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Kawamura M, Parmentier C, Ray S, Clotet-Freixas S, Leung S, John R, Mazilescu L, Nogueira E, Noguchi Y, Goto T, Arulratnam B, Ganesh S, Tamang T, Lees K, Reichman TW, Andreazza AC, Kim PK, Konvalinka A, Selzner M, Robinson LA. Normothermic ex vivo kidney perfusion preserves mitochondrial and graft function after warm ischemia and is further enhanced by AP39. Nat Commun 2024; 15:8086. [PMID: 39278958 PMCID: PMC11402965 DOI: 10.1038/s41467-024-52140-9] [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: 01/07/2024] [Accepted: 08/28/2024] [Indexed: 09/18/2024] Open
Abstract
We previously reported that normothermic ex vivo kidney perfusion (NEVKP) is superior in terms of organ protection compared to static cold storage (SCS), which is still the standard method of organ preservation, but the mechanisms are incompletely understood. We used a large animal kidney autotransplant model to evaluate mitochondrial function during organ preservation and after kidney transplantation, utilizing live cells extracted from fresh kidney tissue. Male porcine kidneys stored under normothermic perfusion showed preserved mitochondrial function and higher ATP levels compared to kidneys stored at 4 °C (SCS). Mitochondrial respiration and ATP levels were further enhanced when AP39, a mitochondria-targeted hydrogen sulfide donor, was administered during warm perfusion. Correspondingly, the combination of NEVKP and AP39 was associated with decreased oxidative stress and inflammation, and with improved graft function after transplantation. In conclusion, our findings suggest that the organ-protective effects of normothermic perfusion are mediated by maintenance of mitochondrial function and enhanced by AP39 administration. Activation of mitochondrial function through the combination of AP39 and normothermic perfusion could represent a new therapeutic strategy for long-term renal preservation.
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Affiliation(s)
- Masataka Kawamura
- Ajmera Transplant Centre, Toronto General Hospital, Toronto, Canada
- Division of Nephrology, The Hospital for Sick Children, Toronto, Canada
- Division of General Surgery, University Health Network, Toronto, Canada
- Department of Urology, Osaka General Medical Center, Osaka, Japan
| | - Catherine Parmentier
- Ajmera Transplant Centre, Toronto General Hospital, Toronto, Canada
- Division of General Surgery, University Health Network, Toronto, Canada
| | - Samrat Ray
- Ajmera Transplant Centre, Toronto General Hospital, Toronto, Canada
- Division of General Surgery, University Health Network, Toronto, Canada
| | - Sergi Clotet-Freixas
- Ajmera Transplant Centre, Toronto General Hospital, Toronto, Canada
- Toronto General Hospital Research Institute, University Health Network, Toronto, Canada
- Division of Nephrology, McMaster University and St. Joseph's Healthcare, Hamilton, Canada
| | - Sharon Leung
- Program in Cell Biology, The Hospital for Sick Children Research Institute, Toronto, Canada
| | - Rohan John
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada
- Department of Pathology, University Health Network, Toronto, Canada
| | - Laura Mazilescu
- Ajmera Transplant Centre, Toronto General Hospital, Toronto, Canada
- Division of Nephrology, The Hospital for Sick Children, Toronto, Canada
- Division of General Surgery, University Health Network, Toronto, Canada
- Department of General, Visceral, and Transplantation Surgery, University Hospital Essen, Essen, Germany
| | - Emmanuel Nogueira
- Ajmera Transplant Centre, Toronto General Hospital, Toronto, Canada
- Division of General Surgery, University Health Network, Toronto, Canada
| | - Yuki Noguchi
- Ajmera Transplant Centre, Toronto General Hospital, Toronto, Canada
- Division of General Surgery, University Health Network, Toronto, Canada
| | - Toru Goto
- Ajmera Transplant Centre, Toronto General Hospital, Toronto, Canada
- Division of General Surgery, University Health Network, Toronto, Canada
| | | | - Sujani Ganesh
- Ajmera Transplant Centre, Toronto General Hospital, Toronto, Canada
| | - Tomas Tamang
- Ajmera Transplant Centre, Toronto General Hospital, Toronto, Canada
| | - Kaitlin Lees
- Ajmera Transplant Centre, Toronto General Hospital, Toronto, Canada
- Program in Cell Biology, The Hospital for Sick Children Research Institute, Toronto, Canada
- Institute of Medical Science, University of Toronto, Toronto, Canada
| | - Trevor W Reichman
- Ajmera Transplant Centre, Toronto General Hospital, Toronto, Canada
- Division of General Surgery, University Health Network, Toronto, Canada
| | - Ana C Andreazza
- Departments of Pharmacology & Toxicology and Psychiatry, Mitochondrial Innovation Initiative, MITO2i, University of Toronto, Toronto, Canada
| | - Peter K Kim
- Program in Cell Biology, The Hospital for Sick Children Research Institute, Toronto, Canada
- Department of Biochemistry, University of Toronto, Toronto, Canada
| | - Ana Konvalinka
- Ajmera Transplant Centre, Toronto General Hospital, Toronto, Canada
- Toronto General Hospital Research Institute, University Health Network, Toronto, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada
- Institute of Medical Science, University of Toronto, Toronto, Canada
- Division of Nephrology, Department of Medicine, University Health Network, Toronto, Canada
| | - Markus Selzner
- Ajmera Transplant Centre, Toronto General Hospital, Toronto, Canada.
- Division of General Surgery, University Health Network, Toronto, Canada.
- Institute of Medical Science, University of Toronto, Toronto, Canada.
| | - Lisa A Robinson
- Division of Nephrology, The Hospital for Sick Children, Toronto, Canada.
- Program in Cell Biology, The Hospital for Sick Children Research Institute, Toronto, Canada.
- Institute of Medical Science, University of Toronto, Toronto, Canada.
- Department of Biochemistry, University of Toronto, Toronto, Canada.
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Steinhauser C, Yakac AE, Markgraf W, Kromnik S, Döcke A, Talhofer P, Thiele C, Malberg H, Füssel S, Thomas C, Putz J. Assessment of hemodynamic and blood parameters that may reflect macroscopic quality of porcine kidneys during normothermic machine perfusion using whole blood. World J Urol 2024; 42:471. [PMID: 39110171 PMCID: PMC11306647 DOI: 10.1007/s00345-024-05139-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 06/21/2024] [Indexed: 08/10/2024] Open
Abstract
PURPOSE Using ex vivo normothermic machine perfusion (NMP) with whole blood we assessed marginal porcine kidneys under reperfusion. The aim was to link measureable machine and clinical blood parameters with the currently used visual assessment. This could serve as a baseline for a standardized evaluation score to identify potentially transplantable kidneys in the future. METHODS Kidneys and autologous whole blood were procured from slaughterhouse pigs (n = 33) and were perfused for 4 h using NMP. The hemodynamic parameters arterial pressure (AP), renal blood flow (RBF) and intrarenal resistance (IRR) were measured. Activity of aspartate transaminase (AST), gamma-glutamyltransferase (GGT), alkaline phosphatase (ALP), lactate dehydrogenase (LDH) and lactate were assessed in blood at 0/1/2/4 h. Kidneys were grouped into "potentially transplantable" (PT) or "not transplantable" (NT) based on their overall macroscopic appearance after NMP by an experienced physician. RESULTS PT-kidneys (n = 20) had a significantly lower IRR and higher RBF than NT-kidneys (n = 13). GGT, ALP and LDH did not differ significantly, but at 4 h, AST was significantly higher in PT-kidneys compared to NT-kidneys. Lactate levels kept increasing during NMP in NT-kidneys and were significantly higher at 1/2/4 h than in PT-kidneys. CONCLUSION The immediately assessed macroscopic aspects of examined kidneys correlated with hemodynamic parameters, increased lactate and lower AST in this study. In the future, NMP with whole blood could be a useful tool to extend the donor pool by allowing the assessment of otherwise unknown characteristics of marginal kidneys before transplantation.
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Affiliation(s)
- Carla Steinhauser
- Department of Urology, Technische Universität Dresden, Fetscherstraße 74, 01307, Dresden, Germany.
| | - Abdulbaki Emre Yakac
- Department of Urology, Technische Universität Dresden, Fetscherstraße 74, 01307, Dresden, Germany
| | - Wenke Markgraf
- Institute of Biomedical Engineering, Technische Universität Dresden, Fetscherstraße 29, 01307, Dresden, Germany
| | - Susanne Kromnik
- Institute of Biomedical Engineering, Technische Universität Dresden, Fetscherstraße 29, 01307, Dresden, Germany
| | - Andreas Döcke
- Institute of Biomedical Engineering, Technische Universität Dresden, Fetscherstraße 29, 01307, Dresden, Germany
| | - Philipp Talhofer
- Institute of Biomedical Engineering, Technische Universität Dresden, Fetscherstraße 29, 01307, Dresden, Germany
| | - Christine Thiele
- Institute of Biomedical Engineering, Technische Universität Dresden, Fetscherstraße 29, 01307, Dresden, Germany
| | - Hagen Malberg
- Institute of Biomedical Engineering, Technische Universität Dresden, Fetscherstraße 29, 01307, Dresden, Germany
| | - Susanne Füssel
- Department of Urology, Technische Universität Dresden, Fetscherstraße 74, 01307, Dresden, Germany
| | - Christian Thomas
- Department of Urology, Technische Universität Dresden, Fetscherstraße 74, 01307, Dresden, Germany
| | - Juliane Putz
- Department of Urology, Technische Universität Dresden, Fetscherstraße 74, 01307, Dresden, Germany
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Pool MBF, Rozenberg KM, Lohmann S, Ottens PJ, Eijken M, Keller AK, Jespersen B, Ploeg RJ, Leuvenink HGD, Moers C. Ex-Vivo Kidney Perfusion With Hemoglobin-Based Oxygen Carriers, Red Blood Cells, or No Oxygen Carrier. J Surg Res 2024; 301:248-258. [PMID: 38970873 DOI: 10.1016/j.jss.2024.06.010] [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: 12/10/2023] [Revised: 05/16/2024] [Accepted: 06/17/2024] [Indexed: 07/08/2024]
Abstract
INTRODUCTION Normothermic machine perfusion (NMP) of donor kidneys provides the opportunity to assess and improve organ viability prior to transplantation. This study explored the necessity of an oxygen carrier during NMP and whether the hemoglobin-based oxygen carrier (HBOC-201) is a suitable alternative to red blood cells (RBCs). METHODS Porcine kidneys were perfused with a perfusion solution containing either no-oxygen carrier, RBCs, or HBOC-201 for 360 min at 37°C. RESULTS Renal flow and resistance did not differ significantly between groups. NMP without an oxygen carrier showed lower oxygen consumption with higher lactate and aspartate aminotransferase levels, indicating that the use of an oxygen carrier is necessary for NMP. Cumulative urine production and creatinine clearance in the RBC group were significantly higher than in the HBOC-201 group. Oxygen consumption, injury markers, and histology did not differ significantly between these two groups. However, methemoglobin levels increased to 45% after 360 min in the HBOC-201 group. CONCLUSIONS We conclude that HBOC-201 could be used as an alternative for RBCs, but accumulating methemoglobin levels during our perfusions indicated that HBOC-201 is probably less suitable for prolonged NMP. Perfusion with RBCs, compared to HBOC-201, resulted in more favorable renal function during NMP.
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Affiliation(s)
- Merel B F Pool
- Department of Surgery - Organ Donation and Transplantation, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
| | - Kaithlyn M Rozenberg
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
| | - Stine Lohmann
- Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark; Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Petra J Ottens
- Department of Surgery - Organ Donation and Transplantation, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Marco Eijken
- Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | | | - Bente Jespersen
- Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark; Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Rutger J Ploeg
- Department of Surgery - Organ Donation and Transplantation, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands; Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
| | - Henri G D Leuvenink
- Department of Surgery - Organ Donation and Transplantation, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Cyril Moers
- Department of Surgery - Organ Donation and Transplantation, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Abraham N, Gao Q, Kahan R, Alderete IS, Wang B, Howell DN, Anwar IJ, Ladowski JM, Nakata K, Jarrett E, Hlewicki K, Cywinska G, Neill R, Aardema C, Gerber DA, Roy-Chaudhury P, Hughes BA, Hartwig MG, Barbas AS. Subnormothermic Oxygenated Machine Perfusion (24 h) in DCD Kidney Transplantation. Transplant Direct 2024; 10:e1633. [PMID: 38807861 PMCID: PMC11132391 DOI: 10.1097/txd.0000000000001633] [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: 01/08/2024] [Revised: 02/07/2024] [Accepted: 02/08/2024] [Indexed: 05/30/2024] Open
Abstract
Background Ex vivo kidney perfusion is an evolving platform that demonstrates promise in preserving and rehabilitating the kidney grafts. Despite this, there is little consensus on the optimal perfusion conditions. Hypothermic perfusion offers limited functional assessment, whereas normothermic perfusion requires a more complex mechanical system and perfusate. Subnormothermic machine perfusion (SNMP) has the potential to combine the advantages of both approaches but has undergone limited investigation. Therefore, the present study sought to determine the suitability of SNMP for extended kidney preservation. Methods SNMP at 22-25 °C was performed on a portable device for 24 h with porcine kidneys. Graft assessment included measurement of mechanical parameters and biochemical analysis of the perfusate using point-of-care tests. To investigate the viability of kidneys preserved by SNMP, porcine kidney autotransplants were performed in a donation after circulatory death (DCD) model. SNMP was also compared with static cold storage (SCS). Finally, follow-up experiments were conducted in a subset of human kidneys to test the translational significance of findings in porcine kidneys. Results In the perfusion-only cohort, porcine kidneys all displayed successful perfusion for 24 h by SNMP, evidenced by stable mechanical parameters and biological markers of graft function. Furthermore, in the transplant cohort, DCD grafts with 30 min of warm ischemic injury demonstrated superior posttransplant graft function when preserved by SNMP in comparison with SCS. Finally, human kidneys that underwent 24-h perfusion exhibited stable functional and biological parameters consistent with observations in porcine organs. Conclusions These observations demonstrate the suitability and cross-species generalizability of subnormothermic machine perfusion to maintain stable kidney perfusion and provide foundational evidence for improved posttransplant graft function of DCD kidneys after SNMP compared with SCS.
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Affiliation(s)
- Nader Abraham
- Department of Surgery, Duke University, Duke Ex-Vivo Organ Lab (DEVOL), Durham, NC
| | - Qimeng Gao
- Department of Surgery, Duke University, Duke Ex-Vivo Organ Lab (DEVOL), Durham, NC
| | - Riley Kahan
- Department of Surgery, Duke University, Duke Ex-Vivo Organ Lab (DEVOL), Durham, NC
| | - Isaac S. Alderete
- Department of Surgery, Duke University, Duke Ex-Vivo Organ Lab (DEVOL), Durham, NC
| | - Bangchen Wang
- Department of Pathology, Duke University, Durham, NC
| | | | - Imran J. Anwar
- Department of Surgery, Duke University, Duke Ex-Vivo Organ Lab (DEVOL), Durham, NC
| | - Joseph M. Ladowski
- Department of Surgery, Duke University, Duke Ex-Vivo Organ Lab (DEVOL), Durham, NC
| | - Kentaro Nakata
- Department of Surgery, Duke University, Duke Ex-Vivo Organ Lab (DEVOL), Durham, NC
| | | | | | - Greta Cywinska
- Department of Surgery, Duke University, Duke Ex-Vivo Organ Lab (DEVOL), Durham, NC
| | - Ryan Neill
- Department of Surgery, Duke University, Duke Ex-Vivo Organ Lab (DEVOL), Durham, NC
| | | | - David A. Gerber
- Department of Surgery, University of North Carolina, Chapel Hill, NC
| | | | - Benjamin A. Hughes
- Department of Surgery, Duke University, Duke Ex-Vivo Organ Lab (DEVOL), Durham, NC
| | - Matthew G. Hartwig
- Department of Surgery, Duke University, Duke Ex-Vivo Organ Lab (DEVOL), Durham, NC
| | - Andrew S. Barbas
- Department of Surgery, Duke University, Duke Ex-Vivo Organ Lab (DEVOL), Durham, NC
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5
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de Haan MJA, Jacobs ME, Witjas FMR, de Graaf AMA, Sánchez-López E, Kostidis S, Giera M, Calderon Novoa F, Chu T, Selzner M, Maanaoui M, de Vries DK, Kers J, Alwayn IPJ, van Kooten C, Heijs B, Wang G, Engelse MA, Rabelink TJ. A cell-free nutrient-supplemented perfusate allows four-day ex vivo metabolic preservation of human kidneys. Nat Commun 2024; 15:3818. [PMID: 38740760 DOI: 10.1038/s41467-024-47106-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 03/20/2024] [Indexed: 05/16/2024] Open
Abstract
The growing disparity between the demand for transplants and the available donor supply, coupled with an aging donor population and increasing prevalence of chronic diseases, highlights the urgent need for the development of platforms enabling reconditioning, repair, and regeneration of deceased donor organs. This necessitates the ability to preserve metabolically active kidneys ex vivo for days. However, current kidney normothermic machine perfusion (NMP) approaches allow metabolic preservation only for hours. Here we show that human kidneys discarded for transplantation can be preserved in a metabolically active state up to 4 days when perfused with a cell-free perfusate supplemented with TCA cycle intermediates at subnormothermia (25 °C). Using spatially resolved isotope tracing we demonstrate preserved metabolic fluxes in the kidney microenvironment up to Day 4 of perfusion. Beyond Day 4, significant changes were observed in renal cell populations through spatial lipidomics, and increases in injury markers such as LDH, NGAL and oxidized lipids. Finally, we demonstrate that perfused kidneys maintain functional parameters up to Day 4. Collectively, these findings provide evidence that this approach enables metabolic and functional preservation of human kidneys over multiple days, establishing a solid foundation for future clinical investigations.
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Affiliation(s)
- Marlon J A de Haan
- Department of Internal Medicine (Nephrology) & Einthoven Laboratory of Vascular and Regenerative Medicine, Leiden University Medical Center, Leiden, The Netherlands
- The Novo Nordisk Foundation Center for Stem Cell Medicine (reNEW), Leiden University Medical Center, Leiden, The Netherlands
| | - Marleen E Jacobs
- Department of Internal Medicine (Nephrology) & Einthoven Laboratory of Vascular and Regenerative Medicine, Leiden University Medical Center, Leiden, The Netherlands
- The Novo Nordisk Foundation Center for Stem Cell Medicine (reNEW), Leiden University Medical Center, Leiden, The Netherlands
| | - Franca M R Witjas
- Department of Internal Medicine (Nephrology) & Einthoven Laboratory of Vascular and Regenerative Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Annemarie M A de Graaf
- Department of Internal Medicine (Nephrology) & Einthoven Laboratory of Vascular and Regenerative Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Elena Sánchez-López
- Center for Proteomics and Metabolomics, Leiden University Medical Center, Leiden, The Netherlands
| | - Sarantos Kostidis
- Center for Proteomics and Metabolomics, Leiden University Medical Center, Leiden, The Netherlands
| | - Martin Giera
- The Novo Nordisk Foundation Center for Stem Cell Medicine (reNEW), Leiden University Medical Center, Leiden, The Netherlands
- Center for Proteomics and Metabolomics, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Tunpang Chu
- Ajmera Transplant Centre, Department of Surgery, University Health Network, Toronto, ON, Canada
| | - Markus Selzner
- Ajmera Transplant Centre, Department of Surgery, University Health Network, Toronto, ON, Canada
| | - Mehdi Maanaoui
- University of Lille, Institut National de la Santé et de la Recherche Médicale (INSERM), Centre Hospitalier Universitaire de Lille (CHU Lille), Institute Pasteur Lille, Lille, France
| | - Dorottya K de Vries
- Transplant Center, Leiden University Medical Center, Leiden, The Netherlands
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Jesper Kers
- Department of Pathology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands
| | - Ian P J Alwayn
- Transplant Center, Leiden University Medical Center, Leiden, The Netherlands
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Cees van Kooten
- Department of Internal Medicine (Nephrology) & Einthoven Laboratory of Vascular and Regenerative Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Bram Heijs
- The Novo Nordisk Foundation Center for Stem Cell Medicine (reNEW), Leiden University Medical Center, Leiden, The Netherlands
- Center for Proteomics and Metabolomics, Leiden University Medical Center, Leiden, The Netherlands
| | - Gangqi Wang
- Department of Internal Medicine (Nephrology) & Einthoven Laboratory of Vascular and Regenerative Medicine, Leiden University Medical Center, Leiden, The Netherlands.
- The Novo Nordisk Foundation Center for Stem Cell Medicine (reNEW), Leiden University Medical Center, Leiden, The Netherlands.
| | - Marten A Engelse
- Department of Internal Medicine (Nephrology) & Einthoven Laboratory of Vascular and Regenerative Medicine, Leiden University Medical Center, Leiden, The Netherlands.
- The Novo Nordisk Foundation Center for Stem Cell Medicine (reNEW), Leiden University Medical Center, Leiden, The Netherlands.
| | - Ton J Rabelink
- Department of Internal Medicine (Nephrology) & Einthoven Laboratory of Vascular and Regenerative Medicine, Leiden University Medical Center, Leiden, The Netherlands.
- The Novo Nordisk Foundation Center for Stem Cell Medicine (reNEW), Leiden University Medical Center, Leiden, The Netherlands.
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Warmuzińska N, Łuczykowski K, Stryjak I, Rosales-Solano H, Urbanellis P, Pawliszyn J, Selzner M, Bojko B. The impact of normothermic and hypothermic preservation methods on kidney lipidome-comparative study using chemical biopsy with microextraction probes. Front Mol Biosci 2024; 11:1341108. [PMID: 38784665 PMCID: PMC11112113 DOI: 10.3389/fmolb.2024.1341108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Accepted: 04/15/2024] [Indexed: 05/25/2024] Open
Abstract
Introduction Normothermic ex vivo kidney perfusion (NEVKP) is designed to replicate physiological conditions to improve graft outcomes. A comparison of the impact of hypothermic and normothermic preservation techniques on graft quality was performed by lipidomic profiling using solid-phase microextraction (SPME) chemical biopsy as a minimally invasive sampling approach. Methods Direct kidney sampling was conducted using SPME probes coated with a mixed-mode extraction phase in a porcine autotransplantation model of the renal donor after cardiac death, comparing three preservation methods: static cold storage (SCS), NEVKP, and hypothermic machine perfusion (HMP). The lipidomic analysis was done using ultra-high-performance liquid chromatography coupled with a Q-Exactive Focus Orbitrap mass spectrometer. Results Chemometric analysis showed that the NEVLP group was separated from SCS and HMP groups. Further in-depth analyses indicated significantly (p < 0.05, VIP > 1) higher levels of acylcarnitines, phosphocholines, ether-linked and longer-chain phosphoethanolamines, triacylglycerols and most lysophosphocholines and lysophosphoethanolamines in the hypothermic preservation group. The results showed that the preservation temperature has a more significant impact on the lipidomic profile of the kidney than the preservation method's mechanical characteristics. Conclusion Higher levels of lipids detected in the hypothermic preservation group may be related to ischemia-reperfusion injury, mitochondrial dysfunction, pro-inflammatory effect, and oxidative stress. Obtained results suggest the NEVKP method's beneficial effect on graft function and confirm that SPME chemical biopsy enables low-invasive and repeated sampling of the same tissue, allowing tracking alterations in the graft throughout the entire transplantation procedure.
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Affiliation(s)
- Natalia Warmuzińska
- Department of Pharmacodynamics and Molecular Pharmacology, Faculty of Pharmacy, Nicolaus Copernicus University in Torun, Collegium Medicum in Bydgoszcz, Bydgoszcz, Poland
| | - Kamil Łuczykowski
- Department of Pharmacodynamics and Molecular Pharmacology, Faculty of Pharmacy, Nicolaus Copernicus University in Torun, Collegium Medicum in Bydgoszcz, Bydgoszcz, Poland
| | - Iga Stryjak
- Department of Pharmacodynamics and Molecular Pharmacology, Faculty of Pharmacy, Nicolaus Copernicus University in Torun, Collegium Medicum in Bydgoszcz, Bydgoszcz, Poland
| | | | - Peter Urbanellis
- Ajmera Transplant Center, Department of Surgery, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Janusz Pawliszyn
- Department of Chemistry, University of Waterloo, Waterloo, ON, Canada
| | - Markus Selzner
- Ajmera Transplant Center, Department of Surgery, Toronto General Hospital, University Health Network, Toronto, ON, Canada
- Department of Medicine, Toronto General Hospital, Toronto, ON, Canada
| | - Barbara Bojko
- Department of Pharmacodynamics and Molecular Pharmacology, Faculty of Pharmacy, Nicolaus Copernicus University in Torun, Collegium Medicum in Bydgoszcz, Bydgoszcz, Poland
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7
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Stryjak I, Warmuzińska N, Łuczykowski K, Jaroch K, Urbanellis P, Selzner M, Bojko B. Metabolomic and lipidomic landscape of porcine kidney associated with kidney perfusion in heart beating donors and donors after cardiac death. Transl Res 2024; 267:79-90. [PMID: 38052298 DOI: 10.1016/j.trsl.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 10/23/2023] [Accepted: 12/01/2023] [Indexed: 12/07/2023]
Abstract
Transplant centers are currently facing a lack of tools to ensure adequate evaluation of the quality of the available organs, as well as a significant shortage of kidney donors. Therefore, efforts are being made to facilitate the effective use of available organs and expand the donor pool, particularly with expanded criteria donors. Fulfilling a need, we aim to present an innovative analytical method based on solid-phase microextraction (SPME) - chemical biopsy. In order to track changes affecting the organ throughout the entire transplant procedure, porcine kidneys were subjected to multiple samplings at various time points. The application of small-diameter SPME probes assured the minimal invasiveness of the procedure. Porcine model kidney autotransplantation was executed for the purpose of simulating two types of donor scenarios: donors with a beating heart (HBD) and donors after cardiac death (DCD). All renal grafts were exposed to continuous normothermic ex vivo perfusion. Following metabolomic and lipidomic profiling using high-performance liquid chromatography coupled to a mass spectrometer, we observed differences in the profiles of HBD and DCD kidneys. The alterations were predominantly related to energy and glucose metabolism, and differences in the levels of essential amino acids, purine nucleosides, lysophosphocholines, phosphoethanolamines, and triacylglycerols were noticed. Our results indicate the potential of implementing chemical biopsy in the evaluation of graft quality and monitoring of renal function during perfusion.
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Affiliation(s)
- Iga Stryjak
- Department of Pharmacodynamics and Molecular Pharmacology, Faculty of Pharmacy, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Bydgoszcz, Poland
| | - Natalia Warmuzińska
- Department of Pharmacodynamics and Molecular Pharmacology, Faculty of Pharmacy, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Bydgoszcz, Poland
| | - Kamil Łuczykowski
- Department of Pharmacodynamics and Molecular Pharmacology, Faculty of Pharmacy, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Bydgoszcz, Poland
| | - Karol Jaroch
- Department of Pharmacodynamics and Molecular Pharmacology, Faculty of Pharmacy, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Bydgoszcz, Poland
| | - Peter Urbanellis
- Ajmera Transplant Center, Department of Surgery, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Markus Selzner
- Ajmera Transplant Center, Department of Surgery, Toronto General Hospital, University Health Network, Toronto, ON, Canada; Department of Medicine, Toronto General Hospital, Toronto, ON, Canada
| | - Barbara Bojko
- Department of Pharmacodynamics and Molecular Pharmacology, Faculty of Pharmacy, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Bydgoszcz, Poland.
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8
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Hamelink TL, Ogurlu B, Pamplona CC, Castelein J, Bennedsgaard SS, Qi H, Weiss T, Lantinga VA, Pool MBF, Laustsen C, Jespersen B, Leuvenink HGD, Ringgaard S, Borra RJH, Keller AK, Moers C. Magnetic resonance imaging as a noninvasive adjunct to conventional assessment of functional differences between kidneys in vivo and during ex vivo normothermic machine perfusion. Am J Transplant 2024:S1600-6135(24)00272-7. [PMID: 38615901 DOI: 10.1016/j.ajt.2024.04.001] [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: 02/27/2024] [Revised: 03/26/2024] [Accepted: 04/07/2024] [Indexed: 04/16/2024]
Abstract
Normothermic machine perfusion (NMP) is increasingly considered for pretransplant kidney quality assessment. However, fundamental questions about differences between in vivo and ex vivo renal function, as well as the impact of ischemic injury on ex vivo physiology, remain unanswered. This study utilized magnetic resonance imaging (MRI), alongside conventional parameters to explore differences between in vivo and ex vivo renal function and the impact of warm ischemia on a kidney's behavior ex vivo. Renal MRI scans and samples were obtained from living pigs (n = 30) in vivo. Next, kidney pairs were procured and exposed to minimal, or 75 minutes of warm ischemia, followed by 6 hours of hypothermic machine perfusion. Both kidneys simultaneously underwent 6-hour ex vivo perfusion in MRI-compatible NMP circuits to obtain multiparametric MRI data. Ischemically injured ex vivo kidneys showed a significantly altered regional blood flow distribution compared to in vivo and minimally damaged organs. Both ex vivo groups showed diffusion restriction relative to in vivo. Our findings underscore the differences between in vivo and ex vivo MRI-based renal characteristics. Therefore, when assessing organ viability during NMP, it should be considered to incorporate parameters beyond the conventional functional markers that are common in vivo.
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Affiliation(s)
- Tim L Hamelink
- Department of Surgery - Organ Donation and Transplantation, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.
| | - Baran Ogurlu
- Department of Surgery - Organ Donation and Transplantation, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Carolina C Pamplona
- Department of Surgery - Organ Donation and Transplantation, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Johannes Castelein
- Department of Radiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands; Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | | | - Haiyun Qi
- Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Thomas Weiss
- Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Veerle A Lantinga
- Department of Surgery - Organ Donation and Transplantation, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Merel B F Pool
- Department of Surgery - Organ Donation and Transplantation, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Christoffer Laustsen
- Department of Clinical Medicine, MR Research Centre, Aarhus University Hospital, Aarhus, Denmark
| | - Bente Jespersen
- Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Henri G D Leuvenink
- Department of Surgery - Organ Donation and Transplantation, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Steffen Ringgaard
- Department of Clinical Medicine, MR Research Centre, Aarhus University Hospital, Aarhus, Denmark
| | - Ronald J H Borra
- Department of Radiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Anna K Keller
- Department of Urology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Cyril Moers
- Department of Surgery - Organ Donation and Transplantation, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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9
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Longchamp A, Fontan FM, Aburawi MM, Eymard C, Karimian N, Detelich D, Pendexter C, Cronin S, Agius T, Nagpal S, Banik PD, Tessier SN, Ozer S, Delmonico FL, Uygun K, Yeh H, Markmann JF. Acellular Perfusate is an Adequate Alternative to Packed Red Blood Cells During Normothermic Human Kidney Perfusion. Transplant Direct 2024; 10:e1609. [PMID: 38481967 PMCID: PMC10936975 DOI: 10.1097/txd.0000000000001609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 12/26/2023] [Accepted: 01/06/2024] [Indexed: 03/17/2024] Open
Abstract
Background Brief normothermic machine perfusion is increasingly used to assess and recondition grafts before transplant. During normothermic machine perfusion, metabolic activity is typically maintained using red blood cell (RBC)-based solutions. However, the utilization of RBCs creates important logistical constraints. This study explored the feasibility of human kidney normothermic perfusion using William's E-based perfusate with no additional oxygen carrier. Methods Sixteen human kidneys declined for transplant were perfused with a perfusion solution containing packed RBCs or William's E medium only for 6 h using a pressure-controlled system. The temperature was set at 37 °C. Renal artery resistance, oxygen extraction, metabolic activity, energy metabolism, and histological features were evaluated. Results Baseline donor demographics were similar in both groups. Throughout perfusion, kidneys perfused with William's E exhibited improved renal flow (P = 0.041) but similar arterial resistance. Lactic acid levels remained higher in kidneys perfused with RBCs during the first 3 h of perfusion but were similar thereafter (P = 0.95 at 6 h). Throughout perfusion, kidneys from both groups exhibited comparable behavior regarding oxygen consumption (P = 0.41) and reconstitution of ATP tissue concentration (P = 0.55). Similarly, nicotinamide adenine dinucleotide levels were preserved during perfusion. There was no evidence of histological damage caused by either perfusate. Conclusions In human kidneys, William's E medium provides a logistically convenient, off-the-shelf alternative to packed RBCs for up to 6 h of normothermic machine perfusion.
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Affiliation(s)
- Alban Longchamp
- Division of Transplantation, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
- Department of Surgery, Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Fermin M. Fontan
- Division of Transplantation, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Mohamed M. Aburawi
- Division of Transplantation, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Corey Eymard
- Division of Transplantation, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
- Department of Surgery, Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Negin Karimian
- Division of Transplantation, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
- Department of Surgery, Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Danielle Detelich
- Department of Surgery, Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Casie Pendexter
- Department of Surgery, Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Stephanie Cronin
- Department of Surgery, Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Thomas Agius
- Division of Transplantation, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
- Department of Surgery, Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Sonal Nagpal
- Department of Surgery, Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Peony Dutta Banik
- Department of Surgery, Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Shannon N. Tessier
- Department of Surgery, Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Sinan Ozer
- Department of Surgery, Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Francis L. Delmonico
- Division of Transplantation, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
- New England Donor Services, Waltham, MA
| | - Korkut Uygun
- Division of Transplantation, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
- Department of Surgery, Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Heidi Yeh
- Division of Transplantation, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
- Department of Surgery, Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - James F. Markmann
- Division of Transplantation, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
- Department of Surgery, Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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10
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Montagud-Marrahi E, Luque Y, Ros RR, Ajami T, Cuadrado-Payan E, Estrella H, Arancibia A, Sánchez-Etayo G, Bohils M, Marrero R, Fundora Y, Ramírez-Bajo MJ, Banon-Maneus E, Rovira J, Larque AB, Campistol JM, Diekmann F, Musquera M. Ex vivo normothermic preservation of a kidney graft from uncontrolled donation after circulatory death over 73 hours. Front Bioeng Biotechnol 2024; 11:1330043. [PMID: 38283171 PMCID: PMC10811075 DOI: 10.3389/fbioe.2023.1330043] [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: 11/17/2023] [Accepted: 12/22/2023] [Indexed: 01/30/2024] Open
Abstract
The transplant community is focused on prolonging the ex vivo preservation time of kidney grafts to allow for long-distance kidney graft transportation, assess the viability of marginal grafts, and optimize a platform for the translation of innovative therapeutics to clinical practice, especially those focused on cell and vector delivery to organ conditioning and reprogramming. We describe the first case of feasible preservation of a kidney from a donor after uncontrolled circulatory death over a 73-h period using normothermic perfusion and analyze hemodynamic, biochemical, histological, and transcriptomic parameters for inflammation and kidney injury. The mean pressure and flow values were 71.24 ± 9.62 mmHg and 99.65 ± 18.54 mL/min, respectively. The temperature range was 36.7°C-37.2°C. The renal resistance index was 0.75 ± 0.15 mmHg/mL/min. The mean pH was 7.29 ± 0.15. The lactate concentration peak increased until 213 mg/dL at 6 h, reaching normal values after 34 h of perfusion (8.92 mg/dL). The total urine output at the end of perfusion was 1.185 mL. Histological analysis revealed no significant increase in acute tubular necrosis (ATN) severity as perfusion progressed. The expression of KIM-1, VEGF, and TGFβ decreased after 6-18 h of perfusion until 60 h in which the expression of these genes increased again together with the expression of β-catenin, Ki67, and TIMP1. We show that normothermic perfusion can maintain a kidney graft viable ex vivo for 3 days, thus allowing a rapid translation of pre-clinical therapeutics to clinical practice.
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Affiliation(s)
- Enrique Montagud-Marrahi
- Kidney Transplant Unit. Nephrology and Kidney Transplantation Department. Hospital Clinic of Barcelona, Barcelona, Spain
- Laboratori Experimental de Nefrologia i Trasplantament (LENIT). Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Red de Investigación Cooperativa Orientada a Resultados en Salud (RICORS 2040), Madrid, Spain
| | - Yosu Luque
- Sorbonne Université - Inserm UMRS_1155, Paris, France
- Assistance Publique Hopitaux de Paris. Soins Intensifs Nephrologiques et Rein Aigu. Departement de Nephrologie. Hopital Tenon. Paris, France
| | - Ruben Rabadan Ros
- Group of Metabolism and Genetic Regulation of Disease, UCAM HiTech Sport & Health Innovation Hub, Universidad Católica de Murcia, Guadalupe, Spain
| | - Tarek Ajami
- Kidney Transplant Unit. Urology Department, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Elena Cuadrado-Payan
- Kidney Transplant Unit. Nephrology and Kidney Transplantation Department. Hospital Clinic of Barcelona, Barcelona, Spain
- Laboratori Experimental de Nefrologia i Trasplantament (LENIT). Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Hector Estrella
- Kidney Transplant Unit. Urology Department, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Andres Arancibia
- Kidney Transplant Unit. Urology Department, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Gerard Sánchez-Etayo
- Donation and Transplant Coordination Section, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Marc Bohils
- Donation and Transplant Coordination Section, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Ramsés Marrero
- Donation and Transplant Coordination Section, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Yilliam Fundora
- Liver Transplant Unit, Institut Clínic de Malalties Digestives I Metabòliques, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Maria José Ramírez-Bajo
- Laboratori Experimental de Nefrologia i Trasplantament (LENIT). Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Red de Investigación Cooperativa Orientada a Resultados en Salud (RICORS 2040), Madrid, Spain
| | - Elisenda Banon-Maneus
- Laboratori Experimental de Nefrologia i Trasplantament (LENIT). Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Red de Investigación Cooperativa Orientada a Resultados en Salud (RICORS 2040), Madrid, Spain
| | - Jordi Rovira
- Laboratori Experimental de Nefrologia i Trasplantament (LENIT). Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Red de Investigación Cooperativa Orientada a Resultados en Salud (RICORS 2040), Madrid, Spain
| | - Ana-Belén Larque
- Department of Pathology. Hospital Clinic of Barcelona. Corresponding Author: Mireia Musquera, Barcelona, Spain
| | - Josep Maria Campistol
- Kidney Transplant Unit. Nephrology and Kidney Transplantation Department. Hospital Clinic of Barcelona, Barcelona, Spain
- Laboratori Experimental de Nefrologia i Trasplantament (LENIT). Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Red de Investigación Cooperativa Orientada a Resultados en Salud (RICORS 2040), Madrid, Spain
| | - Fritz Diekmann
- Kidney Transplant Unit. Nephrology and Kidney Transplantation Department. Hospital Clinic of Barcelona, Barcelona, Spain
- Laboratori Experimental de Nefrologia i Trasplantament (LENIT). Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Red de Investigación Cooperativa Orientada a Resultados en Salud (RICORS 2040), Madrid, Spain
| | - Mireia Musquera
- Kidney Transplant Unit. Urology Department, Hospital Clinic of Barcelona, Barcelona, Spain
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11
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López-Martínez S, Simón C, Santamaria X. Normothermic Machine Perfusion Systems: Where Do We Go From Here? Transplantation 2024; 108:22-44. [PMID: 37026713 DOI: 10.1097/tp.0000000000004573] [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: 04/08/2023]
Abstract
Normothermic machine perfusion (NMP) aims to preserve organs ex vivo by simulating physiological conditions such as body temperature. Recent advancements in NMP system design have prompted the development of clinically effective devices for liver, heart, lung, and kidney transplantation that preserve organs for several hours/up to 1 d. In preclinical studies, adjustments to circuit structure, perfusate composition, and automatic supervision have extended perfusion times up to 1 wk of preservation. Emerging NMP platforms for ex vivo preservation of the pancreas, intestine, uterus, ovary, and vascularized composite allografts represent exciting prospects. Thus, NMP may become a valuable tool in transplantation and provide significant advantages to biomedical research. This review recaps recent NMP research, including discussions of devices in clinical trials, innovative preclinical systems for extended preservation, and platforms developed for other organs. We will also discuss NMP strategies using a global approach while focusing on technical specifications and preservation times.
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Affiliation(s)
- Sara López-Martínez
- Carlos Simon Foundation, Centro de Investigación Príncipe Felipe, Valencia, Spain
| | - Carlos Simón
- Carlos Simon Foundation, Centro de Investigación Príncipe Felipe, Valencia, Spain
- Department of Obstetrics and Gynecology, Universidad de Valencia, Valencia, Spain
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Harvard University, Boston, MA
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX
| | - Xavier Santamaria
- Carlos Simon Foundation, Centro de Investigación Príncipe Felipe, Valencia, Spain
- INCLIVA Biomedical Research Institute, Valencia, Spain
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12
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Castelein J, Pamplona C, Armstrong Junior R, Vidal dos Santos M, Sack I, Dierckx R, Moers C, Borra R. Effects of kidney perfusion on renal stiffness and tissue fluidity measured with tomoelastography in an MRI-compatible ex vivo model. Front Bioeng Biotechnol 2023; 11:1236949. [PMID: 38026891 PMCID: PMC10665518 DOI: 10.3389/fbioe.2023.1236949] [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: 06/08/2023] [Accepted: 10/27/2023] [Indexed: 12/01/2023] Open
Abstract
Stiffness plays a vital role in diagnosing renal fibrosis. However, perfusion influences renal stiffness in various chronic kidney diseases. Therefore, we aimed to characterize the effect of tissue perfusion on renal stiffness and tissue fluidity measured by tomoelastography based on multifrequency magnetic resonance elastography in an ex vivo model. Five porcine kidneys were perfused ex vivo in an MRI-compatible normothermic machine perfusion setup with adjusted blood pressure in the 50/10-160/120 mmHg range. Simultaneously, renal cortical and medullary stiffness and fluidity were obtained by tomoelastography. For the cortex, a statistically significant (p < 0.001) strong positive correlation was observed between both perfusion parameters (blood pressure and resulting flow) and stiffness (r = 0.95, 0.91), as well as fluidity (r = 0.96, 0.92). For the medulla, such significant (p < 0.001) correlations were solely observed between the perfusion parameters and stiffness (r = 0.88, 0.71). Our findings demonstrate a strong perfusion dependency of renal stiffness and fluidity in an ex vivo setup. Moreover, changes in perfusion are rapidly followed by changes in renal mechanical properties-highlighting the sensitivity of tomoelastography to fluid pressure and the potential need for correcting mechanics-derived imaging biomarkers when addressing solid structures in renal tissue.
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Affiliation(s)
- Johannes Castelein
- Department of Radiology & Nuclear Medicine and Molecular Imaging, University Medical Center Groningen, Groningen, Netherlands
- Department for Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Carolina Pamplona
- Department of Surgery, University Medical Center Groningen, Groningen, Netherlands
| | | | | | - Ingolf Sack
- Department of Radiology, Charité University Medicine Berlin, Berlin, Germany
| | - Rudi Dierckx
- Department of Radiology & Nuclear Medicine and Molecular Imaging, University Medical Center Groningen, Groningen, Netherlands
| | - Cyril Moers
- Department of Surgery, University Medical Center Groningen, Groningen, Netherlands
| | - Ronald Borra
- Department of Radiology & Nuclear Medicine and Molecular Imaging, University Medical Center Groningen, Groningen, Netherlands
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13
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Messner F, Soleiman A, Öfner D, Neuwirt H, Schneeberger S, Weissenbacher A. 48 h Normothermic Machine Perfusion With Urine Recirculation for Discarded Human Kidney Grafts. Transpl Int 2023; 36:11804. [PMID: 37901298 PMCID: PMC10603233 DOI: 10.3389/ti.2023.11804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 10/04/2023] [Indexed: 10/31/2023]
Abstract
Normothermic machine perfusion (NMP) has reshaped organ preservation in recent years. In this preclinical study, prolonged normothermic perfusions of discarded human kidney grafts were performed in order to investigate perfusion dynamics and identify potential quality and assessment indicators. Five human discarded kidney grafts were perfused normothermically (37°C) for 48 h using the Kidney Assist device with a red-blood-cell based perfusate with urine recirculation. Perfusion dynamics, perfusate and urine composition as well as injury markers were measured and analyzed. Donor age ranged from 41 to 68 years. All but one kidney were from brain dead donors. Perfusions were performed successfully for 48 h with all discarded kidneys. Median arterial flow ranged from 405 to 841 mL/min. All kidneys excreted urine until the end of perfusion (median 0.43 mL/min at the end of perfusion). While sodium levels were consistently lower in urine compared to perfusate samples, this was only seen for chloride and potassium in kidney KTX 2. Lactate, AST, LDH as well as pro-inflammatory cytokines increased over time, especially in kidneys KTX 3 and 4. Ex vivo normothermic perfusion is able to identify patterns of perfusion, biological function, and changes in inflammatory markers in heterogenous discarded kidney grafts.
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Affiliation(s)
- Franka Messner
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Afschin Soleiman
- INNPATH, Institute of Pathology, Tirol Kliniken Innsbruck, Innsbruck, Austria
| | - Dietmar Öfner
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Hannes Neuwirt
- Department of Internal Medicine IV, Nephrology and Hypertension, Medical University of Innsbruck, Innsbruck, Austria
| | - Stefan Schneeberger
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Annemarie Weissenbacher
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
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14
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Ghoneima AS, Sousa Da Silva RX, Gosteli MA, Barlow AD, Kron P. Outcomes of Kidney Perfusion Techniques in Transplantation from Deceased Donors: A Systematic Review and Meta-Analysis. J Clin Med 2023; 12:3871. [PMID: 37373568 DOI: 10.3390/jcm12123871] [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: 03/14/2023] [Revised: 05/03/2023] [Accepted: 05/09/2023] [Indexed: 06/29/2023] Open
Abstract
The high demand for organs in kidney transplantation and the expansion of the donor pool have led to the widespread implementation of machine perfusion technologies. In this study, we aim to provide an up-to-date systematic review of the developments in this expanding field over the past 10 years, with the aim of answering the question: "which perfusion technique is the most promising technique in kidney transplantation?" A systematic review of the literature related to machine perfusion in kidney transplantation was performed. The primary outcome measure was delayed graft function (DGF), and secondary outcomes included rates of rejection, graft survival, and patient survival rates after 1 year. Based on the available data, a meta-analysis was performed. The results were compared with data from static cold storage, which is still the standard of care in many centers worldwide. A total of 56 studies conducted in humans were included, and 43 studies reported outcomes of hypothermic machine perfusion (HMP), with a DGF rate of 26.4%. A meta-analysis of 16 studies showed significantly lower DGF rates in the HMP group compared to those of static cold storage (SCS). Five studies reported outcomes of hypothermic machine perfusion + O2, with an overall DGF rate of 29.7%. Two studies explored normothermic machine perfusion (NMP). These were pilot studies, designed to assess the feasibility of this perfusion approach in the clinical setting. Six studies reported outcomes of normothermic regional perfusion (NRP). The overall incidence of DGF was 71.5%, as it was primarily used in uncontrolled DCD (Maastricht category I-II). Three studies comparing NRP to in situ cold perfusion showed a significantly lower rate of DGF with NRP. The systematic review and meta-analysis provide evidence that dynamic preservation strategies can improve outcomes following kidney transplantation. More recent approaches such as normothermic machine perfusion and hypothermic machine perfusion + O2 do show promising results but need further results from the clinical setting. This study shows that the implementation of perfusion strategies could play an important role in safely expanding the donor pool.
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Affiliation(s)
- Ahmed S Ghoneima
- Department of HPB and Transplant Surgery, St. James's University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds LS9 7TF, UK
| | - Richard X Sousa Da Silva
- Swiss HPB and Transplantation Center, Department of Surgery and Transplantation, University Hospital Zurich, 8091 Zurich, Switzerland
| | | | - Adam D Barlow
- Department of HPB and Transplant Surgery, St. James's University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds LS9 7TF, UK
| | - Philipp Kron
- Department of HPB and Transplant Surgery, St. James's University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds LS9 7TF, UK
- Swiss HPB and Transplantation Center, Department of Surgery and Transplantation, University Hospital Zurich, 8091 Zurich, Switzerland
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15
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Zarnitz L, Doorschodt BM, Ernst L, Hosseinnejad A, Edgworth E, Fechter T, Theißen A, Djudjaj S, Boor P, Rossaint R, Tolba RH, Bleilevens C. Taurine as Antioxidant in a Novel Cell- and Oxygen Carrier-Free Perfusate for Normothermic Machine Perfusion of Porcine Kidneys. Antioxidants (Basel) 2023; 12:antiox12030768. [PMID: 36979015 PMCID: PMC10045130 DOI: 10.3390/antiox12030768] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 03/14/2023] [Accepted: 03/17/2023] [Indexed: 03/30/2023] Open
Abstract
Donor organ-shortage has resulted in the increased use of marginal grafts; however, normothermic machine perfusion (NMP) holds the potential for organ viability assessment and restoration of marginal grafts prior to transplantation. Additionally, cell-, oxygen carrier-free and antioxidants-supplemented solutions could potentially prevent adverse effects (transfusion reactions, inflammation, hemolysis), associated with the use of autologous packed red blood cell (pRBC)-based perfusates. This study compared 6 h NMP of porcine kidneys, using an established pRBC-based perfusate (pRBC, n = 7), with the novel cell- and oxygen carrier-free organ preservation solution Ecosol, containing taurine (Ecosol, n = 7). Despite the enhanced tissue edema and tubular injury in the Ecosol group, related to a suboptimal molecular mass of polyethylene glycol as colloid present in the solution, functional parameters (renal blood flow, intrarenal resistance, urinary flow, pH) and oxygenation (arterial pO2, absence of hypoxia-inducible factor 1-alpha) were similar to the pRBC group. Furthermore, taurine significantly improved the antioxidant capacity in the Ecosol group, reflected in decreased lactate dehydrogenase, urine protein and tubular vacuolization compared to pRBC. This study demonstrates the feasibility of 6 h NMP using a taurine containing, cell- and oxygen carrier-free perfusate, achieving a comparable organ quality to pRBC perfused porcine kidneys.
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Affiliation(s)
- Laura Zarnitz
- Department of Anesthesiology, Medical Faculty, University Hospital RWTH Aachen, 52074 Aachen, Germany
| | - Benedict M Doorschodt
- Institute for Laboratory Animal Science and Experimental Surgery, Faculty of Medicine, RWTH Aachen University, 52074 Aachen, Germany
| | - Lisa Ernst
- Institute for Laboratory Animal Science and Experimental Surgery, Faculty of Medicine, RWTH Aachen University, 52074 Aachen, Germany
| | - Aisa Hosseinnejad
- DWI-Leibniz-Institute for Interactive Materials e.V., 52056 Aachen, Germany
| | - Eileen Edgworth
- Department of Anesthesiology, Medical Faculty, University Hospital RWTH Aachen, 52074 Aachen, Germany
| | - Tamara Fechter
- Department of Anesthesiology, Medical Faculty, University Hospital RWTH Aachen, 52074 Aachen, Germany
| | - Alexander Theißen
- Department of Anesthesiology, Medical Faculty, University Hospital RWTH Aachen, 52074 Aachen, Germany
| | - Sonja Djudjaj
- Institute of Pathology & Division of Nephrology, Medical Faculty, RWTH Aachen, 52074 Aachen, Germany
| | - Peter Boor
- Institute of Pathology & Division of Nephrology, Medical Faculty, RWTH Aachen, 52074 Aachen, Germany
| | - Rolf Rossaint
- Department of Anesthesiology, Medical Faculty, University Hospital RWTH Aachen, 52074 Aachen, Germany
| | - René H Tolba
- Institute for Laboratory Animal Science and Experimental Surgery, Faculty of Medicine, RWTH Aachen University, 52074 Aachen, Germany
| | - Christian Bleilevens
- Department of Anesthesiology, Medical Faculty, University Hospital RWTH Aachen, 52074 Aachen, Germany
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16
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Meyers A, Pandey S, Kopparthy V, Sadeghi P, Clark RC, Figueroa B, Dasarathy S, Brunengraber H, Papay F, Rampazzo A, Bassiri Gharb B. Weight gain is an early indicator of injury in ex vivo normothermic limb perfusion (EVNLP). Artif Organs 2023; 47:290-301. [PMID: 36305734 PMCID: PMC10100395 DOI: 10.1111/aor.14442] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 09/25/2022] [Accepted: 10/11/2022] [Indexed: 02/03/2023]
Abstract
PURPOSE There are no established criteria for discontinuing ex vivo normothermic limb perfusion (EVNLP) before irreversible damage occurs. This study evaluates weight gain as an indicator of injury during EVNLP. METHODS Sixteen Yorkshire pig forelimbs were procured and preserved using EVNLP with a hemoglobin-based oxygen carrier (HBOC-201) or static cold storage. EVNLP continued until termination criteria were met: arterial pressure ≥ 115 mm Hg, compartment pressure > 30 mm Hg, or 20% reduction of oxygen saturation. Limb weight, contractility, hemodynamics, perfusate electrolytes, metabolites and gases were recorded. Muscles were biopsied 6-h, and muscle injury scores (MIS) calculated. Forearm compartment pressures and indocyanine green (ICG) angiography were recorded at endpoint. Outcomes were compared at 2%, 5%, 10%, and 20% limb weight gain. RESULTS EVNLP lasted 20 ± 3 h. Weight gain was observed after 13 ± 5 h (2%), 15 ± 6 h (5%), 16 ± 6 h (10%), and 19 ± 4 h (20%). Weight correlated positively with MIS (ρ = 0.92, p < 0.0001), potassium (ρ = -1.00, p < 0.0001), pressure (ρ = 0.78, p < 0.0001), and negatively with contractility (ρ = -0.96, p = 0.011). At 5% weight gain, MIS (p < 0.0001), potassium (p = 0.03), and lactate (p < 0.0001) were significantly higher than baseline. Median muscle contractility was 5 [3-5] at 2% weight gain, 4 [1-5] at 5%, 3 [0-4] and 2 [0-2] at 10% and 20%, respectively. At 20% weight gain, contractility was significantly lower than baseline (p = 0.003). Percent weight gain correlated negatively with endpoint ICG hoof fluorescence (r = -0.712, p = 0.047). CONCLUSIONS Weight gain correlated with microscopic muscle injury and was the earliest evidence of limb dysfunction. Weight gain may serve as a criterion for discontinuation of EVNLP.
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Affiliation(s)
- Abigail Meyers
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Sonia Pandey
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Varun Kopparthy
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Payam Sadeghi
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Brian Figueroa
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Srinivasan Dasarathy
- Department of Gastroenterology, Hepatology, Pathobiology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Henri Brunengraber
- Department of Nutrition and Biochemistry, School of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Francis Papay
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Antonio Rampazzo
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
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17
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Li JH, Xu X, Wang YF, Xie HY, Chen JY, Dong NG, Badiwala M, Xin LM, Ribeiro RVP, Yin H, Zhang H, Zhang JZ, Huo F, Yang JY, Yang HJ, Pan H, Li SG, Qiao YB, Luo J, Li HY, Jia JJ, Yu H, Liang H, Yang SJ, Wang H, Liu ZY, Zhang LC, Hu XY, Wu H, Hu YQ, Tang PF, Ye QF, Zheng SS. Chinese expert consensus on organ protection of transplantation (2022 edition). Hepatobiliary Pancreat Dis Int 2022; 21:516-526. [PMID: 36376226 DOI: 10.1016/j.hbpd.2022.10.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 10/24/2022] [Indexed: 11/07/2022]
Affiliation(s)
- Jian-Hui Li
- Department of Hepatobiliary and Pancreatic Surgery, Department of Liver Transplantation, Shulan (Hangzhou) Hospital, Zhejiang Shuren University School of Medicine, Hangzhou 310022, China
| | - Xiao Xu
- Department of Hepatobiliary and Pancreatic Surgery, Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou 310000, China
| | - Yan-Feng Wang
- Zhongnan Hospital of Wuhan University, Institute of Hepatobiliary Diseases of Wuhan University, Transplant Center of Wuhan University, Hubei Key Laboratory of Medical Technology on Transplantation, Wuhan 430062, China
| | - Hai-Yang Xie
- NHC Key Laboratory of Combined Multi-organ Transplantation, Hangzhou 310003, China
| | - Jing-Yu Chen
- Wuxi Lung Transplantation Center, Wuxi People's Hospital Affiliated with Nanjing Medical University, Wuxi 214023, China
| | - Nian-Guo Dong
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Mitesh Badiwala
- Peter Munk Cardiac Centre, Toronto General Hospital-University Health Network, Toronto, Canada
| | - Li-Ming Xin
- School of Computer Engineering and Science, Shanghai University, Shanghai 200444, China
| | | | - Hao Yin
- Organ Transplant Center, Shanghai Changzheng Hospital, Shanghai 200003, China
| | - Hao Zhang
- Department of Orthopedics, Chinese PLA General Hospital, Beijing 100039, China; National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing 100039, China
| | - Jian-Zheng Zhang
- Department of Orthopedics, Chinese PLA General Hospital, Beijing 100039, China; National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing 100039, China
| | - Feng Huo
- Department of Surgery, General Hospital of Guangzhou Military Command of PLA, Guangzhou 510040, China
| | - Jia-Yin Yang
- Department of Liver Surgery, Liver Transplantation Center, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Hong-Ji Yang
- Organ Transplantation Center, Sichuan Provincial People's Hospital and School of Medicine, University of Electronic Science and Technology of China, Chengdu 610072, China
| | - Hui Pan
- Department of Lung Transplantation, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Shao-Guang Li
- Department of Orthopedics, Chinese PLA General Hospital, Beijing 100039, China; National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing 100039, China
| | - Yin-Biao Qiao
- NHC Key Laboratory of Combined Multi-organ Transplantation, Hangzhou 310003, China
| | - Jia Luo
- NHC Key Laboratory of Combined Multi-organ Transplantation, Hangzhou 310003, China
| | - Hao-Yu Li
- NHC Key Laboratory of Combined Multi-organ Transplantation, Hangzhou 310003, China
| | - Jun-Jun Jia
- Division of Hepatobiliary Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Hao Yu
- Division of Hepatobiliary Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Han Liang
- Zhongnan Hospital of Wuhan University, Institute of Hepatobiliary Diseases of Wuhan University, Transplant Center of Wuhan University, Hubei Key Laboratory of Medical Technology on Transplantation, Wuhan 430062, China
| | - Si-Jia Yang
- Department of Lung Transplantation, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Hao Wang
- Department of Orthopedics, Chinese PLA General Hospital, Beijing 100039, China; National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing 100039, China
| | - Zhong-Yang Liu
- Department of Orthopedics, Chinese PLA General Hospital, Beijing 100039, China; National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing 100039, China
| | - Li-Cheng Zhang
- Department of Orthopedics, Chinese PLA General Hospital, Beijing 100039, China; National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing 100039, China
| | - Xiao-Yi Hu
- Division of Hepatobiliary Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Hao Wu
- Division of Hepatobiliary Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Yi-Qing Hu
- Division of Hepatobiliary Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Pei-Fu Tang
- Department of Orthopedics, Chinese PLA General Hospital, Beijing 100039, China; National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing 100039, China
| | - Qi-Fa Ye
- Zhongnan Hospital of Wuhan University, Institute of Hepatobiliary Diseases of Wuhan University, Transplant Center of Wuhan University, Hubei Key Laboratory of Medical Technology on Transplantation, Wuhan 430062, China
| | - Shu-Sen Zheng
- Department of Hepatobiliary and Pancreatic Surgery, Department of Liver Transplantation, Shulan (Hangzhou) Hospital, Zhejiang Shuren University School of Medicine, Hangzhou 310022, China; NHC Key Laboratory of Combined Multi-organ Transplantation, Hangzhou 310003, China; Division of Hepatobiliary Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China.
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18
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Preoperative Function Assessment of Ex Vivo Kidneys with Supervised Machine Learning Based on Blood and Urine Markers Measured during Normothermic Machine Perfusion. Biomedicines 2022; 10:biomedicines10123055. [PMID: 36551812 PMCID: PMC9776285 DOI: 10.3390/biomedicines10123055] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 11/13/2022] [Accepted: 11/23/2022] [Indexed: 11/29/2022] Open
Abstract
Establishing an objective quality assessment of an organ prior to transplantation can help prevent unnecessary discard of the organ and reduce the probability of functional failure. In this regard, normothermic machine perfusion (NMP) offers new possibilities for organ evaluation. However, to date, few studies have addressed the identification of markers and analytical tools to determine graft quality. In this study, function and injury markers were measured in blood and urine during NMP of 26 porcine kidneys and correlated with ex vivo inulin clearance behavior. Significant differentiation of kidneys according to their function could be achieved by oxygen consumption, oxygen delivery, renal blood flow, arterial pressure, intrarenal resistance, kidney temperature, relative urea concentration, and urine production. In addition, classifications were accomplished with supervised learning methods and histological analysis to predict renal function ex vivo. Classificators (support vector machines, k-nearest-neighbor, logistic regression and naive bayes) based on relevant markers in urine and blood achieved 75% and 83% accuracy in the validation and test set, respectively. A correlation between histological damage and function could not be detected. The measurement of blood and urine markers provides information of preoperative renal quality, which can used in future to establish an objective quality assessment.
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19
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Subnormothermic Ex Vivo Porcine Kidney Perfusion Improves Energy Metabolism: Analysis Using 31P Magnetic Resonance Spectroscopic Imaging. Transplant Direct 2022; 8:e1354. [PMID: 36176724 PMCID: PMC9514833 DOI: 10.1097/txd.0000000000001354] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 05/24/2022] [Indexed: 11/26/2022] Open
Abstract
The ideal preservation temperature for donation after circulatory death kidney grafts is unknown. We investigated whether subnormothermic (22 °C) ex vivo kidney machine perfusion could improve kidney metabolism and reduce ischemia-reperfusion injury.
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20
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Messner F, Bogensperger C, Hunter JP, Kaths MJ, Moers C, Weissenbacher A. Normothermic machine perfusion of kidneys: current strategies and future perspectives. Curr Opin Organ Transplant 2022; 27:446-453. [PMID: 35857331 DOI: 10.1097/mot.0000000000001003] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW This review aims to summarize the latest original preclinical and clinical articles in the setting of normothermic machine perfusion (NMP) of kidney grafts. RECENT FINDINGS Kidney NMP can be safely translated into the clinical routine and there is increasing evidence that NMP may be beneficial in graft preservation especially in marginal kidney grafts. Due to the near-physiological state during NMP, this technology may be used as an ex-vivo organ assessment and treatment platform. There are reports on the application of mesenchymal stromal/stem cells, multipotent adult progenitor cells and microRNA during kidney NMP, with first data indicating that these therapies indeed lead to a decrease in inflammatory response and kidney injury. Together with the demonstrated possibility of prolonged ex-vivo perfusion without significant graft damage, NMP could not only be used as a tool to perform preimplant graft assessment. Some evidence exists that it truly has the potential to be a platform to treat and repair injured kidney grafts, thereby significantly reducing the number of declined organs. SUMMARY Kidney NMP is feasible and can potentially increase the donor pool not only by preimplant graft assessment, but also by ex-vivo graft treatment.
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Affiliation(s)
- Franka Messner
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Christina Bogensperger
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - James P Hunter
- Oxford Transplant Centre, Nuffield Department of Surgical Sciences, University of Oxford, Oxford
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Moritz J Kaths
- Department of General, Visceral and Transplantation Surgery, Faculty of Medicine, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Cyril Moers
- Department of Surgery-Organ Donation and Transplantation, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Annemarie Weissenbacher
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
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21
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The Impact of Nutritional Supplementation on Donor Kidneys During Oxygenated Ex Vivo Subnormothermic Preservation. Transplant Direct 2022; 8:e1382. [PMID: 36204184 PMCID: PMC9529041 DOI: 10.1097/txd.0000000000001382] [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: 12/29/2021] [Revised: 07/15/2022] [Accepted: 07/16/2022] [Indexed: 11/27/2022] Open
Abstract
Evidence suggests that nutritional supplementation during normothermic ex vivo perfusion improves organ preservation. However, it is unclear whether the same benefit is observed during room temperature (subnormothermic) oxygenated perfusion. In this study, we tested the impact of providing complete nutrition during subnormothermic perfusion on kidney outcomes.
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22
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Nemeth DV, Baldini E, Sorrenti S, D’Andrea V, Bellini MI. Cancer Metabolism and Ischemia-Reperfusion Injury: Two Sides of the Same Coin. J Clin Med 2022; 11:jcm11175096. [PMID: 36079025 PMCID: PMC9457267 DOI: 10.3390/jcm11175096] [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: 07/04/2022] [Revised: 08/18/2022] [Accepted: 08/29/2022] [Indexed: 11/30/2022] Open
Abstract
Cancer cells are characterized by the reprogramming of certain cell metabolisms via activation of definite pathways and regulation of gene signaling. Ischemia-reperfusion injury (IRI) is characterized by tissue damage and death following a lack of perfusion and oxygenation. It is most commonly seen in the setting of organ transplantation. Interestingly, the microenvironments seen in cancer and ischemic tissues are quite similar, especially due to the hypoxic state that occurs in both. As a consequence, there is genetic signaling involved in response to IRI that has common pathways with cancer. Some of these changes are seen across the board with many cancer cells and are known as Hallmarks of Cancer, among which are aerobic glycolysis and the induction of angiogenesis. This literature review aims to compare the metabolic pathways that are altered in cancer tissues and in normal tissues subjected to IRI in order to find common adaptive processes and to identify key pathways that could represent a therapeutic target in both pathologies. By increasing our understanding of this relationship, clinical correlations can be made and applied practically to improve outcomes of transplanted organs, given the known association with acute rejection, delayed graft function, and poor graft survival. The following metabolic pathways are discussed in our review, both in the setting of cancer and IRI: apoptosis, glycolysis, and angiogenesis. The role of the immune system in both pathologies as well as mitochondrial function and the production of reactive oxygen species (ROS) are reviewed.
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Affiliation(s)
- Denise V. Nemeth
- School of Osteopathic Medicine, University of the Incarnate Word, San Antonio, TX 78235, USA
| | - Enke Baldini
- Department of Surgical Sciences, Sapienza University of Rome, 00185 Rome, Italy
| | - Salvatore Sorrenti
- Department of Surgical Sciences, Sapienza University of Rome, 00185 Rome, Italy
| | - Vito D’Andrea
- Department of Surgical Sciences, Sapienza University of Rome, 00185 Rome, Italy
- Correspondence: (V.D.); (M.I.B.)
| | - Maria Irene Bellini
- Department of Surgical Sciences, Sapienza University of Rome, 00185 Rome, Italy
- Correspondence: (V.D.); (M.I.B.)
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23
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Kirste G. Cold but not too cold: advances in hypothermic and normothermic organ perfusion. KOREAN JOURNAL OF TRANSPLANTATION 2022; 36:2-14. [PMID: 35769433 PMCID: PMC9235527 DOI: 10.4285/kjt.22.0008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 02/21/2022] [Indexed: 11/24/2022] Open
Abstract
Transplantation is the method of choice and, in many cases, the only method of treatment for patients with end-stage organ disease. Excellent results have been achieved, and the main focus today is to extend the number of available donors. The use of extended-criteria donors or donors after circulatory death is standard, but is accompanied by an increased risk of ischemia reperfusion injury. This review presents newly developed machine perfusion techniques using hypothermic, subnormothermic, or normothermic conditions, with or without oxygenation. Possibilities for treatment and quality assessment in decision-making about organ acceptability are also discussed.
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Affiliation(s)
- Guenter Kirste
- Department of Surgery, University Hospital of Freiburg, Albert Ludwig University of Freiburg, Freiburg im Breisgau, Germany
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24
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Sommer F, Sun B, Fischer J, Goldammer M, Thiele C, Malberg H, Markgraf W. Hyperspectral Imaging during Normothermic Machine Perfusion—A Functional Classification of Ex Vivo Kidneys Based on Convolutional Neural Networks. Biomedicines 2022; 10:biomedicines10020397. [PMID: 35203605 PMCID: PMC8962340 DOI: 10.3390/biomedicines10020397] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 01/28/2022] [Accepted: 01/30/2022] [Indexed: 12/18/2022] Open
Abstract
Facing an ongoing organ shortage in transplant medicine, strategies to increase the use of organs from marginal donors by objective organ assessment are being fostered. In this context, normothermic machine perfusion provides a platform for ex vivo organ evaluation during preservation. Consequently, analytical tools are emerging to determine organ quality. In this study, hyperspectral imaging (HSI) in the wavelength range of 550–995 nm was applied. Classification of 26 kidneys based on HSI was established using KidneyResNet, a convolutional neural network (CNN) based on the ResNet-18 architecture, to predict inulin clearance behavior. HSI preprocessing steps were implemented, including automated region of interest (ROI) selection, before executing the KidneyResNet algorithm. Training parameters and augmentation methods were investigated concerning their influence on the prediction. When classifying individual ROIs, the optimized KidneyResNet model achieved 84% and 62% accuracy in the validation and test set, respectively. With a majority decision on all ROIs of a kidney, the accuracy increased to 96% (validation set) and 100% (test set). These results demonstrate the feasibility of HSI in combination with KidneyResNet for non-invasive prediction of ex vivo kidney function. This knowledge of preoperative renal quality may support the organ acceptance decision.
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25
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Hamelink TL, Ogurlu B, De Beule J, Lantinga VA, Pool MBF, Venema LH, Leuvenink HGD, Jochmans I, Moers C. Renal Normothermic Machine Perfusion: The Road Toward Clinical Implementation of a Promising Pretransplant Organ Assessment Tool. Transplantation 2022; 106:268-279. [PMID: 33979315 DOI: 10.1097/tp.0000000000003817] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The increased utilization of high-risk renal grafts for transplantation requires optimization of pretransplant organ assessment strategies. Current decision-making methods to accept an organ for transplantation lack overall predictive power and always contain an element of subjectivity. Normothermic machine perfusion (NMP) creates near-physiological conditions, which might facilitate a more objective assessment of organ quality before transplantation. NMP is rapidly gaining popularity, with various transplant centers developing their own NMP protocols and renal viability criteria. However, to date, no validated sets of on-pump viability markers exist nor are there unified NMP protocols. This review provides a critical overview of the fundamentals of current renal NMP protocols and proposes a framework to approach further development of ex vivo organ evaluation. We also comment on the potential logistical implications of routine clinical use of NMP, which is a more complex procedure compared with static cold storage or even hypothermic machine perfusion.
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Affiliation(s)
- Tim L Hamelink
- Department of Surgery-Organ Donation and Transplantation, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Baran Ogurlu
- Department of Surgery-Organ Donation and Transplantation, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Julie De Beule
- Laboratory of Abdominal Transplantation, Transplantation Research Group, Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium
| | - Veerle A Lantinga
- Department of Surgery-Organ Donation and Transplantation, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Merel B F Pool
- Department of Surgery-Organ Donation and Transplantation, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Leonie H Venema
- Department of Surgery-Organ Donation and Transplantation, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Henri G D Leuvenink
- Department of Surgery-Organ Donation and Transplantation, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Ina Jochmans
- Laboratory of Abdominal Transplantation, Transplantation Research Group, Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium
- Department of Abdominal Transplant Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Cyril Moers
- Department of Surgery-Organ Donation and Transplantation, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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26
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Zulpaite R, Miknevicius P, Leber B, Strupas K, Stiegler P, Schemmer P. Ex-vivo Kidney Machine Perfusion: Therapeutic Potential. Front Med (Lausanne) 2022; 8:808719. [PMID: 35004787 PMCID: PMC8741203 DOI: 10.3389/fmed.2021.808719] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 12/06/2021] [Indexed: 01/11/2023] Open
Abstract
Kidney transplantation remains the gold standard treatment for patients suffering from end-stage kidney disease. To meet the constantly growing organ demands grafts donated after circulatory death (DCD) or retrieved from extended criteria donors (ECD) are increasingly utilized. Not surprisingly, usage of those organs is challenging due to their susceptibility to ischemia-reperfusion injury, high immunogenicity, and demanding immune regulation after implantation. Lately, a lot of effort has been put into improvement of kidney preservation strategies. After demonstrating a definite advantage over static cold storage in reduction of delayed graft function rates in randomized-controlled clinical trials, hypothermic machine perfusion has already found its place in clinical practice of kidney transplantation. Nevertheless, an active investigation of perfusion variables, such as temperature (normothermic or subnormothermic), oxygen supply and perfusate composition, is already bringing evidence that ex-vivo machine perfusion has a potential not only to maintain kidney viability, but also serve as a platform for organ conditioning, targeted treatment and even improve its quality. Many different therapies, including pharmacological agents, gene therapy, mesenchymal stromal cells, or nanoparticles (NPs), have been successfully delivered directly to the kidney during ex-vivo machine perfusion in experimental models, making a big step toward achievement of two main goals in transplant surgery: minimization of graft ischemia-reperfusion injury and reduction of immunogenicity (or even reaching tolerance). In this comprehensive review current state of evidence regarding ex-vivo kidney machine perfusion and its capacity in kidney graft treatment is presented. Moreover, challenges in application of these novel techniques in clinical practice are discussed.
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Affiliation(s)
- Ruta Zulpaite
- General, Visceral and Transplant Surgery, Department of Surgery, Medical University of Graz, Graz, Austria.,Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Povilas Miknevicius
- General, Visceral and Transplant Surgery, Department of Surgery, Medical University of Graz, Graz, Austria.,Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Bettina Leber
- General, Visceral and Transplant Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | | | - Philipp Stiegler
- General, Visceral and Transplant Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Peter Schemmer
- Faculty of Medicine, Vilnius University, Vilnius, Lithuania
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27
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Inulin Clearance During Ex vivo Normothermic Machine Perfusion as a Marker of Renal Function. ASAIO J 2021; 68:1211-1218. [PMID: 34967777 DOI: 10.1097/mat.0000000000001624] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Normothermic machine perfusion (NMP) offers a unique opportunity to objectively assess donor organ quality. This study describes the evaluation of inulin clearance as a potential marker for the ex vivo function of porcine kidneys during NMP. The function assessment was performed in both kidneys from slaughterhouse pigs (n = 20) and kidneys from pigs in a laboratory setting (n = 28). The kidneys were exposed to different warm ischemia times (WIT). After a period of static cold storage, the kidneys underwent a 4-hour NMP with autologous whole blood. Inulin clearance, hemodynamic parameters, and urine output were measured. Based on the inulin excretion behavior laboratory pig kidneys were assigned to three classes (functional, limited functional, and nonfunctional), slaughterhouse pig kidneys to two classes (limited functional and nonfunctional), respectively. Contrary to the marginal kidneys of the slaughterhouse pigs, the functional variation of kidneys of the laboratory pigs was associated with the WIT. A correlation between functional kidneys and a WIT less than 25 min was shown. Because none of the slaughterhouse pig kidneys could be assigned to the functional class, only the laboratory pig kidneys were used for examinations with functional markers. Renal blood flow and urine output during NMP correlated significantly (p < 0.01) with ex vivo kidney function. This study demonstrated that inulin is a marker of high quality for the evaluation of suggested kidney function after NMP with whole blood. Furthermore, surrogate markers measured during NMP can be used to describe and predict the physiologic behavior of kidneys before transplantation.
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28
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Raredon MSB, Engler AJ, Yuan Y, Greaney AM, Niklason LE. Microvascular fluid flow in ex vivo and engineered lungs. J Appl Physiol (1985) 2021; 131:1444-1459. [PMID: 34554016 PMCID: PMC8616606 DOI: 10.1152/japplphysiol.00286.2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 08/23/2021] [Accepted: 09/15/2021] [Indexed: 11/22/2022] Open
Abstract
In recent years, it has become common to experiment with ex vivo perfused lungs for organ transplantation and to attempt regenerative pulmonary engineering using decellularized lung matrices. However, our understanding of the physiology of ex vivo organ perfusion is imperfect; it is not currently well understood how decreasing microvascular barrier affects the perfusion of pulmonary parenchyma. In addition, protocols for lung perfusion and organ culture fluid-handling are far from standardized, with widespread variation on both basic methods and on ideally controlled parameters. To address both of these deficits, a robust, noninvasive, and mechanistic model is needed which is able to predict microvascular resistance and permeability in perfused lungs while providing insight into capillary recruitment. Although validated mathematical models exist for fluid flow in native pulmonary tissue, previous models generally assume minimal intravascular leak from artery to vein and do not assess capillary bed recruitment. Such models are difficult to apply to both ex vivo lung perfusions, in which edema can develop over time and microvessels can become blocked, and to decellularized ex vivo organomimetic cultures, in which microvascular recruitment is variable and arterially perfused fluid enters into the alveolar space. Here, we develop a mathematical model of pulmonary microvascular fluid flow which is applicable in both instances, and we apply our model to data from native, decellularized, and regenerating lungs under ex vivo perfusion. The results provide substantial insight into microvascular pressure-flow mechanics, while producing previously unknown output values for tissue-specific capillary-alveolar hydraulic conductivity, microvascular recruitment, and total organ barrier resistance.NEW & NOTEWORTHY We present a validated model of pulmonary microvascular fluid mechanics and apply this model to study the effects of increased capillary permeability in decellularized and regenerating lungs. We find that decellularization alters microvascular steady-state mechanics and that re-endothelialization partially rescues key biologic parameters. The described model provides powerful insight into intraorgan microvascular dynamics and may be used to guide regenerative engineering experiments. We include all data and derivations necessary to replicate this work.
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Affiliation(s)
- Micha Sam Brickman Raredon
- Department of Biomedical Engineering, Yale University, New Haven, Connecticut
- Vascular Biology and Therapeutics, Yale University, New Haven, Connecticut
- Medical Scientist Training Program, Yale University, New Haven, Connecticut
| | - Alexander J Engler
- Department of Biomedical Engineering, Yale University, New Haven, Connecticut
- Vascular Biology and Therapeutics, Yale University, New Haven, Connecticut
| | - Yifan Yuan
- Vascular Biology and Therapeutics, Yale University, New Haven, Connecticut
- Department of Anesthesiology, Yale University, New Haven, Connecticut
| | - Allison M Greaney
- Department of Biomedical Engineering, Yale University, New Haven, Connecticut
- Vascular Biology and Therapeutics, Yale University, New Haven, Connecticut
| | - Laura E Niklason
- Department of Biomedical Engineering, Yale University, New Haven, Connecticut
- Vascular Biology and Therapeutics, Yale University, New Haven, Connecticut
- Department of Anesthesiology, Yale University, New Haven, Connecticut
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29
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Schutter R, Lantinga VA, Hamelink TL, Pool MBF, van Varsseveld OC, Potze JH, Hillebrands JL, van den Heuvel MC, Dierckx RAJO, Leuvenink HGD, Moers C, Borra RJH. Magnetic resonance imaging assessment of renal flow distribution patterns during ex vivo normothermic machine perfusion in porcine and human kidneys. Transpl Int 2021; 34:1643-1655. [PMID: 34448269 PMCID: PMC9290094 DOI: 10.1111/tri.13991] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 07/13/2021] [Accepted: 07/14/2021] [Indexed: 02/06/2023]
Abstract
Acceptance criteria of deceased donor organs have gradually been extended toward suboptimal quality, posing an urgent need for more objective pre‐transplant organ assessment. Ex vivo normothermic machine perfusion (NMP) combined with magnetic resonance imaging (MRI) could assist clinicians in deciding whether a donor kidney is suitable for transplantation. Aim of this study was to characterize the regional distribution of perfusate flow during NMP, to better understand how ex vivo kidney assessment protocols should eventually be designed. Nine porcine and 4 human discarded kidneys underwent 3 h of NMP in an MRI‐compatible perfusion setup. Arterial spin labeling scans were performed every 15 min, resulting in perfusion‐weighted images that visualize intrarenal flow distribution. At the start of NMP, all kidneys were mainly centrally perfused and it took time for the outer cortex to reach its physiological dominant perfusion state. Calculated corticomedullary ratios based on the perfusion maps reached a physiological range comparable to in vivo observations, but only after 1 to 2 h after the start of NMP. Before that, the functionally important renal cortex appeared severely underperfused. Our findings suggest that early functional NMP quality assessment markers may not reflect actual physiology and should therefore be interpreted with caution.
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Affiliation(s)
- Rianne Schutter
- Department of Surgery - Organ Donation and Transplantation, University of Groningen, University Medical Center, Groningen, The Netherlands
| | - Veerle A Lantinga
- Department of Surgery - Organ Donation and Transplantation, University of Groningen, University Medical Center, Groningen, The Netherlands
| | - Tim L Hamelink
- Department of Surgery - Organ Donation and Transplantation, University of Groningen, University Medical Center, Groningen, The Netherlands
| | - Merel B F Pool
- Department of Surgery - Organ Donation and Transplantation, University of Groningen, University Medical Center, Groningen, The Netherlands
| | - Otis C van Varsseveld
- Department of Surgery - Organ Donation and Transplantation, University of Groningen, University Medical Center, Groningen, The Netherlands
| | - Jan Hendrik Potze
- Department of Radiology, University of Groningen, University Medical Center, Groningen, The Netherlands
| | - Jan-Luuk Hillebrands
- Department of Pathology & Medical Biology, University of Groningen, University Medical Center, Groningen, The Netherlands
| | - Marius C van den Heuvel
- Department of Pathology & Medical Biology, University of Groningen, University Medical Center, Groningen, The Netherlands
| | - Rudi A J O Dierckx
- Department of Radiology, University of Groningen, University Medical Center, Groningen, The Netherlands.,Department of Nuclear Medicine, University of Groningen, University Medical Center, Groningen, The Netherlands
| | - Henri G D Leuvenink
- Department of Surgery - Organ Donation and Transplantation, University of Groningen, University Medical Center, Groningen, The Netherlands
| | - Cyril Moers
- Department of Surgery - Organ Donation and Transplantation, University of Groningen, University Medical Center, Groningen, The Netherlands
| | - Ronald J H Borra
- Department of Radiology, University of Groningen, University Medical Center, Groningen, The Netherlands.,Department of Nuclear Medicine, University of Groningen, University Medical Center, Groningen, The Netherlands
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30
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McEvoy CM, Clotet-Freixas S, Tokar T, Pastrello C, Reid S, Batruch I, RaoPeters AAE, Kaths JM, Urbanellis P, Farkona S, Van JAD, Urquhart BL, John R, Jurisica I, Robinson LA, Selzner M, Konvalinka A. Normothermic Ex-vivo Kidney Perfusion in a Porcine Auto-Transplantation Model Preserves the Expression of Key Mitochondrial Proteins: An Unbiased Proteomics Analysis. Mol Cell Proteomics 2021; 20:100101. [PMID: 34033948 PMCID: PMC8253910 DOI: 10.1016/j.mcpro.2021.100101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 05/19/2021] [Indexed: 12/17/2022] Open
Abstract
Normothermic ex-vivo kidney perfusion (NEVKP) results in significantly improved graft function in porcine auto-transplant models of donation after circulatory death injury compared with static cold storage (SCS); however, the molecular mechanisms underlying these beneficial effects remain unclear. We performed an unbiased proteomics analysis of 28 kidney biopsies obtained at three time points from pig kidneys subjected to 30 min of warm ischemia, followed by 8 h of NEVKP or SCS, and auto-transplantation. 70/6593 proteins quantified were differentially expressed between NEVKP and SCS groups (false discovery rate < 0.05). Proteins increased in NEVKP mediated key metabolic processes including fatty acid ß-oxidation, the tricarboxylic acid cycle, and oxidative phosphorylation. Comparison of our findings with external datasets of ischemia-reperfusion and other models of kidney injury confirmed that 47 of our proteins represent a common signature of kidney injury reversed or attenuated by NEVKP. We validated key metabolic proteins (electron transfer flavoprotein subunit beta and carnitine O-palmitoyltransferase 2, mitochondrial) by immunoblotting. Transcription factor databases identified members of the peroxisome proliferator-activated receptors (PPAR) family of transcription factors as the upstream regulators of our dataset, and we confirmed increased expression of PPARA, PPARD, and RXRA in NEVKP with reverse transcription polymerase chain reaction. The proteome-level changes observed in NEVKP mediate critical metabolic pathways. These effects may be coordinated by PPAR-family transcription factors and may represent novel therapeutic targets in ischemia-reperfusion injury.
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Affiliation(s)
- Caitriona M McEvoy
- Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada; Division of Nephrology, Department of Medicine, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada; Soham and Shaila Ajmera Family Transplant Centre, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada.
| | - Sergi Clotet-Freixas
- Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Tomas Tokar
- Krembil Research Institute, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Chiara Pastrello
- Krembil Research Institute, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Shelby Reid
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Ihor Batruch
- Department of Laboratory Medicine and Pathobiology, Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Adrien A E RaoPeters
- Department of Physiology and Pharmacology, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - J Moritz Kaths
- Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada; Department of General, Visceral, and Transplantation Surgery, University Hospital Essen, University Essen-Duisburg, Essen, Germany
| | - Peter Urbanellis
- Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada; Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Sofia Farkona
- Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Julie A D Van
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Bradley L Urquhart
- Department of Physiology and Pharmacology, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Rohan John
- Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada; Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Igor Jurisica
- Krembil Research Institute, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada; Departments of Medical Biophysics and Computer Science, University of Toronto, Toronto, Ontario, Canada; Institute of Neuroimmunology, Slovak Academy of Sciences, Bratislava, Slovakia
| | - Lisa A Robinson
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada; Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada; Program in Cell Biology, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
| | - Markus Selzner
- Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada; Soham and Shaila Ajmera Family Transplant Centre, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada; Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Ana Konvalinka
- Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada; Division of Nephrology, Department of Medicine, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada; Soham and Shaila Ajmera Family Transplant Centre, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada; Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada; Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada.
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31
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Pool MBF, Hamelink TL, van Goor H, van den Heuvel MC, Leuvenink HGD, Moers C. Prolonged ex-vivo normothermic kidney perfusion: The impact of perfusate composition. PLoS One 2021; 16:e0251595. [PMID: 34003874 PMCID: PMC8130974 DOI: 10.1371/journal.pone.0251595] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 04/29/2021] [Indexed: 12/22/2022] Open
Abstract
Normothermic machine perfusion (NMP) of donor kidneys provides the opportunity for improved graft preservation and objective pre-transplant ex-vivo organ assessment. Currently, a multitude of perfusion solutions exist for renal NMP. This study aimed to evaluate four different perfusion solutions side-by-side and determine the influence of different perfusate compositions on measured renal perfusion parameters. Porcine kidneys and blood were obtained from a slaughterhouse. Kidneys underwent NMP at 37°C for 7 hours, with 4 different perfusion solutions (n = 5 per group). Group 1 consisted of red blood cells (RBCs) and a perfusion solution based on Williams’ Medium E. Group 2 consisted of RBCs, albumin and a balanced electrolyte composition. Group 3 contained RBCs and a medium based on a British clinical NMP solution. Group 4 contained RBCs and a medium used in 24-hour perfusion experiments. NMP flow patterns for solutions 1 and 2 were similar, solutions 3 and 4 showed lower but more stable flow rates. Thiobarbituric acid reactive substances were significantly higher in solution 1 and 4 compared to the other groups. Levels of injury marker N-acetyl-β-D glucosaminidase were significantly lower in solution 2 in comparison with solution 3 and 4. This study illustrates that the perfusate composition during NMP significantly impacts the measured perfusion and injury parameters and thus affects the interpretation of potential viability markers. Further research is required to investigate the individual influences of principal perfusate components to determine the most optimal conditions during NMP and eventually develop universal organ assessment criteria.
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Affiliation(s)
- Merel B. F. Pool
- Department of Surgery–Organ Donation and Transplantation, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- * E-mail:
| | - Tim L. Hamelink
- Department of Surgery–Organ Donation and Transplantation, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Harry van Goor
- Department of Pathology and Medical Biology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Marius C. van den Heuvel
- Department of Pathology and Medical Biology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Henri G. D. Leuvenink
- Department of Surgery–Organ Donation and Transplantation, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Cyril Moers
- Department of Surgery–Organ Donation and Transplantation, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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32
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Weissenbacher A, Huang H, Surik T, Lo Faro ML, Ploeg RJ, Coussios CC, Friend PJ, Kessler BM. Urine recirculation prolongs normothermic kidney perfusion via more optimal metabolic homeostasis-a proteomics study. Am J Transplant 2021; 21:1740-1753. [PMID: 33021021 PMCID: PMC8246941 DOI: 10.1111/ajt.16334] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 08/27/2020] [Accepted: 09/20/2020] [Indexed: 01/25/2023]
Abstract
We describe a proteomics analysis to determine the molecular differences between normothermically perfused (normothermic machine perfusion, NMP) human kidneys with urine recirculation (URC) and urine replacement (UR). Proteins were extracted from 16 kidney biopsies with URC (n = 8 donors after brain death [DBD], n = 8 donors after circulatory death [DCD]) and three with UR (n = 2 DBD, n = 1 DCD), followed by quantitative analysis by mass spectrometry. Damage-associated molecular patterns (DAMPs) were decreased in kidney tissue after 6 hours NMP with URC, suggesting reduced inflammation. Vasoconstriction was also attenuated in kidneys with URC as angiotensinogen levels were reduced. Strikingly, kidneys became metabolically active during NMP, which could be enhanced and prolonged by URC. For instance, mitochondrial succinate dehydrogenase enzyme levels as well as carbonic anhydrase were enhanced with URC, contributing to pH stabilization. Levels of cytosolic and the mitochondrial phosphoenolpyruvate carboxykinase were elevated after 24 hours of NMP, more prevalent in DCD than DBD tissue. Key enzymes involved in glucose metabolism were also increased after 12 and 24 hours of NMP with URC, including mitochondrial malate dehydrogenase and glutamic-oxaloacetic transaminase, predominantly in DCD tissue. We conclude that NMP with URC permits prolonged preservation and revitalizes metabolism to possibly better cope with ischemia reperfusion injury in discarded kidneys.
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Affiliation(s)
- Annemarie Weissenbacher
- Nuffield Department of Surgical SciencesUniversity of OxfordOxfordUK
- Present address:
Annemarie WeissenbacherDepartment of Visceral, Transplant and Thoracic SurgeryMedical University of InnsbruckInnsbruckAustria
| | - Honglei Huang
- Nuffield Department of Surgical SciencesUniversity of OxfordOxfordUK
- Target Discovery InstituteNuffield Department of MedicineUniversity of OxfordOxfordUK
- Present address:
Honglei HuangOxford BioMedica PlcOxfordUK
| | - Tomas Surik
- Nuffield Department of Surgical SciencesUniversity of OxfordOxfordUK
| | - Maria L. Lo Faro
- Nuffield Department of Surgical SciencesUniversity of OxfordOxfordUK
| | - Rutger J. Ploeg
- Nuffield Department of Surgical SciencesUniversity of OxfordOxfordUK
| | - Constantin C. Coussios
- Institute of Biomedical EngineeringDepartment of Engineering ScienceUniversity of OxfordOxfordUK
| | - Peter J. Friend
- Nuffield Department of Surgical SciencesUniversity of OxfordOxfordUK
| | - Benedikt M. Kessler
- Target Discovery InstituteNuffield Department of MedicineUniversity of OxfordOxfordUK
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33
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Elliott TR, Nicholson ML, Hosgood SA. Normothermic kidney perfusion: An overview of protocols and strategies. Am J Transplant 2021; 21:1382-1390. [PMID: 32897651 DOI: 10.1111/ajt.16307] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 08/18/2020] [Accepted: 08/19/2020] [Indexed: 02/06/2023]
Abstract
Normothermic machine perfusion (NMP) technologies are emerging as an important adjunct in organ preservation and transplantation. NMP can enable the reduction or avoidance of cold ischemia and allows for pretransplant measurement of function and metabolic status to assess the suitability of the organ for transplantation. The key requirement of NMP is to provide an environment that is protective to the organ, ensures optimal oxygen delivery and supports metabolic function. Red blood cell-based solutions, artificial hemoglobin solutions, and acellular solutions have all been utilized in NMP. However, there is no clear consensus on perfusion protocols. A period of NMP after hypothermic preservation is the most commonly used strategy. As an alternative, several groups have developed and tested the feasibility of more prolonged periods of NMP. There are only a few reports of the application of NMP in clinical kidney transplantation and each uses different approach and conditions. This review details the rationale for NMP protocols considering duration of NMP and different perfusate compositions in experimental and clinical models. We also include a discussion on the mechanistic action of NMP, comparison of subnormothermic and hypothermic conditions, the different logistical approaches and future requirements.
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Affiliation(s)
| | | | - Sarah A Hosgood
- Department of Surgery, University of Cambridge, Cambridge, UK
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34
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Luke PPW, Jiang L, Ruthirakanthan A, Lee D, Sun Q, Richard-Mohamed M, Kwong J, Aquil S, Alogaili R, Haig A, Sener A, Bhattacharjee RN. Comparison of Centrifugal and Pulsatile Perfusion to Preserve Donor Kidneys Using Ex Vivo Subnormothermic Perfusion. J INVEST SURG 2021; 35:104-110. [PMID: 33400888 DOI: 10.1080/08941939.2020.1829212] [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] [Indexed: 01/14/2023]
Abstract
OBJECTIVE We have previously demonstrated benefits of kidney preservation utilizing an oxygenated subnormothermic ex vivo perfusion platform. Herein, we aim to compare pulsatile versus centrifugal (steady and uniform flow) perfusion with the goal of optimizing renal preservation with these devices. Materials and methods: Pig kidneys were procured following 30 min of warm ischemia by cross-clamping both renal arteries. Paired kidneys were cannulated and underwent either: oxygenated pulsatile or centrifugal perfusion using a hemoglobin oxygen carrier at room temperature with our ex vivo machine perfusion platform for 4 hr. Kidneys were reperfused with whole blood for 4 hr at 37° C. Renal function, pathology and evidence of inflammation were assessed post-perfusion. Results: Both pump systems performed equally well with organs exhibiting similar renal blood flow, and function post-reperfusion. Histologic evidence of renal damage using apoptosis staining and acute tubular necrosis scores was similar between groups. This was corroborated with urinary assessment of renal damage (NGAL 1) and inflammation (IL-6), as levels were similar between groups. Conclusion: In our porcine model with added warm ischemia simulating the effects of reperfusion after transplantation, pulsatile perfusion yielded similar renal protection compared with centrifugal perfusion kidney preservation. Both methods of perfusion can be used in ex vivo kidney perfusion systems.
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Affiliation(s)
- Patrick P W Luke
- Department of Surgery, London Health Sciences Centre, London, Canada.,Multi-Organ Transplant Program, London Health Sciences Centre, London, Canada.,Matthew Mailing Centre for Translational Transplantation Studies, London Health Sciences Centre, London, Canada.,Schulich School of Medicine and Dentistry, Western University, London, Canada
| | - Larry Jiang
- Matthew Mailing Centre for Translational Transplantation Studies, London Health Sciences Centre, London, Canada
| | - Aushanth Ruthirakanthan
- Matthew Mailing Centre for Translational Transplantation Studies, London Health Sciences Centre, London, Canada
| | - Daniel Lee
- Matthew Mailing Centre for Translational Transplantation Studies, London Health Sciences Centre, London, Canada
| | - Qizhi Sun
- Matthew Mailing Centre for Translational Transplantation Studies, London Health Sciences Centre, London, Canada.,Schulich School of Medicine and Dentistry, Western University, London, Canada
| | | | - Justin Kwong
- Multi-Organ Transplant Program, London Health Sciences Centre, London, Canada
| | - Shahid Aquil
- Multi-Organ Transplant Program, London Health Sciences Centre, London, Canada
| | - Rafid Alogaili
- Multi-Organ Transplant Program, London Health Sciences Centre, London, Canada
| | - Aaron Haig
- Schulich School of Medicine and Dentistry, Western University, London, Canada.,Department of Pathology and Laboratory Medicine, London Health Sciences Centre, London, Canada
| | - Alp Sener
- Department of Surgery, London Health Sciences Centre, London, Canada.,Multi-Organ Transplant Program, London Health Sciences Centre, London, Canada.,Schulich School of Medicine and Dentistry, Western University, London, Canada
| | - Rabindra N Bhattacharjee
- Department of Surgery, London Health Sciences Centre, London, Canada.,Matthew Mailing Centre for Translational Transplantation Studies, London Health Sciences Centre, London, Canada.,Schulich School of Medicine and Dentistry, Western University, London, Canada.,Department of Pathology and Laboratory Medicine, London Health Sciences Centre, London, Canada
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35
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Abbas SH, Friend PJ. Principles and current status of abdominal organ preservation for transplantation. SURGERY IN PRACTICE AND SCIENCE 2020. [DOI: 10.1016/j.sipas.2020.100020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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36
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Abstract
Because of the high demand of organs, the usage of marginal grafts has increased. These marginal organs have a higher risk of developing ischemia-reperfusion injury, which can lead to posttransplant complications. Ex situ machine perfusion (MP), compared with the traditional static cold storage, may better protect these organs from ischemia-reperfusion injury. In addition, MP can also act as a platform for dynamic administration of pharmacological agents or gene therapy to further improve transplant outcomes. Numerous therapeutic agents have been studied under both hypothermic (1-8°C) and normothermic settings. Here, we review all the therapeutics used during MP in different organ systems (lung, liver, kidney, heart). The major categories of therapeutic agents include vasodilators, mesenchymal stem cells, antiinflammatory agents, antiinfection agents, siRNA, and defatting agents. Numerous animal and clinical studies have examined MP therapeutic agents, some of which have even led to the successful reconditioning of discarded grafts. More clinical studies, especially randomized controlled trials, will need to be conducted in the future to solidify these promising results and to define the role of MP therapeutic agents in solid organ transplantation.
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37
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Swanson KJ, Aziz F, Garg N, Mohamed M, Mandelbrot D, Djamali A, Parajuli S. Role of novel biomarkers in kidney transplantation. World J Transplant 2020; 10:230-255. [PMID: 32995319 PMCID: PMC7504189 DOI: 10.5500/wjt.v10.i9.230] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 07/21/2020] [Accepted: 08/26/2020] [Indexed: 02/05/2023] Open
Abstract
Clinical application of biomarkers is an integral component of transplant care. Clinicians and scientists alike are in search of better biomarkers than the current serologic (serum creatinine, donor-specific antibodies), urine-derived (urinalysis, urine protein), and histologic ones we now use. The science behind recent biomarker discovery spans across multiple molecular biologic disciplines, including transcriptomics, proteomics, and metabolomics. Innovative methodology and integration of basic and clinical approaches have allowed researchers to unearth molecular phenomena preceding clinical disease. Biomarkers can be classified in several ways. In this review, we have classified them via their origin and outcome: Primarily immunologic, i.e., representative of immune regulation and dysfunction and non-immunologic, pertaining to delayed graft function, cardiovascular events/mortality, infection, malignancy, post-transplant diabetes, graft, and patient survival. Novel biomarker uses to guide the diagnosis and management of transplant-related outcomes is a promising area of research. However, the use of biomarkers to predict outcomes after kidney transplantation is not well studied. In this review, we summarize the recent studies illustrating biomarker use and transplant outcomes.
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Affiliation(s)
- Kurtis J Swanson
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI 53705, United States
| | - Fahad Aziz
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI 53705, United States
| | - Neetika Garg
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI 53705, United States
| | - Maha Mohamed
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI 53705, United States
| | - Didier Mandelbrot
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI 53705, United States
| | - Arjang Djamali
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI 53705, United States
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI 53705, United States
| | - Sandesh Parajuli
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI 53705, United States
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38
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Pool MBF, Vos J, Eijken M, van Pel M, Reinders MEJ, Ploeg RJ, Hoogduijn MJ, Jespersen B, Leuvenink HGD, Moers C. Treating Ischemically Damaged Porcine Kidneys with Human Bone Marrow- and Adipose Tissue-Derived Mesenchymal Stromal Cells During Ex Vivo Normothermic Machine Perfusion. Stem Cells Dev 2020; 29:1320-1330. [PMID: 32772797 DOI: 10.1089/scd.2020.0024] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Pretransplant normothermic machine perfusion (NMP) of donor kidneys offers the unique opportunity to perform active interventions to an isolated renal graft before transplantation. There is increasing evidence that mesenchymal stromal cells (MSCs) could have a paracrine/endocrine regenerative effect on ischemia-reperfusion injury. The purpose of this study was to determine which cytokines are secreted by MSCs during NMP of a porcine kidney. Viable porcine kidneys and autologous whole blood were obtained from a slaughterhouse. Warm ischemia time was standardized at 20 min and subsequent hypothermic machine perfusion was performed during 2-3 h. Thereafter, kidneys were machine perfused at 37°C during 7 h. After 1 h of NMP, 0, 107 cultured human adipose tissue-derived MSCs, or 107 cultured bone marrow-derived MSCs were added (n = 5 per group). In a fourth experimental group, 7-h NMP was performed with 107 adipose tissue-derived MSCs, without a kidney in the circuit. Kidneys perfused with MSCs showed lower lactate dehydrogenase and neutrophil gelatinase-associated lipocalin levels in comparison with the control group. Also, elevated levels of human hepatocyte growth factor, interleukin (IL)-6, and IL-8 were found in the perfusate of the groups perfused with MSCs compared to the control groups. This study suggests that MSCs, in contact with an injured kidney during NMP, could lead to lower levels of injury markers and induce the release of immunomodulatory cytokines.
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Affiliation(s)
- Merel B F Pool
- Department of Surgery-Organ Donation and Transplantation, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Jaël Vos
- Department of Surgery-Organ Donation and Transplantation, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Marco Eijken
- Department of Clinical Immunology, Aarhus University Hospital, Aarhus, Denmark.,Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Melissa van Pel
- Department of Immunohematology and Bloodtransfusion, Leiden University Medical Center, Leiden, the Netherlands
| | - Marlies E J Reinders
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Leiden, the Netherlands
| | - Rutger J Ploeg
- Department of Surgery-Organ Donation and Transplantation, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.,Oxford Transplant Centre, University of Oxford, Oxford, United Kingdom
| | - Martin J Hoogduijn
- Department of Internal Medicine, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Bente Jespersen
- Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Henri G D Leuvenink
- Department of Surgery-Organ Donation and Transplantation, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Cyril Moers
- Department of Surgery-Organ Donation and Transplantation, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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Mariager CØ, Hansen ESS, Bech SK, Munk A, Kjaergaard U, Lyhne MD, Søberg K, Nielsen PF, Ringgaard S, Laustsen C. Graft assessment of the ex vivo perfused porcine kidney using hyperpolarized [1- 13 C]pyruvate. Magn Reson Med 2020; 84:2645-2655. [PMID: 32557782 DOI: 10.1002/mrm.28363] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Revised: 05/07/2020] [Accepted: 05/21/2020] [Indexed: 01/06/2023]
Abstract
PURPOSE Normothermic perfusion is an emerging strategy for donor organ preservation and therapy, incited by the high worldwide demand for organs for transplantation. Hyperpolarized MRI and MRS using [1-13 C]pyruvate and other 13 C-labeled molecules pose a novel way to acquire highly detailed information about metabolism and function in a noninvasive manner. This study investigates the use of this methodology as a means to study and monitor the state of ex vivo perfused porcine kidneys, in the context of kidney graft preservation research. METHODS Kidneys from four 40-kg Danish domestic pigs were perfused ex vivo with whole blood under normothermic conditions, using an MR-compatible perfusion system. Kidneys were investigated using 1 H MRI as well as hyperpolarized [1-13 C]pyruvate MRI and MRS. Using the acquired anatomical, functional and metabolic data, the state of the ex vivo perfused porcine kidney could be quantified. RESULTS Four kidneys were successfully perfused for 120 minutes and verified using a DCE perfusion experiment. Renal metabolism was examined using hyperpolarized [1-13 C]pyruvate MRI and MRS, and displayed an apparent reduction in pyruvate turnover compared with the usual case in vivo. Perfusion and blood gas parameters were in the normal ex vivo range. CONCLUSION This study demonstrates the ability to monitor ex vivo graft metabolism and function in a large animal model, resembling human renal physiology. The ability of hyperpolarized MRI and MRS to directly compare the metabolic state of an organ in vivo and ex vivo, in combination with the simple MR implementation of normothermic perfusion, renders this methodology a powerful future tool for graft preservation research.
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Affiliation(s)
| | | | - Sabrina Kahina Bech
- Department of Clinical Medicine, The MR Research Centre, Aarhus University, Aarhus, Denmark
| | - Anders Munk
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Uffe Kjaergaard
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Mads Dam Lyhne
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Karsten Søberg
- Department of Anesthesia and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Peter Fast Nielsen
- Department of Anesthesia and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Steffen Ringgaard
- Department of Clinical Medicine, The MR Research Centre, Aarhus University, Aarhus, Denmark
| | - Christoffer Laustsen
- Department of Clinical Medicine, The MR Research Centre, Aarhus University, Aarhus, Denmark
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Foucher Y, Fournier MC, Legendre C, Morelon E, Buron F, Girerd S, Ladrière M, Mourad G, Garrigue V, Glotz D, Lefaucheur C, Cassuto E, Albano L, Giral M, Dantal J. Comparison of machine perfusion versus cold storage in kidney transplant recipients from expanded criteria donors: a cohort-based study. Nephrol Dial Transplant 2020; 35:1043-1070. [PMID: 32516809 DOI: 10.1093/ndt/gfz175] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 07/26/2019] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Most studies comparing the efficacy of hypothermic machine perfusion (HMP) versus static cold storage (SCS) are based on short-term outcomes. We aimed to better evaluate the mid-term impact of HMP in patients receiving expanded criteria donor (ECD) kidneys. METHODS The analyses were based on the French Données Informatisées et VAlidées en Transplantation (DIVAT) observational cohort. Patients aged ≥45 years transplanted for the first or second times from an ECD donor since 2010 were studied. Our study reported the graft and/or patient survivals and the incidence of acute rejection episode. The Cox models and the Kaplan-Meier estimators, weighted on the propensity score, were used to study the times-to-events. RESULTS Among the 2019 included patients, 1073 were in the SCS group versus 946 in the HMP group. The mean life expectancy with functioning graft was 5.7 years [95% confidence interval (CI) 5.4-6.1] for the HMP cohort followed-up for 8 years post-transplantation versus 6.0 years (95% CI 5.7-6.2) for the SCS group. These mid-term results were comparable in the patients receiving grafts from donors aged ≥70 years and in the transplantations with cold ischaemia time ≥18 h. CONCLUSIONS Our study challenges the utility of using HMP to improve mid-term patient and graft survival. Nevertheless, the improvement of the short-term outcomes is indisputable. It is necessary to continue technological innovations to obtain long-term results.
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Affiliation(s)
- Yohann Foucher
- INSERM UMR 1246 - SPHERE, Nantes University, Tours University, Nantes, France.,Centre Hospitalier Universitaire de Nantes, Nantes, France
| | | | - Christophe Legendre
- Kidney Transplant Center, Necker University Hospital, APHP, RTRS « Centaure », Paris Descartes and Sorbonne Paris Cité Universities, Paris, France
| | - Emmanuel Morelon
- Nephrology, Transplantation and Clinical Immunology Department, RTRS « Centaure », Edouard Herriot University Hospital, Hospices Civils, Lyon, France
| | - Fanny Buron
- Nephrology, Transplantation and Clinical Immunology Department, RTRS « Centaure », Edouard Herriot University Hospital, Hospices Civils, Lyon, France
| | - Sophie Girerd
- Renal Transplantation Department, Brabois University Hospital, Nancy, France
| | - Marc Ladrière
- Renal Transplantation Department, Brabois University Hospital, Nancy, France
| | - Georges Mourad
- Nephrology, Dialysis and Transplantation Department, Lapeyronie University Hospital, Montpellier, France
| | - Valérie Garrigue
- Nephrology, Dialysis and Transplantation Department, Lapeyronie University Hospital, Montpellier, France
| | - Denis Glotz
- Paris Translational Research Center for Organ Transplantation & Department of Nephrology and Transplantation, Hopital Saint Louis, Université Paris VII and INSERM U 1160, Paris, France
| | - Carmen Lefaucheur
- Paris Translational Research Center for Organ Transplantation & Department of Nephrology and Transplantation, Hopital Saint Louis, Université Paris VII and INSERM U 1160, Paris, France
| | - Elisabeth Cassuto
- Department of Nephrology and Renal Transplantation, Hospital Pasteur, Nice, France
| | - Laetitia Albano
- Department of Nephrology and Renal Transplantation, Hospital Pasteur, Nice, France
| | - Magali Giral
- Centre Hospitalier Universitaire de Nantes, Nantes, France.,Centre d'Investigation Clinique en Biothérapie, Labex Transplantex, Nantes, France.,Centre de Recherche en Transplantation et Immunologie INSERM UMR1064, Université de Nantes, Centre Hospitalier Universitaire de Nantes, RTRS « Centaure », Nantes, France
| | - Jacques Dantal
- Centre Hospitalier Universitaire de Nantes, Nantes, France.,Centre de Recherche en Transplantation et Immunologie INSERM UMR1064, Université de Nantes, Centre Hospitalier Universitaire de Nantes, RTRS « Centaure », Nantes, France
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Normothermic Ex Vivo Kidney Perfusion Improves Early DCD Graft Function Compared With Hypothermic Machine Perfusion and Static Cold Storage. Transplantation 2020; 104:947-955. [DOI: 10.1097/tp.0000000000003066] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Abstract
PURPOSE OF REVIEW The shortage of kidneys for transplantation has led to an urgent need to efficiently utilize the available cadaveric kidneys. Efficient use of machine perfusion may potentially lead to increased use of marginal kidneys by lowering the incidence of delayed graft function (DGF) and improving graft outcomes. RECENT FINDINGS Machine perfusion has had a resurgence in the last 10-15 years over static cold storage (SCS). Hypothermic machine perfusion (HMP), the most commonly utilized type of machine perfusion reduces the rates of DGF when compared with SCS with a trend towards improving the overall graft survival. SUMMARY Despite reduction in the rates of DGF by HMP, its effect on long-term renal and patient outcomes is not clearly known. There is limited clinical literature in the use of normothermic machine perfusion (NMP) but a few pilot studies have shown its potential to resuscitate commonly discarded kidneys. In addition to preservation, machine perfusion also allows for various diagnostic and therapeutic interventions during the preservation period to assess and optimize the viability of the procured kidney.
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Moving the Margins: Updates on the Renaissance in Machine Perfusion for Organ Transplantation. CURRENT TRANSPLANTATION REPORTS 2020. [DOI: 10.1007/s40472-020-00277-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Kidney Perfusion as an Organ Quality Assessment Tool-Are We Counting Our Chickens Before They Have Hatched? J Clin Med 2020; 9:jcm9030879. [PMID: 32210197 PMCID: PMC7141526 DOI: 10.3390/jcm9030879] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 03/16/2020] [Accepted: 03/19/2020] [Indexed: 02/07/2023] Open
Abstract
The final decision to accept an organ for transplantation remains a subjective one. With “poor organ quality” commonly cited as a major reason for kidney discard, accurate, objective, and reliable quality assessment is essential. In an era of increasingly higher-risk deceased donor kidneys, the catch is to accept those where the risk–benefit scale will tip in the right direction. Currently available assessment tools, such as risk-scores predicting outcome and zero-time biopsy, perform unsatisfactory, and assessment options during static cold storage are limited. Kidney perfusion technologies are finding their way into clinical practice, and they bring a new opportunity to assess kidney graft viability and quality, both in hypothermic and normothermic conditions. We give an overview of the current understanding of kidney viability assessment during ex situ kidney perfusion. A pragmatic framework to approach viability assessment is proposed as an interplay of three different compartments: the nephron, the vascular compartment, and the immune compartment. Although many interesting ways to assess kidney injury and function during perfusion have been proposed, none have reached the stage where they can reliably predict posttransplant outcome. Larger well-designed studies and validation cohorts are needed to provide better guidance.
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Urine Recirculation Improves Hemodynamics and Enhances Function in Normothermic Kidney Perfusion. Transplant Direct 2020; 6:e541. [PMID: 32309627 PMCID: PMC7144999 DOI: 10.1097/txd.0000000000000985] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 01/09/2020] [Accepted: 01/28/2020] [Indexed: 01/10/2023] Open
Abstract
Supplemental Digital Content is available in the text. The study compares urine recirculation (URC) to urine replacement (UR) with Ringer’s lactate in a porcine normothermic kidney machine perfusion (NMP) model using a preclinical prototype device.
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Innate Immune Activation in High-risk Donor Kidneys: An Opportunity to Intervene? Transplantation 2019; 104:668. [PMID: 31764764 DOI: 10.1097/tp.0000000000003049] [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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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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Combined Ex Vivo Hypothermic and Normothermic Perfusion for Assessment of High-risk Deceased Donor Human Kidneys for Transplantation. Transplantation 2019; 103:392-400. [PMID: 29952816 PMCID: PMC6365241 DOI: 10.1097/tp.0000000000002299] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background Despite careful clinical examination, procurement biopsy and assessment on hypothermic machine perfusion, a significant number of potentially useable deceased donor kidneys will be discarded because they are deemed unsuitable for transplantation. Ex vivo normothermic perfusion (EVNP) may be useful as a means to further assess high-risk kidneys to determine suitability for transplantation. Methods From June 2014 to October 2015, 7 kidneys (mean donor age, 54.3 years and Kidney Donor Profile Index, 79%) that were initially procured with the intention to transplant were discarded based on a combination of clinical findings, suboptimal biopsies, long cold ischemia time (CIT) and/or poor hypothermic perfusion parameters. They were subsequently placed on EVNP using oxygenated packed red blood cells and supplemental nutrition for a period of 3 hours. Continuous hemodynamic and functional parameters were assessed. Results After a mean CIT of 43.7 hours, all 7 kidneys appeared viable on EVNP with progressively increasing renal blood flow over the 3-hour period of perfusion. Five of the 7 kidneys had excellent macroscopic appearance, rapid increase in blood flow to 200 to 250 mL/min, urine output of 40 to 260 mL/h and increasing creatinine clearance. Conclusions Favorable perfusion characteristics and immediate function after a 3-hour course of EVNP suggests that high-risk kidneys subjected to long CIT may have been considered for transplantation. The combined use of ex vivo hypothermic and normothermic perfusion may be a useful strategy to more adequately assess and preserve high-risk kidneys deemed unsuitable for transplantation. A clinical trial will be necessary to validate the usefulness of this approach. The combined use of ex vivo hypothermic and normothermic perfusion may be a useful strategy to more adequately assess and preserve high-risk kidneys deemed unsuitable for transplantation.
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Mahboub P, Aburawi M, Karimian N, Lin F, Karabacak M, Fontan F, Tessier SN, Markmann J, Yeh H, Uygun K. The efficacy of HBOC-201 in ex situ gradual rewarming kidney perfusion in a rat model. Artif Organs 2019; 44:81-90. [PMID: 31368159 PMCID: PMC6916591 DOI: 10.1111/aor.13534] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 06/03/2019] [Accepted: 07/03/2019] [Indexed: 02/06/2023]
Abstract
Gradual rewarming from hypothermic to normothermic is a novel perfusion modality with superior outcome to sudden rewarming to normothermic. However, the identification of an oxygen carrier that could function at a temperature range from 4 to 7°C or whether it is necessary to use oxygen carrier during kidney rewarming, remains unresolved. This study was designed to test the use of a hemoglobin‐based oxygen carrier (HBOC) during gradual kidney rewarming as an alternative to simple dissolved oxygen. In this study, 10 rat kidneys were randomly divided into the control and the HBOC group. In the control group, no oxygen carrier was used during rewarming perfusion and the perfusion solution was oxygenated only by applying diffused carbogen flow. The protocol mimicked a donor after circulatory death (DCD) kidney transplantation, where after 30 minutes warm ischemia and 120 minutes cold storage in University of Wisconsin solution, the DCD kidneys underwent gradual rewarming from 10 to 37°C during 90 minutes with or without HBOC. This was followed by 30 minutes of warm ischemia in room temperature to mimic the anastomosis time and 120 minutes of reperfusion at 37°C to mimic the early post‐transplant state of the graft. The HBOC group demonstrated superior kidney function which was highlighted by higher ultrafiltrate production, better glomerular filtration rate and improved sodium reabsorption. There was no significant difference between the 2 groups regarding the hemodynamics, tissue injury, and adenosine triphosphate levels. In conclusion, this study suggests better renal function recovery in DCD kidneys after rewarming with HBOC compared to rewarming without an oxygen carrier.
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Affiliation(s)
- Paria Mahboub
- University Medical Center Groningen, Groningen, Netherlands.,Center for Engineering in Medicine, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mohamed Aburawi
- Transplant Center, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Negin Karimian
- Center for Engineering in Medicine, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Florence Lin
- Center for Engineering in Medicine, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Murat Karabacak
- Center for Engineering in Medicine, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Fermin Fontan
- Transplant Center, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Shannon N Tessier
- Center for Engineering in Medicine, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - James Markmann
- Transplant Center, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Heidi Yeh
- Center for Engineering in Medicine, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.,Transplant Center, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Korkut Uygun
- Center for Engineering in Medicine, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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