Ex vivo perfusion: a renal preservation model

Organ preservation: from the past to the future

Organ transplantation is the most effective therapy for patients with end-stage disease. Preservation solutions and techniques are crucial for donor organ quality, which is directly related to morbidity and survival after transplantation. Currently, static cold storage (SCS) is the standard method for organ preservation. However, preservation time with SCS is limited as prolonged cold storage increases the risk of early graft dysfunction that contributes to chronic complications. Furthermore, the growing demand for the use of marginal donor organs requires methods for organ assessment and repair. Machine perfusion has resurfaced and dominates current research on organ preservation. It is credited to its dynamic nature and physiological-like environment. The development of more sophisticated machine perfusion techniques and better perfusates may lead to organ repair/reconditioning. This review describes the history of organ preservation, summarizes the progresses that has been made to date, and discusses future directions for organ preservation.

Cryopreservation of the mammalian kidney. II. Demonstration of immediate ex vivo function after introduction and removal of 7.5 M cryoprotectant

The objective of the present study was to determine whether rabbit kidneys could be perfused with a 7.5 M vitrification solution (VS4, which vitrifies under applied pressure) without loss of function. To answer this question, kidneys were perfused with VS4 using a computer-based machine to gradually raise and lower concentration and then attached to the aorta and vena cava of a perfusor rabbit using an apparatus that permitted renal blood flow and renal function to be measured. About half (6/13) of the kidneys so evaluated resumed substantial immediate function after a transient period of severely reduced blood flow. Loss of function did not occur if cryoprotectant concentration was limited to 3.8 M. The loss of function produced by VS4 could be partially reproduced by artificially limiting blood reflow in control kidneys to simulate the transiently low flows caused by VS4 exposure. These results provide the first evidence that both the parenchyma and the vascular system of a sensitive mammalian organ can survive exposure to a vitrifiable concentration of cryoprotectant.

Reperfusion injury in vascularized bone allografts

A vascularized allograft canine tibia was used to evaluate the preservation of the osseous microcirculation. Six pairs of adult tibiae were harvested, and a vascular washout was performed with mannitol solution. The bones then were perfused continuously (0.03 ml/min at 5 degrees C) for 20 hours with University of Wisconsin solution. Following storage, each pair of bones was transplanted, by microvascular anastomosis, to a recipient dog, and bone blood flow was estimated using the radiolabeled microsphere method. Adrenoreceptor control mechanisms were evaluated in one specimen, and endothelial function was evaluated in the contralateral specimen. Alpha 1-adrenoreceptor blockade produced a significant increase (89 +/- 80%) in bone blood flow (p < 0.05). A further increase (99 +/- 56%) was observed with the addition of alpha 2-blockade (p < 0.01). Acetylcholine produced a decrease (65 +/- 65%) in blood flow (p < 0.01). This effect was inhibited by L-NG-monomethyl-arginine, which resulted in an increase (53 +/- 47%) in bone blood flow (p < 0.05). The no-reflow phenomenon was observed in two vascularized allografts. These results demonstrate that smooth muscle adrenoreceptors were preserved successfully for 24 hours. In contrast, endothelial function was abnormal. There was no evidence that the endothelium was producing endothelium-derived relaxing factor, and the results suggest that an endothelium-derived constricting factor dependent on L-arginine was produced during reperfusion. It is concluded that University of Wisconsin solution does not preserve normal endothelial function in the microcirculation of bone.

Viability assays in organ preservation

Assays to determine the viability of preserved organs ideally must meet two important requirements: (i) in the clinical environment, they should allow the surgeon to determine if an organ will be viable when it is transplanted (this needs to be done in a noninvasive, nondestructive manner, and currently no such assay exists), and (ii) in the research environment, they should aid in the development of improved methods of organ preservation. Currently, however, the only reliable means of assessing viability is actual transplantation. Many conventional biochemical and physiological techniques have been used to describe the mechanism of preservation-induced injury and to help improve preservation. This paper reviews some techniques that have been used to aid in the development of organ preservation.

Comparison of rapid in situ, regular in situ, and ex vivo flushing on hepatic function

The efficacy of three flushing techniques on subsequent liver function was assessed using the in vivo isolated liver perfusion model (ILPM). Livers from brain-dead mongrel dogs were flushed with cold Euro-Collins as follows: Group I, rapid in situ flushing (10 min); Group II, regular in situ flushing (45 min); Group III, ex vivo flushing (10 min). All livers were then heterotopically transplanted into recipients, using the ILPM, by anastomosis of the portal vein, vena cava, and hepatic artery to the recipient's portal vein, iliac vein, and iliac artery. Reperfusion followed for 30 min. Laboratory samples collected at 0, 5, 15, and 30 min showed that hepatic function was not altered by ex vivo flushing and was only slightly altered by rapid in situ flushing. Regular in situ flushing proved to be damaging to livers. Histological analysis confirmed these findings. Therefore, either rapid in situ or ex vivo flushing can be safely used by the transplant specialist.

The effects of oxygen free radicals on the preserved kidney

This study evaluated the effect of specific scavengers of oxygen derived free radicals on the results of kidney preservation. The immediate function of rabbit kidneys preserved for 24 hr by hypothermic perfusion was studied on an ex vivo shunt. A significant improvement in creatinine clearance was seen when the perfusate was treated with superoxide dismutase (SOD) and catalase (CAT), with values of 261 +/- 82 ml/hr vs control values of 203 +/- 72 ml/hr, P less than 0.05. This effect was enhanced if a long-persistent polyethylene glycol-linked form of SOD, namely PEG-SOD, was used (330 +/- 58 ml/hr, P less than 0.01). Recipient treatment and other modifications designed to protect against free radicals resulted in similar improvement in function. In contrast, no effect of free radical scavengers could be demonstrated in kidneys which were preserved by flush cooling, whether the agents were added to the flushing solution, given to the recipient, or both.

Effects of 24-Hour Hypothermic Storage on Isolated-Perfused Canine Heart-Lungs

Isolated-perfused canine heart-lungs were used as a model to measure the effects of 24-hour hypothermic storage on cardiopulmonary function and metabolism. Heart-lungs were stored at 4–7°C in Euro-Collins solution ( n = 6) or TP-V ( n = 6). a hyperosmolar colloid solution containing dextrose, sucrose. ATP and MgCl2. Lung inflation was maintained with 100% nitrogen. Following preservation, the heart-lungs were perfused with an albumin-mannitol perfusate for three hours at 37°C. for functional and laboratory determinations. Cold storage with TP-V soiution resulted in significantly lower enzyme activity for CPK ( p < 0·0005) and LDH ( p < 0·01) at 0, 1, and 3 hours of normothermic isolated perfusion. A significant reduction in lactate production ( p < 0·001) was also seen in the heart-lungs stored in TP-V. No apparent differences were seen in the pH, PCO2. and PO2 among the two groups, nor were there any significant haemodynamic changes. Histological specimens revealed that TP-V was less damaging to both cardiac and pulmonary tissue, as only moderate oedema and congestion was apparent. These results indicate that 24 hour hypothermic storage with TP-V may be a more appropriate preservation solution for canine heart-lungs.

Variation of cooling rate and concentration of dimethyl sulfoxide on rabbit kidney function

Rabbit kidney function was assessed in vitro after cryoprotection with either 3 or 4 M dimethyl sulfoxide. The introduction and removal of the cryoprotectant was carried out in a stepwise progressive manner and the removal in a stepwise progressive manner with hypertonic mannitol solutions. This in vitro model can be shown to respond to various ischemic-like states resulting in poor or absent function. Active tubular transport can be demonstrated. It has been used by many authors as an intermediate step prior to the ultimate test of reimplant and contralateral nephrectomy. Variations in the rate of cooling at cryoprotection levels of 3 and 4 M dimethyl sulfoxide concentration (Me2SO) were carried out. In general, at 3 M concentration of Me2SO, creatinine clearance, sodium and glucose reabsorption are preserved with a fair degree of success after cooling to -10, -15, and -20 degrees C in our model, when the rate of cooling to these levels is 1.0 degree C/min. When a cooling rate of 0.5 degree C/min is used, renal function is significantly reduced whether the final temperature is -10, -15, or -20 degrees C. Control rabbit kidneys will tolerate 4 M concentration of Me2SO and give fairly good function. When cooled to -15 or -20 degrees C, there is poor function at 0.1 and 0.5 degrees C/min. Fair function is obtained at the rate of 1 degree C/min to -10 degrees C. Therefore, at cryoprotectant levels of 3 and 4 M Me2SO, kidney function as assayed by in vitro perfusion, is better when the cooling rate is 1.0 degree C/min.

Optimal redox electrode potential for 24-hour rabbit kidney perfusion

This study was conducted to determine whether an optimum redox electrode potential existed for 24-hr hypothermic perfusion of rabbit kidneys. The perfusate consisted of a Ringer's-albumin solution to which was added varying amounts of the reducing agents, glutathione and ascorbate, either individually or in equimolar amounts. Electrode potential was monitored with a vitreous carbon electrode in relation to a silver-silver chloride reference cell, and kidney function was measured after preservation by connection to the circulation of a perfusor animal via a shunt. The best results were obtained using equimolar amounts of the reducing agents. Under these circumstances a definite optimum range for perfusate electrode potential was identified (Es = 40-70 mV) within which renal function was indistinguishable from unpreserved controls. Higher and lower perfusate electrode potentials were associated with significantly lower creatinine clearances. However, the explanation for these results appeared to be more complex than redox control alone, since kidney function was dependent not only on the redox potential of the perfusate but also on the reducing agents with which the adjustment had been made. Ascorbate proved to be significantly better than glutathione within the optimum potential range.

Effects of short-term hypothermic perfusion and cold storage on function of the isolated-perfused dog kidney

The isolated-perfused dog kidney was used as a model to measure the effects of short-term hypothermic preservation on renal function and metabolism. Kidneys were cold-stored in Collins' solution, hypotonic citrate, or phosphate-buffered sucrose for 4 and 24 hr, or were continuously perfused for 4 and 24 hr with a synthetic perfusate. Following preservation kidneys were perfused with an albumin-containing perfusate at 37 degrees C for 60 min for determination of renal function. The results indicate that many of the effects of short-term preservation on renal function in dog kidneys are similar to results reported for rat and rabbit kidneys. Cold storage for 4 hr resulted in a large decrease in GFR (57%), but only a small decrease in Na reabsorption (from 97 to 87%). Cold storage for 24 hr caused a further decline in renal function (GFR = 95% decrease, Na reabsorption = 49-64%). Results were similar for all cold storage solutions tested. Perfusion for 4 hr was less damaging to renal function than cold storage. The GFR decreased only 14% and urine formation and Na reabsorption were practically normal. After 24 hr of hypothermic perfusion, the GFR was reduced by 79%, urine flow was normal, and Na reabsorption was 78%. There were no obvious biochemical correlates (adenine nucleotides, tissue edema, or electrolyte concentration) with the loss of renal function during short-term preservation. The results suggest that the isolated-perfused dog kidney can be used to test the effects of preservation on renal function, and yields results similar to those obtained using small animal models.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of hypothermic kidney preservation on the isolated perfused kidney: a comparison of reperfusion methods

Two isolated-perfused kidney methods were used to study the effects of hypothermic preservation on renal function in dog kidneys. The isolated-machine-perfused kidney (IMPK) used an in vitro perfusion technique--the perfusate was a Krebs-bicarbonate type delivered to the kidney at 37 degrees C by a mechanical pump at a constant pressure (100 mm Hg). The isolated-blood-perfused kidney (IBPK) utilized transplantation of the preserved kidney to the femoral vasculature. Renal function (urine analysis) was determined over a 1-hr reperfusion interval and included GFR (creatinine clearance), urine formation, and Na+ reabsorption. Kidneys preserved for only 24 hr by cold storage in either Collins'--C3 solution or in hypotonic citrate and kidneys hypothermically perfused for 24 hr demonstrated greater retention of renal function when reperfused by blood (IBPK) than with the in vitro perfusate (IMPK). The GFR was reduced by 38-58% when tested with the IBPK, but by 80-90% when tested with the IMPK. Na+ reabsorption was normal (97%) with blood reperfusion but was reduced to 36-50% in cold-stored kidneys and 82% in hypothermically perfused kidneys determined by machine reperfusion (IMPK). However, kidneys perfused for 72 hr demonstrated more similar renal functions when tested by either IMPK or IBPK. GFR was reduced to 20% (IBPK) and 11% (IMPK) and Na+ reabsorption averaged 76-85% (IBPK or IMPK). These results suggest that either reperfusion method is suitable for determining the effects of renal preservation on kidney function in kidneys preserved for 72 hr but, for short-term preserved kidneys (24 hr), the IBPK model may be preferred.

Beneficial effect of low concentrations of cryoprotective agents on short-term rabbit kidney perfusion

This report describes observations concerning the influence of the addition of 0.3 M cryoprotective agents (propylene glycol or glycerol) to Ringer's albumin solution used for rabbit kidney perfusion for periods of less than 4 and 24 hr. Endogenous creatinine clearance during short-term parabiotic perfusion on a shunt was used to evaluate function after perfusion. The findings were (A) Perfusion for less than 4 hr resulted in a significant loss of function by comparison with 1 hr ice-stored controls. (B) Continuing the perfusion for 24 hr resulted in a further significant fall in function. Much of the early perfusional injury seen in these two groups could be avoided by including 0.3 M cryoprotective agents in the perfusate.

Studies in cryoprotection II: Propylene glycol and glycerol

Propylene glycol (PG), glycerol (G), or a combination of both were introduced into and eluted from 116 rabbit kidneys. The function of the kidneys was then studied on an ex vivo shunt by determining bloodflow and creatinine clearance. The cryoprotective agents ( CPAs ) were introduced and eluted at the rate of about 30 mM/min in an albumin-Ringer's lactate perfusate. In this system, 1.75 to 2.25 M cryoprotectant could be introduced and removed with no demonstrable loss of function. Significant injury was incurred at and above 2.5 M concentrations. When a combination of PG and G (equal proportions) was utilized, both 2.5 and 2.75 M total concentrations were tolerated by the kidney, with no loss of function. These studies demonstrate that in this very rigorous test system, cryoprotectant-induced injury can be significantly diminished by combining two agents of low toxicity. This suggests that osmotic injury may be enhanced by specific toxicities of cryoprotective agents, which can be minimized by using combinations, such as was done in these studies. Also, it has been shown that PG is at least as low in toxicity in the rabbit kidney as is G.

Damaging effect of subzero temperature (-4 degrees C) on rabbit renal function

The effect of exposing rabbit kidneys to -4 degrees C for 1 hr in the unfrozen state was evaluated by means of measurement of tissue slice K/Na ratio and whole organ creatinine clearance. Freezing was prevented in one series (groups SC1-SC3) by supercooling with temperature monitoring and in a second series by a 2 M mixture of propylene glycol and glycerol. The latter agent was introduced prior to storage and later removed before the viability testing using a perfusion method (groups CPA1-CPA4). The results indicated a significant loss of slice and whole organ function during this short period of supercooling. The injury did not appear to result from either the rapidity of cooling or the formation of ice. There was some loss of function resulting from perfusion itself. Since this injury was evident in the whole organ but not in the tissue slice it may be ascribed to a vascular affect. When this damage was taken into account the data indicated that cryoprotective agents appeared to protect against any additional damage resulting from 1 hr storage at -4 degrees C.

Studies in cryoprotection. I. A simple method for the controlled introduction and removal of cryoprotective agents during organ perfusion

A method is presented for the introduction and removal of cyroprotective agents from kidneys, utilizing the principle of gradual addition and elution during continuous perfusion. The method differs from those described previously in that it utilizes a standard perfusion machine (Water MOX 100) and a motorized syringe pump; both of which are widely available in laboratories involved in clinical and experimental organ preservation. In addition, a simple method for measuring vascular resistance is described which relies on a comparison of flow rates through the perfused organs to that through a fixed resistance. The utility of this approach is illustrated by studies of organ function and vascular resistance.

Experimental observations on the mode of action of "intracellular" flush solution

Experiments were conducted using rabbit kidneys stored on ice for 48 hr to elucidate the mode of action of "intracellular" flush solutions. Measurements were made of renal function on a shunt and they were correlated with blood flow and the efficiency of the mechanical expulsion of red cells. By comparison with unflushed, ice-stored kidneys, near complete mechanical expulsion of blood by 30 to 60 min of continuous perfusion with hypertonic Ringer's albumin resulted in significantly higher blood flow with little gain in function. Similarly, increasing the content of nonelectrolyte in Ringer's albumin improved blood flow but not function. A simple flush with a low ionic strength sodium solution (LIE), containing impermeant anions and glucose was superior to that with Ringer's albumin. A high-potassium version of the low ionic strength solution (LIC) was in turn significantly better than LIE for kidney preservation by simple flushing and ice storage. These results were interpreted to mean that whereas mechanical flushing is a relatively minor component of the action of flush solutions, the major benefit results from a reduced sodium and elevated potassium content in the presence of impermeant anions. The primary importance of prevention of cell swelling by the inclusion of nonelectrolytes in "extracellular" flush solutions, is questioned.