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Rossignol G, Muller X, Brunet TA, Bidault V, Hervieu V, Clement Y, Ayciriex S, Mabrut JY, Salvador A, Mohkam K. Comprehensive bile acid pool analysis during ex-vivo liver perfusion in a porcine model of ischemia-reperfusion injury. Sci Rep 2024; 14:2384. [PMID: 38286808 PMCID: PMC10824768 DOI: 10.1038/s41598-024-52504-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 01/19/2024] [Indexed: 01/31/2024] Open
Abstract
Bile acids (BA) are key for liver regeneration and injury. This study aims at analyzing the changes in the BA pool induced by ischemia-reperfusion (IRI) and investigates the impact of hypothermic oxygenated perfusion (HOPE) on the BA pool compared to static cold storage (SCS). In a porcine model of IRI, liver grafts underwent 30 min of asystolic warm ischemia followed by 6 h of SCS (n = 6) ± 2 h of HOPE (n = 6) and 2 h of ex-situ warm reperfusion. The BA pool in bile samples was analyzed with liquid chromatography coupled with tandem mass spectrometry. We identified 16 BA and observed significant changes in response to ischemia-reperfusion, which were associated with both protective and injury mechanisms. Second, HOPE-treated liver grafts exhibited a more protective BA phenotype, characterized by a more hydrophilic BA pool compared to SCS. Key BA, such as GlycoCholic Acid, were identified and were associated with a decreased transaminase release and improved lactate clearance during reperfusion. Partial Least Square-Discriminant Analysis revealed a distinct injury profile for the HOPE group. In conclusion, the BA pool changes with liver graft IRI, and preservation with HOPE results in a protective BA phenotype compared to SCS.
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Affiliation(s)
- Guillaume Rossignol
- Department of General Surgery and Liver Transplantation, Croix Rousse University Hospital, Lyon, France.
- Department of Pediatric Surgery and Liver Transplantation, Femme Mere Enfant University Hospital, Lyon, France.
- The Cancer Research Center of Lyon, INSERM U1052, Lyon, France.
- ED 340 BMIC, Claude Bernard Lyon 1 University, Villeurbanne, France.
- Institute of Analytical Sciences, CNRS UMR 5280, Claude Bernard University Lyon 1, Villeurbanne, France.
| | - Xavier Muller
- Department of General Surgery and Liver Transplantation, Croix Rousse University Hospital, Lyon, France.
- The Cancer Research Center of Lyon, INSERM U1052, Lyon, France.
- ED 340 BMIC, Claude Bernard Lyon 1 University, Villeurbanne, France.
| | - Thomas Alexandre Brunet
- Institute of Analytical Sciences, CNRS UMR 5280, Claude Bernard University Lyon 1, Villeurbanne, France
| | - Valeska Bidault
- Department of Pediatric Surgery and Liver Transplantation, Femme Mere Enfant University Hospital, Lyon, France
| | - Valerie Hervieu
- Department of Pathology, Hospices Civils de Lyon, Claude Bernard Lyon 1 University, Villeurbanne, Lyon, France
| | - Yohann Clement
- Institute of Analytical Sciences, CNRS UMR 5280, Claude Bernard University Lyon 1, Villeurbanne, France
| | - Sophie Ayciriex
- Institute of Analytical Sciences, CNRS UMR 5280, Claude Bernard University Lyon 1, Villeurbanne, France
| | - Jean-Yves Mabrut
- Department of General Surgery and Liver Transplantation, Croix Rousse University Hospital, Lyon, France
- The Cancer Research Center of Lyon, INSERM U1052, Lyon, France
| | - Arnaud Salvador
- Institute of Analytical Sciences, CNRS UMR 5280, Claude Bernard University Lyon 1, Villeurbanne, France
| | - Kayvan Mohkam
- Department of General Surgery and Liver Transplantation, Croix Rousse University Hospital, Lyon, France
- Department of Pediatric Surgery and Liver Transplantation, Femme Mere Enfant University Hospital, Lyon, France
- The Cancer Research Center of Lyon, INSERM U1052, Lyon, France
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2
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Muller X, Rossignol G, Couillerot J, Breton A, Hervieu V, Lesurtel M, Mohkam K, Mabrut JY. A Single Preservation Solution for Static Cold Storage and Hypothermic Oxygenated Perfusion of Marginal Liver Grafts: A Preclinical Study. Transplantation 2024; 108:175-183. [PMID: 37410580 DOI: 10.1097/tp.0000000000004714] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/08/2023]
Abstract
BACKGROUND Hypothermic oxygenated perfusion (HOPE) improves outcomes of marginal liver grafts. However, to date, no preservation solution exists for both static cold storage (SCS) and HOPE. METHODS After 30 min of asystolic warm ischemia, porcine livers underwent 6 h of SCS followed by 2 h of HOPE. Liver grafts were either preserved with a single preservation solution (IGL2) designed for SCS and HOPE (IGL2-Machine Perfusion Solution [MPS] group, n = 6) or with the gold-standard University of Wisconsin designed for for SCS and Belzer MPS designed for HOPE (MPS group, n = 5). All liver grafts underwent warm reperfusion with whole autologous blood for 2 h, and surrogate markers of hepatic ischemia-reperfusion injury (IRI) were assessed in the hepatocyte, cholangiocyte, vascular, and immunological compartments. RESULTS After 2 h of warm reperfusion, livers in the IGL2-MPS group showed no significant differences in transaminase release (aspartate aminotransferase: 65.58 versus 104.9 UI/L/100 g liver; P = 0.178), lactate clearance, and histological IRI compared with livers in the MPS group. There were no significant differences in biliary acid composition, bile production, and histological biliary IRI. Mitochondrial and endothelial damage was also not significantly different and resulted in similar hepatic inflammasome activation. CONCLUSIONS This preclinical study shows that a novel IGL2 allows for the safe preservation of marginal liver grafts with SCS and HOPE. Hepatic IRI was comparable with the current gold standard of combining 2 different preservation solutions (University of Wisconsin + Belzer MPS). These data pave the way for a phase I first-in-human study and it is a first step toward tailored preservation solutions for machine perfusion of liver grafts.
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Affiliation(s)
- Xavier Muller
- Department of General Surgery and Liver Transplantation, Croix Rousse University Hospital, Hospices Civils de Lyon, University of Lyon I, Lyon, France
- Hepatology Institute of Lyon, INSERM U1052, Lyon, France
- Ecole Doctorale 340, Biologie Moléculaire et Intégrative, Université Claude Bernard Lyon 1, Villeurbanne, France
| | - Guillaume Rossignol
- Department of General Surgery and Liver Transplantation, Croix Rousse University Hospital, Hospices Civils de Lyon, University of Lyon I, Lyon, France
- Hepatology Institute of Lyon, INSERM U1052, Lyon, France
- Ecole Doctorale 340, Biologie Moléculaire et Intégrative, Université Claude Bernard Lyon 1, Villeurbanne, France
| | - Joris Couillerot
- Department of General Surgery and Liver Transplantation, Croix Rousse University Hospital, Hospices Civils de Lyon, University of Lyon I, Lyon, France
- Hepatology Institute of Lyon, INSERM U1052, Lyon, France
| | - Antoine Breton
- Department of General Surgery and Liver Transplantation, Croix Rousse University Hospital, Hospices Civils de Lyon, University of Lyon I, Lyon, France
- Hepatology Institute of Lyon, INSERM U1052, Lyon, France
| | - Valérie Hervieu
- Department of Pathology, Hospices Civils de Lyon, Claude Bernard Lyon 1 University, Villeurbanne, Lyon, France
| | - Mickaël Lesurtel
- Department of General Surgery and Liver Transplantation, Croix Rousse University Hospital, Hospices Civils de Lyon, University of Lyon I, Lyon, France
| | - Kayvan Mohkam
- Department of General Surgery and Liver Transplantation, Croix Rousse University Hospital, Hospices Civils de Lyon, University of Lyon I, Lyon, France
- Hepatology Institute of Lyon, INSERM U1052, Lyon, France
| | - Jean-Yves Mabrut
- Department of General Surgery and Liver Transplantation, Croix Rousse University Hospital, Hospices Civils de Lyon, University of Lyon I, Lyon, France
- Hepatology Institute of Lyon, INSERM U1052, Lyon, France
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3
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Li F, Zhang Y, Ruan H, He Y, Zhan L, Chen S, Wang T, Qiu J, Guo Z, Wang D, He X. Addition of a liver to the normothermic perfusion circuit reduces renal pro-inflammatory factors. Artif Organs 2023; 47:1732-1741. [PMID: 37553847 DOI: 10.1111/aor.14626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 07/07/2023] [Accepted: 07/25/2023] [Indexed: 08/10/2023]
Abstract
BACKGROUND Normothermic machine perfusion (NMP) provides a novel platform to preserve isolated organs in an artificial condition. Our study aimed to explore the interaction between the liver and kidney at an ex vivo organ level by adding a liver to the kidney NMP circuit. METHODS Porcine kidney and liver obtained from abattoir were subjected to 9 h NMP after suffering 30-min warm ischemia time and 90-min cold ischemia time. The liver-kidney NMP group (n = 5) and the single-kidney NMP group (n = 5) were designed. During the NMP, perfusion parameters, blood gas analysis, and tissue samples were compared. RESULTS The perfusate of both groups remained stable, and continuous urine production was observed during NMP. In the liver-kidney NMP group, the lactate level was low, while blood urea nitrogen increased and glucose levels decreased. After the NMP, the renal tissue in the liver-kidney group exhibited fewer histological changes such as tubular epithelium vacuolization, along with reduced expression of IL-6, IL-8, IL-1β, NLRP3, and GSDMD. CONCLUSIONS Our results indicated that the expression of renal pro-inflammatory factors was reduced in the liver-kidney NMP system.
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Affiliation(s)
- Fangcong Li
- Organ Transplant Centre, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Organ Donation and Transplant, Immunology, Guangzhou, China
- Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
| | - Yimin Zhang
- Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, China
| | - Hehuan Ruan
- Organ Transplant Centre, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Organ Donation and Transplant, Immunology, Guangzhou, China
- Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
| | - Yu He
- Organ Transplant Centre, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Organ Donation and Transplant, Immunology, Guangzhou, China
- Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
| | - Liqiang Zhan
- Organ Transplant Centre, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Organ Donation and Transplant, Immunology, Guangzhou, China
- Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
| | - Shirui Chen
- Organ Transplant Centre, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Organ Donation and Transplant, Immunology, Guangzhou, China
- Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
| | - Tielong Wang
- Organ Transplant Centre, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Organ Donation and Transplant, Immunology, Guangzhou, China
- Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
| | - Jiang Qiu
- Organ Transplant Centre, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Organ Donation and Transplant, Immunology, Guangzhou, China
- Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
| | - Zhiyong Guo
- Organ Transplant Centre, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Organ Donation and Transplant, Immunology, Guangzhou, China
- Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
| | - Dongping Wang
- Organ Transplant Centre, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Organ Donation and Transplant, Immunology, Guangzhou, China
- Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
| | - Xiaoshun He
- Organ Transplant Centre, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Organ Donation and Transplant, Immunology, Guangzhou, China
- Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou, China
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Ruppelt A, Pijnenburg I, Pappers C, Samsom RA, Kock L, Grinwis GCM, Spee B, Rasponi M, Stijnen M. Are slaughterhouse-obtained livers suitable for use in ex vivo perfusion research? J Int Med Res 2023; 51:3000605231189651. [PMID: 37565647 PMCID: PMC10422909 DOI: 10.1177/03000605231189651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 07/06/2023] [Indexed: 08/12/2023] Open
Abstract
OBJECTIVES The success of the ex vivo machine perfusion of pig livers used for preclinical research depends on organ quality and availability. In this study, we investigated whether livers obtained from slaughterhouses are suitable and equivalent to livers obtained from laboratory pigs. METHODS Livers were obtained from slaughterhouse pigs stunned by electrocution or CO2 inhalation and from laboratory pigs. For the latter group, 45 minutes of warm ischemia was mimicked for a subgroup, ensuring a valid comparison with slaughterhouse-derived livers. RESULTS Livers from CO2-stunned pigs showed lower indocyanine green clearance and bile production, higher blood lactate and potassium concentrations, and higher alanine aminotransferase activities than electrically stunned pigs. Furthermore, livers from electrically stunned pigs, and livers from laboratory pigs, subjected or not to warm ischemia, showed similar performance in terms of perfusion and metabolism. CONCLUSION For an ex vivo liver model generated using slaughterhouse pigs, electrical stunning is preferable to CO2 stunning. Livers from electrically stunned slaughterhouse pigs performed similarly to laboratory pig livers. These findings support the use of livers from electrically stunned slaughterhouse pigs, which may therefore provide an alternative to livers obtained from laboratory pigs, consistent with the principle of the 3Rs.
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Affiliation(s)
- Alicia Ruppelt
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milan, Italy
- LifeTec Group, Eindhoven, The Netherlands
| | | | | | - Roos-Anne Samsom
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Utrecht University, Utrecht, The Netherlands
| | - Linda Kock
- LifeTec Group, Eindhoven, The Netherlands
- Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Guy C. M. Grinwis
- Veterinary Pathology Diagnostic Centre, Department of Biomedical Health Sciences, Faculty of Veterinary Medicine, Utrecht University, Utrecht, The Netherlands
| | - Bart Spee
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Utrecht University, Utrecht, The Netherlands
| | - Marco Rasponi
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milan, Italy
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Parente A, Flores Carvalho M, Schlegel A. Endothelial Cells and Mitochondria: Two Key Players in Liver Transplantation. Int J Mol Sci 2023; 24:10091. [PMID: 37373238 DOI: 10.3390/ijms241210091] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 05/30/2023] [Accepted: 06/02/2023] [Indexed: 06/29/2023] Open
Abstract
Building the inner layer of our blood vessels, the endothelium forms an important line communicating with deeper parenchymal cells in our organs. Previously considered passive, endothelial cells are increasingly recognized as key players in intercellular crosstalk, vascular homeostasis, and blood fluidity. Comparable to other cells, their metabolic function strongly depends on mitochondrial health, and the response to flow changes observed in endothelial cells is linked to their mitochondrial metabolism. Despite the direct impact of new dynamic preservation concepts in organ transplantation, the impact of different perfusion conditions on sinusoidal endothelial cells is not yet explored well enough. This article therefore describes the key role of liver sinusoidal endothelial cells (LSECs) together with their mitochondrial function in the context of liver transplantation. The currently available ex situ machine perfusion strategies are described with their effect on LSEC health. Specific perfusion conditions, including perfusion pressure, duration, and perfusate oxygenation are critically discussed considering the metabolic function and integrity of liver endothelial cells and their mitochondria.
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Affiliation(s)
- Alessandro Parente
- HPB and Transplant Unit, Department of Surgical Science, University of Rome Tor Vergata, 00133 Rome, Italy
- Division of Hepatobiliary and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Republic of Korea
| | | | - Andrea Schlegel
- Department of Experimental and Clinical Medicine, University of Florence, 50121 Florence, Italy
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Centre of Preclinical Research, 20122 Milan, Italy
- Transplantation Center, Digestive Disease and Surgery Institute, Department of Immunity and Inflammation, Lerner Research Institute, Cleveland Clinic, Cleveland, OH 44106, USA
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Parmentier C, Ray S, Mazilescu LI, Kawamura M, Noguchi Y, Nogueira E, Ganesh S, Arulratnam B, Kalimuthu SN, Selzner M, Reichman TW. Normothermic Ex Vivo Machine Perfusion of Discarded Human Pancreas Allografts: A Feasibility Study. Transpl Int 2023; 36:10936. [PMID: 37252614 PMCID: PMC10210159 DOI: 10.3389/ti.2023.10936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 04/28/2023] [Indexed: 05/31/2023]
Abstract
Pancreas transplantation is the only curative treatment for patients with complicated diabetes, and organ shortage is a common and increasing problem. Strategies to expand the donor pool are needed, and normothermic ex vivo perfusion of the pancreas has the potential to test and repair grafts before implantation. Between January 2021 and April 2022, six human pancreases, declined for transplantation or islet isolation, were perfused using a previously established method by our group. All 6 cases were successfully perfused for 4 h, with minimal edema. The mean age of the donors was 44.16 ± 13.8 years. Five grafts were obtained from neurological death donors, and one was obtained from a donation after cardiac death. The mean glucose and lactate levels decreased throughout perfusion and insulin levels increased. All 6 grafts were metabolically active during perfusion and histopathology showed minimal tissue injury and no edema. Human normothermic ex vivo perfusion of the pancreas is feasible and safe and has the potential to expand the donor pool. Future studies will focus on tests and biomarkers for the assessment of grafts.
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Affiliation(s)
- Catherine Parmentier
- Toronto General Hospital, Toronto, ON, Canada
- University Health Network (UHN), Toronto, ON, Canada
| | - Samrat Ray
- Toronto General Hospital, Toronto, ON, Canada
- University Health Network (UHN), Toronto, ON, Canada
| | - Laura I. Mazilescu
- Toronto General Hospital, Toronto, ON, Canada
- University Health Network (UHN), Toronto, ON, Canada
- Essen University Hospital, Essen, North Rhine-Westphalia, Germany
| | - Masataka Kawamura
- Toronto General Hospital, Toronto, ON, Canada
- University Health Network (UHN), Toronto, ON, Canada
| | - Yuki Noguchi
- Toronto General Hospital, Toronto, ON, Canada
- University Health Network (UHN), Toronto, ON, Canada
| | - Emmanuel Nogueira
- Toronto General Hospital, Toronto, ON, Canada
- University Health Network (UHN), Toronto, ON, Canada
| | - Sujani Ganesh
- Toronto General Hospital, Toronto, ON, Canada
- University Health Network (UHN), Toronto, ON, Canada
| | - Bhranavi Arulratnam
- Toronto General Hospital, Toronto, ON, Canada
- University Health Network (UHN), Toronto, ON, Canada
| | - Sangeetha N. Kalimuthu
- Toronto General Hospital, Toronto, ON, Canada
- University Health Network (UHN), Toronto, ON, Canada
| | - Markus Selzner
- Toronto General Hospital, Toronto, ON, Canada
- University Health Network (UHN), Toronto, ON, Canada
| | - Trevor W. Reichman
- Toronto General Hospital, Toronto, ON, Canada
- University Health Network (UHN), Toronto, ON, Canada
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7
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Moeslund N, Ertugrul IA, Hu MA, Dalsgaard FF, Ilkjaer LB, Ryhammer P, Pedersen M, Erasmus ME, Eiskjaer H. Ex-situ oxygenated hypothermic machine perfusion in donation after circulatory death heart transplantation following either direct procurement or in-situ normothermic regional perfusion. J Heart Lung Transplant 2023; 42:730-740. [PMID: 36918339 DOI: 10.1016/j.healun.2023.01.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 01/21/2023] [Accepted: 01/31/2023] [Indexed: 02/10/2023] Open
Abstract
BACKGROUND Heart transplantation in donation after circulatory death (DCD) relies on warm perfusion using either in situ normothermic regional perfusion (NRP) or ex situ normothermic machine perfusion. In this study, we explore an alternative: oxygenated hypothermic machine perfusion (HMP) using a novel clinically applicable perfusion system, which is compared to NRP with static cold storage (SCS). METHODS In a porcine model, a DCD setting was simulated, followed by either (1) NRP and SCS (2) NRP and HMP with the XVIVO Heart preservation system or (3) direct procurement (DPP) and HMP. After preservation, heart transplantation (HTX) was performed. After weaning from cardiopulmonary bypass (CPB), biventricular function was assessed by admittance and Swan-Ganz catheters. RESULTS Only transplanted hearts in the HMP groups showed significantly increased biventricular contractility (end-systole elastance) 2 hour post-CPB (left ventricle absolute change: NRP HMP: +1.8 ± 0.56, p = 0.047, DPP HMP: +1.5 ± 0.43, p = 0.045 and NRP SCS: +0.97 ± 0.47 mmHg/ml, p = 0.21; right ventricle absolute change: NRP HMP: +0.50 ± 0.12, p = 0.025, DPP HMP: +0.82 ± 0.23, p = 0.039 and NRP SCS: +0.28 ± 0.26, p = 0.52) while receiving significantly less dobutamine to maintain a cardiac output >4l/min compared to SCS. Diastolic function was preserved in all groups. Post-HTX, both HMP groups showed significantly less increments in plasma troponin T compared to SCS. CONCLUSION In DCD HTX, increased biventricular contractility post-HTX was only observed in hearts preserved with HMP. In addition, the need for inotropic support and signs of myocardial damage were lower in the HMP groups. DCD HTX can be successfully performed using DPP followed by preservation with HMP in a preclinical setting.
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Affiliation(s)
- Niels Moeslund
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark; Department for Clinical Medicine-Comparative Medicine Lab, Aarhus University, Aarhus, Denmark; Department for Cardiothoracic Surgery, Aarhus University Hospital, Aarhus, Denmark.
| | - Imran A Ertugrul
- Department for Cardiothoracic Surgery, University Medical Centre Groningen, Groningen, The Netherlands
| | - Michiel A Hu
- Department for Cardiothoracic Surgery, University Medical Centre Groningen, Groningen, The Netherlands
| | - Frederik Flyvholm Dalsgaard
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark; Department for Clinical Medicine-Comparative Medicine Lab, Aarhus University, Aarhus, Denmark
| | - Lars Bo Ilkjaer
- Department for Cardiothoracic Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Pia Ryhammer
- Department for Anesthesiology, Region Hospital Silkeborg, Silkeborg, Denmark
| | - Michael Pedersen
- Department for Clinical Medicine-Comparative Medicine Lab, Aarhus University, Aarhus, Denmark
| | - Michiel E Erasmus
- Department for Cardiothoracic Surgery, University Medical Centre Groningen, Groningen, The Netherlands
| | - Hans Eiskjaer
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
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8
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Roushansarai NS, Pascher A, Becker F. Innate Immune Cells during Machine Perfusion of Liver Grafts-The Janus Face of Hepatic Macrophages. J Clin Med 2022; 11:jcm11226669. [PMID: 36431146 PMCID: PMC9696117 DOI: 10.3390/jcm11226669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 11/08/2022] [Accepted: 11/09/2022] [Indexed: 11/13/2022] Open
Abstract
Machine perfusion is an emerging technology in the field of liver transplantation. While machine perfusion has now been implemented in clinical routine throughout transplant centers around the world, a debate has arisen regarding its concurrent effect on the complex hepatic immune system during perfusion. Currently, our understanding of the perfusion-elicited processes involving innate immune cells remains incomplete. Hepatic macrophages (Kupffer cells) represent a special subset of hepatic immune cells with a dual pro-inflammatory, as well as a pro-resolving and anti-inflammatory, role in the sequence of ischemia-reperfusion injury. The purpose of this review is to provide an overview of the current data regarding the immunomodulatory role of machine perfusion and to emphasize the importance of macrophages for hepatic ischemia-reperfusion injury.
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9
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Krüger M, Ruppelt A, Kappler B, Van Soest E, Samsom RA, Grinwis GCM, Geijsen N, Helms JB, Stijnen M, Kock LM, Rasponi M, Kooistra HS, Spee B. Normothermic Ex Vivo Liver Platform Using Porcine Slaughterhouse Livers for Disease Modeling. Bioengineering (Basel) 2022; 9:bioengineering9090471. [PMID: 36135018 PMCID: PMC9495507 DOI: 10.3390/bioengineering9090471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 08/25/2022] [Accepted: 09/07/2022] [Indexed: 11/16/2022] Open
Abstract
Metabolic and toxic liver disorders, such as fatty liver disease (steatosis) and drug-induced liver injury, are highly prevalent and potentially life-threatening. To allow for the study of these disorders from the early stages onward, without using experimental animals, we collected porcine livers in a slaughterhouse and perfused these livers normothermically. With our simplified protocol, the perfused slaughterhouse livers remained viable and functional over five hours of perfusion, as shown by hemodynamics, bile production, indocyanine green clearance, ammonia metabolism, gene expression and histology. As a proof-of-concept to study liver disorders, we show that an infusion of free fatty acids and acetaminophen results in early biochemical signs of liver damage, including reduced functionality. In conclusion, the present platform offers an accessible system to perform research in a functional, relevant large animal model while avoiding using experimental animals. With further improvements to the model, prolonged exposure could make this model a versatile tool for studying liver diseases and potential treatments.
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Affiliation(s)
- Melanie Krüger
- LifeTec Group BV, 5611 ZS Eindhoven, The Netherlands
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Utrecht University, 3584 CT Utrecht, The Netherlands
| | - Alicia Ruppelt
- LifeTec Group BV, 5611 ZS Eindhoven, The Netherlands
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, 20133 Milan, Italy
- Correspondence:
| | | | | | - Roos Anne Samsom
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Utrecht University, 3584 CT Utrecht, The Netherlands
| | - Guy C. M. Grinwis
- Veterinary Pathology Diagnostic Centre, Department of Biomedical Health Sciences, Faculty of Veterinary Medicine, Utrecht University, 3508 TD Utrecht, The Netherlands
| | - Niels Geijsen
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Utrecht University, 3584 CT Utrecht, The Netherlands
| | - J. Bernd Helms
- Department of Biomolecular Health Sciences, Faculty of Veterinary Medicine, Utrecht University, 3584 CL Utrecht, The Netherlands
| | - Marco Stijnen
- LifeTec Group BV, 5611 ZS Eindhoven, The Netherlands
| | - Linda M. Kock
- LifeTec Group BV, 5611 ZS Eindhoven, The Netherlands
- Department of Biomedical Engineering, Eindhoven University of Technology, 5600 MB Eindhoven, The Netherlands
| | - Marco Rasponi
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, 20133 Milan, Italy
| | - Hans S. Kooistra
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Utrecht University, 3584 CT Utrecht, The Netherlands
| | - Bart Spee
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Utrecht University, 3584 CT Utrecht, The Netherlands
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Brüggenwirth IMA, Mueller M, Lantinga VA, Camagni S, De Carlis R, De Carlis L, Colledan M, Dondossola D, Drefs M, Eden J, Ghinolfi D, Koliogiannis D, Lurje G, Manzia TM, Monbaliu D, Muiesan P, Patrono D, Pratschke J, Romagnoli R, Rayar M, Roma F, Schlegel A, Dutkowski P, Porte RJ, de Meijer VE. Prolonged preservation by hypothermic machine perfusion facilitates logistics in liver transplantation: A European observational cohort study. Am J Transplant 2022; 22:1842-1851. [PMID: 35315202 PMCID: PMC9540892 DOI: 10.1111/ajt.17037] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 02/14/2022] [Accepted: 03/11/2022] [Indexed: 01/25/2023]
Abstract
A short period (1-2 h) of hypothermic oxygenated machine perfusion (HOPE) after static cold storage is safe and reduces ischemia-reperfusion injury-related complications after liver transplantation. Machine perfusion time is occasionally prolonged for logistical reasons, but it is unknown if prolonged HOPE is safe and compromises outcomes. We conducted a multicenter, observational cohort study of patients transplanted with a liver preserved by prolonged (≥4 h) HOPE. Postoperative biochemistry, complications, and survival were evaluated. The cohort included 93 recipients from 12 European transplant centers between 2014-2021. The most common reason to prolong HOPE was the lack of an available operating room to start the transplant procedure. Grafts underwent HOPE for a median (range) of 4:42 h (4:00-8:35 h) with a total preservation time of 10:50 h (5:50-20:50 h). Postoperative peak ALT was 675 IU/L (interquartile range 419-1378 IU/L). The incidence of postoperative complications was low, and 1-year graft and patient survival were 94% and 88%, respectively. To conclude, good outcomes are achieved after transplantation of donor livers preserved with prolonged (median 4:42 h) HOPE, leading to a total preservation time of almost 21 h. These results suggest that simple, end-ischemic HOPE may be utilized for safe extension of the preservation time to ease transplantation logistics.
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Affiliation(s)
- Isabel M. A. Brüggenwirth
- Section of Hepatobiliary Surgery and Liver TransplantationDepartment of SurgeryUniversity of Groningen and University Medical Center GroningenGroningenThe Netherlands
| | - Matteo Mueller
- Department of Surgery and TransplantationUniversity Hospital ZurichZurichSwitzerland
| | - Veerle A. Lantinga
- Section of Hepatobiliary Surgery and Liver TransplantationDepartment of SurgeryUniversity of Groningen and University Medical Center GroningenGroningenThe Netherlands
| | - Stefania Camagni
- Department of Organ Failure and TransplantationASST Papa Giovanni XXIIIBergamoItaly
| | - Riccardo De Carlis
- Department of General Surgery and TransplantationASST Grande Ospedale Metropolitano NiguardaMilanItaly
| | - Luciano De Carlis
- Department of General Surgery and TransplantationASST Grande Ospedale Metropolitano NiguardaMilanItaly,School of Medicine and SurgeryUniversity of Milano‐BicoccaMilanItaly
| | - Michele Colledan
- Department of Organ Failure and TransplantationASST Papa Giovanni XXIIIBergamoItaly,School of Medicine and SurgeryUniversity of Milano‐BicoccaMilanItaly
| | - Daniele Dondossola
- General and Liver Transplant Surgery UnitFondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico Milan and Department of Pathophysiology and TransplantationUniversity of MilanMilanItaly
| | - Moritz Drefs
- Department of General, Visceral, and Transplant SurgeryUniversity Hospital of MunichMunichGermany
| | - Janina Eden
- Department of Surgery and TransplantationUniversity Hospital ZurichZurichSwitzerland
| | - Davide Ghinolfi
- Division of Hepatic Surgery and Liver TransplantationUniversity of Pisa Medical School HospitalPisaItaly
| | - Dionysios Koliogiannis
- Department of General, Visceral, and Transplant SurgeryUniversity Hospital of MunichMunichGermany
| | - Georg Lurje
- Department of SurgeryCharité—Universitätsmedizin BerlinBerlinGermany
| | - Tommaso M. Manzia
- Hepato‐Pancreato‐Biliary and Transplant UnitUniversity of Rome Tor VergataRomeItaly
| | - Diethard Monbaliu
- Department of Abdominal Transplant Surgery and Transplant CoordinationUniversity Hospitals LeuvenCatholic University LeuvenLeuvenBelgium
| | - Paolo Muiesan
- General and Liver Transplant Surgery UnitFondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico Milan and Department of Pathophysiology and TransplantationUniversity of MilanMilanItaly
| | - Damiano Patrono
- AOU Città della Salute e della Scienza di TorinoUniversity of TurinTurinItaly
| | - Johann Pratschke
- Department of SurgeryCharité—Universitätsmedizin BerlinBerlinGermany
| | - Renato Romagnoli
- AOU Città della Salute e della Scienza di TorinoUniversity of TurinTurinItaly
| | - Michel Rayar
- CHU Rennes, Service de Chirurgie Hépatobiliaire et DigestiveRennesFrance
| | - Federico Roma
- General and Liver Transplant Surgery UnitFondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico Milan and Department of Pathophysiology and TransplantationUniversity of MilanMilanItaly
| | - Andrea Schlegel
- Department of Surgery and TransplantationUniversity Hospital ZurichZurichSwitzerland,General and Liver Transplant Surgery UnitFondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico Milan and Department of Pathophysiology and TransplantationUniversity of MilanMilanItaly
| | - Philipp Dutkowski
- Department of Surgery and TransplantationUniversity Hospital ZurichZurichSwitzerland
| | - Robert J. Porte
- Section of Hepatobiliary Surgery and Liver TransplantationDepartment of SurgeryUniversity of Groningen and University Medical Center GroningenGroningenThe Netherlands
| | - Vincent E. de Meijer
- Section of Hepatobiliary Surgery and Liver TransplantationDepartment of SurgeryUniversity of Groningen and University Medical Center GroningenGroningenThe Netherlands
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Schlegel A, Porte R, Dutkowski P. Protective mechanisms and current clinical evidence of hypothermic oxygenated machine perfusion (HOPE) in preventing post-transplant cholangiopathy. J Hepatol 2022; 76:1330-1347. [PMID: 35589254 DOI: 10.1016/j.jhep.2022.01.024] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 01/10/2022] [Accepted: 01/31/2022] [Indexed: 12/12/2022]
Abstract
The development of cholangiopathies after liver transplantation impacts on the quality and duration of graft and patient survival, contributing to higher costs as numerous interventions are required to treat strictures and infections at the biliary tree. Prolonged donor warm ischaemia time in combination with additional cold storage are key risk factors for the development of biliary strictures. Based on this, the clinical implementation of dynamic preservation strategies is a current hot topic in the field of donation after circulatory death (DCD) liver transplantation. Despite various retrospective studies reporting promising results, also regarding biliary complications, there are only a few randomised-controlled trials on machine perfusion. Recently, the group from Groningen has published the first randomised-controlled trial on hypothermic oxygenated perfusion (HOPE), demonstrating a significant reduction of symptomatic ischaemic cholangiopathies with the use of a short period of HOPE before DCD liver implantation. The most likely mechanism for this important effect, also shown in several experimental studies, is based on mitochondrial reprogramming under hypothermic aerobic conditions, e.g. exposure to oxygen in the cold, with a controlled and slow metabolism of ischaemically accumulated succinate and simultaneous ATP replenishment. This unique feature prevents mitochondrial oxidative injury and further downstream tissue inflammation. HOPE treatment therefore supports livers by protecting them from ischaemia-reperfusion injury (IRI), and thereby also prevents the development of post-transplant biliary injury. With reduced IRI-associated inflammation, recipients are also protected from activation of the innate immune system, with less acute rejections seen after HOPE.
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Affiliation(s)
- Andrea Schlegel
- Department of Visceral Surgery and Transplantation, University Hospital Zurich, Swiss HPB and Transplant Center, Zurich, Switzerland; General and Liver Transplant Surgery Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20100 Milan, Italy
| | - Robert Porte
- Department of Surgery, Surgical Research Laboratory, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Philipp Dutkowski
- Department of Visceral Surgery and Transplantation, University Hospital Zurich, Swiss HPB and Transplant Center, Zurich, Switzerland.
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12
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Machine perfusion of the liver: applications in transplantation and beyond. Nat Rev Gastroenterol Hepatol 2022; 19:199-209. [PMID: 34997204 DOI: 10.1038/s41575-021-00557-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/17/2021] [Indexed: 12/14/2022]
Abstract
The shortage of donor livers considered suitable for transplantation has driven the development of novel methods for organ preservation and reconditioning. Machine perfusion techniques can improve the quality of marginal livers, extend the time for which they can be preserved and enable an objective assessment of their quality and viability. These benefits can help avoid the needless wastage of organs based on hypothetical concerns regarding quality. As machine perfusion techniques are gaining traction in clinical practice, attention has now shifted to their potential applications beyond transplantation. As well as providing an update on the current status of machine perfusion in clinical practice, this Perspective discusses how this technology is being used as a tool for therapeutic interventions including defatting of steatotic livers, immunomodulation and gene therapies.
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13
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Shaping of Hepatic Ischemia/Reperfusion Events: The Crucial Role of Mitochondria. Cells 2022; 11:cells11040688. [PMID: 35203337 PMCID: PMC8870414 DOI: 10.3390/cells11040688] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 02/09/2022] [Accepted: 02/11/2022] [Indexed: 12/10/2022] Open
Abstract
Hepatic ischemia reperfusion injury (HIRI) is a major hurdle in many clinical scenarios, including liver resection and transplantation. Various studies and countless surgical events have led to the observation of a strong correlation between HIRI induced by liver transplantation and early allograft-dysfunction development. The detrimental impact of HIRI has driven the pursuit of new ways to alleviate its adverse effects. At the core of HIRI lies mitochondrial dysfunction. Various studies, from both animal models and in clinical settings, have clearly shown that mitochondrial function is severely hampered by HIRI and that its preservation or restoration is a key indicator of successful organ recovery. Several strategies have been thus implemented throughout the years, targeting mitochondrial function. This work briefly discusses some the most utilized approaches, ranging from surgical practices to pharmacological interventions and highlights how novel strategies can be investigated and implemented by intricately discussing the way mitochondrial function is affected by HIRI.
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14
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Brüggenwirth IMA, Lantinga VA, Rayar M, van den Berg AP, Blokzijl H, Reyntjens KMEM, Porte RJ, de Meijer VE. Prolonged dual hypothermic oxygenated machine preservation (DHOPE-PRO) in liver transplantation: study protocol for a stage 2, prospective, dual-arm, safety and feasibility clinical trial. BMJ Open Gastroenterol 2022; 9:bmjgast-2021-000842. [PMID: 35039326 PMCID: PMC8764996 DOI: 10.1136/bmjgast-2021-000842] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 12/14/2021] [Indexed: 12/20/2022] Open
Abstract
Introduction End-ischaemic preservation of a donor liver by dual hypothermic oxygenated machine perfusion (DHOPE) for 2 hours prior to transplantation is sufficient to mitigate ischaemia-reperfusion damage and fully restore cellular energy levels. Clinical studies have shown beneficial outcomes after transplantation of liver grafts preserved by DHOPE compared with static cold storage. In addition to graft reconditioning, DHOPE may also be used to prolong preservation time, which could facilitate logistics for allocation and transplantation globally. Methods and analysis This is a prospective, pseudo-randomised, dual-arm, IDEAL-D (Idea, Development, Exploration, Assessment, Long term study-Framework for Devices) stage 2 clinical device trial designed to determine safety and feasibility of prolonged DHOPE (DHOPE-PRO). The end-time of the donor hepatectomy will determine whether the graft will be assigned to the intervention (16:00–3:59 hour) or to the control arm (4:00–15:59 hour). In total, 36 livers will be included in the study. Livers in the intervention group (n=18) will undergo DHOPE-PRO (≥4 hours) until implantation the following morning, whereas livers in the control group (n=18) will undergo regular DHOPE (2 hours) prior to implantation. The primary endpoint of this study is a composite of the occurrence of all (serious) adverse events during DHOPE and up to 30 days after liver transplantation. Ethics and dissemination The protocol was approved by the Medical Ethical Committee of Groningen, METc2020.126 in June 2020, and the study was registered in the Netherlands National Trial Registry (https://www.trialregister.nl/) prior to initiation. Trial registration number NL8740.
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Affiliation(s)
- Isabel M A Brüggenwirth
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University of Groningen and University Medical Center Groningen, Groningen, The Netherlands
| | - Veerle A Lantinga
- Organ Preservation and Resuscitation Unit, University of Groningen and University Medical Center Groningen, Groningen, The Netherlands
| | - Michel Rayar
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University of Groningen and University Medical Center Groningen, Groningen, The Netherlands.,Centre Hospitalier Universitaire de Rennes, Rennes, France
| | - Aad P van den Berg
- Hepatology, University of Groningen and University Medical Center Groningen, Groningen, The Netherlands
| | - Hans Blokzijl
- Hepatology, University of Groningen and University Medical Center Groningen, Groningen, The Netherlands
| | - Koen M E M Reyntjens
- Anesthesiology, University of Groningen and University Medical Center Groningen, Groningen, The Netherlands
| | - Robert J Porte
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University of Groningen and University Medical Center Groningen, Groningen, The Netherlands
| | - Vincent E de Meijer
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University of Groningen and University Medical Center Groningen, Groningen, The Netherlands
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15
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Abstract
Machine perfusion techniques are becoming standard care in the clinical donation and transplantation setting. However, more research is needed to understand the mechanisms of the protective effects of machine perfusion. For preservation related experiments, porcine kidneys are acceptable alternatives to human kidneys, because of their size and similar physiology. In this experiment, the use of slaughterhouse kidneys was evaluated with normothermic kidney perfusion (NKP), thereby avoiding the use of laboratory animals. Porcine kidneys were derived from two local abattoirs. To induce different degrees of injury, different warm ischemic times and preservation techniques were used. After preservation, kidneys were reperfused for 4 h with two different NKP solutions to test renal function and damage. The effect of the preservation technique or a short warm ischemic time was clearly seen in functional markers, such as creatinine clearance and fractional sodium excretion levels, as well as in the generic damage marker lactate dehydrogenase (LDH). Porcine slaughterhouse kidneys are a useful alternative to laboratory animals for transplantation- and preservation-related research questions. To maintain kidney function during NKP, a short warm ischemic time or hypothermic machine perfusion during the preservation phase are mandatory.
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16
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Brüggenwirth IMA, van der Plas WS, van Leeuwen OB, Thorne AM, Rayar M, de Meijer VE, Porte RJ. Oxygenated versus non-oxygenated flush out and storage of donor livers-An experimental study. Artif Organs 2021; 46:201-209. [PMID: 34866205 PMCID: PMC9299999 DOI: 10.1111/aor.14135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Revised: 09/18/2021] [Accepted: 10/20/2021] [Indexed: 11/28/2022]
Abstract
Background During donor organ procurement and subsequent static cold storage (SCS), hepatic adenosine triphosphate (ATP) levels are progressively depleted, which contributes to ischemia‐reperfusion injury (IRI). We sought to investigate a simple approach to prevent ATP depletion and IRI using a porcine donation after circulatory death (DCD) liver reperfusion model. Methods After 30 min warm ischemia, porcine livers were flushed via the portal vein with cold (4°C) non‐oxygenated University of Wisconsin (UW) preservation solution (n = 6, control group) or with oxygenated UW (n = 6, OxyFlush group). Livers were then subjected to 4 h SCS in non‐oxygenated (control) or oxygenated (OxyFlush) UW, followed by 4 h normothermic reperfusion using whole blood. Hepatic ATP levels were compared, and hepatobiliary function and injury were assessed. Results At the end of SCS, ATP was higher in the OxyFlush group compared to controls (delta ATP of +0.26 vs. −0.68 µmol/g protein, p = 0.04). All livers produced bile and metabolized lactate, and there were no differences between the groups. Grafts in the OxyFlush group had lower blood glucose levels after reperfusion (p = 0.04). Biliary pH, glucose and bicarbonate were not different between the groups. Injury markers including liver transaminases, lactate dehydrogenase, malondialdehyde, cell‐free DNA and flavin mononucleotide in the SCS solution and during reperfusion were also similar. Histological assessment of the parenchyma and bile ducts did not reveal differences between the groups. Conclusion Oxygenated flush out and storage of DCD porcine livers prevents ATP depletion during ischemia, but this does not seem sufficient to mitigate early signs of IRI.
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Affiliation(s)
- Isabel M A Brüggenwirth
- Department of Surgery, Section of Hepatobiliary Surgery and Liver Transplantation, University Medical Center Groningen, Groningen, The Netherlands
| | - Willemijn S van der Plas
- Department of Surgery, Section of Hepatobiliary Surgery and Liver Transplantation, University Medical Center Groningen, Groningen, The Netherlands
| | - Otto B van Leeuwen
- Department of Surgery, Section of Hepatobiliary Surgery and Liver Transplantation, University Medical Center Groningen, Groningen, The Netherlands
| | - Adam M Thorne
- Department of Surgery, Section of Hepatobiliary Surgery and Liver Transplantation, University Medical Center Groningen, Groningen, The Netherlands
| | - Michel Rayar
- Department of Surgery, Section of Hepatobiliary Surgery and Liver Transplantation, University Medical Center Groningen, Groningen, The Netherlands.,Centre Hospitalier Universitaire de Rennes, Service de Chirurgie Hépatobiliaire et Digestive, Rennes, France
| | - Vincent E de Meijer
- Department of Surgery, Section of Hepatobiliary Surgery and Liver Transplantation, University Medical Center Groningen, Groningen, The Netherlands
| | - Robert J Porte
- Department of Surgery, Section of Hepatobiliary Surgery and Liver Transplantation, University Medical Center Groningen, Groningen, The Netherlands
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17
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Pavicevic S, Uluk D, Reichelt S, Fikatas P, Globke B, Raschzok N, Schmelzle M, Öllinger R, Schöning W, Eurich D, Pratschke J, Lurje G. Hypothermic oxygenated machine perfusion for extended criteria donor allografts-Preliminary experience with extended organ preservation times in the setting of organ reallocation. Artif Organs 2021; 46:306-311. [PMID: 34724239 DOI: 10.1111/aor.14103] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 10/04/2021] [Accepted: 10/28/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND In times of critical organ shortage, poor organ pool utilization and increased use of extended-criteria donor (ECD) allografts remain a major problem. Hypothermic oxygenated machine perfusion (HOPE) has emerged as a promising and feasible strategy in ECD liver transplantation (LT). However, potential safety limits regarding the duration of perfusion are yet to be explored. Besides marginal allograft quality (steatosis), prolonged cold ischemia time remains the most important factor for a high number of liver allografts being declined for transplantation. PATIENTS AND METHODS Two ECD-allografts were each allocated to two recipients, who proved to be unsuitable to receive the assigned allograft upon arrival at the transplant center. The organs were reallocated by Eurotransplant and accepted by our center for two different backup patients. During that time, HOPE was commenced and continued until the recipient hepatectomy was completed. Postoperative allograft function was assessed by serum levels of alanine aminotransferase (ALT), aspartate aminotransferase (AST), bilirubin, and International Normalized Ratio. Incidence of early allograft dysfunction (EAD), postoperative complications, and length of hospital stay were analyzed. RESULTS HOPE was applied for 4 h 35 min and 4 h 20 min, resulting in a total cold preservation time of 17 h 29 min and 15 h 20 min, respectively. Both recipients displayed decreasing serum transaminases and bilirubin levels postoperatively. No EAD or major postoperative complications occurred in either patient. Serum ALT and AST levels were within the normal range at discharge. CONCLUSIONS Extended HOPE enables the safe extension of preservation time for up to 18 h in human LT. End-ischemic HOPE may significantly improve organ pool utilization, while simultaneously facilitating operating room logistics and preventing organ injury.
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Affiliation(s)
- Sandra Pavicevic
- Department of Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Deniz Uluk
- Department of Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Sophie Reichelt
- Department of Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Panagiotis Fikatas
- Department of Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Brigitta Globke
- Department of Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Nathanael Raschzok
- Department of Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Moritz Schmelzle
- Department of Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Robert Öllinger
- Department of Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Wenzel Schöning
- Department of Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Dennis Eurich
- Department of Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Johann Pratschke
- Department of Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Georg Lurje
- Department of Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
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18
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Boteon YL, Martins PN, Muiesan P, Schlegel A. Machine perfusion of the liver: Putting the puzzle pieces together. World J Gastroenterol 2021; 27:5727-5736. [PMID: 34629797 PMCID: PMC8473597 DOI: 10.3748/wjg.v27.i34.5727] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 05/03/2021] [Accepted: 07/21/2021] [Indexed: 02/06/2023] Open
Abstract
The realm of extended criteria liver transplantation created the 'adjacent possible' for dynamic organ preservation. Machine perfusion of the liver greatly expanded donor organ preservation possibilities, reaching before unattainable goals, including the mitigation of ischemia-reperfusion injury, viability assessment, and organ reconditioning prior to transplantation. However, current scientific evidence lacks uniformity between studies, perfusion protocols, and acceptance criteria. Construction of collaborative research networks for sharing knowledge should, therefore, enable the development of high-level evidence and guidelines for machine perfusion utilization, including donor acceptance criteria. Finally, this approach shall guarantee conditions for further progress to occur.
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Affiliation(s)
- Yuri L Boteon
- Liver Unit, Hospital Israelita Albert Einstein, São Paulo 05652-900, Brazil
- Instituto Israelita de Ensino e Pesquisa Albert Einstein, Faculdade Israelita de Ciências da Saúde Albert Einstein, São Paulo 05652-900, Brazil
| | - Paulo N Martins
- Department of Surgery, Transplant Division, University of Massachusetts Medical School, Worcester, MA 01655, United States
| | - Paolo Muiesan
- Hepatobiliary Unit, Careggi University Hospital, University of Florence, Florence 50134, Italy
| | - Andrea Schlegel
- Hepatobiliary Unit, Careggi University Hospital, University of Florence, Florence 50134, Italy
- Department of Visceral Surgery and Transplantation, University Hospital Zurich, Swiss HPB and Transplant Center, Zurich 8091, Switzerland
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19
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A Novel Oxygen Carrier (M101) Attenuates Ischemia-Reperfusion Injuries during Static Cold Storage in Steatotic Livers. Int J Mol Sci 2021; 22:ijms22168542. [PMID: 34445250 PMCID: PMC8395216 DOI: 10.3390/ijms22168542] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 07/30/2021] [Accepted: 08/05/2021] [Indexed: 12/14/2022] Open
Abstract
The combined impact of an increasing demand for liver transplantation and a growing incidence of nonalcoholic liver disease has provided the impetus for the development of innovative strategies to preserve steatotic livers. A natural oxygen carrier, HEMO2life®, which contains M101 that is extracted from a marine invertebrate, has been used for static cold storage (SCS) and has shown superior results in organ preservation. A total of 36 livers were procured from obese Zucker rats and randomly divided into three groups, i.e., control, SCS-24H and SCS-24H + M101 (M101 at 1 g/L), mimicking the gold standard of organ preservation. Ex situ machine perfusion for 2 h was used to evaluate the quality of the livers. Perfusates were sampled for functional assessment, biochemical analysis and subsequent biopsies were performed for assessment of ischemia-reperfusion markers. Transaminases, GDH and lactate levels at the end of reperfusion were significantly lower in the group preserved with M101 (p < 0.05). Protection from reactive oxygen species (low MDA and higher production of NO2-NO3) and less inflammation (HMGB1) were also observed in this group (p < 0.05). Bcl-1 and caspase-3 were higher in the SCS-24H group (p < 0.05) and presented more histological damage than those preserved with HEMO2life®. These data demonstrate, for the first time, that the addition of HEMO2life® to the preservation solution significantly protects steatotic livers during SCS by decreasing reperfusion injury and improving graft function.
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20
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Dual Versus Single Oxygenated Hypothermic Machine Perfusion of Porcine Livers: Impact on Hepatobiliary and Endothelial Cell Injury. Transplant Direct 2021; 7:e741. [PMID: 34386578 PMCID: PMC8354629 DOI: 10.1097/txd.0000000000001184] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 05/09/2021] [Indexed: 12/12/2022] Open
Abstract
Supplemental Digital Content is available in the text. Background. Hypothermic oxygenated machine perfusion (HOPE) reduces ischemia-reperfusion injury of donor livers and is increasingly used in clinical transplantation. However, it remains unclear whether perfusion via the portal vein alone (HOPE) or via both the portal vein and hepatic artery (dual HOPE or DHOPE) is superior. Methods. Twelve porcine livers donated after circulatory death were randomized for 2 h of HOPE (n = 6) or DHOPE (n = 6), followed by 4 h of warm reperfusion with whole blood, to mimic transplantation. Hepatobiliary and endothelial cell function and injury markers were determined in perfusate and bile samples. Biopsies of bile ducts, hepatic arteries, and liver parenchyma were collected to assess histological damage and the expression of endothelial protective genes (KLF-2, eNOS, ET-1, CD31, VWF, VEGF-A). Results. There were no differences in hepatobiliary function and injury after warm reperfusion between the groups, apart from a 2-fold lower concentration of alanine aminotransferase in the perfusate (P = 0.045) and a lower peak lactate dehydrogenase in bile (P = 0.04) of livers preserved by DHOPE. Endothelial cell function and injury, as assessed by perfusate nitric oxide and von Willebrand factor antigen levels, as well as endothelial protective gene expressions, were similar between the groups. The hepatic arteries of both groups showed no microscopic evidence of injury. Conclusions. This study did not reveal major differences in hepatobiliary or endothelial function and injury after preservation by single or dual HOPE of porcine livers donated after circulatory death.
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21
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Eshmuminov D, Hefti M, Mueller M, Schuler MJ, Bautista Borrego L, Schneider MA, Koch K, Weisskopf M, Tibbitt MW, Dutkowski P, Rudolf von Rohr P, Studt JD, Becker D, Clavien PA. Synthesis of coagulation factors during long-term ex situ liver perfusion. Artif Organs 2021; 46:273-280. [PMID: 34287985 DOI: 10.1111/aor.14041] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 06/10/2021] [Accepted: 07/06/2021] [Indexed: 01/04/2023]
Abstract
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.
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Affiliation(s)
- Dilmurodjon Eshmuminov
- Department of Surgery, Swiss Hepato-Pancreato-Biliary and Transplantation Center, University Hospital Zurich, Zurich, Switzerland.,Wyss Zurich - ETH Zurich/University of Zurich, Zurich, Switzerland
| | - Max Hefti
- Wyss Zurich - ETH Zurich/University of Zurich, Zurich, Switzerland.,Transport Processes and Reactions Laboratory, Department of Mechanical and Process Engineering, ETH Zurich, Zurich, Switzerland
| | - Matteo Mueller
- Department of Surgery, Swiss Hepato-Pancreato-Biliary and Transplantation Center, University Hospital Zurich, Zurich, Switzerland.,Wyss Zurich - ETH Zurich/University of Zurich, Zurich, Switzerland
| | - Martin J Schuler
- Wyss Zurich - ETH Zurich/University of Zurich, Zurich, Switzerland.,Transport Processes and Reactions Laboratory, Department of Mechanical and Process Engineering, ETH Zurich, Zurich, Switzerland
| | - Lucia Bautista Borrego
- Department of Surgery, Swiss Hepato-Pancreato-Biliary and Transplantation Center, University Hospital Zurich, Zurich, Switzerland.,Wyss Zurich - ETH Zurich/University of Zurich, Zurich, Switzerland
| | - Marcel André Schneider
- Department of Surgery, Swiss Hepato-Pancreato-Biliary and Transplantation Center, University Hospital Zurich, Zurich, Switzerland
| | - Karin Koch
- Department of Medical Oncology and Hematology, University Hospital Zurich, Zurich, Switzerland
| | - Miriam Weisskopf
- Center of Surgical Research, University Hospital Zürich University of Zürich, Zurich, Switzerland
| | - Mark W Tibbitt
- Macromolecular Engineering Laboratory, Department of Mechanical and Process Engineering, ETH Zurich, Zurich, Switzerland
| | - Philipp Dutkowski
- Department of Surgery, Swiss Hepato-Pancreato-Biliary and Transplantation Center, University Hospital Zurich, Zurich, Switzerland
| | - Philipp Rudolf von Rohr
- Wyss Zurich - ETH Zurich/University of Zurich, Zurich, Switzerland.,Transport Processes and Reactions Laboratory, Department of Mechanical and Process Engineering, ETH Zurich, Zurich, Switzerland
| | - Jan-Dirk Studt
- Department of Medical Oncology and Hematology, University Hospital Zurich, Zurich, Switzerland
| | - Dustin Becker
- Wyss Zurich - ETH Zurich/University of Zurich, Zurich, Switzerland.,Transport Processes and Reactions Laboratory, Department of Mechanical and Process Engineering, ETH Zurich, Zurich, Switzerland
| | - Pierre-Alain Clavien
- Department of Surgery, Swiss Hepato-Pancreato-Biliary and Transplantation Center, University Hospital Zurich, Zurich, Switzerland.,Wyss Zurich - ETH Zurich/University of Zurich, Zurich, Switzerland
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22
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Mitochondrial Reprogramming—What Is the Benefit of Hypothermic Oxygenated Perfusion in Liver Transplantation? TRANSPLANTOLOGY 2021. [DOI: 10.3390/transplantology2020015] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Although machine perfusion is a hot topic today, we are just at the beginning of understanding the underlying mechanisms of protection. Recently, the first randomized controlled trial reported a significant reduction of ischemic cholangiopathies after transplantation of livers donated after circulatory death, provided the grafts were treated with an endischemic hypothermic oxygenated perfusion (HOPE). This approach has been known for more than fifty years, and was initially mainly used to preserve kidneys before implantation. Today there is an increasing interest in this and other dynamic preservation technologies and various centers have tested different approaches in clinical trials and cohort studies. Based on this, there is a need for uniform perfusion settings (perfusion route and duration), and the development of general guidelines regarding the duration of cold storage in context of the overall donor risk is also required to better compare various trial results. This article will highlight how cold perfusion protects organs mechanistically, and target such technical challenges with the perfusion setting. Finally, the options for viability testing during hypothermic perfusion will be discussed.
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23
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Bile formation in long-term ex situ perfused livers. Surgery 2021; 169:894-902. [PMID: 33422346 DOI: 10.1016/j.surg.2020.11.042] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 11/18/2020] [Accepted: 11/27/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Long-term ex situ liver perfusion may rescue injured grafts. Little is known about bile flow during long-term perfusion. We report the development of a bile stimulation protocol and motivate bile flow as a viability marker during long-term ex situ liver perfusion. METHODS Porcine and human livers were perfused with blood at close to physiologic conditions. Our perfusion protocol was established during phase 1 with porcine livers (n = 23). Taurocholic acid was applied to stimulate bile flow. The addition of piperacillin-tazobactam (tazobac) and methylprednisolone was modified from daily bolus to controlled continuous application. We adapted the protocol to human livers (n = 12) during phase 2. Taurocholic acid was replaced with medical grade ursodeoxycholic acid. RESULTS Phase 2: Despite administering taurocholic acid, bile flow declined from 29.3 ± 6.5 to 9.3 ± 1.4 mL/h (P < .001). Shortly after bolus of tazobac/methylprednisolone, bile flow recovered to 39.0 ± 9.7 mL/h with a decrease of solid bile components. This implied bile salt independent bile flow stimulation by tazobac/methylprednisolone. Phase 2: Ursodeoxycholic acid was shown to stimulate bile flow ex situ in human livers. Eight livers were perfused successfully for 1 week with continuous bile flow. The other 4 livers demonstrated progressive cell death, of which only 1 exhibited bile flow. CONCLUSION A lack of bile flow stimulation leads to a decline in bile flow and is not necessarily a sign of deterioration in liver function. Proper administration of stimulators can induce constant bile flow during ex situ liver perfusion for up to 1 week. Medical grade ursodeoxycholic acid is a suitable replacement for nonmedical grade taurocholic acid. The presence of bile flow alone is not sufficient to assess liver viability.
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24
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Gao J, He K, Xia Q, Zhang J. Research progress on hepatic machine perfusion. Int J Med Sci 2021; 18:1953-1959. [PMID: 33850464 PMCID: PMC8040389 DOI: 10.7150/ijms.56139] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 02/12/2021] [Indexed: 01/08/2023] Open
Abstract
Nowadays, liver transplantation is the most effective treatment for end-stage liver disease. However, the increasing imbalance between growing demand for liver transplantation and the shortage of donor pool restricts the development of liver transplantation. How to expand the donor pool is a significant problem to be solved clinically. Many doctors have devoted themselves to marginal grafting, which introduces livers with barely passable quality but a high risk of transplant failure into the donor pool. However, existing common methods of preserving marginal grafts lead to both high risk of postoperative complications and high mortality. The application of machine perfusion allows surgeons to make marginal livers meet the standard criteria for transplant, which shows promising prospect in preserving and repairing donor livers and improving ischemia reperfusion injury. This review summarizes the progress of recent researches on hepatic machine perfusion.
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Affiliation(s)
- Junda Gao
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Kang He
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Qiang Xia
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jianjun Zhang
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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25
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Oxygen Transport during Ex Situ Machine Perfusion of Donor Livers Using Red Blood Cells or Artificial Oxygen Carriers. Int J Mol Sci 2020; 22:ijms22010235. [PMID: 33379394 PMCID: PMC7795786 DOI: 10.3390/ijms22010235] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 12/14/2020] [Accepted: 12/24/2020] [Indexed: 12/21/2022] Open
Abstract
Oxygenated ex situ machine perfusion of donor livers is an alternative for static cold preservation that can be performed at temperatures from 0 °C to 37 °C. Organ metabolism depends on oxygen to produce adenosine triphosphate and temperatures below 37 °C reduce the metabolic rate and oxygen requirements. The transport and delivery of oxygen in machine perfusion are key determinants in preserving organ viability and cellular function. Oxygen delivery is more challenging than carbon dioxide removal, and oxygenation of the perfusion fluid is temperature dependent. The maximal oxygen content of water-based solutions is inversely related to the temperature, while cellular oxygen demand correlates positively with temperature. Machine perfusion above 20 °C will therefore require an oxygen carrier to enable sufficient oxygen delivery to the liver. Human red blood cells are the most physiological oxygen carriers. Alternative artificial oxygen transporters are hemoglobin-based oxygen carriers, perfluorocarbons, and an extracellular oxygen carrier derived from a marine invertebrate. We describe the principles of oxygen transport, delivery, and consumption in machine perfusion for donor livers using different oxygen carrier-based perfusion solutions and we discuss the properties, advantages, and disadvantages of these carriers and their use.
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26
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Parente A, Osei-Bordom DC, Ronca V, Perera MTPR, Mirza D. Organ Restoration With Normothermic Machine Perfusion and Immune Reaction. Front Immunol 2020; 11:565616. [PMID: 33193335 PMCID: PMC7641637 DOI: 10.3389/fimmu.2020.565616] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 08/20/2020] [Indexed: 12/12/2022] Open
Abstract
Liver transplantation is the only recognized effective treatment for end-stage liver disease. However, organ shortages have become the main challenge for patients and physicians within the transplant community. Waiting list mortality remains an issue with around 10% of patients dying whilst waiting for an available organ. The post-transplantation period is also associated with an adverse complication rate for these specific cohorts of high-risk patients, particularly regarding patient and graft survival. Ischaemia reperfusion injury (IRI) has been highlighted as the mechanism of injury that increases parenchymal damage, which eventually lead to significant graft dysfunction and other poor outcome indicators. The consequences of IRI in clinical practice such as reperfusion syndrome, primary non-function of graft, allograft dysfunction, ischaemic biliary damage and early biliary complications can be life-threatening. IRI dictates the development of a significant inflammatory response that drives the pathway to eventual cell death. The main mechanisms of IRI are mitochondrial damage due to low oxygen tension within the hepatic micro-environment and severe adenosine triphosphate (ATP) depletion during the ischaemic period. After the restoration of normal blood flow, this damage is further enhanced by reoxygenation as the mitochondria respond to reperfusion by releasing reactive oxygen species (ROS), which in turn activate Kupffer cells within the hepatic micro-environment, leading to a pro-inflammatory response and eventual parenchymal cell apoptosis and associated tissue degradation. Machine perfusion (MP) is one emergent strategy considered to be one of the most important advances in organ preservation, restoration and transplantation. Indeed, MP has the potential to rescue frequently discarded organs and has been shown to limit the extent of IRI, leading to suppression of the deleterious pro-inflammatory response. This immunomodulation reduces the prevalence of allograft rejection, the use of immunosuppression therapy and minimizes post-transplant complications. This review aims to update the current knowledge of MP with a focus on normothermic machine liver perfusion (NMLP) and its potential role in immune response pathways.
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Affiliation(s)
- Alessandro Parente
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Daniel-Clement Osei-Bordom
- 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.,National Institute for Health Research Birmingham Liver Biomedical Research Centre, University Hospitals Birmingham National Health Service Foundation Trust, Birmingham, United Kingdom
| | - Vincenzo Ronca
- 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.,Division of Gastroenterology and Centre for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
| | - M Thamara P R Perera
- Liver Unit, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Darius 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, University of Birmingham, Birmingham, United Kingdom
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27
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The importance of adequate oxygenation during hypothermic machine perfusion. JHEP Rep 2020; 3:100194. [PMID: 33305200 PMCID: PMC7718475 DOI: 10.1016/j.jhepr.2020.100194] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 09/29/2020] [Accepted: 10/05/2020] [Indexed: 12/13/2022] Open
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28
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Panisello Rosello A, Teixeira da Silva R, Castro C, G. Bardallo R, Calvo M, Folch-Puy E, Carbonell T, Palmeira C, Roselló Catafau J, Adam R. Polyethylene Glycol 35 as a Perfusate Additive for Mitochondrial and Glycocalyx Protection in HOPE Liver Preservation. Int J Mol Sci 2020; 21:E5703. [PMID: 32784882 PMCID: PMC7461048 DOI: 10.3390/ijms21165703] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 08/03/2020] [Accepted: 08/04/2020] [Indexed: 02/08/2023] Open
Abstract
Organ transplantation is a multifactorial process in which proper graft preservation is a mandatory step for the success of the transplantation. Hypothermic preservation of abdominal organs is mostly based on the use of several commercial solutions, including UW, Celsior, HTK and IGL-1. The presence of the oncotic agents HES (in UW) and PEG35 (in IGL-1) characterize both solution compositions, while HTK and Celsior do not contain any type of oncotic agent. Polyethylene glycols (PEGs) are non-immunogenic, non-toxic and water-soluble polymers, which present a combination of properties of particular interest in the clinical context of ischemia-reperfusion injury (IRI): they limit edema and nitric oxide induction and modulate immunogenicity. Besides static cold storage (SCS), there are other strategies to preserve the organ, such as the use of machine perfusion (MP) in dynamic preservation strategies, which increase graft function and survival as compared to the conventional static hypothermic preservation. Here we report some considerations about using PEG35 as a component of perfusates for MP strategies (such as hypothermic oxygenated perfusion, HOPE) and its benefits for liver graft preservation. Improved liver preservation is closely related to mitochondria integrity, making this organelle a good target to increase graft viability, especially in marginal organs (e.g., steatotic livers). The final goal is to increase the pool of suitable organs, and thereby shorten patient waiting lists, a crucial problem in liver transplantation.
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Affiliation(s)
- Arnau Panisello Rosello
- Experimental Hepatic Ischemia-Reperfusion Unit, Institut d’Investigacions Biomèdiques de Barcelona (IIBB), Spanish National Research Council (CSIC)-IDIBAPS, CIBEREHD, 08036 Barcelona, Catalonia, Spain; (A.P.R.); (R.T.d.S.); (E.F.-P.)
- Centre Hépato-Biliaire, AP-PH, Hôpital Paul Brousse, 94800 Villejuif, France; (C.C.); (R.A.)
| | - Rui Teixeira da Silva
- Experimental Hepatic Ischemia-Reperfusion Unit, Institut d’Investigacions Biomèdiques de Barcelona (IIBB), Spanish National Research Council (CSIC)-IDIBAPS, CIBEREHD, 08036 Barcelona, Catalonia, Spain; (A.P.R.); (R.T.d.S.); (E.F.-P.)
- Center for Neuroscience and Cell Biology, Universidade Coimbra, 3000-370 Coimbra, Portugal;
| | - Carlos Castro
- Centre Hépato-Biliaire, AP-PH, Hôpital Paul Brousse, 94800 Villejuif, France; (C.C.); (R.A.)
| | - Raquel G. Bardallo
- Department of Cell Biology, Physiology and Immunology, Universitat de Barcelona, 08028 Barcelona, Catalonia, Spain; (R.G.B.); (T.C.)
| | - Maria Calvo
- Serveis Cientifico Tècnics, 08036-Campus Hospital Clínic, Universitat de Barcelona, 08919 Barcelona, Catalonia, Spain;
| | - Emma Folch-Puy
- Experimental Hepatic Ischemia-Reperfusion Unit, Institut d’Investigacions Biomèdiques de Barcelona (IIBB), Spanish National Research Council (CSIC)-IDIBAPS, CIBEREHD, 08036 Barcelona, Catalonia, Spain; (A.P.R.); (R.T.d.S.); (E.F.-P.)
| | - Teresa Carbonell
- Department of Cell Biology, Physiology and Immunology, Universitat de Barcelona, 08028 Barcelona, Catalonia, Spain; (R.G.B.); (T.C.)
| | - Carlos Palmeira
- Center for Neuroscience and Cell Biology, Universidade Coimbra, 3000-370 Coimbra, Portugal;
| | - Joan Roselló Catafau
- Experimental Hepatic Ischemia-Reperfusion Unit, Institut d’Investigacions Biomèdiques de Barcelona (IIBB), Spanish National Research Council (CSIC)-IDIBAPS, CIBEREHD, 08036 Barcelona, Catalonia, Spain; (A.P.R.); (R.T.d.S.); (E.F.-P.)
| | - René Adam
- Centre Hépato-Biliaire, AP-PH, Hôpital Paul Brousse, 94800 Villejuif, France; (C.C.); (R.A.)
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29
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Bonaccorsi-Riani E, Brüggenwirth IMA, Buchwald JE, Iesari S, Martins PN. Machine Perfusion: Cold versus Warm, versus Neither. Update on Clinical Trials. Semin Liver Dis 2020; 40:264-281. [PMID: 32557478 DOI: 10.1055/s-0040-1713118] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Machine perfusion (MP) preservation is potentially one of the most significant improvements in the field of liver transplantation in the last 20 years, and it has been considered a promising strategy for improved preservation and ex situ evaluation of extended criteria donor (ECD) organs. However, MP preservation adds significant cost and logistical considerations to liver transplantation. MP protocols are mainly classified according to the perfusion temperature with hypothermic machine perfusion (HMP) and normothermic machine perfusion (NMP) being the two categories most studied so far. After extensive preclinical work, MP entered the clinical setting, and there are now several studies that demonstrated feasibility and safety. However, because of the limited quality of clinical trials, there is no compelling evidence of superiority in preservation quality, and liver MP is still considered experimental in most countries. MP preservation is moving to a more mature phase, where ongoing and future studies will bring new evidence in order to confirm their superiority in terms of clinical outcomes, organ utilization, and cost-effectiveness. Here, we present an overview of all preclinical MP studies using discarded human livers and liver MP clinical trials, and discuss their results. We describe the different perfusion protocols, pitfalls in MP study design, and provide future perspectives. Recent trials in liver MP have revealed unique challenges beyond those seen in most clinical studies. Randomized trials, correct trial design, and interpretation of data are essential to generate the data necessary to prove if MP will be the new gold standard method of liver preservation.
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Affiliation(s)
- E Bonaccorsi-Riani
- Abdominal Transplant Unit, Cliniques Universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium.,Pôle de Chirurgie Expérimentale et Transplantation, Université Catholique de Louvain, Brussels, Belgium
| | - I M A Brüggenwirth
- Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - J E Buchwald
- Division of Transplant, Department of Surgery, UMass Memorial Medical Center, University of Massachusetts, Worcester, Massachusetts
| | - S Iesari
- Pôle de Chirurgie Expérimentale et Transplantation, Université Catholique de Louvain, Brussels, Belgium.,Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - P N Martins
- Division of Transplant, Department of Surgery, UMass Memorial Medical Center, University of Massachusetts, Worcester, Massachusetts
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30
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Restoring Mitochondrial Function While Avoiding Redox Stress: The Key to Preventing Ischemia/Reperfusion Injury in Machine Perfused Liver Grafts? Int J Mol Sci 2020; 21:ijms21093132. [PMID: 32365506 PMCID: PMC7246795 DOI: 10.3390/ijms21093132] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 04/18/2020] [Accepted: 04/27/2020] [Indexed: 02/07/2023] Open
Abstract
Mitochondria sense changes resulting from the ischemia and subsequent reperfusion of an organ and mitochondrial reactive oxygen species (ROS) production initiates a series of events, which over time result in the development of full-fledged ischemia-reperfusion injury (IRI), severely affecting graft function and survival after transplantation. ROS activate the innate immune system, regulate cell death, impair mitochondrial and cellular performance and hence organ function. Arresting the development of IRI before the onset of ROS production is currently not feasible and clinicians are faced with limiting the consequences. Ex vivo machine perfusion has opened the possibility to ameliorate or antagonize the development of IRI and may be particularly beneficial for extended criteria donor organs. The molecular events occurring during machine perfusion remain incompletely understood. Accumulation of succinate and depletion of adenosine triphosphate (ATP) have been considered key mechanisms in the initiation; however, a plethora of molecular events contribute to the final tissue damage. Here we discuss how understanding mitochondrial dysfunction linked to IRI may help to develop novel strategies for the prevention of ROS-initiated damage in the evolving era of machine perfusion.
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31
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Karangwa S, Panayotova G, Dutkowski P, Porte RJ, Guarrera JV, Schlegel A. Hypothermic machine perfusion in liver transplantation. Int J Surg 2020; 82S:44-51. [PMID: 32353556 DOI: 10.1016/j.ijsu.2020.04.057] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 04/14/2020] [Accepted: 04/22/2020] [Indexed: 12/24/2022]
Abstract
Dynamic preservation strategies are a promising option to improve graft quality before transplantation, and to extend preservation time for either logistic or treatment reasons. In contrast to normothermic oxygenated perfusion, which intends to mimic physiological conditions in the human body, with subsequent clinical application for up to 24 hrs, hypothermic perfusion is mainly used for a relatively short period with protection of mitochondria and subsequent reduction of oxidative injury upon implantation. The results from two randomized controlled trials, where recruitment has finished are expected this year. Both ex situ perfusion techniques are increasingly applied in clinical transplantation including recent reports on viability assessment, which could open the door for an increased liver utilization in the future.
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Affiliation(s)
- S Karangwa
- 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
| | - G Panayotova
- Department of Surgery, Division of Transplant and HPB Surgery, Rutgers NJMS/ University Hospital, Newark, NJ, USA
| | - P Dutkowski
- Department of Surgery & Transplantation, University Hospital Zurich, Switzerland
| | - R J Porte
- 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
| | - J V Guarrera
- Department of Surgery, Division of Transplant and HPB Surgery, Rutgers NJMS/ University Hospital, Newark, NJ, USA
| | - A Schlegel
- The Liver Unit, Queen Elizabeth University Hospital Birmingham, United Kingdom.
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32
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Sherman M. The second volume. JHEP Rep 2020; 2:100095. [PMID: 32195458 PMCID: PMC7078376 DOI: 10.1016/j.jhepr.2020.100095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Accepted: 02/28/2020] [Indexed: 11/22/2022] Open
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