Observations and findings during the development of a subnormothermic/normothermic long-term ex vivo liver perfusion machine

BACKGROUND

Ex situliver machine perfusion at subnormothermic/normothermic temperature isincreasingly applied in the field of transplantation to store and evaluateorgans on the machine prior transplantation. Currently, various perfusionconcepts are in clinical and preclinical applications. Over the last 6 years ina multidisciplinary team, a novel blood based perfusion technology wasdeveloped to keep a liver alive and metabolically active outside of the bodyfor at least one week.

METHODS

Within thismanuscript, we present and compare three scenarios (Group 1, 2 and 3) we werefacing during our research and development (R&D) process, mainly linked tothe measurement of free hemoglobin and lactate in the blood based perfusate. Apartfrom their proven value in liver viability assessment (ex situ), these twoparameters are also helpful in R&D of a long-term liver perfusion machine and moreover supportive in the biomedical engineering process.

RESULTS

Group 1 ("good" liver on the perfusion machine) represents the best liver clearance capacity for lactate and free hemoglobin wehave observed. In contrast to Group 2 ("poor" liver on the perfusion machine), that has shown the worst clearance capacity for free hemoglobin. Astonishingly,also for Group 2, lactate is cleared till the first day of perfusion andafterwards, rising lactate values are detected due to the poor quality of theliver. These two perfusate parametersclearly highlight the impact of the organ quality/viability on the perfusion process. Whereas Group 3 is a perfusion utilizing a blood loop only (without a liver).

CONCLUSION

Knowing the feasible ranges (upper- and lower bound) and the courseover time of free hemoglobin and lactate is helpful to evaluate the quality ofthe organ perfusion itself and the maturity of the developed perfusion device. Freehemoglobin in the perfusate is linked to the rate of hemolysis that indicates how optimizing (gentle blood handling, minimizing hemolysis) the perfusion machine actually is. Generally, a reduced lactate clearancecapacity can be an indication for technical problems linked to the blood supplyof the liver and therefore helps to monitor the perfusion experiments.Moreover, the possibility is given to compare, evaluate and optimize developed liverperfusion systems based on the given ranges for these two parameters. Otherresearch groups can compare/quantify their perfusate (blood) parameters withthe ones in this manuscript. The presented data, findings and recommendations willfinally support other researchers in developing their own perfusion machine ormodifying commercially availableperfusion devices according to their needs.

Transplantation of a human liver following 3 days of ex situ normothermic preservation

Current organ preservation methods provide a narrow window (usually <12 hours) to assess, transport and implant donor grafts for human transplantation. Here we report the transplantation of a human liver discarded by all centers, which could be preserved for several days using ex situ normothermic machine perfusion. The transplanted liver exhibited normal function, with minimal reperfusion injury and the need for only a minimal immunosuppressive regimen. The patient rapidly recovered a normal quality of life without any signs of liver damage, such as rejection or injury to the bile ducts, according to a 1-year follow up. This inaugural clinical success opens new horizons in clinical research and promises an extended time window of up to 10 days for assessment of viability of donor organs as well as converting an urgent and highly demanding surgery into an elective procedure.

Synthesis of coagulation factors during long-term ex situ liver perfusion

Robust viability assessment of grafts during normothermic liver perfusion is a prerequisite for organ use. Coagulation parameters are used commonly for liver assessment in patients. However, they are not yet included in viability assessment during ex situ perfusion. In this study, we analysed coagulation parameters during one week ex situ perfusion at 34℃. Eight discarded human livers were perfused with blood-based, heparinised perfusate for one week; perfusions in a further four livers were terminated on day 4 due to massive ongoing cell death. Coagulation parameters were well below the physiologic range at perfusion start. Physiologic levels were achieved within the first two perfusion days for factor V (68.5 ± 35.5%), factor VII (83.5 ± 26.2%), fibrinogen (2.1 ± 0.4 g/L) and antithrombin (107 ± 26.5%) in the livers perfused for one week. Despite the increased production of coagulation factors, INR was detectable only at 24h of perfusion (2.1 ± 0.3) and prolonged thereafter (INR > 9). The prolongation of INR was related to the high heparin level in the perfusate (anti-FXa > 3 U/mL). Intriguingly, livers with ongoing massive cell death also disclosed synthesis of factor V and improved INR. In summary, perfused livers were able to produce coagulation factors at a physiological level ex situ. We propose that single coagulation factor analysis is more reliable for assessing the synthetic function of perfused livers as compared to INR when using a heparinised perfusate.

FDG-PET/CT: novel method for viability assessment of livers perfused ex vivo

PURPOSE

Ex vivo liver machine perfusion is a promising option to rescue marginal liver grafts mitigating the donated organ shortage. Recently, a novel liver perfusion machine that can keep injured liver grafts alive for 1 week ex vivo was developed and reported in Nature Biotechnology. However, liver viability assessment ex vivo is an unsolved issue and the value of 18F-fluorodeoxyglucose (FDG)-PET/CT for such purpose was explored.

MATERIALS AND METHODS

Discarded two human and six porcine liver grafts underwent FDG-PET/CT for viability assessment after 1 week of ex vivo perfusion. PET parameters [standardized uptake value (SUV)max, SUVmean, SUVpeak and total lesion glycolysis] were compared between hepatic lobes and between porcine and human livers. The prevalence of FDG-negative organ parts was recorded. The estimated effective radiation dose for PET/CT was calculated.

RESULTS

All organs were viable with essentially homogeneous FDG uptake. Of note, viability was preserved in contact areas disclosing the absence of pressure necrosis. Four porcine and two human organs had small superficial FDG-negative areas confirmed as biopsy sites. Total lesion glycolysis was significantly higher in the right hepatic lobe (P = 0.012), while there was no significant difference of SUVmax, SUVmean and SUVpeak between hepatic lobes. There was no significant difference in FDG uptake parameters between porcine and human organs. The estimated effective radiation dose was 1.99 ± 1.67 mSv per organ.

CONCLUSION

This study demonstrates the feasibility of FDG-PET/CT for viability assessment of ex vivo perfused liver grafts after 1 week.

Sources and prevention of graft infection during long-term ex situ liver perfusion

INTRODUCTION

The use of normothermic liver machine perfusion to repair injured grafts ex situ is an emerging topic of clinical importance. However, a major concern is the possibility of microbial contamination in the absence of a fully functional immune system. Here, we report a standardized approach to maintain sterility during normothermic liver machine perfusion of porcine livers for one week.

METHODS

Porcine livers (n = 42) were procured and perfused with blood at 34°C following aseptic technique and standard operating procedures. The antimicrobial prophylaxis was adapted and improved in a step-wise manner taking into account the pathogens that were detected during the development phase. Piperacillin-Tazobactam was applied as a single dose initially and modified to continuous application in the final protocol. In addition, the perfusion machine was improved to recapitulate partially the host's defense system. The final protocol was tested for infection prevention during one week of perfusion.

RESULTS

During the development phase, microbial contamination occurred in 27 out of 39 (69%) livers with a mean occurrence of growth on 4 ± 1.6 perfusion days. The recovered microorganisms suggested an exogenous source of microbial contamination. The antimicrobial agents (piperacillin/tazobactam) could be maintained above the targeted minimal inhibitory concentration (8-16 mg/L) only with continuous application. In addition to continuous application of piperacillin/tazobactam, partial recapitulation of the host immune system ex situ accompanied by strict preventive measures for contact and air contamination maintained sterility during one week of perfusion.

CONCLUSION

The work demonstrates feasibility of sterility maintenance for one week during ex situ normothermic liver perfusion.

An integrated perfusion machine preserves injured human livers for 1 week

The ability to preserve metabolically active livers ex vivo for 1 week or more could allow repair of poor-quality livers that would otherwise be declined for transplantation. Current approaches for normothermic perfusion can preserve human livers for only 24 h. Here we report a liver perfusion machine that integrates multiple core physiological functions, including automated management of glucose levels and oxygenation, waste-product removal and hematocrit control. We developed the machine in a stepwise fashion using pig livers. Study of multiple ex vivo parameters and early phase reperfusion in vivo demonstrated the viability of pig livers perfused for 1 week without the need for additional blood products or perfusate exchange. We tested the approach on ten injured human livers that had been declined for transplantation by all European centers. After a 7-d perfusion, six of the human livers showed preserved function as indicated by bile production, synthesis of coagulation factors, maintained cellular energy (ATP) and intact liver structure.

Livers are stored long term in a sophisticated perfusion system.

Perfusion settings and additives in liver normothermic machine perfusion with red blood cells as oxygen carrier. A systematic review of human and porcine perfusion protocols

Liver machine perfusion (MP) at normothermic temperature (NMP) is a promising way to preserve and evaluate extended criteria donor livers. Currently, no consensus exists in methodology and perfusion protocols. Here, the authors performed a systematic literature search to identify human and porcine studies reporting on liver NMP with red blood cells. A qualitative synthesis was performed concerning technical aspects of MP, fluid composition, gas supply, and liver positioning. Thirty-seven publications including 11 human and 26 porcine studies were considered for qualitative synthesis. Control mode, pressure, flow, perfusate additives, and targeted blood gas parameters varied across human as well as porcine studies. For future analyses, it is advisable to report flow adjusted to liver weight and exact pressure parameters including mean, systolic, and diastolic pressure. Parenteral nutrition and insulin addition was common. Parenteral nutrition included amino acids and/or glucose without lipids. Taurocholic acid derivatives were used as bile flow promoters. However, short-term human NMP without taurocholic acid derivatives seems to be possible. This finding is relevant due to the lack of clinical grade bile salts. Near physiological oxygen tension in the perfusate is doable by adjusting gas flows, while blood gas parameters regulation needs more detailed description.

Detection of numerical chromosomal aberrations by flow cytometry: a novel process for identifying aneugenic agents

Aneuploidy plays a significant role in adverse human health conditions including birth defects, pregnancy wastage, and cancer. Currently, there is no screening method sufficiently validated that can be used routinely to identify aneugenic agents in vitro because most conventional test systems rely on the labor-intensive microscopic assessment of the aneuploid cell population. Our laboratory has recently developed a flow cytometry-based procedure for assessing numerical chromosomal aberrations in mitotic populations of lymphocytes on the basis of DNA content. Studies were conducted in 24 h treated human lymphocyte cultures to determine the sensitivity of this flow cytometry-based procedure to detect aneugenic agents. A comparison between the microscopic and the flow cytometry-based procedures for scoring polyploidy shows a strong agreement exists between the two methods. Treatments with two known aneugenic agents, griseofulvin, and paclitaxel (taxol), resulted in a dose-related increase in the mitotic index, aneuploidy, and polyploidy. In contrast, results from the treatments with two known clastogenic agents, mitomycin-C, and etoposide, show a dose-related decrease in the mitotic index with a slight increase in the frequency of hypodiploidy at concentrations that produce severe chromosomal breakage. There were no increases in hyperdiploidy and polyploidy observed. In conclusion, the reproducibility of the results obtained in this study indicates that this flow cytometry-based procedure for assessing numerical chromosomal effects in mitotic populations on the basis of DNA content is promising for the routine detection and characterization of aneugenic agents.

Measuring the mitotic index in chemically-treated human lymphocyte cultures by flow cytometry

In the human lymphocyte chromosome aberration assay, the mitotic index (MI) is the standard cytotoxic parameter for determining which test concentrations will be evaluated for chromosome aberrations. Assessment of the MI is performed microscopically by determining the frequency of mitotic cells in a population of 1000 cells. With the commercial availability of antibodies to the mitosis-specific marker, phosphorylated-histone H3 at serine 10, automating the assessment of the MI using flow cytometry is now possible [Cytometry 32 (1998) 71]. Our laboratory has utilized and validated this technology to measure the mitotic index of chemically-treated human lymphocyte cultures. Comparisons between the microscopic and flow MI frequencies from 24h treatments with mitomycin-C, aphidicolin, eugenol, etoposide, hydroxyrurea, potassium cyanide, staurosporine, ethyl alcohol, noscapine and colcemid((R)) are presented. Our results show that the mitosis specific H3-P marker is excellent for measuring the MI frequency in human lymphocyte cultures treated up to toxic concentrations. In addition, this study demonstrates that automation of analysis by flow cytometry is an excellent alternative to the microscopic method of analysis producing less variability than the microscopic scoring and a more complete dose response curve.

Enhancing the in vitro and in vivo detection of aneuploidy by fluorescence in situ hybridization with the use of bromodeoxyuridine as a proliferation marker

Aneuploidy is associated with spontaneous abortions, birth defects, and many types of human cancers. Currently there are few assays developed for the efficient detection of aneuploidy in vivo. However, with the recent availability of chromosome-specific DNA probes for the rat, fluorescence in situ hybridization (FISH) techniques could be used for the rapid and sensitive detection of aneuploidy in different tissue and cell types. In order to develop a system that can detect alterations in chromosome number in rat cells in vitro, we treated cultured rat lymphocytes with three aneugens-noscapine hydrochloride (0-150 microM) and vincristine and vinblastine sulfate (0-0.06 microM). 5-Bromo-2-deoxyuridine (BrdU; 1 microM) was added to the culture medium to allow proliferating and non-proliferating cells to be distinguished. To test this assay under in vivo conditions, 21-day-old male Sprague-Dawley rats were subcutaneously implanted with osmotic pumps that delivered BrdU (approximately 12 mg/kg per day) continuously. These rats were administered vinblastine sulfate (0, 0.5 and 1mg/kg) by intraperitoneal injection. The rat lymphocytes and hepatocytes incorporating BrdU were detected by immuno-fluorescent labeling, and FISH with a rat chromosome 4 probe was performed on the labeled and unlabeled cells. Highly significant increases in hyperdiploidy were seen in the replicating rat lymphocytes treated with noscapine, vincristine or vinblastine in vitro and in the rat hepatocytes treated with vinblastine in vivo. In contrast, no significant increase in hyperdiploidy was observed in the non-replicating cells. These results demonstrate that this BrdU-enhanced FISH assay with chromosome-specific rat probes can be used to efficiently detect numerical chromosomal aberrations in vitro and in vivo in slowly or moderately replicating rat tissues. The combination of BrdU-labeling and FISH allows the scoring of hyperdiploidy to be focused on the actively replicating cells, thereby increasing the sensitivity of the FISH technique.

Effects of contractile activity and hypothyroidism on nuclear hormone receptor mRNA isoforms in rat skeletal muscle

Absolute molecule numbers of thyroid hormone receptor isoforms T3Ralpha1, T3Ralpha2, T3Rbeta1, and the 9-cis retinoic acid receptor gamma were measured in adult fast extensor digitorum longus (EDL) and slow soleus (SOL) muscles of rat by competitive reverse transcriptase (RT)-PCR. The nuclear hormone receptor corepressor (NCoR) mRNA was quantified by noncompetitive RT-PCR in the same muscles. T3Rbeta1 mRNA was the most abundant isoform in both muscle types. All nuclear hormone receptor (NHR) mRNAs were found at lower molecule numbers in fast than in slow muscle. No differences existed with regard to NCoR mRNA. With the exception of T3Ralpha1 in the EDL, hypothyroidism led to decreases in NHR mRNAs, especially in SOL, but did not significantly affect the level of NCoR mRNA. Enhanced neuromuscular activity of the fast EDL muscle, as induced by chronic low-frequency stimulation, transiently increased NHR mRNAs, but decreased NCoR mRNA. These chronic-low-frequency-stimulation-induced changes were attenuated by hypothyroidism.

Quantification of thyroid hormone receptor isoforms, 9-cis retinoic acid receptor gamma, and nuclear receptor co-repressor by reverse-transcriptase PCR in maturing and adult skeletal muscles of rat

Quantitative competitive reverse-transcriptase polymerase chain reaction (qcRT-PCR) was established for determining absolute molecule numbers of the thyroid hormone receptor (T3R) isoforms T3Ralpha1, T3Ralpha2, T3Rbeta1, and the 9-cis retinoic acid receptor gamma (RXRgamma) in developing and adult fast-twitch extensor digitorum longus (EDL) and slow-twitch soleus (SOL) muscles of rat. Expression levels of the nuclear receptor co-repressor (NCoR) were measured in the same muscles because responses to thyroid hormones during muscle maturation might not only depend on the expression levels of the various receptors but might also be modulated by changes in the expression of NCoR. The qcRT-PCR method was based on the addition of known amounts of homologous competitor RNAs to the reverse transcriptase (RT) reaction. We show that all nuclear receptors under study were expressed in fast and slow muscles. Transcript numbers of T3Rbeta1, which was the most abundant isoform, were higher in SOL than in EDL during all developmental stages. The mRNAs for T3Ralpha1, T3Ralpha2, RXRgamma and the NCoR displayed molecule numbers in similar ranges, but were differentially expressed. T3Ralpha1 mRNA increased in SOL during postnatal development, while T3Ralpha2 mRNA initially decreased, then increased to adult levels. Conversely, pronounced decreases were observed for T3Ralpha1 (10-fold) and T3Ralpha2 (28-fold) mRNAs in the EDL muscle during postnatal maturation. RXRgamma mRNA was 10-fold downregulated during EDL maturation, but unaltered in maturing SOL. NCoR transcript number displayed only minor changes in both muscles.