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Chen SF, Yang BY, Zhang TY, Song XY, Jia ZB, Chen LJ, Cui MY, Xu WJ, Peng J. Study on the preservation effects of the amputated forelimb by machine perfusion at physiological temperature. Chin J Traumatol 2024; 27:114-120. [PMID: 37311687 PMCID: PMC11075101 DOI: 10.1016/j.cjtee.2023.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 03/31/2023] [Accepted: 05/02/2023] [Indexed: 06/15/2023] Open
Abstract
PURPOSE Ischemia and hypoxia are the main factors limiting limb replantation and transplantation. Static cold storage (SCS), a common preservation method for tissues and organs, can only prolong limb ischemia time to 4 - 6 h. The normothermic machine perfusion (NMP) is a promising method for the preservation of tissues and organs, which can extend the preservation time in vitro by providing continuous oxygen and nutrients. This study aimed to evaluate the difference in the efficacy of the 2 limb preservation methods. METHODS The 6 forelimbs from beagle dogs were divided into 2 groups. In the SCS group (n = 3), the limbs were preserved in a sterile refrigerator at 4 °C for 24 h, and in the NMP group (n = 3), the perfusate prepared with autologous blood was used for the oxygenated machine perfusion at physiological temperature for 24 h, and the solution was changed every 6 h. The effects of limb storage were evaluated by weight gain, perfusate biochemical analysis, enzyme-linked immunosorbent assay, and histological analysis. All statistical analyses and graphs were performed using GraphPad Prism 9.0 one-way or two-way analysis of variance. The p value of less than 0.05 was considered to indicate statistical significance. RESULTS In the NMP group, the weight gained percentage was 11.72% ± 4.06%; the hypoxia-inducible factor-1α contents showed no significant changes; the shape of muscle fibers was normal; the gap between muscle fibers slightly increased, showing the intercellular distance of (30.19 ± 2.83) μm; and the vascular α-smooth muscle actin (α-SMA) contents were lower than those in the normal blood vessels. The creatine kinase level in the perfusate of the NMP group increased from the beginning of perfusion, decreased after each perfusate change, and remained stable at the end of perfusion showing a peak level of 4097.6 U/L. The lactate dehydrogenase level of the NMP group increased near the end of perfusion and reached the peak level of 374.4 U/L. In the SCS group, the percentage of weight gain was 0.18% ± 0.10%, and the contents of hypoxia-inducible factor-1α increased gradually and reached the maximum level of (164.85 ± 20.75) pg/mL at the end of the experiment. The muscle fibers lost their normal shape and the gap between muscle fibers increased, showing an intercellular distance of (41.66 ± 5.38) μm. The contents of vascular α-SMA were much lower in the SCS group as compared to normal blood vessels. CONCLUSIONS NMP caused lesser muscle damage and contained more vascular α-SMA as compared to SCS. This study demonstrated that NMP of the amputated limb with perfusate solution based on autologous blood could maintain the physiological activities of the limb for at least 24 h.
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Affiliation(s)
| | - Bo-Yao Yang
- Medical School of PLA, Beijing, 100048, China
| | - Tie-Yuan Zhang
- Beijing Key Lab of Regenerative Medicine in Orthopedics, Key Laboratory of Musculoskeletal Trauma and War Injuries PLA, Department of Orthopedics, The Fourth Medical Center, Chinese PLA General Hospital, Beijing, 100048, China
| | - Xiang-Yu Song
- Beijing Key Lab of Regenerative Medicine in Orthopedics, Key Laboratory of Musculoskeletal Trauma and War Injuries PLA, Department of Orthopedics, The Fourth Medical Center, Chinese PLA General Hospital, Beijing, 100048, China; Hebei North University, Zhangjiakou, 075000, Hebei Province, China
| | - Zhi-Bo Jia
- Beijing Key Lab of Regenerative Medicine in Orthopedics, Key Laboratory of Musculoskeletal Trauma and War Injuries PLA, Department of Orthopedics, The Fourth Medical Center, Chinese PLA General Hospital, Beijing, 100048, China; Hebei North University, Zhangjiakou, 075000, Hebei Province, China
| | - Lei-Jia Chen
- Beijing Key Lab of Regenerative Medicine in Orthopedics, Key Laboratory of Musculoskeletal Trauma and War Injuries PLA, Department of Orthopedics, The Fourth Medical Center, Chinese PLA General Hospital, Beijing, 100048, China; Hebei North University, Zhangjiakou, 075000, Hebei Province, China
| | - Meng-Yi Cui
- Beijing Key Lab of Regenerative Medicine in Orthopedics, Key Laboratory of Musculoskeletal Trauma and War Injuries PLA, Department of Orthopedics, The Fourth Medical Center, Chinese PLA General Hospital, Beijing, 100048, China
| | - Wen-Jing Xu
- Beijing Key Lab of Regenerative Medicine in Orthopedics, Key Laboratory of Musculoskeletal Trauma and War Injuries PLA, Department of Orthopedics, The Fourth Medical Center, Chinese PLA General Hospital, Beijing, 100048, China
| | - Jiang Peng
- Guizhou Medical University, Guiyang, 550025, China; Beijing Key Lab of Regenerative Medicine in Orthopedics, Key Laboratory of Musculoskeletal Trauma and War Injuries PLA, Department of Orthopedics, The Fourth Medical Center, Chinese PLA General Hospital, Beijing, 100048, China.
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Muss TE, Loftin AH, Oh BC, Brandacher G. Current opinion: advances in machine perfusion and preservation of vascularized composite allografts - will time still matter? Curr Opin Organ Transplant 2023; 28:419-424. [PMID: 37823760 DOI: 10.1097/mot.0000000000001107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
PURPOSE OF REVIEW A major hurdle hindering more widespread application of reconstructive transplantation is the very limited cold ischemia time (CIT) of vascularized composite allografts (VCAs). In this review, we discuss cutting edge machine perfusion protocols and preservation strategies to overcome this limitation. RECENT FINDINGS Several preclinical machine perfusion studies have demonstrated the multifactorial utility of this technology to extend preservation windows, assess graft viability prior to transplantation and salvage damaged tissue, yet there are currently no clinically approved machine perfusion protocols for reconstructive transplantation. Thus, machine perfusion remains an open challenge in VCA due to the complexity of the various tissue types. In addition, multiple other promising avenues to prolong preservation of composite allografts have emerged. These include cryopreservation, high subzero preservation, vitrification and nanowarming. Despite several studies demonstrating extended preservation windows, there are several limitations that must be overcome prior to clinical translation. As both machine perfusion and subzero preservation protocols have rapidly advanced in the past few years, special consideration should be given to their potential complementary utilization. SUMMARY Current and emerging machine perfusion and preservation technologies in VCA have great promise to transform the field of reconstructive transplantation, as every extra hour of CIT helps ease the complexities of the peri-transplant workflow. Amongst the many advantages, longer preservation windows may allow for elective procedures, improved matching, establishment of novel immunomodulatory protocols and global transport of grafts, ultimately enabling us the ability to offer this life changing procedure to more patients.
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Affiliation(s)
- Tessa E Muss
- Department of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation (VCA) Laboratory
| | - Amanda H Loftin
- Department of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation (VCA) Laboratory
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Byoung Chol Oh
- Department of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation (VCA) Laboratory
| | - Gerald Brandacher
- Department of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation (VCA) Laboratory
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Berkane Y, Hayau J, Filz von Reiterdank I, Kharga A, Charlès L, Mink van der Molen AB, Coert JH, Bertheuil N, Randolph MA, Cetrulo CL, Longchamp A, Lellouch AG, Uygun K. Supercooling: A Promising Technique for Prolonged Organ Preservation in Solid Organ Transplantation, and Early Perspectives in Vascularized Composite Allografts. FRONTIERS IN TRANSPLANTATION 2023; 2:1269706. [PMID: 38682043 PMCID: PMC11052586 DOI: 10.3389/frtra.2023.1269706] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Accepted: 09/29/2023] [Indexed: 05/01/2024]
Abstract
Ex-vivo preservation of transplanted organs is undergoing spectacular advances. Machine perfusion is now used in common practice for abdominal and thoracic organ transportation and preservation, and early results are in favor of substantially improved outcomes. It is based on decreasing ischemia-reperfusion phenomena by providing physiological or sub-physiological conditions until transplantation. Alternatively, supercooling techniques involving static preservation at negative temperatures while avoiding ice formation have shown encouraging results in solid organs. Here, the rationale is to decrease the organ's metabolism and need for oxygen and nutrients, allowing for extended preservation durations. The aim of this work is to review all advances of supercooling in transplantation, browsing the literature for each organ. A specific objective was also to study the initial evidence, the prospects, and potential applications of supercooling preservation in Vascularized Composite Allotransplantation (VCA). This complex entity needs a substantial effort to improve long-term outcomes, marked by chronic rejection. Improving preservation techniques is critical to ensure the favorable evolution of VCAs, and supercooling techniques could greatly participate in these advances.
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Affiliation(s)
- Yanis Berkane
- Vascularized Composite Allotransplantation Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- Shriners Children’s Boston, Harvard Medical School, Boston, MA, United States
- Department of Plastic, Reconstructive and Aesthetic Surgery, Hôpital Sud, CHU Rennes, University of Rennes, Rennes, France
- MOBIDIC, UMR INSERM 1236, Rennes University Hospital, Rennes, France
| | - Justine Hayau
- Division of Plastic Surgery, Lausanne University Hospital, Lausanne, Switzerland
| | - Irina Filz von Reiterdank
- Vascularized Composite Allotransplantation Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- Shriners Children’s Boston, Harvard Medical School, Boston, MA, United States
- Department of Plastic, Reconstructive and Hand Surgery, University Medical Center Utrecht, Utrecht, Netherlands
- Center for Engineering for Medicine and Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Anil Kharga
- Shriners Children’s Boston, Harvard Medical School, Boston, MA, United States
- Center for Engineering for Medicine and Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Laura Charlès
- Vascularized Composite Allotransplantation Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- Shriners Children’s Boston, Harvard Medical School, Boston, MA, United States
| | - Abele B. Mink van der Molen
- Department of Plastic, Reconstructive and Hand Surgery, University Medical Center Utrecht, Utrecht, Netherlands
| | - J. Henk Coert
- Department of Plastic, Reconstructive and Hand Surgery, University Medical Center Utrecht, Utrecht, Netherlands
| | - Nicolas Bertheuil
- Department of Plastic, Reconstructive and Aesthetic Surgery, Hôpital Sud, CHU Rennes, University of Rennes, Rennes, France
- MOBIDIC, UMR INSERM 1236, Rennes University Hospital, Rennes, France
| | - Mark A. Randolph
- Vascularized Composite Allotransplantation Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- Shriners Children’s Boston, Harvard Medical School, Boston, MA, United States
| | - Curtis L. Cetrulo
- Vascularized Composite Allotransplantation Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- Shriners Children’s Boston, Harvard Medical School, Boston, MA, United States
| | - Alban Longchamp
- Shriners Children’s Boston, Harvard Medical School, Boston, MA, United States
- Center for Engineering for Medicine and Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- Department of Vascular Surgery, Lausanne University Hospital, Lausanne, Switzerland
- Center for Transplant Sciences, Massachusetts General Hospital, Boston, MA, United States
| | - Alexandre G. Lellouch
- Vascularized Composite Allotransplantation Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- Shriners Children’s Boston, Harvard Medical School, Boston, MA, United States
| | - Korkut Uygun
- Shriners Children’s Boston, Harvard Medical School, Boston, MA, United States
- Center for Engineering for Medicine and Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- Center for Transplant Sciences, Massachusetts General Hospital, Boston, MA, United States
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Abstract
Asking 'can we balance the risks and benefits?' implies that a quantification of both risk and benefit in hand transplantation (here the terms hand transplant and hand transplantation refer to allotransplantation of the human hand or hand and part or all of the upper limb or limbs) is possible. Despite all we have learned in recent years about hand transplantation, much remains unknown. Even if reliable methods for quantification of risk and benefit were available, fundamental issues relating to effective communication across the gulf of lived experience between the (presumably) handed surgeon and the handless patient remain. Inherent complexities mean some consider hand transplantation an unsolved problem, but we believe the medical and technical considerations fall within the ambit of a competent multidisciplinary team, and that psychosocial and ethical challenges are open to management through robust frameworks for assessment and decision making, underpinned by an extended period of assessment and dialogue, with candid acknowledgement where uncertainty remains. This respects the patient's autonomy while addressing the need for a prolonged period of informing consent.Level of evidence: V.
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Affiliation(s)
- Simon P J Kay
- Hand Transplant UK, Leeds Teaching Hospitals Trust, Leeds, UK
| | - David A Leonard
- Hand Transplant UK, Leeds Teaching Hospitals Trust, Leeds, UK.,School of Medicine, Dentistry & Nursing, University of Glasgow, Glasgow, UK
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Meyers A, Pandey S, Kopparthy V, Sadeghi P, Clark RC, Figueroa B, Dasarathy S, Brunengraber H, Papay F, Rampazzo A, Bassiri Gharb B. Weight gain is an early indicator of injury in ex vivo normothermic limb perfusion (EVNLP). Artif Organs 2023; 47:290-301. [PMID: 36305734 PMCID: PMC10100395 DOI: 10.1111/aor.14442] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 09/25/2022] [Accepted: 10/11/2022] [Indexed: 02/03/2023]
Abstract
PURPOSE There are no established criteria for discontinuing ex vivo normothermic limb perfusion (EVNLP) before irreversible damage occurs. This study evaluates weight gain as an indicator of injury during EVNLP. METHODS Sixteen Yorkshire pig forelimbs were procured and preserved using EVNLP with a hemoglobin-based oxygen carrier (HBOC-201) or static cold storage. EVNLP continued until termination criteria were met: arterial pressure ≥ 115 mm Hg, compartment pressure > 30 mm Hg, or 20% reduction of oxygen saturation. Limb weight, contractility, hemodynamics, perfusate electrolytes, metabolites and gases were recorded. Muscles were biopsied 6-h, and muscle injury scores (MIS) calculated. Forearm compartment pressures and indocyanine green (ICG) angiography were recorded at endpoint. Outcomes were compared at 2%, 5%, 10%, and 20% limb weight gain. RESULTS EVNLP lasted 20 ± 3 h. Weight gain was observed after 13 ± 5 h (2%), 15 ± 6 h (5%), 16 ± 6 h (10%), and 19 ± 4 h (20%). Weight correlated positively with MIS (ρ = 0.92, p < 0.0001), potassium (ρ = -1.00, p < 0.0001), pressure (ρ = 0.78, p < 0.0001), and negatively with contractility (ρ = -0.96, p = 0.011). At 5% weight gain, MIS (p < 0.0001), potassium (p = 0.03), and lactate (p < 0.0001) were significantly higher than baseline. Median muscle contractility was 5 [3-5] at 2% weight gain, 4 [1-5] at 5%, 3 [0-4] and 2 [0-2] at 10% and 20%, respectively. At 20% weight gain, contractility was significantly lower than baseline (p = 0.003). Percent weight gain correlated negatively with endpoint ICG hoof fluorescence (r = -0.712, p = 0.047). CONCLUSIONS Weight gain correlated with microscopic muscle injury and was the earliest evidence of limb dysfunction. Weight gain may serve as a criterion for discontinuation of EVNLP.
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Affiliation(s)
- Abigail Meyers
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Sonia Pandey
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Varun Kopparthy
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Payam Sadeghi
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Brian Figueroa
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Srinivasan Dasarathy
- Department of Gastroenterology, Hepatology, Pathobiology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Henri Brunengraber
- Department of Nutrition and Biochemistry, School of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Francis Papay
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Antonio Rampazzo
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
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Chen M, Chen X, Wang J, Ren H, Cao K, Cheng M, Yu W, Ding Y. Application of a novel artificial perfusate based on oxygen-carrying nanoparticles in normothermic machine perfusion for porcine liver preservation after cardiac death. Zhejiang Da Xue Xue Bao Yi Xue Ban 2022; 51:697-706. [PMID: 36915981 PMCID: PMC10262012 DOI: 10.3724/zdxbyxb-2022-0402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 11/06/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To investigate the efficacy of a novel artificial perfusate based on oxygen-carrying perfluoronaphthalene-albumin nanoparticles in normothermic machine perfusion (NMP) for preservation of porcine liver donation after cardiac death. METHODS Artificial perfusate with perfluoronaphthalene-albumin nanoparticles was prepared at 5% albumin (w/v) and its oxygen carrying capacity was calculated. The livers of 16 Landrace pigs were isolated after 1 h of warm ischemia, and then they were divided into 4 groups and preserved continuously for 24 h with different preservation methods: cold preservation with UW solution (SCS group), NMP preservation by whole blood (blood NMP group), NMP preservation by artificial perfusate without nanoparticles (non-nanoparticles NMP group) and NMP preservation by artificial perfusate containing nanoparticles (nanoparticles NMP group). Hemodynamics, tissue metabolism, biochemical indices of perfusate and bile were monitored every 4 h after the beginning of NMP. Liver tissue samples were collected for histological examination (HE and TUNEL staining) before preservation, 12 h and 24 h after preservation. RESULTS The oxygen carrying capacity of nanoparticles in 100 mL artificial perfusate was 6.94 μL/mmHg (1 mmHg=0.133 kPa). The hepatic artery and portal vein resistance of nanoparticles NMP group and blood NMP group remained stable during perfusion, and the vascular resistance of nanoparticles NMP group was lower than that of blood NMP group. The concentration of lactic acid in the perfusate decreased to the normal range within 8 h in both nanoparticles NMP group and blood NMP group. There were no significant differences in accumulated bile production, alanine aminotransferase and aspartate aminotransferase in perfusate between nanoparticles NMP group and blood NMP group (all P>0.05). After 24 h perfusion, the histological Suzuki score in blood NMP group and nanoparticles NMP group was lower than that in SCS group and non-nanoparticles NMP group (all P<0.05), and the quantities of TUNEL staining positive cells in blood NMP group and non-nanoparticles NMP group was higher than those in nanoparticles NMP group and SCS group 12 h and 24 h after preservation (all P<0.05). CONCLUSION Artificial perfusate based on oxygen-carrying nanoparticles can meet the oxygen supply requirements of porcine livers donation after cardiac death during NMP preservation, and it may has superiorities in improving tissue microcirculation and alleviating ischemia-reperfusion injury.
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Affiliation(s)
- Ming Chen
- 1. Department of Critical Care Medicine, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing 210008, China
| | - Xiancheng Chen
- 1. Department of Critical Care Medicine, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing 210008, China
| | - Jinglin Wang
- 2. Department of Hepatobiliary Surgery, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing 210008, China
| | - Haozhen Ren
- 2. Department of Hepatobiliary Surgery, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing 210008, China
| | - Ke Cao
- 1. Department of Critical Care Medicine, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing 210008, China
| | - Minhua Cheng
- 1. Department of Critical Care Medicine, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing 210008, China
| | - Wenkui Yu
- 1. Department of Critical Care Medicine, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing 210008, China
| | - Yitao Ding
- 2. Department of Hepatobiliary Surgery, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing 210008, China
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He J, Khan UZ, Qing L, Wu P, Tang J. Improving the ischemia-reperfusion injury in vascularized composite allotransplantation: Clinical experience and experimental implications. Front Immunol 2022; 13:998952. [PMID: 36189311 PMCID: PMC9523406 DOI: 10.3389/fimmu.2022.998952] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 08/29/2022] [Indexed: 11/21/2022] Open
Abstract
Long-time ischemia worsening transplant outcomes in vascularized composite allotransplantation (VCA) is often neglected. Ischemia-reperfusion injury (IRI) is an inevitable event that follows reperfusion after a period of cold static storage. The pathophysiological mechanism activates local inflammation, which is a barrier to allograft long-term immune tolerance. The previous publications have not clearly described the relationship between the tissue damage and ischemia time, nor the rejection grade. In this review, we found that the rejection episodes and rejection grade are usually related to the ischemia time, both in clinical and experimental aspects. Moreover, we summarized the potential therapeutic measures to mitigate the ischemia-reperfusion injury. Compare to static preservation, machine perfusion is a promising method that can keep VCA tissue viability and extend preservation time, which is especially beneficial for the expansion of the donor pool and better MHC-matching.
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Affiliation(s)
- Jiqiang He
- Department of Hand and Microsurgery, Xiangya Hospital of Central South University, Changsha, China
| | - Umar Zeb Khan
- Department of Hand and Microsurgery, Xiangya Hospital of Central South University, Changsha, China
| | - Liming Qing
- Department of Hand and Microsurgery, Xiangya Hospital of Central South University, Changsha, China
| | - Panfeng Wu
- Department of Hand and Microsurgery, Xiangya Hospital of Central South University, Changsha, China
| | - Juyu Tang
- Department of Hand and Microsurgery, Xiangya Hospital of Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital of Central South University, Changsha, China
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