1
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Risbey CWG, Lau NS, Niu A, Zhang WB, Crawford M, Pulitano C. Return of the cold: How hypothermic oxygenated machine perfusion is changing liver transplantation. Transplant Rev (Orlando) 2024; 38:100853. [PMID: 38581881 DOI: 10.1016/j.trre.2024.100853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 03/28/2024] [Accepted: 04/01/2024] [Indexed: 04/08/2024]
Abstract
Hypothermic Oxygenated machine PErfusion (HOPE) has recently emerged as a preservation technique which can reduce ischemic injury and improve clinical outcomes following liver transplantation. First developed with the advent solid organ transplantation techniques, hypothermic machine perfusion largely fell out of favour following the development of preservation solutions which can satisfactorily preserve grafts using the cheap and simple method, static cold storage (SCS). However, with an increasing need to develop techniques to reduce graft injury and better utilise marginal and donation after circulatory death (DCD) grafts, HOPE has emerged as a relatively simple and safe technique to optimise clinical outcomes following liver transplantation. Perfusing the graft with cold, acellular, oxygenated perfusate either via the portal vein (PV) alone, or via both the PV and hepatic artery (HA), HOPE is generally commenced for a period of 1-2 h immediately prior to implantation. The technique has been validated by multiple randomised control trials, and pre-clinical evidence suggests HOPE primarily reduces graft injury by decreasing the accumulation of harmful mitochondrial intermediates, and subsequently, the severity of post-reperfusion injury. HOPE can also facilitate real time graft assessment, most notably via the measurement of flavin mononucleotide (FMN) in the perfusate, allowing transplant teams to make better informed clinical decisions prior to transplantation. HOPE may also provide a platform to administer novel therapeutic agents to ex situ organs without risk of systemic side effects. As such, HOPE is uniquely positioned to revolutionise how liver transplantation is approached and facilitate optimised clinical outcomes for liver transplant recipients.
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Affiliation(s)
- Charles W G Risbey
- Department of Transplant Surgery, Royal Prince Alfred Hospital, 50 Missenden Rd, Camperdown 2050, NSW, Australia; Centre for Organ Assessment, Repair, & Optimization (COARO), 145 Missenden Rd, Camperdown 2050, NSW, Australia; Royal Prince Alfred Hospital Transplant Institute (RPATI), 145 Missenden Rd, Camperdown 2050, NSW, Australia; Central Clinical School, The University of Sydney, John Hopkins Dr, Camperdown 2050, NSW, Australia
| | - Ngee-Soon Lau
- Department of Transplant Surgery, Royal Prince Alfred Hospital, 50 Missenden Rd, Camperdown 2050, NSW, Australia; Centre for Organ Assessment, Repair, & Optimization (COARO), 145 Missenden Rd, Camperdown 2050, NSW, Australia; Royal Prince Alfred Hospital Transplant Institute (RPATI), 145 Missenden Rd, Camperdown 2050, NSW, Australia
| | - Anita Niu
- Department of Transplant Surgery, Royal Prince Alfred Hospital, 50 Missenden Rd, Camperdown 2050, NSW, Australia; Centre for Organ Assessment, Repair, & Optimization (COARO), 145 Missenden Rd, Camperdown 2050, NSW, Australia; Royal Prince Alfred Hospital Transplant Institute (RPATI), 145 Missenden Rd, Camperdown 2050, NSW, Australia
| | - Wesley B Zhang
- Centre for Organ Assessment, Repair, & Optimization (COARO), 145 Missenden Rd, Camperdown 2050, NSW, Australia
| | - Michael Crawford
- Department of Transplant Surgery, Royal Prince Alfred Hospital, 50 Missenden Rd, Camperdown 2050, NSW, Australia; Centre for Organ Assessment, Repair, & Optimization (COARO), 145 Missenden Rd, Camperdown 2050, NSW, Australia; Royal Prince Alfred Hospital Transplant Institute (RPATI), 145 Missenden Rd, Camperdown 2050, NSW, Australia; Central Clinical School, The University of Sydney, John Hopkins Dr, Camperdown 2050, NSW, Australia
| | - Carlo Pulitano
- Department of Transplant Surgery, Royal Prince Alfred Hospital, 50 Missenden Rd, Camperdown 2050, NSW, Australia; Centre for Organ Assessment, Repair, & Optimization (COARO), 145 Missenden Rd, Camperdown 2050, NSW, Australia; Royal Prince Alfred Hospital Transplant Institute (RPATI), 145 Missenden Rd, Camperdown 2050, NSW, Australia; Central Clinical School, The University of Sydney, John Hopkins Dr, Camperdown 2050, NSW, Australia.
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2
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Westhaver LP, Nersesian S, Arseneau RJ, Hefler J, Hargreaves BK, Edgar A, Azizieh Y, Cuesta-Gomez N, Izquierdo DL, Shapiro AJ, Gala-Lopez BL, Boudreau JE. Mitochondrial DNA levels in perfusate and bile during ex vivo normothermic machine correspond with donor liver quality. Heliyon 2024; 10:e27122. [PMID: 38463874 PMCID: PMC10920371 DOI: 10.1016/j.heliyon.2024.e27122] [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: 02/09/2024] [Accepted: 02/23/2024] [Indexed: 03/12/2024] Open
Abstract
Ex vivo normothermic machine perfusion (NMP) preserves donor organs and permits real-time assessment of allograft health, but the most effective indicators of graft viability are uncertain. Mitochondrial DNA (mtDNA), released consequent to traumatic cell injury and death, including the ischemia-reperfusion injury inherent in transplantation, may meet the need for a biomarker in this context. We describe a real time PCR-based approach to assess cell-free mtDNA during NMP as a universal biomarker of allograft quality. Measured in the perfusate fluid of 29 livers, the quantity of mtDNA correlated with metrics of donor liver health including International Normalized Ratio (INR), lactate, and warm ischemia time, and inversely correlated with inferior vena cava (IVC) flow during perfusion. Our findings endorse mtDNA as a simple and rapidly measured feature that can inform donor liver health, opening the possibility to better assess livers acquired from extended criteria donors to improve organ supply.
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Affiliation(s)
| | - Sarah Nersesian
- Department of Microbiology and Immunology, Dalhousie University, Halifax, NS, Canada
- Beatrice Hunter Cancer Research Institute, Halifax, NS, Canada
| | | | - Joshua Hefler
- Department of Surgery, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada
| | | | - Alexander Edgar
- Department of Microbiology and Immunology, Dalhousie University, Halifax, NS, Canada
| | - Yara Azizieh
- Department of Pathology, Dalhousie University, Halifax, NS, Canada
| | - Nerea Cuesta-Gomez
- Department of Surgery, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada
- Alberta Diabetes Institute, University of Alberta, Edmonton, AB, Canada
| | - Dayne L. Izquierdo
- Department of Surgery, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada
| | - A.M. James Shapiro
- Department of Surgery, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada
- Alberta Diabetes Institute, University of Alberta, Edmonton, AB, Canada
| | - Boris L. Gala-Lopez
- Department of Pathology, Dalhousie University, Halifax, NS, Canada
- Department of Microbiology and Immunology, Dalhousie University, Halifax, NS, Canada
- Beatrice Hunter Cancer Research Institute, Halifax, NS, Canada
- Department of Surgery, Dalhousie University, Halifax, NS, Canada
| | - Jeanette E. Boudreau
- Department of Pathology, Dalhousie University, Halifax, NS, Canada
- Department of Microbiology and Immunology, Dalhousie University, Halifax, NS, Canada
- Beatrice Hunter Cancer Research Institute, Halifax, NS, Canada
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3
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Watson CJ, Gaurav R, Butler AJ. Current Techniques and Indications for Machine Perfusion and Regional Perfusion in Deceased Donor Liver Transplantation. J Clin Exp Hepatol 2024; 14:101309. [PMID: 38274508 PMCID: PMC10806097 DOI: 10.1016/j.jceh.2023.101309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 11/27/2023] [Indexed: 01/27/2024] Open
Abstract
Since the advent of University of Wisconsin preservation solution in the 1980s, clinicians have learned to work within its confines. While affording improved outcomes, considerable limitations still exist and contribute to the large number of livers that go unused each year, often for fear they may never work. The last 10 years have seen the widespread availability of new perfusion modalities which provide an opportunity for assessing organ viability and prolonged organ storage. This review will discuss the role of in situ normothermic regional perfusion for livers donated after circulatory death. It will also describe the different modalities of ex situ perfusion, both normothermic and hypothermic, and discuss how they are thought to work and the opportunities afforded by them.
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Affiliation(s)
- Christopher J.E. Watson
- University of Cambridge Department of Surgery, Box 210, Addenbrooke's Hospital, Cambridge, CB2 2QQ, UK
- The Roy Calne Transplant Unit, Addenbrooke's Hospital, Cambridge, CB2 2QQ, UK
| | - Rohit Gaurav
- The Roy Calne Transplant Unit, Addenbrooke's Hospital, Cambridge, CB2 2QQ, UK
| | - Andrew J. Butler
- University of Cambridge Department of Surgery, Box 210, Addenbrooke's Hospital, Cambridge, CB2 2QQ, UK
- The Roy Calne Transplant Unit, Addenbrooke's Hospital, Cambridge, CB2 2QQ, UK
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4
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Abstract
Despite significant advances in the field of transplantation in the past two decades, current clinically available therapeutic options for immunomodulation remain fairly limited. The advent of calcineurin inhibitor-based immunosuppression has led to significant success in improving short-term graft survival; however, improvements in long-term graft survival have stalled. Solid organ transplantation provides a unique opportunity for immunomodulation of both the donor organ prior to implantation and the recipient post transplantation. Furthermore, therapies beyond targeting the adaptive immune system have the potential to ameliorate ischemic injury to the allograft and halt its aging process, augment its repair, and promote recipient immune tolerance. Other recent advances include expanding the donor pool by reducing organ discard, and bioengineering and genetically modifying organs from other species to generate transplantable organs. Therapies discussed here will likely be most impactful if individualized on the basis of specific donor and recipient considerations.
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Affiliation(s)
- Irma Husain
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA;
| | - Xunrong Luo
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA;
- Duke Transplant Center, Duke University School of Medicine, Durham, North Carolina, USA
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5
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Amin A, Panayotova GG, Guarrera JV. Maximizing the Donor Potential for Patients with Acute-on-Chronic Liver Failure Listed for Liver Transplant. Clin Liver Dis 2023; 27:763-775. [PMID: 37380296 DOI: 10.1016/j.cld.2023.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Abstract
Owing to inherent limitations of static cold storage, marginal liver grafts from donors after circulatory death and extended criteria donors after brain death are prone to be discarded secondary to the increased risk of severe early allograft dysfunction and ischemic cholangiopathy. Marginal liver grafts resuscitated with hypothermic machine perfusion and normothermic machine perfusion demonstrate lower degree of ischemia-reperfusion injury and have decreased risk of severe early allograft dysfunction and ischemic cholangiopathy. Marginal grafts preserved by ex vivo machine perfusion technology can be used to rescue patients with acute-on-chronic liver failure who are underserved by the current deceased donor liver allocation system.
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Affiliation(s)
- Arpit Amin
- Division of Transplant and HPB Surgery, Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Guergana G Panayotova
- Division of Transplant and HPB Surgery, Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - James V Guarrera
- Division of Transplant and HPB Surgery, Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA.
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6
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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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7
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Coliță CI, Olaru DG, Coliță D, Hermann DM, Coliță E, Glavan D, Popa-Wagner A. Induced Coma, Death, and Organ Transplantation: A Physiologic, Genetic, and Theological Perspective. Int J Mol Sci 2023; 24:ijms24065744. [PMID: 36982814 PMCID: PMC10059721 DOI: 10.3390/ijms24065744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Revised: 03/13/2023] [Accepted: 03/15/2023] [Indexed: 03/19/2023] Open
Abstract
In the clinic, the death certificate is issued if brain electrical activity is no longer detectable. However, recent research has shown that in model organisms and humans, gene activity continues for at least 96 h postmortem. The discovery that many genes are still working up to 48 h after death questions our definition of death and has implications for organ transplants and forensics. If genes can be active up to 48 h after death, is the person technically still alive at that point? We discovered a very interesting parallel between genes that were upregulated in the brain after death and genes upregulated in the brains that were subjected to medically-induced coma, including transcripts involved in neurotransmission, proteasomal degradation, apoptosis, inflammation, and most interestingly, cancer. Since these genes are involved in cellular proliferation, their activation after death could represent the cellular reaction to escape mortality and raises the question of organ viability and genetics used for transplantation after death. One factor limiting the organ availability for transplantation is religious belief. However, more recently, organ donation for the benefit of humans in need has been seen as “posthumous giving of organs and tissues can be a manifestation of love spreading also to the other side of death”.
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Affiliation(s)
- Cezar-Ivan Coliță
- Doctoral School, University of Medicine and Pharmacy Carol Davila, 020276 Bucharest, Romania; (C.-I.C.)
| | - Denissa-Greta Olaru
- Department of Psychiatry, University for Medicine and Pharmacy Craiova, 200349 Craiova, Romania;
| | - Daniela Coliță
- Doctoral School, University of Medicine and Pharmacy Carol Davila, 020276 Bucharest, Romania; (C.-I.C.)
| | - Dirk M. Hermann
- Chair of Vascular Neurology, Dementia and Ageing, Department of Neurology, University Hospital Essen, 45147 Essen, Germany
| | - Eugen Coliță
- Doctoral School, University of Medicine and Pharmacy Carol Davila, 020276 Bucharest, Romania; (C.-I.C.)
| | - Daniela Glavan
- Department of Psychiatry, University for Medicine and Pharmacy Craiova, 200349 Craiova, Romania;
- Correspondence: (D.G.); (A.P.-W.)
| | - Aurel Popa-Wagner
- Department of Psychiatry, University for Medicine and Pharmacy Craiova, 200349 Craiova, Romania;
- Chair of Vascular Neurology, Dementia and Ageing, Department of Neurology, University Hospital Essen, 45147 Essen, Germany
- Correspondence: (D.G.); (A.P.-W.)
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8
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Banker A, Bhatt N, Rao PS, Agrawal P, Shah M, Nayak M, Mohanka R. A Review of Machine Perfusion Strategies in Liver Transplantation. J Clin Exp Hepatol 2023; 13:335-349. [PMID: 36950485 PMCID: PMC10025749 DOI: 10.1016/j.jceh.2022.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 07/26/2022] [Accepted: 08/02/2022] [Indexed: 02/17/2023] Open
Abstract
The acceptance of liver transplantation as the standard of care for end-stage liver diseases has led to a critical shortage of donor allografts. To expand the donor organ pool, many countries have liberalized the donor criteria including extended criteria donors and donation after circulatory death. These marginal livers are at a higher risk of injury when they are preserved using the standard static cold storage (SCS) preservation techniques. In recent years, research has focused on optimizing organ preservation techniques to protect these marginal livers. Machine perfusion (MP) of the expanded donor liver has witnessed considerable advancements in the last decade. Research has showed MP strategies to confer significant advantages over the SCS techniques, such as longer preservation times, viability assessment and the potential to recondition high risk allografts prior to implantation. In this review article, we address the topic of MP in liver allograft preservation, with emphasis on current trends in clinical application. We discuss the relevant clinical trials related to the techniques of hypothermic MP, normothermic MP, hypothermic oxygenated MP, and controlled oxygenated rewarming. We also discuss the potential applications of ex vivo therapeutics which may be relevant in the future to further optimize the allograft prior to transplantation.
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Key Words
- ALP, Alkaline phosphatase
- ALT, Alanine transaminase
- ASO, Antisense oligonucleotides
- AST, Aspartate transaminase
- CIT, Cold ischemia times
- COPE, Consortium for Organ Preservation in Europe
- COR, Controlled oxygenated rewarming
- DBD, Donation after brain death
- DCD, Donation after circulatory death
- DHOPE, dual hypothermic oxygenated machine perfusion
- EAD, Early allograft dysfunction
- ECD, Extended criteria donors
- ETC, Electron transport chain
- GGT, Gamma glutamyl transferase
- HCV, Hepatitis C virus
- HMP, Hypothermic machine perfusion
- HOPE, Hypothermic oxygenated machine perfusion
- ICU, Intensive care unit
- IGL, Institute George Lopez-1
- INR, International normalized ratio
- IRI, ischemia reperfusion injury
- LDH, Lactate dehydrogenase
- MELD, Model for end-stage liver disease
- MP, Machine perfusion
- NAS, Non-anastomotic biliary strictures
- NMP, Normothermic machine perfusion
- NO, Nitric oxide
- PNF, Primary nonfunction
- ROS, Reactive oxygen species
- RT-PCR, Reverse transcription polymerase chain reaction
- SNMP, Sub-normothermic machine perfusion
- UW, University of Wisconsin
- WIT, Warm ischemia times
- hypothermic machine perfusion
- hypothermic oxygenated machine perfusion
- machine perfusion
- normothermic machine perfusion
- static cold storage
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Affiliation(s)
- Amay Banker
- Department of Liver Transplant and HPB Surgery, Sir HN Reliance Foundation Hospital, Mumbai, India
| | - Neha Bhatt
- Department of Liver Transplant and HPB Surgery, Sir HN Reliance Foundation Hospital, Mumbai, India
| | - Prashantha S. Rao
- Department of Liver Transplant and HPB Surgery, Sir HN Reliance Foundation Hospital, Mumbai, India
| | - Pravin Agrawal
- Department of Liver Transplant and HPB Surgery, Sir HN Reliance Foundation Hospital, Mumbai, India
| | - Mitul Shah
- Department of Liver Transplant and HPB Surgery, Sir HN Reliance Foundation Hospital, Mumbai, India
| | - Madhavi Nayak
- Department of Liver Transplant and HPB Surgery, Sir HN Reliance Foundation Hospital, Mumbai, India
| | - Ravi Mohanka
- Department of Liver Transplant and HPB Surgery, Sir HN Reliance Foundation Hospital, Mumbai, India
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9
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Farshbafnadi M, Razi S, Rezaei N. Transplantation. Clin Immunol 2023. [DOI: 10.1016/b978-0-12-818006-8.00008-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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10
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Azizieh Y, Westhaver LP, Badrudin D, Boudreau JE, Gala-Lopez BL. Changing liver utilization and discard rates in clinical transplantation in the ex-vivo machine preservation era. FRONTIERS IN MEDICAL TECHNOLOGY 2023; 5:1079003. [PMID: 36908294 PMCID: PMC9996101 DOI: 10.3389/fmedt.2023.1079003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 01/30/2023] [Indexed: 02/25/2023] Open
Abstract
Liver transplantation is a well-established treatment for many with end-stage liver disease. Unfortunately, the increasing organ demand has surpassed the donor supply, and approximately 30% of patients die while waiting for a suitable liver. Clinicians are often forced to consider livers of inferior quality to increase organ donation rates, but ultimately, many of those organs end up being discarded. Extensive testing in experimental animals and humans has shown that ex-vivo machine preservation allows for a more objective characterization of the graft outside the body, with particular benefit for suboptimal organs. This review focuses on the history of the implementation of ex-vivo liver machine preservation and how its enactment may modify our current concept of organ acceptability. We provide a brief overview of the major drivers of organ discard (age, ischemia time, steatosis, etc.) and how this technology may ultimately revert such a trend. We also discuss future directions for this technology, including the identification of new markers of injury and repair and the opportunity for other ex-vivo regenerative therapies. Finally, we discuss the value of this technology, considering current and future donor characteristics in the North American population that may result in a significant organ discard.
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Affiliation(s)
- Yara Azizieh
- Department of Pathology, Dalhousie University, Halifax, NS, Canada
| | | | - David Badrudin
- Department of Surgery, Université de Montréal, Montréal, QC, Canada
| | - Jeanette E Boudreau
- Department of Pathology, Dalhousie University, Halifax, NS, Canada.,Department of Microbiology and Immunology, Dalhousie University, Halifax, NS, Canada.,Beatrice Hunter Cancer Research Institute, Halifax, NS, Canada
| | - Boris L Gala-Lopez
- Department of Pathology, Dalhousie University, Halifax, NS, Canada.,Department of Microbiology and Immunology, Dalhousie University, Halifax, NS, Canada.,Beatrice Hunter Cancer Research Institute, Halifax, NS, Canada.,Department of Surgery, Dalhousie University, Halifax, NS, Canada
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11
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Kruit AS, Hummelink S, Eshuis L, Kusters B, Ulrich D. Superior preservation of capillaries, myofibrils and mitochondria after long-term extracorporeal perfusion of free muscle flaps - A descriptive electron microscopy study. Clin Hemorheol Microcirc 2023; 83:11-18. [PMID: 36189585 PMCID: PMC9986692 DOI: 10.3233/ch-211262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Extracorporeal perfusion (ECP) is a promising technique for prolonged tissue preservation, but might have side effects. For instance, increased radical oxygen species or capillary endothelial damage. OBJECTIVE To assess ultra-morphological muscle damage during 36-hour ECP of porcine musculocutaneous flaps, hypothesizing that it would delay the onset of damage compared to static cold storage (SCS). METHODS Bilateral flaps were retrieved from three Dutch Landrace pigs. Three flaps were preserved for 36 hours by hypothermic storage 4-6°C (control group) and three flaps by ECP with cooled University of Wisconsin solution. Muscle biopsies were taken at 0 h, 12 h and 36 h and assessed with transmission electron microscopy. RESULTS Muscle architecture was best preserved by ECP, with a delayed onset and decreased severity of muscle damage. After 36 hours, damage was two-fold lower in ECP-flaps compared to SCS-flaps. Myofibril architecture was best preserved. Mitochondria were greatly preserved with swelling being the most prominent feature. Capillaries were moderately but differently damaged during ECP, with focal endothelial thinning as opposed to luminal obstruction in SCS-preserved flaps. CONCLUSIONS This experiment described favourable cellular preservation of skeletal muscle flaps during ECP compared to SCS. Results showed less severe ultra-morphological damage and a later onset of damage.
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Affiliation(s)
- Anne Sophie Kruit
- Department of Plastic and Reconstructive Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Stefan Hummelink
- Department of Plastic and Reconstructive Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Lilian Eshuis
- Department of Pathology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Benno Kusters
- Department of Pathology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Dietmar Ulrich
- Department of Plastic and Reconstructive Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
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12
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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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13
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Baboudjian M, Gondran-Tellier B, Boissier R, Ancel P, Marjollet J, Lyonnet L, François P, Sabatier F, Lechevallier E, Dutour A, Paul P. An enhanced level of VCAM in transplant preservation fluid is an independent predictor of early kidney allograft dysfunction. Front Immunol 2022; 13:966951. [PMID: 36032101 PMCID: PMC9403542 DOI: 10.3389/fimmu.2022.966951] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Accepted: 07/11/2022] [Indexed: 11/29/2022] Open
Abstract
Background We aimed to evaluate whether donor-related inflammatory markers found in kidney transplant preservation fluid can associate with early development of kidney allograft dysfunction. Methods Our prospective study enrolled 74 consecutive donated organs who underwent kidney transplantation in our center between September 2020 and June 2021. Kidneys from 27 standard criteria donors were allocated to static cold storage and kidneys from 47 extended criteria donors to hypothermic machine perfusion. ELISA assessment of inflammatory biomarkers (IL-6, IL6-R, ICAM, VCAM, TNFα, IFN-g, CXCL1 and Fractalkine) was analyzed in view of a primary endpoint defined as the occurrence of delayed graft function or slow graft function during the first week following transplantation. Results Soluble VCAM levels measured in transplant conservation fluid were significantly associated with recipient serum creatinine on day 7. Multivariate stepwise logistic regression analysis identified VCAM as an independent non-invasive predictor of early graft dysfunction, both at 1 week (OR: 3.57, p = .04, 95% CI: 1.06-12.03) and 3 Months (OR: 4.039, p = .034, 95% CI: 1.11-14.73) after transplant surgery. Conclusions This prospective pilot study suggests that pre-transplant evaluation of VCAM levels could constitute a valuable indicator of transplant health and identify the VCAM-CD49d pathway as a target to limit donor-related vascular injury of marginal transplants.
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Affiliation(s)
- Michael Baboudjian
- Department of Urology and Transplantation, La Conception Hospital, Assistance Publique-Hôpitaux Marseille, Marseille, France
- Department of Urology, Assistance Publique-Hôpitaux de Marseille, Hopital Nord, Aix-Marseille University, Marseille, France
- Institut national de la santé et de la recherche médicale (INSERM) 1263, Aix Marseille University, French national research institute for agriculture, food and the environment (INRAE), Centre de recherche en CardioVasculaire et Nutrition (C2VN), Marseille, France
| | - Bastien Gondran-Tellier
- Department of Urology and Transplantation, La Conception Hospital, Assistance Publique-Hôpitaux Marseille, Marseille, France
- Institut national de la santé et de la recherche médicale (INSERM) 1263, Aix Marseille University, French national research institute for agriculture, food and the environment (INRAE), Centre de recherche en CardioVasculaire et Nutrition (C2VN), Marseille, France
| | - Romain Boissier
- Department of Urology and Transplantation, La Conception Hospital, Assistance Publique-Hôpitaux Marseille, Marseille, France
- Institut national de la santé et de la recherche médicale (INSERM) 1263, Aix Marseille University, French national research institute for agriculture, food and the environment (INRAE), Centre de recherche en CardioVasculaire et Nutrition (C2VN), Marseille, France
| | - Patricia Ancel
- Institut national de la santé et de la recherche médicale (INSERM) 1263, Aix Marseille University, French national research institute for agriculture, food and the environment (INRAE), Centre de recherche en CardioVasculaire et Nutrition (C2VN), Marseille, France
| | - Juline Marjollet
- Institut national de la santé et de la recherche médicale (INSERM) 1263, Aix Marseille University, French national research institute for agriculture, food and the environment (INRAE), Centre de recherche en CardioVasculaire et Nutrition (C2VN), Marseille, France
| | - Luc Lyonnet
- Department of Hematology, Hopital de la Conception, Assistance Publique-Hôpitaux Marseille, Marseille, France
| | - Pauline François
- Institut national de la santé et de la recherche médicale (INSERM) 1263, Aix Marseille University, French national research institute for agriculture, food and the environment (INRAE), Centre de recherche en CardioVasculaire et Nutrition (C2VN), Marseille, France
| | - Florence Sabatier
- Institut national de la santé et de la recherche médicale (INSERM) 1263, Aix Marseille University, French national research institute for agriculture, food and the environment (INRAE), Centre de recherche en CardioVasculaire et Nutrition (C2VN), Marseille, France
- Cell Therapy Laboratory, Centre d'Investigation Clinique (CIC)-149, La Conception Hospital, Assistance Publique-Hôpitaux Marseille, Marseille, France
| | - Eric Lechevallier
- Department of Urology and Transplantation, La Conception Hospital, Assistance Publique-Hôpitaux Marseille, Marseille, France
| | - Anne Dutour
- Institut national de la santé et de la recherche médicale (INSERM) 1263, Aix Marseille University, French national research institute for agriculture, food and the environment (INRAE), Centre de recherche en CardioVasculaire et Nutrition (C2VN), Marseille, France
- Endocrinology, Metabolic Diseases and Nutrition Department, Assistance Publique Hôpitaux de Marseille, Marseille, France
| | - Pascale Paul
- Institut national de la santé et de la recherche médicale (INSERM) 1263, Aix Marseille University, French national research institute for agriculture, food and the environment (INRAE), Centre de recherche en CardioVasculaire et Nutrition (C2VN), Marseille, France
- Department of Hematology, Hopital de la Conception, Assistance Publique-Hôpitaux Marseille, Marseille, France
- Institut national de la santé et de la recherche médicale (INSERM) unité mixte de recherche (UMR)_1090, Aix Marseille University, TAGC Theories and Approaches of Genomic Complexity, Parc Scientifique de Luminy Case 928, Marseille, France
- *Correspondence: Pascale Paul,
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Knijff LWD, van Kooten C, Ploeg RJ. The Effect of Hypothermic Machine Perfusion to Ameliorate Ischemia-Reperfusion Injury in Donor Organs. Front Immunol 2022; 13:848352. [PMID: 35572574 PMCID: PMC9099247 DOI: 10.3389/fimmu.2022.848352] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 04/04/2022] [Indexed: 12/23/2022] Open
Abstract
Hypothermic machine perfusion (HMP) has become the new gold standard in clinical donor kidney preservation and a promising novel strategy in higher risk donor livers in several countries. As shown by meta-analysis for the kidney, HMP decreases the risk of delayed graft function (DGF) and improves graft survival. For the liver, HMP immediately prior to transplantation may reduce the chance of early allograft dysfunction (EAD) and reduce ischemic sequelae in the biliary tract. Ischemia-reperfusion injury (IRI), unavoidable during transplantation, can lead to massive cell death and is one of the main causes for DGF, EAD or longer term impact. Molecular mechanisms that are affected in IRI include levels of hypoxia inducible factor (HIF), induction of cell death, endothelial dysfunction and immune responses. In this review we have summarized and discussed mechanisms on how HMP can ameliorate IRI. Better insight into how HMP influences IRI in kidney and liver transplantation may lead to new therapies and improved transplant outcomes.
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Affiliation(s)
- Laura W. D. Knijff
- Nephrology, Department of Internal Medicine, Leiden University Medical Centre, Leiden, Netherlands
- Transplant Centre of the Leiden University Medical Centre, Leiden University Medical Centre, Leiden, Netherlands
| | - Cees van Kooten
- Nephrology, Department of Internal Medicine, Leiden University Medical Centre, Leiden, Netherlands
- Transplant Centre of the Leiden University Medical Centre, Leiden University Medical Centre, Leiden, Netherlands
| | - Rutger J. Ploeg
- Transplant Centre of the Leiden University Medical Centre, Leiden University Medical Centre, Leiden, Netherlands
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
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15
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Amin A, Panayotova G, Guarrera JV. Hypothermic machine perfusion for liver graft preservation. Curr Opin Organ Transplant 2022; 27:98-105. [PMID: 35184093 DOI: 10.1097/mot.0000000000000973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Ex-vivo machine perfusion has emerged as a promising alternative to static cold storage (SCS) for preservation of liver grafts over the last decade. This review describes the mechanistic benefits associated with hypothermic machine perfusion (HMP) for preservation of liver grafts and highlights clinical outcomes of liver transplantation using HMP technology. RECENT FINDINGS Over the last decade, several single-centre studies have shown decreased biliary complications, decreased early allograft dysfunction (EAD) rates and improved patient survival in liver transplant recipients after application of HMP for liver graft preservation. This has led to initiation of prospective, multicentre, randomized controlled trials (RCTs) in both Europe and North America focused on clinical outcomes in liver transplant recipients using HMP-preserved liver grafts. In addition, recent single-centre studies have shown the utility of perfusate biomarker analysis during HMP in predicting EAD after liver transplantation. SUMMARY HMP technology has potential to increase the available donor liver organ pool for liver transplant recipients and improve clinical outcomes after liver transplantation. Broader clinical application of HMP in resuscitation and preservation of liver grafts is anticipated over the next decade once regulatory, logistical and financial challenges are overcome.
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Affiliation(s)
- Arpit Amin
- Division of Abdominal Transplant Surgery, Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
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16
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Li J, Peng Q, Yang R, Li K, Zhu P, Zhu Y, Zhou P, Szabó G, Zheng S. Application of Mesenchymal Stem Cells During Machine Perfusion: An Emerging Novel Strategy for Organ Preservation. Front Immunol 2022; 12:713920. [PMID: 35024039 PMCID: PMC8744145 DOI: 10.3389/fimmu.2021.713920] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 12/03/2021] [Indexed: 12/24/2022] Open
Abstract
Although solid organ transplantation remains the definitive management for patients with end-stage organ failure, this ultimate treatment has been limited by the number of acceptable donor organs. Therefore, efforts have been made to expand the donor pool by utilizing marginal organs from donation after circulatory death or extended criteria donors. However, marginal organs are susceptible to ischemia-reperfusion injury (IRI) and entail higher requirements for organ preservation. Recently, machine perfusion has emerged as a novel preservation strategy for marginal grafts. This technique continually perfuses the organs to mimic the physiologic condition, allows the evaluation of pretransplant graft function, and more excitingly facilitates organ reconditioning during perfusion with pharmacological, gene, and stem cell therapy. As mesenchymal stem cells (MSCs) have anti-oxidative, immunomodulatory, and regenerative properties, mounting studies have demonstrated the therapeutic effects of MSCs on organ IRI and solid organ transplantation. Therefore, MSCs are promising candidates for organ reconditioning during machine perfusion. This review provides an overview of the application of MSCs combined with machine perfusion for lung, kidney, liver, and heart preservation and reconditioning. Promising preclinical results highlight the potential clinical translation of this innovative strategy to improve the quality of marginal grafts.
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Affiliation(s)
- Jiale Li
- Department of Cardiovascular Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Qinbao Peng
- Department of Cardiovascular Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Ronghua Yang
- Department of Burn Surgery and Skin Regeneration, The First People's Hospital of Foshan, Foshan, China
| | - Kunsheng Li
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, Nanjing University Medical School, Nanjing, China
| | - Peng Zhu
- Department of Cardiovascular Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yufeng Zhu
- Laboratory Animal Research Center, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Pengyu Zhou
- Department of Cardiovascular Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Gábor Szabó
- Department of Cardiac Surgery, Heidelberg University Hospital, Heidelberg, Germany.,Department of Cardiac Surgery, University Hospital Halle (Saale), Halle, Germany
| | - Shaoyi Zheng
- Department of Cardiovascular Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
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17
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Jakubauskiene L, Jakubauskas M, Stiegler P, Leber B, Schemmer P, Strupas K. Ischemic Preconditioning for Liver Transplantation: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Visc Med 2021; 37:329-337. [PMID: 34722716 DOI: 10.1159/000516608] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 04/08/2021] [Indexed: 01/01/2023] Open
Abstract
Background In recent decades, liver transplantation (LTx) has increased the survival and quality of life of patients with end-stage organ failure. Unfortunately, LTx is limited due to the shortage of donors. A lot of effort is put into finding new ways to reduce ischemia-reperfusion injury (IRI) in liver grafts to increase the number of suitable organs procured from expanded-criteria donors (ECD). The aim of this study was to systematically review the literature reporting LTx outcomes when using ischemic preconditioning (IPC) or remote ischemic preconditioning (RIPC) to reduce IRI in liver grafts. Methods A literature search was performed in the MEDLINE, Web of Science, and EMBASE databases. The following combination was used: "Liver" OR "Liver Transplantation" AND "Ischemic preconditioning" OR "occlusion" OR "clamping" OR "Pringle." The following outcome data were retrieved: the rates of graft primary nonfunction (PNF), retransplantation, graft loss, and mortality; stay in hospital and the intensive care unit; and postoperative serum liver damage parameters. Results The initial search retrieved 4,522 potentially relevant studies. After evaluating 17 full-text articles, a total of 9 randomized controlled trials (RCTs) were included (7 IPC and 2 RIPC studies) in the qualitative synthesis; the meta-analysis was only performed on the data from the IPC studies. RIPC studies had considerable methodological differences. The meta-analysis revealed the beneficial effect of IPC when comparing postoperative aspartate aminotransferase (AST) corresponding to a statistically lower mortality rate in the IPC group (odds ratio [OR] 0.51; 95% confidence interval [CI] 0.27-0.98; p = 0.04). Conclusion IPC lowers postoperative AST levels and reduces the mortality rate; however, data on the benefits of RIPC are lacking.
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Affiliation(s)
- Lina Jakubauskiene
- General, Visceral and Transplant Surgery, Department of Surgery, Medical University of Graz, Graz, Austria.,Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Matas Jakubauskas
- General, Visceral and Transplant Surgery, Department of Surgery, Medical University of Graz, Graz, Austria.,Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Philipp Stiegler
- General, Visceral and Transplant Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Bettina Leber
- General, Visceral and Transplant Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Peter Schemmer
- General, Visceral and Transplant Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
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18
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Mitochondrial respiratory chain and Krebs cycle enzyme function in human donor livers subjected to end-ischaemic hypothermic machine perfusion. PLoS One 2021; 16:e0257783. [PMID: 34710117 PMCID: PMC8553115 DOI: 10.1371/journal.pone.0257783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 09/09/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Marginal human donor livers are highly susceptible to ischaemia reperfusion injury and mitochondrial dysfunction. Oxygenation during hypothermic machine perfusion (HMP) was proposed to protect the mitochondria but the mechanism is unclear. Additionally, the distribution and uptake of perfusate oxygen during HMP are unknown. This study aimed to examine the feasibility of mitochondrial function analysis during end-ischaemic HMP, assess potential mitochondrial viability biomarkers, and record oxygenation kinetics. METHODS This was a randomised pilot study using human livers retrieved for transplant but not utilised. Livers (n = 38) were randomised at stage 1 into static cold storage (n = 6), hepatic artery HMP (n = 7), and non-oxygen supplemented portal vein HMP (n = 7) and at stage 2 into oxygen supplemented and non-oxygen supplemented portal vein HMP (n = 11 and 7, respectively). Mitochondrial parameters were compared between the groups and between low- and high-risk marginal livers based on donor history, organ steatosis and preservation period. The oxygen delivery efficiency was assessed in additional 6 livers using real-time measurements of perfusate and parenchymal oxygen. RESULTS The change in mitochondrial respiratory chain (complex I, II, III, IV) and Krebs cycle enzyme activity (aconitase, citrate synthase) before and after 4-hour preservation was not different between groups in both study stages (p > 0.05). Low-risk livers that could have been used clinically (n = 8) had lower complex II-III activities after 4-hour perfusion, compared with high-risk livers (73 nmol/mg/min vs. 113 nmol/mg/min, p = 0.01). Parenchymal pO2 was consistently lower than perfusate pO2 (p ≤ 0.001), stabilised in 28 minutes compared to 3 minutes in perfusate (p = 0.003), and decreased faster upon oxygen cessation (75 vs. 36 minutes, p = 0.003). CONCLUSIONS Actively oxygenated and air-equilibrated end-ischaemic HMP did not induce oxidative damage of aconitase, and respiratory chain complexes remained intact. Mitochondria likely respond to variable perfusate oxygen levels by adapting their respiratory function during end-ischaemic HMP. Complex II-III activities should be further investigated as viability biomarkers.
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19
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Amin A, Ripa V, Paterno F, Guarrera JV. Support for Ex Vivo Organ Perfusion in Kidney and Liver Transplantation. CURRENT TRANSPLANTATION REPORTS 2021. [DOI: 10.1007/s40472-021-00347-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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20
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The Potential Role for N-Acetylcysteine in Improving Procurement and Preservation Strategies in Liver Transplantation-A Commentary. Transplantation 2021; 105:2144-2145. [PMID: 33196622 DOI: 10.1097/tp.0000000000003534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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21
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Patel PM, Connolly MR, Coe TM, Calhoun A, Pollok F, Markmann JF, Burdorf L, Azimzadeh A, Madsen JC, Pierson RN. Minimizing Ischemia Reperfusion Injury in Xenotransplantation. Front Immunol 2021; 12:681504. [PMID: 34566955 PMCID: PMC8458821 DOI: 10.3389/fimmu.2021.681504] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 08/12/2021] [Indexed: 12/21/2022] Open
Abstract
The recent dramatic advances in preventing "initial xenograft dysfunction" in pig-to-non-human primate heart transplantation achieved by minimizing ischemia suggests that ischemia reperfusion injury (IRI) plays an important role in cardiac xenotransplantation. Here we review the molecular, cellular, and immune mechanisms that characterize IRI and associated "primary graft dysfunction" in allotransplantation and consider how they correspond with "xeno-associated" injury mechanisms. Based on this analysis, we describe potential genetic modifications as well as novel technical strategies that may minimize IRI for heart and other organ xenografts and which could facilitate safe and effective clinical xenotransplantation.
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Affiliation(s)
- Parth M. Patel
- Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Margaret R. Connolly
- Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Taylor M. Coe
- Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Anthony Calhoun
- Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
- Department of Surgery, Division of Cardiac Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Franziska Pollok
- Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
- Department of Anesthesiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - James F. Markmann
- Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
- Department of Surgery, Division of Transplantation, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Lars Burdorf
- Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
- Department of Surgery, Division of Cardiac Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Agnes Azimzadeh
- Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
- Department of Surgery, Division of Cardiac Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Joren C. Madsen
- Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
- Department of Surgery, Division of Cardiac Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Richard N. Pierson
- Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
- Department of Surgery, Division of Cardiac Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
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22
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van Beekum CJ, Vilz TO, Glowka TR, von Websky MW, Kalff JC, Manekeller S. Normothermic Machine Perfusion (NMP) of the Liver - Current Status and Future Perspectives. Ann Transplant 2021; 26:e931664. [PMID: 34426566 PMCID: PMC8400594 DOI: 10.12659/aot.931664] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 06/21/2021] [Indexed: 12/24/2022] Open
Abstract
A shortage of available organs for liver transplantation has led transplant surgeons and researchers to seek for innovative approaches in hepatoprotection and improvement of marginal allografts. The most exciting development in the past decade has been continuous mechanical perfusion of livers with blood or preservation solution to mitigate ischemia-reperfusion injury in contrast to the current standard of static cold storage. Two variations of machine perfusion have emerged in clinical practice. During hypothermic oxygenated perfusion the liver is perfused using a red blood cell-free perfusate at 2-10°C. In contrast, normothermic machine perfusion mimics physiologic liver perfusion using a red blood cell-based solution at 35.5-037.5°C, offering a multitude of potential advantages. Putative effects of normothermic perfusion include abrogation of hyperfibrinolysis after reperfusion and inflammation, glycogen repletion, and regeneration of adenosine triphosphate. Research in normothermic machine perfusion focuses on development of biomarkers predicting allograft quality and susceptibility to ischemia-reperfusion injury. Moreover, normothermic perfusion of marginal allografts allows for application of a variety of therapeutic interventions potentially enhancing organ quality. Both methods need to be subjected to translational investigation and evaluation in clinical trials. A clear advantage is transformation of an emergency procedure at night into a planned daytime surgery. Current clinical trials suggest that normothermic perfusion not only increases the use of hepatic allografts but is also associated with milder ischemia-reperfusion injury, resulting in a reduced risk of early allograft dysfunction and less biliary complications, including ischemic cholangiopathy, compared to static cold storage. The aim of this review is to give a concise overview of normothermic machine perfusion and its current applications, benefits, and possible advances in the future.
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23
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Rohde E, Goudarzi M, Madajka M, Said SAD, Ordenana C, Rezaei M, Fahradyan V, Pozza ED, Willard B, Brunengraber H, Dasarathy S, Rampazzo A, Gharb BB. Metabolic Profiling of Skeletal Muscle During Ex-Vivo Normothermic Limb Perfusion. Mil Med 2021; 186:358-363. [PMID: 33499445 DOI: 10.1093/milmed/usaa268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 07/29/2020] [Accepted: 08/18/2020] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Ex vivo normothermic limb perfusion (EVNLP) provides several advantages for the preservation of limbs following amputation: the ability to maintain oxygenation and temperature of the limb close to physiological values, a perfusion solution providing all necessary nutrients at optimal concentrations, and the ability to maintain physiological pH and electrolytes. However, EVNLP cannot preserve the organ viability infinitely. We identified evidence of mitochondrial injury (swelling, elongation, and membrane disruption) after 24 hours of EVNLP of human upper extremities. The goal of this study was to identify metabolic derangements in the skeletal muscle during EVNLP. MATERIALS AND METHODS Fourteen human upper extremities were procured from organ donors after family consent. Seven limbs underwent EVNLP for an average of 41.6 ± 9.4 hours, and seven contralateral limbs were preserved at 4°C for the same amount of time. Muscle biopsies were performed at 24 hours of perfusion, both from the EVNLP and control limbs. Perturbations in the metabolic profiles of the muscle during EVNLP were determined via untargeted liquid chromatography-mass spectrometry (MS) operated in positive and negative electrospray ionization modes, over a mass range of 50 to 750 Da. The data were deconvoluted using the XCMS software and further statistically analyzed using the in-house statistical package, MetaboLyzer. Putative identification of metabolites using exact mass within ±7 ppm mass error and MS/MS spectral matching to the mzCloud spectral library were performed via Compound Discoverer v.2.1 (Thermo Scientific, Fremont, CA, USA). We further validated the identity of candidate metabolites by matching the fragmentation pattern of these metabolites to those of their reference pure chemicals. A nonparametric Mann-Whitney U-test was used to compare EVNLP and control group spectral features. Differences were considered significantly different when P-value < 0.05. RESULTS We detected over 13,000 spectral features of which 58 met the significance criteria with biologically relevant putative identifications. Furthermore we were able to confirm the identities of the ions taurine (P-value: 0.002) and tryptophan (P-value: 0.002), which were among the most significantly perturbed ions at 24 hours between the experimental and control groups. Metabolites belonging to the following pathways were the most perturbed at 24 hours: neuroactive ligand-receptor interaction (P-values: 0.031 and 0.036) and amino acid metabolism, including tyrosine and tryptophan metabolism (P-values: 0.015, 0.002, and 0.017). Taurine abundance decreased and tryptophan abundance increased at 24 hours. Other metabolites also identified at 24 hours included phenylalanine, xanthosine, and citric acid (P-values: 0.002, 0.002, and 0.0152). DISCUSSION This study showed presence of active metabolism during EVNLP and metabolic derangement toward the end of perfusion, which correlated with detection of altered mitochondrial structure, swelling, and elongation.
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Affiliation(s)
- Elizabeth Rohde
- Cleveland Clinic Department of Plastic Surgery, Cleveland, OH 44195, USA
| | - Maryam Goudarzi
- Cleveland Clinic Lerner Research Institute Proteomics and Metabolomics Core, Cleveland, OH 44195, USA
| | - Maria Madajka
- Cleveland Clinic Department of Plastic Surgery, Cleveland, OH 44195, USA
| | - Sayf Al-Deen Said
- Cleveland Clinic Department of Plastic Surgery, Cleveland, OH 44195, USA
| | - Carlos Ordenana
- Cleveland Clinic Department of Plastic Surgery, Cleveland, OH 44195, USA
| | - Majid Rezaei
- Cleveland Clinic Department of Plastic Surgery, Cleveland, OH 44195, USA
| | - Vahe Fahradyan
- Cleveland Clinic Department of Plastic Surgery, Cleveland, OH 44195, USA
| | - Edoardo Dall Pozza
- Cleveland Clinic Department of Plastic Surgery, Cleveland, OH 44195, USA
| | - Belinda Willard
- Cleveland Clinic Lerner Research Institute Proteomics and Metabolomics Core, Cleveland, OH 44195, USA
| | - Henri Brunengraber
- Case Western Reserve University School of Medicine Department of Nutrition and Biochemistry, Cleveland, OH 44106, USA
| | - Srinivasan Dasarathy
- Cleveland Clinic Lerner Research Institute Department of Pathobiology, Cleveland, OH 44195, USA
| | - Antonio Rampazzo
- Cleveland Clinic Department of Plastic Surgery, Cleveland, OH 44195, USA
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Serifis N, Matheson R, Cloonan D, Rickert CG, Markmann JF, Coe TM. Machine Perfusion of the Liver: A Review of Clinical Trials. Front Surg 2021; 8:625394. [PMID: 33842530 PMCID: PMC8033162 DOI: 10.3389/fsurg.2021.625394] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 03/01/2021] [Indexed: 12/20/2022] Open
Abstract
Although efforts have been made by transplant centers to increase the pool of available livers by extending the criteria of liver acceptance, this practice creates risks for recipients that include primary non-function of the graft, early allograft dysfunction and post-operative complications. Donor liver machine perfusion (MP) is a promising novel strategy that not only decreases cold ischemia time, but also serves as a method of assessing the viability of the graft. In this review, we summarize the data from liver machine perfusion clinical trials and discuss the various techniques available to date as well as future applications of machine perfusion. A variety of approaches have been reported including hypothermic machine perfusion (HMP) and normothermic machine perfusion (NMP); the advantages and disadvantages of each are just now beginning to be resolved. Important in this effort is developing markers of viability with lactate being the most predictive of graft functionality. The advent of machine perfusion has also permitted completely ischemia free transplantation by utilization of in situ NMP showed promising results. Animal studies that focus on defatting steatotic livers via NMP as well as groups that work on regenerating liver tissue ex vivo via MP. The broad incorporation of machine perfusion into routine clinical practice seems incredible.
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Affiliation(s)
| | | | | | | | - James F. Markmann
- Center for Transplantation Sciences, Massachusetts General Hospital, Boston, MA, United States
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25
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Wang PP, Huang X, Yang MW, Fang SY, Hong FF, Yang SL. Effects of non-drug treatment on liver cells apoptosis during hepatic ischemia-reperfusion injury. Life Sci 2021; 275:119321. [PMID: 33711387 DOI: 10.1016/j.lfs.2021.119321] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 02/27/2021] [Accepted: 03/01/2021] [Indexed: 01/20/2023]
Abstract
Hepatic ischemia reperfusion injury (HIRI) is an important cause of liver dysfunction after liver transplantation for the patients suffered from fatty liver, non-alcoholic cirrhosis, or liver cancer. It is closely related to liver cells apoptosis. Therefore, how to maintain the stable state of cell apoptosis is important to protect the liver from HIRI. Drug treatment basically applies some active substances directly or indirectly, reducing HIRI. But their toxic side effects limit the clinical applications. Differently, non-drug treatment means making use of other kinds of measures to reduce the damage, such as non-pharmaceutical preparations, surgical methods, inhalation or perfusion gas, and so on. Non-drug treatments have been shown to balance cell apoptosis and reduce liver damage during HIRI. This review summarized the progresses in the roles of non-drug treatments on liver cells apoptosis during HIRI in recent years, focusing on apoptosis inducing factors, its signal transduction pathway, and downstream molecules, etc., expecting to elucidate non-drug treatments of anti-HIRI more systematically.
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Affiliation(s)
- Pei-Pei Wang
- Department of Physiology, College of Medicine, Nanchang University, Nanchang 330006, China; Department of Stomatology, Affiliated Third Hospital of Soochow University, The First People's Hospital of Changzhou, Changzhou 213003, China
| | - Xia Huang
- Department of Physiology, College of Medicine, Nanchang University, Nanchang 330006, China
| | - Mei-Wen Yang
- Department of Nurse, Nanchang University Hospital, Nanchang 330006, Jiangxi Province, China
| | - Shi-Yao Fang
- Department of Physiology, College of Medicine, Nanchang University, Nanchang 330006, China
| | - Fen-Fang Hong
- Department of Experimental Teaching Center, Nanchang University, Nanchang 330031, China.
| | - Shu-Long Yang
- Department of Physiology, College of Medicine, Nanchang University, Nanchang 330006, China.
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26
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Tatum R, O'Malley TJ, Bodzin AS, Tchantchaleishvili V. Machine perfusion of donor organs for transplantation. Artif Organs 2021; 45:682-695. [PMID: 33349946 DOI: 10.1111/aor.13894] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 11/25/2020] [Accepted: 12/17/2020] [Indexed: 12/16/2022]
Abstract
The ever-widening gap between organ supply and demand has resulted in an organ shortage crisis that affects patients all over the world. For decades, static cold storage (SCS) was the gold standard preservation strategy because of its simplicity and cost-effectiveness, but the rising unmet demand for donor organ transplants has prompted investigation into preservation strategies that can expand the available donor pool. Through ex vivo functional assessment of the organ prior to transplant, newer methods to preserve organs such as perfusion-based therapy can potentially expand the available organ pool. This review will explain the physiologic rationale for SCS before exploring the advantages and disadvantages associated with the two broad classes of preservation strategies that have emerged to address the crisis: hypothermic and normothermic machine perfusion. A detailed analysis of how each preservation strategy works will be provided before investigating the current status of clinical data for each preservation strategy for the kidney, liver, pancreas, heart, and lung. For some organs there is robust data to support the use of machine perfusion technologies over SCS, and in others the data are less clear. Nonetheless, machine perfusion technologies represent an exciting frontier in organ preservation research and will remain a crucial component of closing the gap between organ supply and recipient demand.
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Affiliation(s)
- Robert Tatum
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Thomas J O'Malley
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Adam S Bodzin
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA, USA
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27
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Panconesi R, Flores Carvalho M, Mueller M, Meierhofer D, Dutkowski P, Muiesan P, Schlegel A. Viability Assessment in Liver Transplantation-What Is the Impact of Dynamic Organ Preservation? Biomedicines 2021; 9:biomedicines9020161. [PMID: 33562406 PMCID: PMC7915925 DOI: 10.3390/biomedicines9020161] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 02/02/2021] [Accepted: 02/03/2021] [Indexed: 02/07/2023] Open
Abstract
Based on the continuous increase of donor risk, with a majority of organs classified as marginal, quality assessment and prediction of liver function is of utmost importance. This is also caused by the notoriously lack of effective replacement of a failing liver by a device or intensive care treatment. While various parameters of liver function and injury are well-known from clinical practice, the majority of specific tests require prolonged diagnostic time and are more difficult to assess ex situ. In addition, viability assessment of procured organs needs time, because the development of the full picture of cellular injury and the initiation of repair processes depends on metabolic active tissue and reoxygenation with full blood over several hours or days. Measuring injury during cold storage preservation is therefore unlikely to predict the viability after transplantation. In contrast, dynamic organ preservation strategies offer a great opportunity to assess organs before implantation through analysis of recirculating perfusates, bile and perfused liver tissue. Accordingly, several parameters targeting hepatocyte or cholangiocyte function or metabolism have been recently suggested as potential viability tests before organ transplantation. We summarize here a current status of respective machine perfusion tests, and report their clinical relevance.
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Affiliation(s)
- Rebecca Panconesi
- Hepatobiliary Unit, Careggi University Hospital, University of Florence, 50134 Florence, Italy; (R.P.); (M.F.C.); (P.M.)
| | - Mauricio Flores Carvalho
- Hepatobiliary Unit, Careggi University Hospital, University of Florence, 50134 Florence, Italy; (R.P.); (M.F.C.); (P.M.)
| | - Matteo Mueller
- Department of Visceral Surgery and Transplantation, University Hospital Zurich, Swiss HPB and Transplant Center, 8091 Zurich, Switzerland; (M.M.); (P.D.)
| | - David Meierhofer
- Max Planck Institute for Molecular Genetics, Mass Spectrometry Facility, 14195 Berlin, Germany;
| | - Philipp Dutkowski
- Department of Visceral Surgery and Transplantation, University Hospital Zurich, Swiss HPB and Transplant Center, 8091 Zurich, Switzerland; (M.M.); (P.D.)
| | - Paolo Muiesan
- Hepatobiliary Unit, Careggi University Hospital, University of Florence, 50134 Florence, Italy; (R.P.); (M.F.C.); (P.M.)
| | - Andrea Schlegel
- Hepatobiliary Unit, Careggi University Hospital, University of Florence, 50134 Florence, Italy; (R.P.); (M.F.C.); (P.M.)
- Department of Visceral Surgery and Transplantation, University Hospital Zurich, Swiss HPB and Transplant Center, 8091 Zurich, Switzerland; (M.M.); (P.D.)
- Correspondence:
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28
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Zhang Y, Pan Q, Cheng Y, Liu Y. Effects of SP600125 and hypothermic machine perfusion on livers donated after cardiac death in a pig allograft transplantation model. Eur J Med Res 2021; 26:15. [PMID: 33546770 PMCID: PMC7863371 DOI: 10.1186/s40001-020-00472-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 12/14/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Hypothermic machine perfusion (HMP) improves the quality of donor livers for transplantation, both in animal models and in clinical practice. Treatment with SP600125, an inhibitor of c-Jun N-terminal kinase (JNK), can suppress the JNK signaling pathway to alleviate donor liver ischemia-reperfusion injury (IRI). We performed the present study with the objective of exploring the protective effects exerted by a combination of HMP and SP600125 on liver xenograft viability for donation after cardiac death (DCD) in a porcine model. METHODS 54 adult BAMA mini-pigs were randomly assigned to 5 groups, including sham, cold storage for 4 h (CS 4 h), CS 4 h + SP600125, CS 2 h + HMP 2 h, and CS 2 h + HMP 2 h + SP600125 groups. Donor livers in the CS 4 h and CS 4 h + SP600125 groups were conventionally cold preserved for 4 h, whereas donor livers in the CS 2 h + HMP 2 h and CS 2 h + HMP 2 h + SP600125 groups were cold preserved for 2 h and then treated with HMP for 2 h. The preservation and perfusion solutions contained SP600125 (20 µM). Follow-up was conducted for 5 days after liver transplantation to compare the surgical outcomes by means of serological examination, pathological results, and survival rate. RESULTS The most satisfactory outcome after liver transplantation was observed in the CS 2 h + HMP 2 h + SP600125 group, which presented with minimal damage of donor livers during 5 days' follow-up. Additionally, serological examination, pathological results, and survival rate concurred in showing better results in the CS 2 h + HMP 2 h ± SP600125 group than in the CS 4 h ± SP600125 group. CONCLUSION HMP in combination with SP600125 has hepatoprotective properties and improves the quality and viability of porcine livers collected after DCD, thus improving prognosis after liver transplantation.
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Affiliation(s)
- Yijie Zhang
- Department of Organ Transplantation and Hepatobiliary, The First Affiliated Hospital of China Medical University, No. 155, Nanjing Street, Shenyang, 110001, Liaoning, People's Republic of China.,The Key Laboratory of Organ Transplantation of Liaoning Province, The First Affiliated Hospital of China Medical University, No. 155, Nanjing Street, Shenyang, 110001, Liaoning, People's Republic of China
| | - Qi Pan
- Department of Organ Transplantation and Hepatobiliary, The First Affiliated Hospital of China Medical University, No. 155, Nanjing Street, Shenyang, 110001, Liaoning, People's Republic of China.,The Key Laboratory of Organ Transplantation of Liaoning Province, The First Affiliated Hospital of China Medical University, No. 155, Nanjing Street, Shenyang, 110001, Liaoning, People's Republic of China
| | - Ying Cheng
- Department of Organ Transplantation and Hepatobiliary, The First Affiliated Hospital of China Medical University, No. 155, Nanjing Street, Shenyang, 110001, Liaoning, People's Republic of China.,The Key Laboratory of Organ Transplantation of Liaoning Province, The First Affiliated Hospital of China Medical University, No. 155, Nanjing Street, Shenyang, 110001, Liaoning, People's Republic of China
| | - Yongfeng Liu
- Department of Organ Transplantation and Hepatobiliary, The First Affiliated Hospital of China Medical University, No. 155, Nanjing Street, Shenyang, 110001, Liaoning, People's Republic of China. .,The Key Laboratory of Organ Transplantation of Liaoning Province, The First Affiliated Hospital of China Medical University, No. 155, Nanjing Street, Shenyang, 110001, Liaoning, People's Republic of China.
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29
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Aufhauser DD, Foley DP. Beyond Ice and the Cooler: Machine Perfusion Strategies in Liver Transplantation. Clin Liver Dis 2021; 25:179-194. [PMID: 33978577 DOI: 10.1016/j.cld.2020.08.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Machine perfusion (MP) has emerged as a promising preservation technique to reduce the risks associated with transplant of high risk (steatotic, elderly, and donation after circulatory death) hepatic allografts. Multiple strategies for MP are under investigation. MP facilitates assessment of organ viability and enables liver-directed therapy before transplant. Clinical trials suggest MP may improve the use of hepatic allografts, mitigate ischemia-reperfusion injury, and reduce the incidences of early allograft dysfunction, biliary complications, and ischemic cholangiopathy. As MP sees more widespread use outside of trial settings, more investigation will be needed to establish optimal application of this technology.
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Affiliation(s)
- David D Aufhauser
- Department of Surgery, Division of Transplantation, University of Wisconsin, 600 Highland Avenue, MC 7375, Madison, WI 53792, USA
| | - David P Foley
- Department of Surgery, Division of Transplantation, University of Wisconsin, CSC H5/701, 600 Highland Avenue, Madison, WI 52792, USA.
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30
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Michelotto J, Gassner JMGV, Moosburner S, Muth V, Patel MS, Selzner M, Pratschke J, Sauer IM, Raschzok N. Ex vivo machine perfusion: current applications and future directions in liver transplantation. Langenbecks Arch Surg 2021; 406:39-54. [PMID: 33216216 PMCID: PMC7870621 DOI: 10.1007/s00423-020-02014-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 07/21/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Liver transplantation is the only curative treatment option for end-stage liver disease; however, its use remains limited due to a shortage of suitable organs. In recent years, ex vivo liver machine perfusion has been introduced to liver transplantation, as a means to expand the donor organ pool. PURPOSE To present a systematic review of prospective clinical studies on ex vivo liver machine perfusion, in order to assess current applications and highlight future directions. METHODS A systematic literature search of both PubMed and ISI web of science databases as well as the ClinicalTrials.gov registry was performed. RESULTS Twenty-one articles on prospective clinical trials on ex vivo liver machine perfusion were identified. Out of these, eight reported on hypothermic, eleven on normothermic, and two on sequential perfusion. These trials have demonstrated the safety and feasibility of ex vivo liver machine perfusion in both standard and expanded criteria donors. Currently, there are twelve studies enrolled in the clinicaltrials.gov registry, and these focus on use of ex vivo perfusion in extended criteria donors and declined organs. CONCLUSION Ex vivo liver machine perfusion seems to be a suitable strategy to expand the donor pool for liver transplantation and holds promise as a platform for reconditioning diseased organs.
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Affiliation(s)
- Julian Michelotto
- Charité - Universitätsmedizin Berlin, Department of Surgery, Experimental Surgery, corporate member of Freie Universität Berlin, Humboldt- Universität zu Berlin and Berlin Institute of Health, Campus Charité Mitte | Campus Virchow-Klinikum, Berlin, Germany
| | - Joseph M G V Gassner
- Charité - Universitätsmedizin Berlin, Department of Surgery, Experimental Surgery, corporate member of Freie Universität Berlin, Humboldt- Universität zu Berlin and Berlin Institute of Health, Campus Charité Mitte | Campus Virchow-Klinikum, Berlin, Germany
| | - Simon Moosburner
- Charité - Universitätsmedizin Berlin, Department of Surgery, Experimental Surgery, corporate member of Freie Universität Berlin, Humboldt- Universität zu Berlin and Berlin Institute of Health, Campus Charité Mitte | Campus Virchow-Klinikum, Berlin, Germany
| | - Vanessa Muth
- Charité - Universitätsmedizin Berlin, Department of Surgery, Experimental Surgery, corporate member of Freie Universität Berlin, Humboldt- Universität zu Berlin and Berlin Institute of Health, Campus Charité Mitte | Campus Virchow-Klinikum, Berlin, Germany
| | - Madhukar S Patel
- Department of Surgery, Abdominal Transplant and HPB Surgery, Ajmera Family Transplant Centre, Toronto General Hospital, Toronto, ON, Canada
| | - Markus Selzner
- Department of Surgery, Abdominal Transplant and HPB Surgery, Ajmera Family Transplant Centre, Toronto General Hospital, Toronto, ON, Canada
| | - Johann Pratschke
- Charité - Universitätsmedizin Berlin, Department of Surgery, Experimental Surgery, corporate member of Freie Universität Berlin, Humboldt- Universität zu Berlin and Berlin Institute of Health, Campus Charité Mitte | Campus Virchow-Klinikum, Berlin, Germany
| | - Igor M Sauer
- Charité - Universitätsmedizin Berlin, Department of Surgery, Experimental Surgery, corporate member of Freie Universität Berlin, Humboldt- Universität zu Berlin and Berlin Institute of Health, Campus Charité Mitte | Campus Virchow-Klinikum, Berlin, Germany
| | - Nathanael Raschzok
- Charité - Universitätsmedizin Berlin, Department of Surgery, Experimental Surgery, corporate member of Freie Universität Berlin, Humboldt- Universität zu Berlin and Berlin Institute of Health, Campus Charité Mitte | Campus Virchow-Klinikum, Berlin, Germany.
- Department of Surgery, Abdominal Transplant and HPB Surgery, Ajmera Family Transplant Centre, Toronto General Hospital, Toronto, ON, Canada.
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Avolio AW, Franco A, Schlegel A, Lai Q, Meli S, Burra P, Patrono D, Ravaioli M, Bassi D, Ferla F, Pagano D, Violi P, Camagni S, Dondossola D, Montalti R, Alrawashdeh W, Vitale A, Teofili L, Spoletini G, Magistri P, Bongini M, Rossi M, Mazzaferro V, Di Benedetto F, Hammond J, Vivarelli M, Agnes S, Colledan M, Carraro A, Cescon M, De Carlis L, Caccamo L, Gruttadauria S, Muiesan P, Cillo U, Romagnoli R, De Simone P. Development and Validation of a Comprehensive Model to Estimate Early Allograft Failure Among Patients Requiring Early Liver Retransplant. JAMA Surg 2020; 155:e204095. [PMID: 33112390 PMCID: PMC7593884 DOI: 10.1001/jamasurg.2020.4095] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Question Can the individual risk estimation for early allograft failure (EAF) be improved in view of liver retransplant? Findings In this multicenter cohort study investigating the association between donor-recipient factors and EAF, a novel Early Allograft Failure Simplified Estimation (EASE) score was developed. The score includes Model for End-stage Liver Disease score, transfused packed red blood cells, and hepatic vessel early thrombosis as well as transaminases, platelet, and bilirubin kinetics as variables on day 10 after transplant. The EASE score outperformed previous model scores, estimating EAF risk with 87% accuracy on day 90 after transplant; EASE was developed on a multicenter Italian database (1609 recipients) and validated on an external UK database (538 recipients). Meaning In this study, the EASE score rated the EAF risk (0%-100%) and identified cases at unsustainable risk to be listed for retransplant. Importance Expansion of donor acceptance criteria for liver transplant increased the risk for early allograft failure (EAF), and although EAF prediction is pivotal to optimize transplant outcomes, there is no consensus on specific EAF indicators or timing to evaluate EAF. Recently, the Liver Graft Assessment Following Transplantation (L-GrAFT) algorithm, based on aspartate transaminase, bilirubin, platelet, and international normalized ratio kinetics, was developed from a single-center database gathered from 2002 to 2015. Objective To develop and validate a simplified comprehensive model estimating at day 10 after liver transplant the EAF risk at day 90 (the Early Allograft Failure Simplified Estimation [EASE] score) and, secondarily, to identify early those patients with unsustainable EAF risk who are suitable for retransplant. Design, Setting, and Participants This multicenter cohort study was designed to develop a score capturing a continuum from normal graft function to nonfunction after transplant. Both parenchymal and vascular factors, which provide an indication to list for retransplant, were included among the EAF determinants. The L-GrAFT kinetic approach was adopted and modified with fewer data entries and novel variables. The population included 1609 patients in Italy for the derivation set and 538 patients in the UK for the validation set; all were patients who underwent transplant in 2016 and 2017. Main Outcomes and Measures Early allograft failure was defined as graft failure (codified by retransplant or death) for any reason within 90 days after transplant. Results At day 90 after transplant, the incidence of EAF was 110 of 1609 patients (6.8%) in the derivation set and 41 of 538 patients (7.6%) in the external validation set. Median (interquartile range) ages were 57 (51-62) years in the derivation data set and 56 (49-62) years in the validation data set. The EASE score was developed through 17 entries derived from 8 variables, including the Model for End-stage Liver Disease score, blood transfusion, early thrombosis of hepatic vessels, and kinetic parameters of transaminases, platelet count, and bilirubin. Donor parameters (age, donation after cardiac death, and machine perfusion) were not associated with EAF risk. Results were adjusted for transplant center volume. In receiver operating characteristic curve analyses, the EASE score outperformed L-GrAFT, Model for Early Allograft Function, Early Allograft Dysfunction, Eurotransplant Donor Risk Index, donor age × Model for End-stage Liver Disease, and Donor Risk Index scores, estimating day 90 EAF in 87% (95% CI, 83%-91%) of cases in both the derivation data set and the internal validation data set. Patients could be stratified in 5 classes, with those in the highest class exhibiting unsustainable EAF risk. Conclusions and Relevance This study found that the developed EASE score reliably estimated EAF risk. Knowledge of contributing factors may help clinicians to mitigate risk factors and guide them through the challenging clinical decision to allocate patients to early liver retransplant. The EASE score may be used in translational research across transplant centers.
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Affiliation(s)
- Alfonso W Avolio
- Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
| | - Antonio Franco
- Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Rome, Italy
| | | | | | | | | | | | | | | | | | - Duilio Pagano
- ISMETT (Mediterranean Institute for Transplantation and Advanced Specialized Therapies), Palermo, Italy
| | | | | | - Daniele Dondossola
- Fondazione IRCCS Ospedale Maggiore Policlinico, Università degli Studi, Milan, Italy
| | | | | | | | - Luciana Teofili
- Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
| | - Gabriele Spoletini
- Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Rome, Italy.,Newcastle Upon Tyne Hospital, Newcastle Upon Tyne, United Kingdom
| | | | - Marco Bongini
- Istituto Nazionale Tumori, IRCCS, and Università degli Studi, Milan, Italy
| | | | | | | | - John Hammond
- Newcastle Upon Tyne Hospital, Newcastle Upon Tyne, United Kingdom
| | | | - Salvatore Agnes
- Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
| | | | | | - Matteo Cescon
- S. Orsola-Malpighi University Hospital, Bologna, Italy
| | | | - Lucio Caccamo
- Fondazione IRCCS Ospedale Maggiore Policlinico, Università degli Studi, Milan, Italy
| | - Salvatore Gruttadauria
- ISMETT (Mediterranean Institute for Transplantation and Advanced Specialized Therapies), Palermo, Italy
| | - Paolo Muiesan
- Queen Elizabeth Hospital, Birmingham, United Kingdom
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32
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Panayotova GG, Rosado J, Paterno F, Deo D, Dikdan G, McCarty MA, Arrington B, Giudice A, Fano A, Dhaduk N, Lunsford KE, Rao P, Guarrera JV. Novel oxygenation technique for hypothermic machine perfusion of liver grafts: Validation in porcine Donation after Cardiac Death (DCD) liver model. Am J Surg 2020; 220:1270-1277. [PMID: 32892979 DOI: 10.1016/j.amjsurg.2020.06.072] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 04/29/2020] [Accepted: 06/26/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Hypothermic oxygenated machine perfusion improves outcomes in Liver Transplantation, but application is limited as O2 is supplied by a stationary circuit. A novel technique of O2 "pre-charge" in a portable pump would broaden use and further mitigate ischemia damage from organ transport. METHODS Porcine DCD livers were randomized to static cold storage (SCS, n = 8) or hypothermic machine perfusion (HMP). HMP was stratified into HMP-O2 (n = 5), non-O2 open to air HMP-RA (n = 5), and non-O2 with sealed lids or no air HMP-NA (n = 5). HMP-O2 was "pre-charged" using 100% O2 delivered at 10 L/min over 15 min. Perfusate and tissue O2 tension (pO2), liver biopsies, and fluid chemistries were analyzed. RESULTS "Pre-charge" achieves sustained tissue and perfusate pO2 vs others. HMP-O2 results in decreased markers of hepatocyte injury: ALT (p < 0.05) and LDH (p < 0.05), lower expression of CRP and higher expression of SOD1 vs SCS. This suggests decreased inflammation and improved ROS scavenging. CONCLUSIONS "Pre-charge" is an effective technique, which allows portability and transport without an O2 source and improves graft parameters.
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Affiliation(s)
- Guergana G Panayotova
- Department of Surgery, Division of Transplant and Hepatobiliary Surgery, Rutgers New Jersey Medical School, 185 South Orange Ave MSB G586, Newark, NJ, 07103, USA.
| | - Jesus Rosado
- Department of Surgery, Division of Transplant and Hepatobiliary Surgery, Rutgers New Jersey Medical School, 185 South Orange Ave MSB G586, Newark, NJ, 07103, USA
| | - Flavio Paterno
- Department of Surgery, Division of Transplant and Hepatobiliary Surgery, Rutgers New Jersey Medical School, 185 South Orange Ave MSB G586, Newark, NJ, 07103, USA
| | - Dayanand Deo
- New Jersey Sharing Network, 691 Central Avenue, New Providence, NJ, 07974, USA
| | - George Dikdan
- Department of Surgery, Division of Transplant and Hepatobiliary Surgery, Rutgers New Jersey Medical School, 185 South Orange Ave MSB G586, Newark, NJ, 07103, USA
| | - Matthew A McCarty
- Department of Surgery, Division of Transplant and Hepatobiliary Surgery, Rutgers New Jersey Medical School, 185 South Orange Ave MSB G586, Newark, NJ, 07103, USA
| | - Ben Arrington
- Organ Recovery Systems, One Pierce Place, Suite 475W, Itasca, IL, 60143, USA
| | - Anthony Giudice
- Organ Recovery Systems, One Pierce Place, Suite 475W, Itasca, IL, 60143, USA
| | - Adam Fano
- Department of Surgery, Division of Transplant and Hepatobiliary Surgery, Rutgers New Jersey Medical School, 185 South Orange Ave MSB G586, Newark, NJ, 07103, USA
| | - Nehal Dhaduk
- Department of Surgery, Division of Transplant and Hepatobiliary Surgery, Rutgers New Jersey Medical School, 185 South Orange Ave MSB G586, Newark, NJ, 07103, USA
| | - Keri E Lunsford
- Department of Surgery, Division of Transplant and Hepatobiliary Surgery, Rutgers New Jersey Medical School, 185 South Orange Ave MSB G586, Newark, NJ, 07103, USA
| | - Prakash Rao
- New Jersey Sharing Network, 691 Central Avenue, New Providence, NJ, 07974, USA
| | - James V Guarrera
- Department of Surgery, Division of Transplant and Hepatobiliary Surgery, Rutgers New Jersey Medical School, 185 South Orange Ave MSB G586, Newark, NJ, 07103, USA.
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Baidya R, Crawford DHG, Gautheron J, Wang H, Bridle KR. Necroptosis in Hepatosteatotic Ischaemia-Reperfusion Injury. Int J Mol Sci 2020; 21:ijms21165931. [PMID: 32824744 PMCID: PMC7460692 DOI: 10.3390/ijms21165931] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 08/12/2020] [Accepted: 08/12/2020] [Indexed: 02/07/2023] Open
Abstract
While liver transplantation remains the sole treatment option for patients with end-stage liver disease, there are numerous limitations to liver transplantation including the scarcity of donor livers and a rise in livers that are unsuitable to transplant such as those with excess steatosis. Fatty livers are susceptible to ischaemia-reperfusion (IR) injury during transplantation and IR injury results in primary graft non-function, graft failure and mortality. Recent studies have described new cell death pathways which differ from the traditional apoptotic pathway. Necroptosis, a regulated form of cell death, has been associated with hepatic IR injury. Receptor-interacting protein kinase 3 (RIPK3) and mixed-lineage kinase domain-like pseudokinase (MLKL) are thought to be instrumental in the execution of necroptosis. The study of hepatic necroptosis and potential therapeutic approaches to attenuate IR injury will be a key factor in improving our knowledge regarding liver transplantation with fatty donor livers. In this review, we focus on the effect of hepatic steatosis during liver transplantation as well as molecular mechanisms of necroptosis and its involvement during liver IR injury. We also discuss the immune responses triggered during necroptosis and examine the utility of necroptosis inhibitors as potential therapeutic approaches to alleviate IR injury.
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Affiliation(s)
- Raji Baidya
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland QLD 4006, Australia; (R.B.); (D.H.G.C.)
- Gallipoli Medical Research Institute, Brisbane, Queensland QLD 4120, Australia;
| | - Darrell H. G. Crawford
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland QLD 4006, Australia; (R.B.); (D.H.G.C.)
- Gallipoli Medical Research Institute, Brisbane, Queensland QLD 4120, Australia;
| | - Jérémie Gautheron
- Sorbonne University, Inserm, Centre de Recherche Saint-Antoine (CRSA), 75012 Paris, France;
- Institute of Cardiometabolism and Nutrition (ICAN), 75013 Paris, France
| | - Haolu Wang
- Gallipoli Medical Research Institute, Brisbane, Queensland QLD 4120, Australia;
- Diamantina Institute, The University of Queensland, Brisbane, Queensland QLD 4102, Australia
| | - Kim R. Bridle
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland QLD 4006, Australia; (R.B.); (D.H.G.C.)
- Gallipoli Medical Research Institute, Brisbane, Queensland QLD 4120, Australia;
- Correspondence: ; Tel.: +61-7-3346-0698
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Jia J, Nie Y, Li J, Xie H, Zhou L, Yu J, Zheng SS. A Systematic Review and Meta-Analysis of Machine Perfusion vs. Static Cold Storage of Liver Allografts on Liver Transplantation Outcomes: The Future Direction of Graft Preservation. Front Med (Lausanne) 2020; 7:135. [PMID: 32528963 PMCID: PMC7247831 DOI: 10.3389/fmed.2020.00135] [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: 02/05/2020] [Accepted: 03/30/2020] [Indexed: 12/19/2022] Open
Abstract
Background: Machine perfusion (MP) and static cold storage (CS) are two prevalent methods for liver allograft preservation. However, the preferred method remains controversial. Aim: To conduct a meta-analysis on the impact of MP preservation on liver transplant outcome. Methods: PubMed, EMBASE, and Cochrane Library databases were systematically searched to identify relevant trials comparing the efficacy of MP vs. CS. Odds ratios (OR) and fixed-effects models were calculated to compare the pooled data. Results: Ten prospective cohort studies and two randomized controlled trials (RCTs) were included (MP livers vs. CS livers = 315:489). Machine perfusion demonstrated superior outcomes in posttransplantation aspartate aminotransferase levels compared to CS (P < 0.05). The overall incidence of early allograft dysfunction (EAD) was significantly reduced with MP preservation than CS [OR = 0.46; 95% confidence interval (CI) = 0.31–0.67; P < 0.0001]. The incidence of total biliary complications (OR = 0.53; 95% CI = 0.34–0.83; P = 0.006) and that of ischemic cholangiopathy (OR = 0.39; 95% CI = 0.18–0.85; P = 0.02) were significantly lower in recipients with MP preservation compared with CS preservation. Hypothermic machine perfusion (HMP) but not normothermic machine perfusion (NMP) was found to significantly protect grafts from total biliary complications and ischemic cholangiopathy (P < 0.05). However, no significant differences could be detected utilizing either HMP or NMP in primary nonfunction, hepatic artery thrombosis, postreperfusion syndrome, 1-year patient survival, or 1-year graft survival (P > 0.05). Conclusions: Machine perfusion is superior to CS on improving short-term outcomes for human liver transplantation, with a less clear effect in the longer term. Hypothermic machine perfusion but not NMP conducted significantly protective effects on EAD and biliary complications. Further RCTs are warranted to confirm MP's superiority and applications.
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Affiliation(s)
- Junjun Jia
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, College of Medicine, Hangzhou, China.,Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health, Hangzhou, China
| | - Yu Nie
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, College of Medicine, Hangzhou, China.,Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health, Hangzhou, China
| | - Jianhui Li
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, College of Medicine, Hangzhou, China.,Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health, Hangzhou, China
| | - Haiyang Xie
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, College of Medicine, Hangzhou, China.,Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health, Hangzhou, China
| | - Lin Zhou
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, College of Medicine, Hangzhou, China.,Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health, Hangzhou, China
| | - Jun Yu
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, College of Medicine, Hangzhou, China.,Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health, Hangzhou, China
| | - Shu-Sen Zheng
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, College of Medicine, Hangzhou, China.,Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health, Hangzhou, China
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Aoudjehane L, Gautheron J, Le Goff W, Goumard C, Gilaizeau J, Nget CS, Savier E, Atif M, Lesnik P, Morichon R, Chrétien Y, Calmus Y, Scatton O, Housset C, Conti F. Novel defatting strategies reduce lipid accumulation in primary human culture models of liver steatosis. Dis Model Mech 2020; 13:dmm042663. [PMID: 32094147 PMCID: PMC7197711 DOI: 10.1242/dmm.042663] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 02/13/2020] [Indexed: 12/13/2022] Open
Abstract
Normothermic perfusion provides a means to rescue steatotic liver grafts, including by pharmacological defatting. In this study, we tested the potential of new drug combinations to trigger defatting in three human culture models, primary hepatocytes with induced steatosis, primary hepatocytes isolated from steatotic liver, and precision-cut liver slices (PCLS) of steatotic liver. Forskolin, L-carnitine and a PPARα agonist were all combined with rapamycin, an immunosuppressant that induces autophagy, in a D-FAT cocktail. D-FAT was tested alone or in combination with necrosulfonamide, an inhibitor of mixed lineage kinase domain like pseudokinase involved in necroptosis. Within 24 h, in all three models, D-FAT induced a decrease in triglyceride content by 30%, attributable to an upregulation of genes involved in free fatty acid β-oxidation and autophagy, and a downregulation of those involved in lipogenesis. Defatting was accompanied by a decrease in endoplasmic reticulum stress and in the production of reactive oxygen species. The addition of necrosulfonamide increased the efficacy of defatting by 8%-12% in PCLS, with a trend towards increased autophagy. In conclusion, culture models, notably PCLS, are insightful to design strategies for liver graft rescue. Defatting can be rapidly achieved by combinations of drugs targeting mitochondrial oxidative metabolism, macro-autophagy and lipogenesis.
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Affiliation(s)
- Lynda Aoudjehane
- Institute of Cardiometabolism and Nutrition (ICAN), Sorbonne Université, INSERM, Paris 75012, France
- Centre de Recherche Saint-Antoine (CRSA), Sorbonne Université, INSERM, Paris 75013, France
| | - Jérémie Gautheron
- Institute of Cardiometabolism and Nutrition (ICAN), Sorbonne Université, INSERM, Paris 75012, France
- Centre de Recherche Saint-Antoine (CRSA), Sorbonne Université, INSERM, Paris 75013, France
| | - Wilfried Le Goff
- Institute of Cardiometabolism and Nutrition (ICAN), Sorbonne Université, INSERM, Paris 75012, France
| | - Claire Goumard
- Institute of Cardiometabolism and Nutrition (ICAN), Sorbonne Université, INSERM, Paris 75012, France
- Centre de Recherche Saint-Antoine (CRSA), Sorbonne Université, INSERM, Paris 75013, France
- Department of Hepatobiliary and Liver Transplantation Surgery, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris, Paris 75013, France
| | - Julia Gilaizeau
- Institute of Cardiometabolism and Nutrition (ICAN), Sorbonne Université, INSERM, Paris 75012, France
- Centre de Recherche Saint-Antoine (CRSA), Sorbonne Université, INSERM, Paris 75013, France
| | - Chan Sonavine Nget
- Institute of Cardiometabolism and Nutrition (ICAN), Sorbonne Université, INSERM, Paris 75012, France
- Centre de Recherche Saint-Antoine (CRSA), Sorbonne Université, INSERM, Paris 75013, France
| | - Eric Savier
- Institute of Cardiometabolism and Nutrition (ICAN), Sorbonne Université, INSERM, Paris 75012, France
- Centre de Recherche Saint-Antoine (CRSA), Sorbonne Université, INSERM, Paris 75013, France
- Department of Hepatobiliary and Liver Transplantation Surgery, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris, Paris 75013, France
| | - Muhammad Atif
- Centre d'immunologie et maladies infectieuses, Sorbonne Université, INSERM, U1135, Paris 75013, France
| | - Philippe Lesnik
- Institute of Cardiometabolism and Nutrition (ICAN), Sorbonne Université, INSERM, Paris 75012, France
| | - Romain Morichon
- Production et Analyse des données en Sciences de la vie et en Santé (PASS), Sorbonne Université, INSERM, UMS 37, Paris 75013, France
| | - Yves Chrétien
- Institute of Cardiometabolism and Nutrition (ICAN), Sorbonne Université, INSERM, Paris 75012, France
- Centre de Recherche Saint-Antoine (CRSA), Sorbonne Université, INSERM, Paris 75013, France
| | - Yvon Calmus
- Department of Medical Liver Transplantation, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris, Paris 75013, France
| | - Olivier Scatton
- Institute of Cardiometabolism and Nutrition (ICAN), Sorbonne Université, INSERM, Paris 75012, France
- Centre de Recherche Saint-Antoine (CRSA), Sorbonne Université, INSERM, Paris 75013, France
- Department of Hepatobiliary and Liver Transplantation Surgery, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris, Paris 75013, France
| | - Chantal Housset
- Institute of Cardiometabolism and Nutrition (ICAN), Sorbonne Université, INSERM, Paris 75012, France
- Centre de Recherche Saint-Antoine (CRSA), Sorbonne Université, INSERM, Paris 75013, France
- Department of Hepatology, Reference Center for Inflammatory Biliary Diseases and Autoimmune Hepatitis, Saint-Antoine Hospital, Assistance Publique-Hôpitaux de Paris, Paris 75012, France
| | - Filomena Conti
- Institute of Cardiometabolism and Nutrition (ICAN), Sorbonne Université, INSERM, Paris 75012, France
- Centre de Recherche Saint-Antoine (CRSA), Sorbonne Université, INSERM, Paris 75013, France
- Department of Medical Liver Transplantation, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris, Paris 75013, France
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36
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Czigany Z, Lurje I, Schmelzle M, Schöning W, Öllinger R, Raschzok N, Sauer IM, Tacke F, Strnad P, Trautwein C, Neumann UP, Fronek J, Mehrabi A, Pratschke J, Schlegel A, Lurje G. Ischemia-Reperfusion Injury in Marginal Liver Grafts and the Role of Hypothermic Machine Perfusion: Molecular Mechanisms and Clinical Implications. J Clin Med 2020; 9:E846. [PMID: 32244972 PMCID: PMC7141496 DOI: 10.3390/jcm9030846] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 03/09/2020] [Accepted: 03/11/2020] [Indexed: 12/19/2022] Open
Abstract
Ischemia-reperfusion injury (IRI) constitutes a significant source of morbidity and mortality after orthotopic liver transplantation (OLT). The allograft is metabolically impaired during warm and cold ischemia and is further damaged by a paradox reperfusion injury after revascularization and reoxygenation. Short-term and long-term complications including post-reperfusion syndrome, delayed graft function, and immune activation have been associated with IRI. Due to the current critical organ shortage, extended criteria grafts are increasingly considered for transplantation, however, with an elevated risk to develop significant features of IRI. In recent years, ex vivo machine perfusion (MP) of the donor liver has witnessed significant advancements. Here, we describe the concept of hypothermic (oxygenated) machine perfusion (HMP/HOPE) approaches and highlight which allografts may benefit from this technology. This review also summarizes clinical applications and the main aspects of ongoing randomized controlled trials on hypothermic perfusion. The mechanistic aspects of IRI and hypothermic MP-which include tissue energy replenishment, optimization of mitochondrial function, and the reduction of oxidative and inflammatory damage following reperfusion-will be comprehensively discussed within the context of current preclinical and clinical evidence. Finally, we highlight novel trends and future perspectives in the field of hypothermic MP in the context of recent findings of basic and translational research.
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Affiliation(s)
- Zoltan Czigany
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, 52074 Aachen, Germany; (Z.C.); (U.P.N.)
| | - Isabella Lurje
- Department of Surgery, Campus Charité Mitte | Campus Virchow-Klinikum—Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany; (I.L.); (M.S.); (W.S.); (R.Ö.); (N.R.); (I.M.S.); (J.P.)
| | - Moritz Schmelzle
- Department of Surgery, Campus Charité Mitte | Campus Virchow-Klinikum—Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany; (I.L.); (M.S.); (W.S.); (R.Ö.); (N.R.); (I.M.S.); (J.P.)
| | - Wenzel Schöning
- Department of Surgery, Campus Charité Mitte | Campus Virchow-Klinikum—Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany; (I.L.); (M.S.); (W.S.); (R.Ö.); (N.R.); (I.M.S.); (J.P.)
| | - Robert Öllinger
- Department of Surgery, Campus Charité Mitte | Campus Virchow-Klinikum—Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany; (I.L.); (M.S.); (W.S.); (R.Ö.); (N.R.); (I.M.S.); (J.P.)
| | - Nathanael Raschzok
- Department of Surgery, Campus Charité Mitte | Campus Virchow-Klinikum—Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany; (I.L.); (M.S.); (W.S.); (R.Ö.); (N.R.); (I.M.S.); (J.P.)
| | - Igor M. Sauer
- Department of Surgery, Campus Charité Mitte | Campus Virchow-Klinikum—Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany; (I.L.); (M.S.); (W.S.); (R.Ö.); (N.R.); (I.M.S.); (J.P.)
| | - Frank Tacke
- Department of Hepatology and Gastroenterology, Campus Charité Mitte | Campus Virchow-Klinikum—Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany;
| | - Pavel Strnad
- Department of Gastroenterology, Metabolic Disorders and Intensive Care, University Hospital RWTH Aachen, 52074 Aachen, Germany; (P.S.); (C.T.)
| | - Christian Trautwein
- Department of Gastroenterology, Metabolic Disorders and Intensive Care, University Hospital RWTH Aachen, 52074 Aachen, Germany; (P.S.); (C.T.)
| | - Ulf Peter Neumann
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, 52074 Aachen, Germany; (Z.C.); (U.P.N.)
| | - Jiri Fronek
- Department of Transplant Surgery, Institute for Clinical and Experimental Medicine, 140 21 Prague, Czech Republic;
| | - Arianeb Mehrabi
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, 69120 Heidelberg, Germany;
| | - Johann Pratschke
- Department of Surgery, Campus Charité Mitte | Campus Virchow-Klinikum—Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany; (I.L.); (M.S.); (W.S.); (R.Ö.); (N.R.); (I.M.S.); (J.P.)
| | - Andrea Schlegel
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham B15 2TH, UK;
| | - Georg Lurje
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, 52074 Aachen, Germany; (Z.C.); (U.P.N.)
- Department of Surgery, Campus Charité Mitte | Campus Virchow-Klinikum—Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany; (I.L.); (M.S.); (W.S.); (R.Ö.); (N.R.); (I.M.S.); (J.P.)
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37
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Kvietkauskas M, Leber B, Strupas K, Stiegler P, Schemmer P. Machine Perfusion of Extended Criteria Donor Organs: Immunological Aspects. Front Immunol 2020; 11:192. [PMID: 32180769 PMCID: PMC7057848 DOI: 10.3389/fimmu.2020.00192] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Accepted: 01/24/2020] [Indexed: 12/20/2022] Open
Abstract
Due to higher vulnerability and immunogenicity of extended criteria donor (ECD) organs used for organ transplantation (Tx), the discovery of new treatment strategies, involving tissue allorecognition pathways, is important. The implementation of machine perfusion (MP) led to improved estimation of the organ quality and introduced the possibility to achieve graft reconditioning prior to Tx. A significant number of experimental and clinical trials demonstrated increasing support for MP as a promising method of ECD organ preservation compared to classical static cold storage. MP reduced ischemia-reperfusion injury resulting in the protection from inadequate activation of innate immunity. However, there are no general agreements on MP protocols, and clinical application is limited. The objective of this comprehensive review is to summarize literature on immunological effects of MP of ECD organs based on experimental studies and clinical trials.
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Affiliation(s)
- Mindaugas Kvietkauskas
- Department of General, Visceral and Transplant Surgery, Medical University of Graz, Graz, Austria.,Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Bettina Leber
- Department of General, Visceral and Transplant Surgery, Medical University of Graz, Graz, Austria
| | | | - Philipp Stiegler
- Department of General, Visceral and Transplant Surgery, Medical University of Graz, Graz, Austria
| | - Peter Schemmer
- Department of General, Visceral and Transplant Surgery, Medical University of Graz, Graz, Austria
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38
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Cell release during perfusion reflects cold ischemic injury in rat livers. Sci Rep 2020; 10:1102. [PMID: 31980677 PMCID: PMC6981218 DOI: 10.1038/s41598-020-57589-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 12/28/2019] [Indexed: 12/13/2022] Open
Abstract
The global shortage of donor organs has made it crucial to deeply understand and better predict donor liver viability. However, biomarkers that effectively assess viability of marginal grafts for organ transplantation are currently lacking. Here, we showed that hepatocytes, sinusoidal endothelial, stellate, and liver-specific immune cells were released into perfusates from Lewis rat livers as a result of cold ischemia and machine perfusion. Perfusate comparison analysis of fresh livers and cold ischemic livers showed that the released cell profiles were significantly altered by the duration of cold ischemia. Our findings show for the first time that parenchymal cells are released from organs under non-proliferative pathological conditions, correlating with the degree of ischemic injury. Thus, perfusate cell profiles could serve as potential biomarkers of graft viability and indicators of specific injury mechanisms during organ handling and transplantation. Further, parenchymal cell release may have applications in other pathological conditions beyond organ transplantation.
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Buchwald JE, Xu J, Bozorgzadeh A, Martins PN. Therapeutics administered during ex vivo liver machine perfusion: An overview. World J Transplant 2020; 10:1-14. [PMID: 32110510 PMCID: PMC7031625 DOI: 10.5500/wjt.v10.i1.1] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Revised: 10/26/2019] [Accepted: 12/06/2019] [Indexed: 02/06/2023] Open
Abstract
Although the use of extended criteria donors has increased the pool of available livers for transplant, it has also introduced the need to develop improved methods of protection against ischemia-reperfusion injury (IRI), as these "marginal" organs are particularly vulnerable to IRI during the process of procurement, preservation, surgery, and post-transplantation. In this review, we explore the current basic science research investigating therapeutics administered during ex vivo liver machine perfusion aimed at mitigating the effects of IRI in the liver transplantation process. These various categories of therapeutics are utilized during the perfusion process and include invoking the RNA interference pathway, utilizing defatting cocktails, and administering classes of agents such as vasodilators, anti-inflammatory drugs, human liver stem cell-derived extracellular vesicles, and δ-opioid agonists in order to reduce the damage of IRI. Ex vivo machine perfusion is an attractive alternative to static cold storage due to its ability to continuously perfuse the organ, effectively deliver substrates and oxygen required for cellular metabolism, therapeutically administer pharmacological or cytoprotective agents, and continuously monitor organ viability during perfusion. The use of administered therapeutics during machine liver perfusion has demonstrated promising results in basic science studies. While novel therapeutic approaches to combat IRI are being developed through basic science research, their use in clinical medicine and treatment in patients for liver transplantation has yet to be explored.
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Affiliation(s)
- Julianna E Buchwald
- Division of Transplantation, Department of Surgery, University of Massachusetts Medical School, Worcester, MA 01655, United States
| | - Jing Xu
- Division of Transplantation, Department of Surgery, University of Massachusetts Medical School, Worcester, MA 01655, United States
| | - Adel Bozorgzadeh
- Division of Transplantation, Department of Surgery, University of Massachusetts Medical School, Worcester, MA 01655, United States
| | - Paulo N Martins
- Division of Transplantation, Department of Surgery, University of Massachusetts Medical School, Worcester, MA 01655, United States
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40
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Relaxin Positively Influences Ischemia-Reperfusion Injury in Solid Organ Transplantation: A Comprehensive Review. Int J Mol Sci 2020; 21:ijms21020631. [PMID: 31963613 PMCID: PMC7013572 DOI: 10.3390/ijms21020631] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 01/07/2020] [Accepted: 01/17/2020] [Indexed: 02/07/2023] Open
Abstract
In recent decades, solid organ transplantation (SOT) has increased the survival and quality of life for patients with end-stage organ failure by providing a potentially long-term treatment option. Although the availability of organs for transplantation has increased throughout the years, the demand greatly outweighs the supply. One possible solution for this problem is to extend the potential donor pool by using extended criteria donors. However, organs from such donors are more prone to ischemia reperfusion injury (IRI) resulting in higher rates of delayed graft function, acute and chronic graft rejection and worse overall SOT outcomes. This can be overcome by further investigating donor preconditioning strategies, graft perfusion and storage and by finding novel therapeutic agents that could reduce IRI. relaxin (RLX) is a peptide hormone with antifibrotic, antioxidant, anti-inflammatory and cytoprotective properties. The main research until now focused on heart failure; however, several preclinical studies showed its potentials for reducing IRI in SOT. The aim of this comprehensive review is to overview currently available literature on the possible role of RLX in reducing IRI and its positive impact on SOT.
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Hypothermic Oxygenated Machine Perfusion Alleviates Donation After Circulatory Death Liver Injury Through Regulating P-selectin-dependent and -independent Pathways in Mice. Transplantation 2019; 103:918-928. [PMID: 31033856 DOI: 10.1097/tp.0000000000002621] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Hypothermic oxygenated machine perfusion (HOPE) has been shown to improve the quality of liver donation after circulatory death (DCD) compared to cold storage (CS). However, the mechanism by which HOPE works is unclear. In this study, a mouse liver HOPE system was developed to characterize the role of P-selectin in the protective effect of HOPE on DCD livers. METHODS A warm ischemia model of the liver and an isolated perfused liver system were established to determine a suitable flow rate for HOPE. Perfusate and tissue samples from wild-type and P-selectin knockout (KO) mice were used to determine liver function, apoptosis and necrosis rates, deoxyribonucleic acid injury and oxidative stress levels, leukocyte and endothelial cell activation, and inflammatory reactions. RESULTS A mouse liver HOPE system was successfully established. HOPE at flow rates between 0.1 and 0.5 mL/min · g were shown to have a protective effect on the DCD liver. P-selectin KO improved the quality of the DCD liver in the CS group, and reduction of P-selectin expression in the wild-type HOPE group had similar protective effects. Moreover, there was a reduction in the degree of oxidative stress and deoxyribonucleic acid injury in the P-selectin KO HOPE group compared with the P-selectin KO CS group. CONCLUSIONS We established a mouse HOPE system and determined its suitable flow. We also proved that P-selectin deficiency alleviated DCD liver injury. HOPE protected the DCD liver through regulating P-selectin-dependent and -independent pathways.
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Agopian VG, Harlander-Locke MP, Markovic D, Dumronggittigule W, Xia V, Kaldas FM, Zarrinpar A, Yersiz H, Farmer DG, Hiatt JR, Busuttil RW. Evaluation of Early Allograft Function Using the Liver Graft Assessment Following Transplantation Risk Score Model. JAMA Surg 2019; 153:436-444. [PMID: 29261831 DOI: 10.1001/jamasurg.2017.5040] [Citation(s) in RCA: 99] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Importance Early allograft dysfunction (EAD) following a liver transplant (LT) unequivocally portends adverse graft and patient outcomes, but a widely accepted classification or grading system is lacking. Objective To develop a model for individualized risk estimation of graft failure after LT and then compare the model's prognostic performance with the existing binary EAD definition (bilirubin level of ≥10 mg/dL on postoperative day 7, international normalized ratio of ≥1.6 on postoperative day 7, or aspartate aminotransferase or alanine aminotransferase level of >2000 U/L within the first 7 days) and the Model for Early Allograft Function (MEAF) score. Design, Setting, and Participants This retrospective single-center analysis used a transplant database to identify all adult patients who underwent a primary LT and had data on 10 days of post-LT laboratory variables at the Dumont-UCLA Transplant Center of the David Geffen School of Medicine at UCLA between February 1, 2002, and June 30, 2015. Data collection took place from January 4, 2016, to June 30, 2016. Data analysis was conducted from July 1, 2016, to August 30, 2017. Main Outcomes and Measures Three-month graft failure-free survival. Results Of 2021 patients who underwent primary LT over the study period, 2008 (99.4%) had available perioperative data and were included in the analysis. The median (interquartile range [IQR]) age of recipients was 56 (49-62) years, and 1294 recipients (64.4%) were men. Overall survival and graft-failure-free survival rates were 83% and 81% at year 1, 74% and 71% at year 3, and 69% and 65% at year 5, with an 11.1% (222 recipients) incidence of 3-month graft failure or death. Multivariate factors associated with 3-month graft failure-free survival included post-LT aspartate aminotransferase level, international normalized ratio, bilirubin level, and platelet count, measures of which were used to calculate the Liver Graft Assessment Following Transplantation (L-GrAFT) risk score. The L-GrAFT model had an excellent C statistic of 0.85, with a significantly superior discrimination of 3-month graft failure-free survival compared with the existing EAD definition (C statistic, 0.68; P < .001) and the MEAF score (C statistic, 0.70; P < .001). Compared with patients with lower L-GrAFT risk, LT recipients in the highest 10th percentile of L-GrAFT scores had higher Model for End-Stage Liver Disease scores (median [IQR], 34 [26-40] vs 31 [25-38]; P = .005); greater need for pretransplant hospitalization (56.8% vs 44.8%; P = .003), renal replacement therapy (42.9% vs 30.5%; P < .001), mechanical ventilation (35.8% vs 18.1%; P < .001), and vasopressors (22.9% vs 11.0%; P < .001); longer cold ischemia times (median [IQR], 436 [311-539] vs 401 [302-506] minutes; P = .04); greater intraoperative blood transfusions (median [IQR], 17 [10-26] vs 10 [6-17] units of packed red blood cells; P < .001); and older donors (median [IQR] age, 47 [28-56] vs 41 [25-52] years; P < .001). Conclusions and Relevance The L-GrAFT risk score allows a highly accurate, individualized risk estimation of 3-month graft failure following LT that is more accurate than existing EAD and MEAF scores. Multicenter validation may allow for the adoption of the L-GrAFT as a tool for evaluating the need for a retransplant, for establishing standardized grading of early allograft function across transplant centers, and as a highly accurate clinical end point in translational studies aiming to mitigate ischemia or reperfusion injury by modulating donor quality and recipient factors.
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Affiliation(s)
- Vatche G Agopian
- Dumont-UCLA (University of California, Los Angeles) Transplant and Liver Cancer Centers, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles
| | - Michael P Harlander-Locke
- Dumont-UCLA (University of California, Los Angeles) Transplant and Liver Cancer Centers, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles
| | | | - Wethit Dumronggittigule
- Dumont-UCLA (University of California, Los Angeles) Transplant and Liver Cancer Centers, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles.,Department of Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Salaya, Thailand
| | - Victor Xia
- Department of Anesthesia, David Geffen School of Medicine at UCLA, Los Angeles
| | - Fady M Kaldas
- Dumont-UCLA (University of California, Los Angeles) Transplant and Liver Cancer Centers, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles
| | - Ali Zarrinpar
- Dumont-UCLA (University of California, Los Angeles) Transplant and Liver Cancer Centers, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles
| | - Hasan Yersiz
- Dumont-UCLA (University of California, Los Angeles) Transplant and Liver Cancer Centers, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles
| | - Douglas G Farmer
- Dumont-UCLA (University of California, Los Angeles) Transplant and Liver Cancer Centers, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles
| | - Jonathan R Hiatt
- Dumont-UCLA (University of California, Los Angeles) Transplant and Liver Cancer Centers, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles
| | - Ronald W Busuttil
- Dumont-UCLA (University of California, Los Angeles) Transplant and Liver Cancer Centers, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles
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Effect of the Selective NLRP3 Inflammasome Inhibitor mcc950 on Transplantation Outcome in a Pig Liver Transplantation Model With Organs From Donors After Circulatory Death Preserved by Hypothermic Machine Perfusion. Transplantation 2019; 103:353-362. [PMID: 30247318 DOI: 10.1097/tp.0000000000002461] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND We investigated whether the outcome of organs from donors after circulatory death (DCD) can be improved by the addition of mcc950 to the perfusate of the hypothermic machine perfusion (HMP) system and intravenous mcc950 injection after transplantation in a pig liver transplantation model. METHODS Thirty-six healthy Bama mini pigs randomized into 3 groups. All the DCD livers were preserved in an HMP system after 2 hours of simple cold storage. In HMP-Postop group, mcc950 was added to the perfusate; in the control group and Postop group, the perfusate was normal LPS. After transplantation, the pigs in the Postop group and HMP-Postop group were intravenously administered 3 mg/kg mcc950, at the time of reperfusion and on day 2 and day 3 after transplantation. During the 3-day follow-up period, general operative characteristics, and serological markers and histological features related to ischemia reperfusion injury were examined. RESULTS The HMP-Postop group suffer the lightest ischemia reperfusion injury (IRI), and functioned best after transplantation. Model for the Early Allograft Function Score (predictor of long-term survival), degree of injury in the hepatocytes and rate of apoptosis was lowest in the HMP-Postop group. Further, in the HMP-Postop group, the nucleotide-binding domain leucine-rich repeat containing family pyrin domain containing 3 inflammasome pathway activation was lowest, and the level of IL-1β was lowest. Postop group functioned better than control group, but not comparable with HMP-Postop group. CONCLUSIONS The outcome of DCD organs can be improved by the addition of mcc950 to the perfusate of the HMP system and intravenous injection of mcc950 after transplantation.
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Hessheimer AJ, Riquelme F, Fundora-Suárez Y, García Pérez R, Fondevila C. Normothermic perfusion and outcomes after liver transplantation. Transplant Rev (Orlando) 2019; 33:200-208. [PMID: 31239189 DOI: 10.1016/j.trre.2019.06.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 06/04/2019] [Accepted: 06/09/2019] [Indexed: 01/04/2023]
Abstract
Ischemia has been a persistent and largely unavoidable element in solid organ transplantation, contributing to graft deterioration and adverse post-transplant outcomes. In liver transplantation, where available organs arise with greater frequency from marginal donors (i.e., ones that are older, obese, and/or declared dead following cardiac arrest through the donation after circulatory death process), there is increasing interest using dynamic perfusion strategies to limit, assess, and even reverse the adverse effects of ischemia in these grafts. Normothermic perfusion, in particular, is used to restore the flow of oxygen and other metabolic substrates at physiological temperatures. It may be used in liver transplantation both in situ following cardiac arrest in donation after circulatory death donors or during part or all of the ex situ preservation phase. This review article addresses issues relevant to use of normothermic perfusion strategies in liver transplantation, including technical and logistical aspects associated with establishing and maintaining normothermic perfusion in its different forms and clinical outcomes that have been reported to date.
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Affiliation(s)
- Amelia J Hessheimer
- Hepatopancreatobiliary Surgery & Transplantation, General & Digestive Surgery Service, Digestive & Metabolic Disease Institute (ICMDM), Hospital Clínic, CIBERehd, IDIBAPS, University of Barcelona, Spain.
| | - Francisco Riquelme
- Hepatopancreatobiliary Surgery & Transplantation, General & Digestive Surgery Service, Digestive & Metabolic Disease Institute (ICMDM), Hospital Clínic, CIBERehd, IDIBAPS, University of Barcelona, Spain
| | - Yiliam Fundora-Suárez
- Hepatopancreatobiliary Surgery & Transplantation, General & Digestive Surgery Service, Digestive & Metabolic Disease Institute (ICMDM), Hospital Clínic, CIBERehd, IDIBAPS, University of Barcelona, Spain
| | - Rocío García Pérez
- Hepatopancreatobiliary Surgery & Transplantation, General & Digestive Surgery Service, Digestive & Metabolic Disease Institute (ICMDM), Hospital Clínic, CIBERehd, IDIBAPS, University of Barcelona, Spain
| | - Constantino Fondevila
- Hepatopancreatobiliary Surgery & Transplantation, General & Digestive Surgery Service, Digestive & Metabolic Disease Institute (ICMDM), Hospital Clínic, CIBERehd, IDIBAPS, University of Barcelona, Spain
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Jia JJ, Xie HY, Li JH, He Y, Jiang L, He N, Zhou L, Wang W, Zheng SS. Graft protection of the liver by hypothermic machine perfusion involves recovery of graft regeneration in rats. J Int Med Res 2019; 47:427-437. [PMID: 30791830 PMCID: PMC6384453 DOI: 10.1177/0300060518787726] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Objective This study was performed to evaluate the impact and underlying mechanisms of hypothermic machine perfusion (HMP) on half-size liver graft regeneration. Methods Forty rats were randomly assigned to five groups: two in vitro groups (static cold storage [SCS] and HMP) and three in vivo groups (orthotopic liver transplantation, SCS, and HMP). Perfusates and plasma samples were collected for analysis of hepatic enzymes. Liver tissue was obtained for evaluation of histology, immunohistochemistry (Ki67 and proliferating cell nuclear antigen [PCNA]), and the regeneration rate. Cell cycle genes were analyzed by quantitative real-time polymerase chain reaction, and cyclin D1 and cyclin E1 were semiquantified by western blot. Results HMP improved histopathological outcomes and decreased hepatic enzyme release. The expression of Ki67 and PCNA demonstrated a greater proliferation activity in the HMP than SCS group, and the expression of almost all cell cycle genes was elevated following HMP. Western blot results showed higher protein levels of cyclin D1 and cyclin E1 in the HMP than SCS group. Conclusions Our findings suggest for the first time that half-size liver graft protection by HMP involves recovery of graft regeneration.
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Affiliation(s)
- Jun-Jun Jia
- 1 Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,*These authors contributed equally to this work
| | - Hai-Yang Xie
- 1 Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,2 Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health, Hangzhou, China.,3 Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Hangzhou, China.,*These authors contributed equally to this work
| | - Jian-Hui Li
- 1 Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yong He
- 1 Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Li Jiang
- 1 Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Ning He
- 1 Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,2 Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health, Hangzhou, China
| | - Lin Zhou
- 1 Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,2 Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health, Hangzhou, China.,3 Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Hangzhou, China
| | - Weilin Wang
- 1 Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,2 Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health, Hangzhou, China.,3 Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Hangzhou, China
| | - Shu-Sen Zheng
- 1 Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,2 Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health, Hangzhou, China.,3 Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Hangzhou, China
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Zhang Y, Zhang Y, Zhang M, Ma Z, Wu S. Hypothermic machine perfusion reduces the incidences of early allograft dysfunction and biliary complications and improves 1-year graft survival after human liver transplantation: A meta-analysis. Medicine (Baltimore) 2019; 98:e16033. [PMID: 31169745 PMCID: PMC6571373 DOI: 10.1097/md.0000000000016033] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND The worldwide organ shortage continues to be the main limitation of liver transplantation. To bridge the gap between the demand and supply of liver grafts, it becomes necessary to use extended criteria donor livers for transplantation. Hypothermic machine perfusion (HMP) is designed to improve the quality of preserved organs before implantation. In clinical liver transplantation, HMP is still in its infancy. METHODS A systematic search of the PubMed, EMBASE, Springer, and Cochrane Library databases was performed to identify studies comparing the outcomes in patients with HMP versus static cold storage (SCS) of liver grafts. The parameters analyzed included the incidences of primary nonfunction (PNF), early allograft dysfunction (EAD), vascular complications, biliary complications, length of hospital stay, and 1-year graft survival. RESULTS A total of 6 studies qualified for the review, involving 144 and 178 liver grafts with HMP or SCS preservation, respectively. The incidences of EAD and biliary complications were significantly reduced with an odds ratio (OR) of 0.36 (95% confidence interval [CI] 0.17-0.77, P = .008) and 0.47 (95% CI 0.28-0.76, P = .003), respectively, and 1-year graft survival was significantly increased with an OR of 2.19 (95% CI 1.14-4.20, P = .02) in HMP preservation compared to SCS. However, there was no difference in the incidence of PNF (OR 0.30, 95% CI 0.06-1.47, P = .14), vascular complications (OR 0.69, 95% CI 0.29-1.66, P = .41), and the length of hospital stay (mean difference -0.30, 95% CI -4.10 to 3.50, P = .88) between HMP and SCS preservation. CONCLUSIONS HMP was associated with a reduced incidence of EAD and biliary complications, as well as an increased 1-year graft survival, but it was not associated with the incidence of PNF, vascular complications, and the length of hospital stay.
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Affiliation(s)
- Yili Zhang
- Department of Medical Imaging, The First Affiliated Hospital of Xi’an Jiaotong University
| | - Yangmin Zhang
- Department of Blood Transfusion, Xi’an Central Hospital
| | - Mei Zhang
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi, P.R. China
| | - Zhenhua Ma
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi, P.R. China
| | - Shengli Wu
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi, P.R. China
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Tchilikidi KY. Liver graft preservation methods during cold ischemia phase and normothermic machine perfusion. World J Gastrointest Surg 2019; 11:126-142. [PMID: 31057698 PMCID: PMC6478595 DOI: 10.4240/wjgs.v11.i3.126] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 03/21/2019] [Accepted: 03/25/2019] [Indexed: 02/06/2023] Open
Abstract
The growing demand for donor organs requires measures to expand donor pool. Those include extended criteria donors, such as elderly people, steatotic livers, donation after cardiac death, etc. Static cold storage to reduce metabolic requirements developed by Collins in late 1960s is the mainstay and the golden standard for donated organ protection. Hypothermic machine perfusion provides dynamic organ preservation at 4°C with protracted infusion of metabolic substrates to the graft during the ex vivo period. It has been used instead of static cold storage or after it as short perfusion in transplant center. Normothermic machine perfusion (NMP) delivers oxygen, and nutrition at physiological temperature mimicking regular environment in order to support cellular function. This would minimize effects of ischemia/reperfusion injury. Potentially, NMP may help to estimate graft functionality before implantation into a recipient. Clinical studies demonstrated at least its non-inferiority or better outcomes vs static cold storage. Regular grafts donated after brain death could be safely preserved with convenient static cold storage. Except for prolonged ischemia time where hypothermic machine perfusion started in transplant center could be estimated to provide possible positive reconditioning effect. Use of hypothermic machine perfusion in regular donation instead of static cold storage or in extended criteria donors requires further investigation. Multicenter randomized clinical trial supposed to be completed in December 2021. Extended criteria donors need additional measures for graft storage and assessment until its implantation. NMP is actively evaluating promising method for this purpose. Future studies are necessary for precise estimation and confirmation to issue clinical practice recommendations.
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Czigany Z, Lurje I, Tolba RH, Neumann UP, Tacke F, Lurje G. Machine perfusion for liver transplantation in the era of marginal organs-New kids on the block. Liver Int 2019; 39:228-249. [PMID: 30129192 DOI: 10.1111/liv.13946] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 07/26/2018] [Accepted: 08/16/2018] [Indexed: 12/12/2022]
Abstract
In the face of a critical organ shortage in the Western world, various strategies are employed to expand the donor pool for orthotopic liver transplantation (OLT). Among them is the transplantation of organs from extended criteria donors, a valuable source of liver allografts, however, characterized by potential risks for post-OLT complications and inferior outcomes. In recent years, machine perfusion (MP) of the explanted donor liver as well as regional perfusion techniques has witnessed significant advancements. Here, we aim to discuss different modes of dynamic organ preservation in OLT. These include hypothermic and normothermic MP, hypothermic oxygenated machine perfusion (HOPE), controlled oxygenated rewarming as well as regional perfusion protocols. Over recent years, multiple feasibility trials have demonstrated the clinical prospects of MP. In the context of OLT using organs from extended criteria donors, MP has numerous advantages compared to conventional cold storage, some of which include the preservation and reconditioning of borderline transplantable organs and the viability assessment of high-risk donor allografts. This review aims to address the topic of liver allograft MP, highlighting particularly the current trends in clinical applications and future perspectives. Furthermore, different approaches of liver storage and reconditioning are reviewed in the context of ongoing research.
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Affiliation(s)
- Zoltan Czigany
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Isabella Lurje
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Rene H Tolba
- Institute for Laboratory Animal Science, University Hospital RWTH Aachen, Aachen, Germany
| | - Ulf P Neumann
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany.,Department of Surgery, Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands
| | - Frank Tacke
- Department of Gastroenterology, Metabolic Disorders and Intensive Care, University Hospital RWTH Aachen, Aachen, Germany
| | - Georg Lurje
- Department of Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
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Eschbach D, Horst K, Sassen M, Andruszkow J, Mohr J, Debus F, Vogt N, Steinfeldt T, Hildebrand F, Schöller K, Uhl E, Wulf H, Ruchholtz S, Pape H, Frink M. Hypothermia does not influence liver damage and function in a porcine polytrauma model. Technol Health Care 2018; 26:209-221. [PMID: 28968251 DOI: 10.3233/thc-171043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Previous studies revealed evidence that induced hypothermia attenuates ischemic organ injuries after severe trauma. In the present study, the effect of hypothermia on liver damage was investigated in a porcine long term model of multi-system injury, consisting of blunt chest trauma, penetrating abdominal trauma, musculoskeletal injury, and hemorrhagic shockMETHODS: In 30 pigs, a standardized polytrauma including blunt chest trauma, penetrating abdominal trauma, musculoskeletal injury, and hemorrhagic shock of 45% of total blood volume was induced. Following trauma, hypothermia of 33∘C was induced for 12 h and intensive care treatment was evaluated for 48 h. As outcome parameters, we assessed liver function and serum transaminase levels as well as a histopathological analysis of tissue samples. A further 10 animals served as controls. RESULTS Serum transaminase levels were increased at the end of the observation period following hypothermia without reaching statistical significance compared to normothermic groups. Liver function was preserved (p⩽ 0.05) after the rewarming period in hypothermic animals but showed no difference at the end of the observation period. In H&E staining, cell death was slightly increased hypothermic animals and caspase-3 staining displayed tendency towards more apoptosis in hypothermic group as well. CONCLUSIONS Induction of hypothermia could not significantly improve hepatic damage during the first 48 h following major trauma. Further studies focusing on multi-organ failure including a longer observation period are required to illuminate the impact of hypothermia on hepatic function in multiple trauma patients.
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Affiliation(s)
- D Eschbach
- Center for Orthopedics and Trauma Surgery, University Hospital Giessen and Marburg, Marburg, Germany
| | - K Horst
- Trauma Department, University of Aachen, Aachen, Germany
| | - M Sassen
- Department of Anesthesiology and Critical Care, University Hospital Giessen and Marburg, Marburg, Germany
| | - J Andruszkow
- Institute of Pathology, University of Aachen, Aachen, Germany
| | - J Mohr
- Department of Trauma Surgery, University of Magdeburg, Magdeburg, Germany
| | - F Debus
- Center for Orthopedics and Trauma Surgery, University Hospital Giessen and Marburg, Marburg, Germany
| | - N Vogt
- Department of Neurosurgery, University Hospital Giessen and Marburg, Giessen, Germany
| | - T Steinfeldt
- Department of Anesthesiology and Critical Care, Diakonie-Klinikum Schwäbisch Hall, Germany
| | - F Hildebrand
- Trauma Department, University of Aachen, Aachen, Germany
| | - K Schöller
- Department of Neurosurgery, University Hospital Giessen and Marburg, Giessen, Germany
| | - E Uhl
- Department of Neurosurgery, University Hospital Giessen and Marburg, Giessen, Germany
| | - H Wulf
- Department of Anesthesiology and Critical Care, University Hospital Giessen and Marburg, Marburg, Germany
| | - S Ruchholtz
- Center for Orthopedics and Trauma Surgery, University Hospital Giessen and Marburg, Marburg, Germany
| | - H Pape
- Department of Trauma, University of Zurich, Zurich, Switzerland
| | - M Frink
- Center for Orthopedics and Trauma Surgery, University Hospital Giessen and Marburg, Marburg, Germany
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Abudhaise H, Davidson BR, DeMuylder P, Luong TV, Fuller B. Evolution of dynamic, biochemical, and morphological parameters in hypothermic machine perfusion of human livers: A proof-of-concept study. PLoS One 2018; 13:e0203803. [PMID: 30216378 PMCID: PMC6138380 DOI: 10.1371/journal.pone.0203803] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 08/07/2018] [Indexed: 12/28/2022] Open
Abstract
INTRODUCTION Hypothermic machine perfusion (HMP) is increasingly investigated as a means to assess liver quality, but data on viability markers is inconsistent and the effects of different perfusion routes and oxygenation on perfusion biomarkers are unclear. METHODS This is a single-centre, randomised, multi-arm, parallel study using discarded human livers for evaluation of HMP using arterial, oxygen-supplemented venous and non-oxygen-supplemented venous perfusion. The study included 2 stages: in the first stage, 25 livers were randomised into static cold storage (n = 7), hepatic artery HMP (n = 10), and non-oxygen-supplemented portal vein HMP (n = 8). In the second stage, 20 livers were randomised into oxygen-supplemented and non-oxygen-supplemented portal vein HMP (n = 11 and 9, respectively). Changes in dynamic, biochemical, and morphologic parameters during 4-hour preservation were compared between perfusion groups, and between potentially transplantable and non-transplantable livers. RESULTS During arterial perfusion, resistance was higher and flow was lower than venous perfusion (p = 0.001 and 0.01, respectively); this was associated with higher perfusate markers during arterial perfusion (p>0.05). Supplementary oxygen did not cause a significant alteration in the studied parameters. Morphology was similar between static and dynamic preservation groups. Perfusate markers were 2 fold higher in non-transplantable livers (p>0.05). CONCLUSIONS Arterial only perfusion might not be adequate for graft perfusion. Hepatocellular injury markers are accessible and easy to perform and could offer insight into graft quality, but large randomised trials are needed to identify reliable quality assessment biomarkers.
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Affiliation(s)
- H. Abudhaise
- UCL Division of Surgery and Interventional Sciences, Royal Free Hospital, London, United Kingdom
- * E-mail:
| | - B. R. Davidson
- UCL Division of Surgery and Interventional Sciences, Royal Free Hospital, London, United Kingdom
| | | | - T. V. Luong
- Department of Cellular Pathology, Royal Free London NHS Foundation Trust, London, United Kingdom
| | - B. Fuller
- UCL Division of Surgery and Interventional Sciences, Royal Free Hospital, London, United Kingdom
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