow rate ≥150 mL/min and a portal venous flow rate ≥500 mL/min, a pH ≥7.30 and/or maintain a homogeneous perfusion-will be considered viable and transplanted into a suitable consented recipient. The coprimary outcome measures are the success rate of NMP-L to produce a transplantable organ and 90-day patient post-transplant survival. ETHICS AND DISSEMINATION The protocol was approved by the National Research Ethics Service (London-Dulwich Research Ethics Committee, 16/LO/1056), the Medicines and Healthcare Products Regulatory Agency and is endorsed by the National Health Service Blood and Transplant Research, Innovation and Novel Technologies Advisory Group. The findings of this trial will be disseminated through national and international presentations and peer-reviewed publications. TRIAL REGISTRATION NUMBER NCT02740608; Pre-results.
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Affiliation(s)
- Richard W Laing
- Department of Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Department of Liver Biomedical Research Unit, National Institute for Health Research (NIHR), Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Hynek Mergental
- Department of Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Department of Liver Biomedical Research Unit, National Institute for Health Research (NIHR), Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Christina Yap
- Department of Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Amanda Kirkham
- Department of Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Manpreet Whilku
- Department of Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Darren Barton
- Department of Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Stuart Curbishley
- Department of Liver Biomedical Research Unit, National Institute for Health Research (NIHR), Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Yuri L Boteon
- Department of Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Department of Liver Biomedical Research Unit, National Institute for Health Research (NIHR), Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Desley A Neil
- Department of Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Stefan G Hübscher
- Department of Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Department of Liver Biomedical Research Unit, National Institute for Health Research (NIHR), Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - M Thamara P R Perera
- Department of Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Department of Liver Biomedical Research Unit, National Institute for Health Research (NIHR), Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Paolo Muiesan
- Department of Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Department of Liver Biomedical Research Unit, National Institute for Health Research (NIHR), Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - John Isaac
- Department of Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Keith J Roberts
- Department of Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Hentie Cilliers
- Department of Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Simon C Afford
- Department of Liver Biomedical Research Unit, National Institute for Health Research (NIHR), Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Darius F Mirza
- Department of Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Department of Liver Biomedical Research Unit, National Institute for Health Research (NIHR), Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
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Dasari BV, Mergental H, Isaac JR, Muiesan P, Mirza DF, Perera T. Systematic review and meta-analysis of liver transplantation using grafts from deceased donors aged over 70 years. Clin Transplant 2017; 31. [PMID: 29044682 DOI: 10.1111/ctr.13139] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/01/2017] [Indexed: 01/15/2023]
Abstract
INTRODUCTION Due to the current organ shortage, nearly 20% of patients die waiting for a liver transplant (LT). The average donor age is on the rise, and grafts from elderly donors are offered as extended criteria grafts. METHODS This is a meta-analysis comparing the outcome differences of adult patients undergoing LT using grafts from <70-year-old donors vs >70-year-old donors. The primary end-points were graft and patient survival. Secondary outcomes were biliary and vascular complications as well as graft function. The odds ratio (OR) is a summary statistic with the corresponding 95% confidence interval; P < .05 was considered to be statistically significant. RESULTS Eight nonrandomized comparative studies with 4376 LT recipients were included. About 79.9% and 20.1% of the grafts were from <70-year-old and >70-year-old donors, respectively. Graft survival at 1 year was similar between the two groups (P = .11), but there was better 3-year and 5-year graft survival in the >70-year-old group (P = .006 and P < .0001, respectively). Patient survival was also similar between the groups at 1 year (P = .54), but with better survival at 3-year and 5-year follow-ups (P = .007 and P < .0001, respectively) in the >70-year-old group. There were no statistically significant differences in the incidence of biliary, vascular, and graft functional-related complications. CONCLUSION Liver grafts from selected >70-year-old donors do not pose added organ-specific risks and thus have comparable transplantation outcomes.
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Affiliation(s)
- Bobby V Dasari
- The Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
| | | | - John R Isaac
- The Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
| | - Paolo Muiesan
- The Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
| | - Darius F Mirza
- The Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
| | - Thamara Perera
- The Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
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43
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Mergental H, Roll GR. Normothermic machine perfusion of the liver. Clin Liver Dis (Hoboken) 2017; 10:97-99. [PMID: 31186895 PMCID: PMC6499222 DOI: 10.1002/cld.661] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2017] [Revised: 08/01/2017] [Accepted: 08/02/2017] [Indexed: 02/04/2023] Open
Affiliation(s)
- Hynek Mergental
- Liver Unit, Queen Elizabeth HospitalUniversity Hospitals Birmingham NHS Foundation TrustBirminghamUnited Kingdom
| | - Garrett R. Roll
- Division of Transplant, Department of SurgeryUniversity of California, San FranciscoSan FranciscoCA
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44
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Than NN, Ghazanfar A, Hodson J, Tehami N, Coldham C, Mergental H, Manas D, Shah T, Newsome PN, Reeves H, Shetty S. Comparing clinical presentations, treatments and outcomes of hepatocellular carcinoma due to hepatitis C and non-alcoholic fatty liver disease. QJM 2017; 110:73-81. [PMID: 27634970 PMCID: PMC5444673 DOI: 10.1093/qjmed/hcw151] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Indexed: 01/06/2023] Open
Abstract
INTRODUCTION Hepatocellular carcinoma (HCC) is increasing in incidence in the UK and globally. Liver cirrhosis is the common cause for developing HCC. The common reasons for liver cirrhosis are viral hepatitis C (HCV), viral hepatitis B and alcohol. However, HCC caused by non-alcoholic fatty liver disease (NAFLD)-cirrhosis is now increasingly as a result of rising worldwide obesity. AIM : To compare the clinical presentation, treatment options and outcomes of HCC due to HCV and NAFLD patients. METHODS Data were collected from two liver transplant centres in the UK (Birmingham and Newcastle upon Tyne) between 2000 and 2014. We compared 275 patients with HCV-related HCC against 212 patients with NAFLD- related HCC. RESULTS Patients in the NAFLD group were found to be significantly older ( P < 0.001) and more likely to be Caucasian ( P < 0.001). They had lower rates of cirrhosis ( P < 0.001) than those in HCV-HCC group. The NAFLD group presented with significantly larger tumours ( P = 0.009), whilst HCV patients had a higher alpha fetoprotein ( P = 0.018). NAFLD patients were more commonly treated with TACE ( P = 0.005) than the HCV patients, whilst the HCV group were significantly more likely to be transplanted ( P < 0.001). In patients selected for liver transplantation, 5-year survival rates in NAFLD were not significantly different from HCV-HCC (44 and 56% respectively, P = 0.102). CONCLUSION In this study, NAFLD patients presented with larger tumours that were less likely to be amenable to curative therapy, as compared with HCV patients. Despite this disadvantage, patients with NAFLD had similar overall survival compared to patients with HCV.
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Affiliation(s)
- Nwe Ni Than
- From the Liver Unit, University Hospitals Birmingham NHS Trust, Birmingham, Edgbaston, UK
- National Institute for Health Research (NIHR) Birmingham Liver Biomedical Research Unit and Centre for Liver Research, University of Birmingham, Birmingham, UK
| | - Anwar Ghazanfar
- Liver Unit, Newcastle Upon Tyne NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - James Hodson
- From the Liver Unit, University Hospitals Birmingham NHS Trust, Birmingham, Edgbaston, UK
| | - Nadeem Tehami
- From the Liver Unit, University Hospitals Birmingham NHS Trust, Birmingham, Edgbaston, UK
- National Institute for Health Research (NIHR) Birmingham Liver Biomedical Research Unit and Centre for Liver Research, University of Birmingham, Birmingham, UK
| | - Chris Coldham
- National Institute for Health Research (NIHR) Birmingham Liver Biomedical Research Unit and Centre for Liver Research, University of Birmingham, Birmingham, UK
| | - Hynek Mergental
- From the Liver Unit, University Hospitals Birmingham NHS Trust, Birmingham, Edgbaston, UK
- National Institute for Health Research (NIHR) Birmingham Liver Biomedical Research Unit and Centre for Liver Research, University of Birmingham, Birmingham, UK
| | - Derek Manas
- Liver Unit, Newcastle Upon Tyne NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Tahir Shah
- From the Liver Unit, University Hospitals Birmingham NHS Trust, Birmingham, Edgbaston, UK
| | - Philip N. Newsome
- From the Liver Unit, University Hospitals Birmingham NHS Trust, Birmingham, Edgbaston, UK
- National Institute for Health Research (NIHR) Birmingham Liver Biomedical Research Unit and Centre for Liver Research, University of Birmingham, Birmingham, UK
| | - Helen Reeves
- Liver Unit, Newcastle Upon Tyne NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Shishir Shetty
- From the Liver Unit, University Hospitals Birmingham NHS Trust, Birmingham, Edgbaston, UK
- National Institute for Health Research (NIHR) Birmingham Liver Biomedical Research Unit and Centre for Liver Research, University of Birmingham, Birmingham, UK
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45
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Mergental H, Perera MTPR, Laing RW, Muiesan P, Isaac JR, Smith A, Stephenson BTF, Cilliers H, Neil DAH, Hübscher SG, Afford SC, Mirza DF. Transplantation of Declined Liver Allografts Following Normothermic Ex-Situ Evaluation. Am J Transplant 2016; 16:3235-3245. [PMID: 27192971 DOI: 10.1111/ajt.13875] [Citation(s) in RCA: 224] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Revised: 04/28/2016] [Accepted: 04/28/2016] [Indexed: 01/25/2023]
Abstract
The demand for liver transplantation (LT) exceeds supply, with rising waiting list mortality. Utilization of high-risk organs is low and a substantial number of procured livers are discarded. We report the first series of five transplants with rejected livers following viability assessment by normothermic machine perfusion of the liver (NMP-L). The evaluation protocol consisted of perfusate lactate, bile production, vascular flows, and liver appearance. All livers were exposed to a variable period of static cold storage prior to commencing NMP-L. Four organs were recovered from donors after circulatory death and rejected due to prolonged donor warm ischemic times; one liver from a brain-death donor was declined for high liver function tests (LFTs). The median (range) total graft preservation time was 798 (range 724-951) min. The transplant procedure was uneventful in every recipient, with immediate function in all grafts. The median in-hospital stay was 10 (range 6-14) days. At present, all recipients are well, with normalized LFTs at median follow-up of 7 (range 6-19) months. Viability assessment of high-risk grafts using NMP-L provides specific information on liver function and can permit their transplantation while minimizing the recipient risk of primary graft nonfunction. This novel approach may increase organ availability for LT.
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Affiliation(s)
- H Mergental
- Liver Unit, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,National Institute for Health Research (NIHR) Birmingham Liver Biomedical Research Unit and Centre for Liver Research, Institute of Immunology and Immunotherapy, Institute for Biomedical Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - M T P R Perera
- Liver Unit, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - R W Laing
- National Institute for Health Research (NIHR) Birmingham Liver Biomedical Research Unit and Centre for Liver Research, Institute of Immunology and Immunotherapy, Institute for Biomedical Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - P Muiesan
- Liver Unit, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - J R Isaac
- Liver Unit, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - A Smith
- Liver Unit, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - B T F Stephenson
- National Institute for Health Research (NIHR) Birmingham Liver Biomedical Research Unit and Centre for Liver Research, Institute of Immunology and Immunotherapy, Institute for Biomedical Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - H Cilliers
- Liver Unit, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - D A H Neil
- Liver Unit, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - S G Hübscher
- Liver Unit, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - S C Afford
- National Institute for Health Research (NIHR) Birmingham Liver Biomedical Research Unit and Centre for Liver Research, Institute of Immunology and Immunotherapy, Institute for Biomedical Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - D F Mirza
- Liver Unit, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK. .,National Institute for Health Research (NIHR) Birmingham Liver Biomedical Research Unit and Centre for Liver Research, Institute of Immunology and Immunotherapy, Institute for Biomedical Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.
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46
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Karangwa SA, Dutkowski P, Fontes P, Friend PJ, Guarrera JV, Markmann JF, Mergental H, Minor T, Quintini C, Selzner M, Uygun K, Watson CJ, Porte RJ. Machine Perfusion of Donor Livers for Transplantation: A Proposal for Standardized Nomenclature and Reporting Guidelines. Am J Transplant 2016; 16:2932-2942. [PMID: 27129409 PMCID: PMC5132023 DOI: 10.1111/ajt.13843] [Citation(s) in RCA: 97] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Revised: 03/28/2016] [Accepted: 04/19/2016] [Indexed: 02/06/2023]
Abstract
With increasing demand for donor organs for transplantation, machine perfusion (MP) promises to be a beneficial alternative preservation method for donor livers, particularly those considered to be of suboptimal quality, also known as extended criteria donor livers. Over the last decade, numerous studies researching MP of donor livers have been published and incredible advances have been made in both experimental and clinical research in this area. With numerous research groups working on MP, various techniques are being explored, often applying different nomenclature. The objective of this review is to catalog the differences observed in the nomenclature used in the current literature to denote various MP techniques and the manner in which methodology is reported. From this analysis, we propose a standardization of nomenclature on liver MP to maximize consistency and to enable reliable comparison and meta-analyses of studies. In addition, we propose a standardized set of guidelines for reporting the methodology of future studies on liver MP that will facilitate comparison as well as clinical implementation of liver MP procedures.
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Affiliation(s)
- S. A. Karangwa
- Section of Hepatobiliary Surgery and Liver TransplantationDepartment of SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
- Surgical Research LaboratoryUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
| | - P. Dutkowski
- Department of Surgery & TransplantationUniversity Hospital ZurichZurichSwitzerland
| | - P. Fontes
- Thomas E. Starzl Transplantation Institute Department of SurgeryUniversity of Pittsburgh Medical CenterPittsburghPA
- McGowan Institute of Regenerative MedicineUniversity of PittsburghPittsburghPA
| | - P. J. Friend
- Nuffield Department of SurgeryOxford Transplant CentreUniversity of OxfordChurchill HospitalOxfordUK
| | - J. V. Guarrera
- Department of SurgeryCenter for Liver Disease and TransplantationColumbia University Medical CenterNew YorkNY
| | | | - H. Mergental
- Liver UnitUniversity Hospital BirminghamBirminghamUK
| | - T. Minor
- Department of Surgical ResearchClinic for General Visceral and Transplantation SurgeryUniversity Hospital EssenEssenGermany
| | - C. Quintini
- Department of SurgeryTransplant CenterDigestive Disease InstituteCleveland Clinic FoundationClevelandOH
| | - M. Selzner
- Department of SurgeryMulti Organ Transplant ProgramToronto General HospitalTorontoONCanada
| | - K. Uygun
- Department of SurgeryCenter for Engineering in MedicineMassachusetts General HospitalHarvard Medical SchoolBostonMA
| | - C. J. Watson
- University of Cambridge Department of Surgery and the NIHR Blood and Transplant Research Unit in Organ Donation and Transplantation University of CambridgeAddenbrooke's HospitalCambridgeUK
| | - R. J. Porte
- Section of Hepatobiliary Surgery and Liver TransplantationDepartment of SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
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47
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Pitchaimuthu M, Roll GR, Zia Z, Olliff S, Mehrzad H, Hodson J, Gunson BK, Perera MTPR, Isaac JR, Muiesan P, Mirza DF, Mergental H. Long-term follow-up after endovascular treatment of hepatic venous outflow obstruction following liver transplantation. Transpl Int 2016; 29:1106-16. [DOI: 10.1111/tri.12817] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 03/07/2016] [Accepted: 06/28/2016] [Indexed: 01/10/2023]
Affiliation(s)
- Maheswaran Pitchaimuthu
- Liver Unit Queen Elizabeth Hospital; University Hospitals Birmingham NHS Foundation Trust; Birmingham UK
| | - Garrett R. Roll
- Liver Unit Queen Elizabeth Hospital; University Hospitals Birmingham NHS Foundation Trust; Birmingham UK
- Division of Transplant Surgery; University of California; San Francisco CA USA
| | - Zergham Zia
- Department of Radiology; Queen Elizabeth Hospital; University Hospitals Birmingham NHS Foundation Trust; Birmingham UK
| | - Simon Olliff
- Department of Radiology; Queen Elizabeth Hospital; University Hospitals Birmingham NHS Foundation Trust; Birmingham UK
| | - Homoyoon Mehrzad
- Department of Radiology; Queen Elizabeth Hospital; University Hospitals Birmingham NHS Foundation Trust; Birmingham UK
| | - James Hodson
- National Institute for Health Research Birmingham; Liver Biomedical Research Unit and Centre for Liver Research; Institute of Immunology and Immunotherapy; College of Medical and Dental Sciences; University of Birmingham; Birmingham UK
| | - Bridget K. Gunson
- National Institute for Health Research Birmingham; Liver Biomedical Research Unit and Centre for Liver Research; Institute of Immunology and Immunotherapy; College of Medical and Dental Sciences; University of Birmingham; Birmingham UK
| | - M. Thamara P. R. Perera
- Liver Unit Queen Elizabeth Hospital; University Hospitals Birmingham NHS Foundation Trust; Birmingham UK
| | - John R. Isaac
- Liver Unit Queen Elizabeth Hospital; University Hospitals Birmingham NHS Foundation Trust; Birmingham UK
| | - Paolo Muiesan
- Liver Unit Queen Elizabeth Hospital; University Hospitals Birmingham NHS Foundation Trust; Birmingham UK
| | - Darius F. Mirza
- Liver Unit Queen Elizabeth Hospital; University Hospitals Birmingham NHS Foundation Trust; Birmingham UK
- National Institute for Health Research Birmingham; Liver Biomedical Research Unit and Centre for Liver Research; Institute of Immunology and Immunotherapy; College of Medical and Dental Sciences; University of Birmingham; Birmingham UK
| | - Hynek Mergental
- Liver Unit Queen Elizabeth Hospital; University Hospitals Birmingham NHS Foundation Trust; Birmingham UK
- National Institute for Health Research Birmingham; Liver Biomedical Research Unit and Centre for Liver Research; Institute of Immunology and Immunotherapy; College of Medical and Dental Sciences; University of Birmingham; Birmingham UK
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48
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Laing RW, Scalera I, Isaac J, Mergental H, Mirza DF, Hodson J, Wilkin RJW, Perera MTPR, Muiesan P. Liver Transplantation Using Grafts From Donors After Circulatory Death: A Propensity Score-Matched Study From a Single Center. Am J Transplant 2016; 16:1795-804. [PMID: 26725645 DOI: 10.1111/ajt.13699] [Citation(s) in RCA: 99] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Revised: 11/29/2015] [Accepted: 12/15/2015] [Indexed: 01/25/2023]
Abstract
The use of livers from donation after circulatory death (DCD) is increasing, but concerns exist regarding outcomes following use of grafts from "marginal" donors. To compare outcomes in transplants using DCD and donation after brain death (DBD), propensity score matching was performed for 973 patients with chronic liver disease and/or malignancy who underwent primary whole-liver transplant between 2004 and 2014 at University Hospitals Birmingham NHS Foundation Trust. Primary end points were overall graft and patient survival. Secondary end points included postoperative, biliary and vascular complications. Over 10 years, 234 transplants were carried out using DCD grafts. Of the 187 matched DCDs, 82.9% were classified as marginal per British Transplantation Society guidelines. Kaplan-Meier analysis of graft and patient survival found no significant differences for either outcome between the paired DCD and DBD patients (p = 0.162 and p = 0.519, respectively). Aspartate aminotransferase was significantly higher in DCD recipients until 48 h after transplant (p < 0.001). The incidences of acute kidney injury and ischemic cholangiopathy were greater in DCD recipients (32.6% vs. 15% [p < 0.001] and 9.1% vs. 1.1% [p < 0.001], respectively). With appropriate recipient selection, the use of DCDs, including those deemed marginal, can be safe and can produce outcomes comparable to those seen using DBD grafts in similar recipients.
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Affiliation(s)
- R W Laing
- Department of Liver Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,NIHR Liver Biomedical Research Unit, University Hospitals Birmingham, Birmingham, UK
| | - I Scalera
- Department of Liver Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - J Isaac
- Department of Liver Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Department of Liver Surgery, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - H Mergental
- Department of Liver Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - D F Mirza
- Department of Liver Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Department of Liver Surgery, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - J Hodson
- Department of Liver Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - R J W Wilkin
- Department of Liver Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,NIHR Liver Biomedical Research Unit, University Hospitals Birmingham, Birmingham, UK
| | - M T P R Perera
- Department of Liver Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Department of Liver Surgery, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - P Muiesan
- Department of Liver Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Department of Liver Surgery, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, UK
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49
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Ravikumar R, Jassem W, Mergental H, Heaton N, Mirza D, Perera MTPR, Quaglia A, Holroyd D, Vogel T, Coussios CC, Friend PJ. Liver Transplantation After Ex Vivo Normothermic Machine Preservation: A Phase 1 (First-in-Man) Clinical Trial. Am J Transplant 2016; 16:1779-87. [PMID: 26752191 DOI: 10.1111/ajt.13708] [Citation(s) in RCA: 321] [Impact Index Per Article: 40.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2015] [Accepted: 12/08/2015] [Indexed: 01/25/2023]
Abstract
The number of donor organs suitable for liver transplantation is restricted by cold preservation and ischemia-reperfusion injury. We present the first patients transplanted using a normothermic machine perfusion (NMP) device that transports and stores an organ in a fully functioning state at 37°C. In this Phase 1 trial, organs were retrieved using standard techniques, attached to the perfusion device at the donor hospital, and transported to the implanting center in a functioning state. NMP livers were matched 1:2 to cold-stored livers. Twenty patients underwent liver transplantation after NMP. Median NMP time was 9.3 (3.5-18.5) h versus median cold ischaemia time of 8.9 (4.2-11.4) h. Thirty-day graft survival was similar (100% NMP vs. 97.5% control, p = 1.00). Median peak aspartate aminotransferase in the first 7 days was significantly lower in the NMP group (417 IU [84-4681]) versus (902 IU [218-8786], p = 0.03). This first report of liver transplantation using NMP-preserved livers demonstrates the safety and feasibility of using this technology from retrieval to transplantation, including transportation. NMP may be valuable in increasing the number of donor livers and improving the function of transplantable organs.
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Affiliation(s)
- R Ravikumar
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK.,Institute of Biomedical Engineering, University of Oxford, Oxford, UK
| | - W Jassem
- Liver Unit, Kings College Hospital, London, UK
| | - H Mergental
- Liver Unit, University Hospital Birmingham, Birmingham, UK
| | - N Heaton
- Liver Unit, Kings College Hospital, London, UK
| | - D Mirza
- Liver Unit, University Hospital Birmingham, Birmingham, UK
| | - M T P R Perera
- Liver Unit, University Hospital Birmingham, Birmingham, UK
| | - A Quaglia
- Liver Unit, Kings College Hospital, London, UK
| | - D Holroyd
- Institute of Biomedical Engineering, University of Oxford, Oxford, UK
| | - T Vogel
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - C C Coussios
- Institute of Biomedical Engineering, University of Oxford, Oxford, UK
| | - P J Friend
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
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50
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Perera T, Mergental H, Stephenson B, Roll GR, Cilliers H, Liang R, Angelico R, Hubscher S, Neil DA, Reynolds G, Isaac J, Adams DA, Afford S, Mirza DF, Muiesan P. First human liver transplantation using a marginal allograft resuscitated by normothermic machine perfusion. Liver Transpl 2016; 22:120-4. [PMID: 26566737 DOI: 10.1002/lt.24369] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2015] [Revised: 09/23/2015] [Accepted: 10/14/2015] [Indexed: 12/12/2022]
Affiliation(s)
- Thamara Perera
- The Liver Unit Queen Elizabeth Hospital Birmingham Institute of Liver Studies Institute of Biomedical Research School of Medicine and Dentistry, University of Birmingham, Birmingham, UK
| | - Hynek Mergental
- The Liver Unit Queen Elizabeth Hospital Birmingham Institute of Liver Studies Institute of Biomedical Research School of Medicine and Dentistry, University of Birmingham, Birmingham, UK
| | - Barney Stephenson
- The Liver Unit Queen Elizabeth Hospital Birmingham Institute of Liver Studies Institute of Biomedical Research School of Medicine and Dentistry, University of Birmingham, Birmingham, UK
| | - Garrett R Roll
- The Liver Unit Queen Elizabeth Hospital Birmingham Institute of Liver Studies Institute of Biomedical Research School of Medicine and Dentistry, University of Birmingham, Birmingham, UK
| | - Hentie Cilliers
- The Liver Unit Queen Elizabeth Hospital Birmingham Institute of Liver Studies Institute of Biomedical Research School of Medicine and Dentistry, University of Birmingham, Birmingham, UK
| | - Richard Liang
- The Liver Unit Queen Elizabeth Hospital Birmingham Institute of Liver Studies Institute of Biomedical Research School of Medicine and Dentistry, University of Birmingham, Birmingham, UK
| | - Roberta Angelico
- The Liver Unit Queen Elizabeth Hospital Birmingham Institute of Liver Studies Institute of Biomedical Research School of Medicine and Dentistry, University of Birmingham, Birmingham, UK
| | - Stefan Hubscher
- The Liver Unit Queen Elizabeth Hospital Birmingham Institute of Liver Studies Institute of Biomedical Research School of Medicine and Dentistry, University of Birmingham, Birmingham, UK
| | - Desley A Neil
- The Liver Unit Queen Elizabeth Hospital Birmingham Institute of Liver Studies Institute of Biomedical Research School of Medicine and Dentistry, University of Birmingham, Birmingham, UK
| | - Gary Reynolds
- The Liver Unit Queen Elizabeth Hospital Birmingham Institute of Liver Studies Institute of Biomedical Research School of Medicine and Dentistry, University of Birmingham, Birmingham, UK
| | - John Isaac
- The Liver Unit Queen Elizabeth Hospital Birmingham Institute of Liver Studies Institute of Biomedical Research School of Medicine and Dentistry, University of Birmingham, Birmingham, UK
| | - David A Adams
- The Liver Unit Queen Elizabeth Hospital Birmingham Institute of Liver Studies Institute of Biomedical Research School of Medicine and Dentistry, University of Birmingham, Birmingham, UK
| | - Simon Afford
- The Liver Unit Queen Elizabeth Hospital Birmingham Institute of Liver Studies Institute of Biomedical Research School of Medicine and Dentistry, University of Birmingham, Birmingham, UK
| | - Darius F Mirza
- The Liver Unit Queen Elizabeth Hospital Birmingham Institute of Liver Studies Institute of Biomedical Research School of Medicine and Dentistry, University of Birmingham, Birmingham, UK
| | - Paolo Muiesan
- The Liver Unit Queen Elizabeth Hospital Birmingham Institute of Liver Studies Institute of Biomedical Research School of Medicine and Dentistry, University of Birmingham, Birmingham, UK
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