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Nykänen AI, Keshavjee S, Liu M. Creating superior lungs for transplantation with next-generation gene therapy during ex vivo lung perfusion. J Heart Lung Transplant 2024; 43:838-848. [PMID: 38310996 DOI: 10.1016/j.healun.2024.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Revised: 12/23/2023] [Accepted: 01/29/2024] [Indexed: 02/06/2024] Open
Abstract
Engineering donor organs to better tolerate the harmful non-immunological and immunological responses inherently related to solid organ transplantation would improve transplant outcomes. Our enhanced knowledge of ischemia-reperfusion injury, alloimmune responses and pathological fibroproliferation after organ transplantation, and the advanced toolkit available for gene therapies, have brought this goal closer to clinical reality. Ex vivo organ perfusion has evolved rapidly especially in the field of lung transplantation, where clinicians routinely use ex vivo lung perfusion (EVLP) to confirm the quality of marginal donor lungs before transplantation, enabling safe transplantation of organs originally considered unusable. EVLP would also be an attractive platform to deliver gene therapies, as treatments could be administered to an isolated organ before transplantation, thereby providing a window for sophisticated organ engineering while minimizing off-target effects to the recipient. Here, we review the status of lung transplant first-generation gene therapies that focus on inducing transgene expression in the target cells. We also highlight recent advances in next-generation gene therapies, that enable gene editing and epigenetic engineering, that could be used to permanently change the donor organ genome and to induce widespread transcriptional gene expression modulation in the donor lung. In a future vision, dedicated organ repair and engineering centers will use gene editing and epigenetic engineering, to not only increase the donor organ pool, but to create superior organs that will function better and longer in the recipient.
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Affiliation(s)
- Antti I Nykänen
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada; Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Cardiothoracic Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Shaf Keshavjee
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada; Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Division of Thoracic Surgery, Department of Surgery, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Mingyao Liu
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada; Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
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Chao BT, McInnis MC, Sage AT, Yeung JC, Cypel M, Liu M, Wang B, Keshavjee S. A radiographic score for human donor lungs on ex vivo lung perfusion predicts transplant outcomes. J Heart Lung Transplant 2024; 43:797-805. [PMID: 38211838 DOI: 10.1016/j.healun.2024.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 01/02/2024] [Accepted: 01/05/2024] [Indexed: 01/13/2024] Open
Abstract
BACKGROUND Ex vivo lung perfusion (EVLP) is an advanced platform for isolated lung assessment and treatment. Radiographs acquired during EVLP provide a unique opportunity to assess lung injury. The purpose of our study was to define and evaluate EVLP radiographic findings and their association with lung transplant outcomes. METHODS We retrospectively evaluated 113 EVLP cases from 2020-21. Radiographs were scored by a thoracic radiologist blinded to outcome. Six lung regions were scored for 5 radiographic features (consolidation, infiltrates, atelectasis, nodules, and interstitial lines) on a scale of 0 to 3 to derive a score. Spearman's correlation was used to correlate radiographic scores to biomarkers of lung injury. Machine learning models were developed using radiographic features and EVLP functional data. Predictive performance was assessed using the area under the curve. RESULTS Consolidation and infiltrates were the most frequent findings at 1 hour EVLP (radiographic lung score 2.6 (3.3) and 4.6 (4.3)). Consolidation (r = -0.536 and -0.608, p < 0.0001) and infiltrates (r = -0.492 and -0.616, p < 0.0001) were inversely correlated with oxygenation (∆pO2) at 1 hour and 3 hours of EVLP. First-hour consolidation and infiltrate lung scores predicted transplant suitability with an area under the curve of 87% and 88%, respectively. Prediction of transplant outcomes using a machine learning model yielded an area under the curve of 80% in the validation set. CONCLUSIONS EVLP radiographs provide valuable insight into donor lungs being assessed for transplantation. Consolidation and infiltrates were the most common abnormalities observed in EVLP lungs, and radiographic lung scores predicted the suitability of donor lungs for transplant.
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Affiliation(s)
- Bonnie T Chao
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada; Institute of Biomedical Engineering, University of Toronto, Toronto, Ontario, Canada
| | - Micheal C McInnis
- University Medical Imaging Toronto, Toronto General Hospital, University Health Network, Toronto, ON, Canada; Department of Medical Imaging, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Andrew T Sage
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada; Department of Surgery, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jonathan C Yeung
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Marcelo Cypel
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada; Department of Surgery, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Mingyao Liu
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada; Department of Surgery, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Bo Wang
- Vector Institute, University of Toronto, Toronto, Ontario, Canada; Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Shaf Keshavjee
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada; Institute of Biomedical Engineering, University of Toronto, Toronto, Ontario, Canada; Department of Surgery, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
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3
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Heise EL, Salman J, Webs KS, Höffler K, Brandenberger C, Böthig D, Mühlfeld C, Haverich A. Hypoxic perfusion of pulmonary arterial vasa vasorum increases pulmonary arterial pressure. Am J Physiol Lung Cell Mol Physiol 2024. [PMID: 38651234 DOI: 10.1152/ajplung.00346.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 04/19/2024] [Indexed: 04/25/2024] Open
Abstract
The pathophysiology of pulmonary hypertension (PH) is not fully understood. Here, we tested the hypothesis that hypoxic perfusion of the vasa vasorum of the pulmonary arterial (PA) wall causes PH. Young adult pig lungs were explanted and placed into a modified ex vivo lung perfusion unit (Organ care system, OCS) allowing the separate adjustment of parameters for mechanical ventilation, as well as PA perfusion and bronchial arterial (BA) perfusion. PA vasa vasorum are branches of the BA. The lungs were used either as control (n=3) or intervention group (n=8). The protocol of the intervention group was as follows: normoxic ventilation and perfusion (steady state) -hypoxic BA perfusion -steady state -hypoxic BA perfusion. During hypoxic BA perfusion, ventilation and PA perfusion maintained normal. Control lungs were kept under steady state conditions for 105 minutes. During the experiments, PA pressure (PAP) and blood gas analysis was frequently monitored. Hypoxic perfusion of the BA resulted in an increase in systolic and mean PAP, a reaction that was reversible upon normoxic BA perfusion. The PAP increase was reproducible in the second hypoxic BA perfusion. Under control conditions the PAP stayed constant until about 80 minutes of the experiment. In conclusion, the results of the current study prove that hypoxic perfusion of the vasa vasorum of the PA directly increases PAP in an ex situ lung perfusion setup suggesting that PA vasa vasorum function and wall ischemia may contribute to the development of PH.
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Affiliation(s)
- Emma L Heise
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Jawad Salman
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Karolin S Webs
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Klaus Höffler
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | | | - Dietmar Böthig
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Christian Mühlfeld
- Institute of Functional and Applied Anatomy, Medizinische Hochschule Hannover, Hannover, Germany
| | - Axel Haverich
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
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4
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De Wolf J, Gouin C, Jouneau L, Glorion M, Premachandra A, Pascale F, Huriet M, Estephan J, Leplat JJ, Egidy G, Richard C, Gelin V, Urien C, Roux A, Le Guen M, Schwartz-Cornil I, Sage E. Prolonged dialysis during ex vivo lung perfusion promotes inflammatory responses. Front Immunol 2024; 15:1365964. [PMID: 38585271 PMCID: PMC10995259 DOI: 10.3389/fimmu.2024.1365964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 03/04/2024] [Indexed: 04/09/2024] Open
Abstract
Ex-vivo lung perfusion (EVLP) has extended the number of transplantable lungs by reconditioning marginal organs. However, EVLP is performed at 37°C without homeostatic regulation leading to metabolic wastes' accumulation in the perfusate and, as a corrective measure, the costly perfusate is repeatedly replaced during the standard of care procedure. As an interesting alternative, a hemodialyzer could be placed on the EVLP circuit, which was previously shown to rebalance the perfusate composition and to maintain lung function and viability without appearing to impact the global gene expression in the lung. Here, we assessed the biological effects of a hemodialyzer during EVLP by performing biochemical and refined functional genomic analyses over a 12h procedure in a pig model. We found that dialysis stabilized electrolytic and metabolic parameters of the perfusate but enhanced the gene expression and protein accumulation of several inflammatory cytokines and promoted a genomic profile predicting higher endothelial activation already at 6h and higher immune cytokine signaling at 12h. Therefore, epuration of EVLP with a dialyzer, while correcting features of the perfusate composition and maintaining the respiratory function, promotes inflammatory responses in the tissue. This finding suggests that modifying the metabolite composition of the perfusate by dialysis during EVLP can have detrimental effects on the tissue response and that this strategy should not be transferred as such to the clinic.
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Affiliation(s)
- Julien De Wolf
- Department of Thoracic Surgery and Lung Transplantation, Foch Hospital, Suresnes, France
- Université Paris-Saclay, INRAE, UVSQ, VIM, Jouy-en-Josas, France
| | - Carla Gouin
- Université Paris-Saclay, INRAE, UVSQ, VIM, Jouy-en-Josas, France
| | - Luc Jouneau
- Université Paris-Saclay, INRAE, UVSQ, VIM, Jouy-en-Josas, France
| | - Matthieu Glorion
- Department of Thoracic Surgery and Lung Transplantation, Foch Hospital, Suresnes, France
- Université Paris-Saclay, INRAE, UVSQ, VIM, Jouy-en-Josas, France
| | | | - Florentina Pascale
- Department of Thoracic Surgery and Lung Transplantation, Foch Hospital, Suresnes, France
- Université Paris-Saclay, INRAE, UVSQ, VIM, Jouy-en-Josas, France
| | - Maxime Huriet
- Université Paris-Saclay, INRAE, UVSQ, VIM, Jouy-en-Josas, France
| | - Jérôme Estephan
- Université Paris-Saclay, INRAE, UVSQ, VIM, Jouy-en-Josas, France
| | | | - Giorgia Egidy
- Université Paris-Saclay, INRAE, AgroParisTech, GABI, Jouy-en-Josas, France
| | - Christophe Richard
- Université Paris-Saclay, UVSQ, INRAE, BREED, MIMA2, CIMA, Jouy-en-Josas, France
| | - Valérie Gelin
- Université Paris-Saclay, UVSQ, INRAE, BREED, MIMA2, CIMA, Jouy-en-Josas, France
| | - Céline Urien
- Université Paris-Saclay, INRAE, UVSQ, VIM, Jouy-en-Josas, France
| | - Antoine Roux
- Université Paris-Saclay, INRAE, UVSQ, VIM, Jouy-en-Josas, France
- Department of Pulmonology, Foch Hospital, Suresnes, France
| | - Morgan Le Guen
- Université Paris-Saclay, INRAE, UVSQ, VIM, Jouy-en-Josas, France
- Department of Anesthesiology, Foch Hospital, Suresnes, France
| | | | - Edouard Sage
- Department of Thoracic Surgery and Lung Transplantation, Foch Hospital, Suresnes, France
- Université Paris-Saclay, INRAE, UVSQ, VIM, Jouy-en-Josas, France
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5
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Steinkühler T, Yang S, Hu MA, Jainandunsing JS, Jager NM, Erasmus ME, Struys MMRF, Bosch DJ, van Meurs M, Jabaudon M, Richard D, Timens W, Leuvenink HGD, Nieuwenhuijs-Moeke GJ. Ex Vivo Optimization of Donor Lungs with Inhaled Sevoflurane during Normothermic Ex Vivo Lung Perfusion (VITALISE): A Pilot and Feasibility Study in Sheep. Int J Mol Sci 2024; 25:2413. [PMID: 38397090 PMCID: PMC10888671 DOI: 10.3390/ijms25042413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 02/09/2024] [Accepted: 02/15/2024] [Indexed: 02/25/2024] Open
Abstract
Volatile anesthetics have been shown in different studies to reduce ischemia reperfusion injury (IRI). Ex vivo lung perfusion (EVLP) facilitates graft evaluation, extends preservation time and potentially enables injury repair and improvement of lung quality. We hypothesized that ventilating lungs with sevoflurane during EVLP would reduce lung injury and improve lung function. We performed a pilot study to test this hypothesis in a slaughterhouse sheep DCD model. Lungs were harvested, flushed and stored on ice for 3 h, after which EVLP was performed for 4 h. Lungs were ventilated with either an FiO2 of 0.4 (EVLP, n = 5) or FiO2 of 0.4 plus sevoflurane at a 2% end-tidal concentration (Cet) (S-EVLP, n = 5). Perfusate, tissue samples and functional measurements were collected and analyzed. A steady state of the target Cet sevoflurane was reached with measurable concentrations in perfusate. Lungs in the S-EVLP group showed significantly better dynamic lung compliance than those in the EVLP group (p = 0.003). Oxygenation capacity was not different in treated lungs for delta partial oxygen pressure (PO2; +3.8 (-4.9/11.1) vs. -11.7 (-12.0/-3.2) kPa, p = 0.151), but there was a trend of a better PO2/FiO2 ratio (p = 0.054). Perfusate ASAT levels in S-EVLP were significantly reduced compared to the control group (198.1 ± 93.66 vs. 223.9 ± 105.7 IU/L, p = 0.02). We conclude that ventilating lungs with sevoflurane during EVLP is feasible and could be useful to improve graft function.
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Affiliation(s)
- Timo Steinkühler
- Department of Anesthesiology, University Medical Center Groningen, 9713 GZ Groningen, The Netherlands
| | - Shuqi Yang
- Department of Anesthesiology, University Medical Center Groningen, 9713 GZ Groningen, The Netherlands
| | - Michiel A. Hu
- Department of Thoracic Surgery, University Medical Center Groningen, 9713 GZ Groningen, The Netherlands
| | - Jayant S. Jainandunsing
- Department of Anesthesiology, University Medical Center Groningen, 9713 GZ Groningen, The Netherlands
| | - Neeltina M. Jager
- Department of Anesthesiology, University Medical Center Groningen, 9713 GZ Groningen, The Netherlands
| | - Michiel E. Erasmus
- Department of Thoracic Surgery, University Medical Center Groningen, 9713 GZ Groningen, The Netherlands
| | - Michel M. R. F. Struys
- Department of Anesthesiology, University Medical Center Groningen, 9713 GZ Groningen, The Netherlands
- Department of Basic and Applied Medical Sciences, Ghent University, 9000 Ghent, Belgium
| | - Dirk J. Bosch
- Department of Anesthesiology, University Medical Center Groningen, 9713 GZ Groningen, The Netherlands
| | - Matijs van Meurs
- Department of Critical Care, University Medical Center Groningen, 9713 GZ Groningen, The Netherlands
| | - Matthieu Jabaudon
- Department of Perioperative Medicine, University Hospital Clermont-Ferrand, 63001 Clermont-Ferrand, France
- Institute of Genetics, Reproduction & Development, University Clermont Auvergne, 63001 Clermont-Ferrand, France
- National Institute of Health and Medical Research (INSERM), National Center for Scientific Research (CNRS), 75794 Paris, France
| | - Damien Richard
- Department of Pharmacology and Toxicology, University Hospital Clermont-Ferrand, University Clermont Auvergne, 63001 Clermont-Ferrand, France
| | - Wim Timens
- Department of Pathology and Medical Biology, University Medical Center Groningen, 9713 GZ Groningen, The Netherlands
| | - Henri G. D. Leuvenink
- Department of Surgery, University Medical Center Groningen, 9713 GZ Groningen, The Netherlands
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García-Villegas R, Arni S. Hemoadsorption in Organ Preservation and Transplantation: A Narrative Review. Life (Basel) 2023; 14:65. [PMID: 38255680 PMCID: PMC10817660 DOI: 10.3390/life14010065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 12/19/2023] [Accepted: 12/27/2023] [Indexed: 01/24/2024] Open
Abstract
Cytokine adsorption can resolve different complications characteristic of transplantation medicine, such as cytokine storm activation and blood ABO and immune incompatibilities. Cytokine adsorption is also performed for the treatment of various life-threatening conditions, such as endotoxic septic shock, acute respiratory distress syndrome, and cardiogenic shock, all potentially leading to adverse clinical outcomes during transplantation. After surgery, dysmetabolism and stress response limit successful graft survival and can lead to primary or secondary graft dysfunction. In this clinical context, and given that a major problem in transplant medicine is that the demand for organs far exceeds the supply, a technological innovation such as a hemoadsorption system could greatly contribute to increasing the number of usable organ donors. The objectives of this review are to describe the specific advantages and disadvantages of the application of cytokine adsorption in the context of transplantation and examine, before and/or after organ transplantation, the benefits of the addition of a cytokine adsorption therapy protocol.
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Affiliation(s)
- Refugio García-Villegas
- Departamento de Fisiología, Biofísica y Neurociencias, Centro de Investigación y de Estudios Avanzados del Instituto Politécnico Nacional, D.F., Mexico City 07360, Mexico;
| | - Stephan Arni
- Department of Thoracic Surgery, University Hospital Zürich, 8091 Zürich, Switzerland
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7
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Zhou AL, Larson EL, Ruck JM, Ha JS, Casillan AJ, Bush EL. Current status and future potential of ex vivo lung perfusion in clinical lung transplantation. Artif Organs 2023; 47:1700-1709. [PMID: 37455548 DOI: 10.1111/aor.14607] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 05/29/2023] [Accepted: 06/19/2023] [Indexed: 07/18/2023]
Abstract
Lung transplantation is accepted as a well-established and effective treatment for patients with end-stage lung disease. While the number of candidates added to the waitlist continues to rise, the number of transplants performed remains limited by the number of suitable organ donors. Ex vivo lung perfusion (EVLP) emerged as a method of addressing the organ shortage by allowing the evaluation and potential reconditioning of marginal donor lungs or minimizing risks of prolonged ischemic time due to logistical challenges. The currently available FDA-approved EVLP systems have demonstrated excellent outcomes in clinical trials, and retrospective studies have demonstrated similar post-transplant survival between recipients who received marginal donor lungs perfused using EVLP and recipients who received standard criteria lungs stored using conventional methods. Despite this, widespread utilization has plateaued in the last few years, likely due to the significant costs associated with initiating EVLP programs. Centralized, dedicated EVLP perfusion centers are currently being investigated as a potential method of further expanding utilization of this technology. In the preclinical setting, potential applications of EVLP that are currently being studied include prolongation of organ preservation, reconditioning of unsuitable lungs, and further enhancement of already suitable lungs. As adoption of EVLP technology becomes more widespread, we may begin to see future implementation of these potential applications into the clinical setting.
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Affiliation(s)
- Alice L Zhou
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Emily L Larson
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Jessica M Ruck
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Jinny S Ha
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Alfred J Casillan
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Errol L Bush
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
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8
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Niroomand A, Hirdman G, Pierre L, Ghaidan H, Kjellström S, Stenlo M, Hyllén S, Olm F, Lindstedt S. Proteomic changes to immune and inflammatory processes underlie lung preservation using ex vivo cytokine adsorption. Front Cardiovasc Med 2023; 10:1274444. [PMID: 37849943 PMCID: PMC10577429 DOI: 10.3389/fcvm.2023.1274444] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 09/13/2023] [Indexed: 10/19/2023] Open
Abstract
Introduction In recent years, the field of graft preservation has made considerable strides in improving outcomes related to solid organ restoration and regeneration. Ex vivo lung perfusion (EVLP) in line with the related devices and treatments has yielded promising results within preclinical and clinical studies, with the potential to improve graft quality. Its main benefit is to render marginal and declined donor lungs suitable for transplantation, ultimately increasing the donor pool available for transplantation. In addition, using such therapies in machine perfusion could also increase preservation time, facilitating logistical planning. Cytokine adsorption has been demonstrated as a potentially safe and effective therapy when applied to the EVLP circuit and post-transplantation. However, the mechanism by which this therapy improves the donor lung on a molecular basis is not yet fully understood. Methods We hypothesized that there were characteristic inflammatory and immunomodulatory differences between the lungs treated with and without cytokine adsorption, reflecting proteomic changes in the gene ontology pathways and across inflammation-related proteins. In this study, we investigate the molecular mechanisms and signaling pathways of how cytokine adsorption impacts lung function when used during EVLP and post-transplantation as hemoperfusion in a porcine model. Lung tissues during EVLP and post-lung transplantation were analyzed for their proteomic profiles using mass spectrometry. Results We found through gene set enrichment analysis that the inflammatory and immune processes and coagulation pathways were significantly affected by the cytokine treatment after EVLP and transplantation. Conclusion In conclusion, we showed that the molecular mechanisms are using a proteomic approach behind the previously reported effects of cytokine adsorption when compared to the non-treated transplant recipients undergoing EVLP.
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Affiliation(s)
- Anna Niroomand
- Department of Clinical Sciences, Lund University, Lund, Sweden
- Lund Stem Cell Center, Lund University, Lund, Sweden
- School of Medicine, Rutgers Robert Wood Johnson University, New Brunswick, NJ, United States
| | - Gabriel Hirdman
- Department of Clinical Sciences, Lund University, Lund, Sweden
- Lund Stem Cell Center, Lund University, Lund, Sweden
- Wallenberg Center for Molecular Medicine, Lund University, Lund, Sweden
| | - Leif Pierre
- Department of Clinical Sciences, Lund University, Lund, Sweden
- Lund Stem Cell Center, Lund University, Lund, Sweden
- Wallenberg Center for Molecular Medicine, Lund University, Lund, Sweden
- Department of Cardiothoracic Surgery and Transplantation, Skåne University Hospital, Lund, Sweden
| | - Haider Ghaidan
- Department of Clinical Sciences, Lund University, Lund, Sweden
- Lund Stem Cell Center, Lund University, Lund, Sweden
- Wallenberg Center for Molecular Medicine, Lund University, Lund, Sweden
- Department of Cardiothoracic Surgery and Transplantation, Skåne University Hospital, Lund, Sweden
| | - Sven Kjellström
- Department of Clinical Sciences, BioMS, Lund University, Lund, Sweden
| | - Martin Stenlo
- Department of Clinical Sciences, Lund University, Lund, Sweden
- Lund Stem Cell Center, Lund University, Lund, Sweden
- Wallenberg Center for Molecular Medicine, Lund University, Lund, Sweden
- Department of Cardiothoracic Surgery and Transplantation, Skåne University Hospital, Lund, Sweden
- Department of Cardiothoracic Anesthesia and Intensive Care, Skåne University Hospital, Lund, Sweden
| | - Snejana Hyllén
- Department of Clinical Sciences, Lund University, Lund, Sweden
- Lund Stem Cell Center, Lund University, Lund, Sweden
- Wallenberg Center for Molecular Medicine, Lund University, Lund, Sweden
- Department of Cardiothoracic Anesthesia and Intensive Care, Skåne University Hospital, Lund, Sweden
| | - Franziska Olm
- Department of Clinical Sciences, Lund University, Lund, Sweden
- Lund Stem Cell Center, Lund University, Lund, Sweden
- Wallenberg Center for Molecular Medicine, Lund University, Lund, Sweden
| | - Sandra Lindstedt
- Department of Clinical Sciences, Lund University, Lund, Sweden
- Lund Stem Cell Center, Lund University, Lund, Sweden
- Wallenberg Center for Molecular Medicine, Lund University, Lund, Sweden
- Department of Cardiothoracic Surgery and Transplantation, Skåne University Hospital, Lund, Sweden
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9
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Radomsky L, Koch A, Olbertz C, Liu Y, Beushausen K, Keil J, Rauen U, Falk CS, Kühne JF, Kamler M. Composition of ex vivo perfusion solutions and kinetics define differential cytokine/chemokine secretion in a porcine cardiac arrest model of lung preservation. Front Cardiovasc Med 2023; 10:1245618. [PMID: 37808880 PMCID: PMC10556242 DOI: 10.3389/fcvm.2023.1245618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 08/31/2023] [Indexed: 10/10/2023] Open
Abstract
Background Ex vivo lung perfusion (EVLP) uses continuous normothermic perfusion to reduce ischemic damage and to improve post-transplant outcomes, specifically for marginal donor lungs after the donation after circulatory death. Despite major efforts, the optimal perfusion protocol and the composition of the perfusate in clinical lung transplantation have not been identified. Our study aims to compare the concentration levels of cytokine/chemokine in different perfusion solutions during EVLP, after 1 and 9 h of cold static preservation (CSP) in a porcine cardiac arrest model, and to correlate inflammatory parameters to oxygenation capacities. Methods Following cardiac arrest, the lungs were harvested and were categorized into two groups: immediate (I-EVLP) and delayed EVLP (D-EVLP), after 1 and 9 h of CSP, respectively. The D-EVLP lungs were perfused with either Steen or modified Custodiol-N solution containing only dextran (CD) or dextran and albumin (CDA). The cytokine/chemokine levels were analyzed at baseline (0 h) and after 1 and 4 h of EVLP using Luminex-based multiplex assays. Results Within 4 h of EVLP, the concentration levels of TNF-α, IL-6, CXCL8, IFN-γ, IL-1α, and IL-1β increased significantly (P < 0.05) in all experimental groups. The CD solution contained lower concentration levels of TNF-α, IL-6, CXCL8, IFN-γ, IL-2, IL-12, IL-10, IL-4, IL-1RA, and IL-18 (P < 0.05) compared with those of the Steen solution. The concentration levels of all experimental groups have correlated negatively with the oxygenation capacity values (P < 0.05). Protein concentration levels did not reach statistical significance for I-EVLP vs. D-EVLP and CD vs. CDA solutions. Conclusion In a porcine cardiac arrest model, a longer period of CSP prior to EVLP did not result in an enhanced protein secretion into perfusates. The CD solution reduced the cytokine/chemokine secretion most probably by iron chelators and/or by the protecting effects of dextran. Supplementing with albumin did not further reduce the cytokine/chemokine secretion into perfusates. These findings may help in optimizing the preservation procedure of the lungs, thereby increasing the donor pool of organs.
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Affiliation(s)
- Lena Radomsky
- Institute of Transplant Immunology, Hannover Medical School, Hannover, Germany
| | - Achim Koch
- Department of Thoracic and Cardiovascular Surgery, West German Heart Center, University Hospital Essen, Essen, Germany
| | - Carolin Olbertz
- Department of Thoracic and Cardiovascular Surgery, West German Heart Center, University Hospital Essen, Essen, Germany
| | - Yongjie Liu
- Department of Thoracic and Cardiovascular Surgery, West German Heart Center, University Hospital Essen, Essen, Germany
| | - Kerstin Beushausen
- Institute of Transplant Immunology, Hannover Medical School, Hannover, Germany
| | - Jana Keil
- Institute of Transplant Immunology, Hannover Medical School, Hannover, Germany
| | - Ursula Rauen
- Institute of Biochemistry, University of Duisburg-Essen, Essen, Germany
| | - Christine S. Falk
- Institute of Transplant Immunology, Hannover Medical School, Hannover, Germany
- DZIF, German Center for Infectious Diseases, Germany, TTU-IICH, Hannover—Braunschweig site, Braunschweig,Germany
- DZL, German Center for Lung Diseases, BREATH site, Hannover, Germany
| | - Jenny F. Kühne
- Institute of Transplant Immunology, Hannover Medical School, Hannover, Germany
| | - Markus Kamler
- Department of Thoracic and Cardiovascular Surgery, West German Heart Center, University Hospital Essen, Essen, Germany
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10
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Ojanguren A, Parapanov R, Debonneville A, Lugrin J, Szabo C, Hasenauer A, Rosner L, Gonzalez M, Perentes JY, Krueger T, Liaudet L. Therapeutic reconditioning of damaged lungs by transient heat stress during ex vivo lung perfusion. Am J Transplant 2023; 23:1130-1144. [PMID: 37217006 DOI: 10.1016/j.ajt.2023.05.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 05/15/2023] [Accepted: 05/15/2023] [Indexed: 05/24/2023]
Abstract
Ex vivo lung perfusion (EVLP) may serve as a platform for the pharmacologic repair of lung grafts before transplantation (LTx). We hypothesized that EVLP could also permit nonpharmacologic repair through the induction of a heat shock response, which confers stress adaptation via the expression of heat shock proteins (HSPs). Therefore, we evaluated whether transient heat application during EVLP (thermal preconditioning [TP]) might recondition damaged lungs before LTx. TP was performed during EVLP (3 hours) of rat lungs damaged by warm ischemia by transiently heating (30 minutes, 41.5 °C) the EVLP perfusate, followed by LTx (2 hours) reperfusion. We also assessed the TP (30 minutes, 42 °C) during EVLP (4 hours) of swine lungs damaged by prolonged cold ischemia. In rat lungs, TP induced HSP expression, reduced nuclear factor κB and inflammasome activity, oxidative stress, epithelial injury, inflammatory cytokines, necroptotic death signaling, and the expression of genes involved in innate immune and cell death pathways. After LTx, heated lungs displayed reduced inflammation, edema, histologic damage, improved compliance, and unchanged oxygenation. In pig lungs, TP induced HSP expression, reduced oxidative stress, inflammation, epithelial damage, vascular resistance, and ameliorated compliance. Collectively, these data indicate that transient heat application during EVLP promotes significant reconditioning of damaged lungs and improves their outcomes after transplantation.
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Affiliation(s)
- Amaia Ojanguren
- Service of Thoracic Surgery, Lausanne University Hospital, Lausanne, Switzerland; Service of Thoracic Surgery, Germans Trias i Pujol University Hospital, Barcelona, Spain
| | - Roumen Parapanov
- Service of Thoracic Surgery, Lausanne University Hospital, Lausanne, Switzerland; Service of Adult Intensive Care Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | - Anne Debonneville
- Service of Thoracic Surgery, Lausanne University Hospital, Lausanne, Switzerland; Service of Adult Intensive Care Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | - Jérôme Lugrin
- Service of Thoracic Surgery, Lausanne University Hospital, Lausanne, Switzerland; Service of Adult Intensive Care Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | - Csaba Szabo
- Department of Pharmacology, Faculty of Science and Medicine, University of Fribourg, Fribourg, Switzerland
| | - Arpad Hasenauer
- Service of Thoracic Surgery, Lausanne University Hospital, Lausanne, Switzerland
| | - Lorenzo Rosner
- Service of Anesthesiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Michel Gonzalez
- Service of Thoracic Surgery, Lausanne University Hospital, Lausanne, Switzerland
| | - Jean-Yannis Perentes
- Service of Thoracic Surgery, Lausanne University Hospital, Lausanne, Switzerland
| | - Thorsten Krueger
- Service of Thoracic Surgery, Lausanne University Hospital, Lausanne, Switzerland.
| | - Lucas Liaudet
- Service of Adult Intensive Care Medicine, Lausanne University Hospital, Lausanne, Switzerland
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11
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Nykänen AI, Liu M, Keshavjee S. Mesenchymal Stromal Cell Therapy in Lung Transplantation. Bioengineering (Basel) 2023; 10:728. [PMID: 37370659 DOI: 10.3390/bioengineering10060728] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Revised: 06/14/2023] [Accepted: 06/15/2023] [Indexed: 06/29/2023] Open
Abstract
Lung transplantation is often the only viable treatment option for a patient with end-stage lung disease. Lung transplant results have improved substantially over time, but ischemia-reperfusion injury, primary graft dysfunction, acute rejection, and chronic lung allograft dysfunction (CLAD) continue to be significant problems. Mesenchymal stromal cells (MSC) are pluripotent cells that have anti-inflammatory and protective paracrine effects and may be beneficial in solid organ transplantation. Here, we review the experimental studies where MSCs have been used to protect the donor lung against ischemia-reperfusion injury and alloimmune responses, as well as the experimental and clinical studies using MSCs to prevent or treat CLAD. In addition, we outline ex vivo lung perfusion (EVLP) as an optimal platform for donor lung MSC delivery, as well as how the therapeutic potential of MSCs could be further leveraged with genetic engineering.
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Affiliation(s)
- Antti I Nykänen
- Latner Thoracic Surgery Research Laboratories, Toronto General Research Hospital Institute, University Health Network, Toronto, ON M5G 1L7, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada
- Department of Cardiothoracic Surgery, Helsinki University Hospital and University of Helsinki, FI-00029 Helsinki, Finland
| | - Mingyao Liu
- Latner Thoracic Surgery Research Laboratories, Toronto General Research Hospital Institute, University Health Network, Toronto, ON M5G 1L7, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada
| | - Shaf Keshavjee
- Latner Thoracic Surgery Research Laboratories, Toronto General Research Hospital Institute, University Health Network, Toronto, ON M5G 1L7, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada
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12
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Hunt ML, Cantu E. Primary graft dysfunction after lung transplantation. Curr Opin Organ Transplant 2023; 28:180-186. [PMID: 37053083 PMCID: PMC10214980 DOI: 10.1097/mot.0000000000001065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2023]
Abstract
PURPOSE OF REVIEW Primary graft dysfunction (PGD) is a clinical syndrome occurring within the first 72 h after lung transplantation and is characterized clinically by progressive hypoxemia and radiographically by patchy alveolar infiltrates. Resulting from ischemia-reperfusion injury, PGD represents a complex interplay between donor and recipient immunologic factors, as well as acute inflammation leading to alveolar cell damage. In the long term, chronic inflammation invoked by PGD can contribute to the development of chronic lung allograft dysfunction, an important cause of late mortality after lung transplant. RECENT FINDINGS Recent work has aimed to identify risk factors for PGD, focusing on donor, recipient and technical factors both inherent and potentially modifiable. Although no PGD-specific therapy currently exists, supportive care remains paramount and early initiation of ECMO can improve outcomes in select patients. Initial success with ex-vivo lung perfusion platforms has been observed with respect to decreasing PGD risk and increasing lung transplant volume; however, the impact on survival is not well delineated. SUMMARY This review will summarize the pathogenesis and clinical features of PGD, as well as highlight treatment strategies and emerging technologies to mitigate PGD risk in patients undergoing lung transplantation.
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Affiliation(s)
- Mallory L. Hunt
- Division of Cardiovascular Surgery, University of Pennsylvania Perelman School of Medicine, 1 Convention Avenue Pavilion 2 City, Philadelphia PA, 19104 USA
| | - Edward Cantu
- Division of Cardiovascular Surgery, University of Pennsylvania Perelman School of Medicine, 1 Convention Avenue Pavilion 2 City, Philadelphia PA, 19104 USA
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13
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Wu WK, Guenthart BA, O’Neill JD, Hozain AE, Tipograf Y, Ukita R, Stokes JW, Patel YJ, Pinezich M, Talackine JR, Cardwell NL, Fung K, Vunjak-Novakovic G, Bacchetta M. Technique for xenogeneic cross-circulation to support human donor lungs ex vivo. J Heart Lung Transplant 2023; 42:335-344. [PMID: 36456408 PMCID: PMC9985920 DOI: 10.1016/j.healun.2022.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 09/30/2022] [Accepted: 11/03/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Xenogeneic cross-circulation (XC) is an experimental method for ex vivo organ support and recovery that could expand the pool of donor lungs suitable for transplantation. The objective of this study was to establish and validate a standardized, reproducible, and broadly applicable technique for performing xenogeneic XC to support and recover injured human donor lungs ex vivo. METHODS Human donor lungs (n = 9) declined for transplantation were procured, cannulated, and subjected to 24 hours of xenogeneic XC with anesthetized xeno-support swine (Yorkshire/Landrace) treated with standard immunosuppression (methylprednisolone, mycophenolate mofetil, tacrolimus) and complement-depleting cobra venom factor. Standard lung-protective perfusion and ventilation strategies, including periodic lung recruitment maneuvers, were used throughout xenogeneic XC. Every 6 hours, ex vivo donor lung function (gas exchange, compliance, airway pressures, pulmonary vascular dynamics, lung weight) was evaluated. At the experimental endpoint, comprehensive assessments of the lungs were performed by bronchoscopy, histology, and electron microscopy. Student's t-test and 1-way analysis of variance with Dunnett's post-hoc test was performed, and p < 0.05 was considered significant. RESULTS After 24 hours of xenogeneic XC, gas exchange (PaO2/FiO2) increased by 158% (endpoint: 364 ± 142 mm Hg; p = 0.06), and dynamic compliance increased by 127% (endpoint: 46 ± 20 ml/cmH2O; p = 0.04). Airway pressures, pulmonary vascular pressures, and lung weight remained stable (p > 0.05) and within normal ranges. Over 24 hours of xenogeneic XC, gross and microscopic lung architecture were preserved: airway bronchoscopy and parenchymal histomorphology appeared normal, with intact blood-gas barrier. CONCLUSIONS Xenogeneic cross-circulation is a robust method for ex vivo support, evaluation, and improvement of injured human donor lungs declined for transplantation.
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Affiliation(s)
- W. Kelly Wu
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Brandon A. Guenthart
- Department of Cardiothoracic Surgery, Stanford University, Palo Alto, California
| | - John D. O’Neill
- Xylyx Bio, Inc., Brooklyn, New York;,Department of Cell Biology, State University of New York Downstate Medical Center, Brooklyn, New York
| | - Ahmed E. Hozain
- Department of Surgery, State University of New York Downstate Medical Center, Brooklyn, New York
| | - Yuliya Tipograf
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Rei Ukita
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - John W. Stokes
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Yatrik J. Patel
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Meghan Pinezich
- Department of Biomedical Engineering, Columbia University, New York, New York
| | - Jennifer R. Talackine
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Nancy L. Cardwell
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kenmond Fung
- Perfusion Services, New York – Presbyterian Hospital, New York, New York
| | - Gordana Vunjak-Novakovic
- Department of Biomedical Engineering, Columbia University, New York, New York;,Department of Medicine, Columbia University Medical Center, New York, New York
| | - Matthew Bacchetta
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee.
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14
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Noda K, Chan EG, Furukawa M, Ryan JP, Clifford S, Luketich JD, Sanchez PG. Single-center experience of ex vivo lung perfusion and subsequent lung transplantation. Clin Transplant 2023; 37:e14901. [PMID: 36588340 DOI: 10.1111/ctr.14901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 12/21/2022] [Accepted: 12/28/2022] [Indexed: 01/03/2023]
Abstract
BACKGROUND The safety of lung transplantation using ex vivo lung perfusion (EVLP) has been confirmed in multiple clinical studies; however, limited evidence is currently available regarding the potential effects of EVLP on posttransplant graft complications and survival with mid- to long-term follow-up. In this study, we reviewed our institutional data to better understand the impact of EVLP. METHODS Lungs placed on EVLP from 2014 through 2020 and transplant outcomes were retrospectively analyzed. Data were compared between lungs transplanted and declined after EVLP, between patients with severe primary graft dysfunction (PGD3) and no PGD3 after EVLP, and between matched patients with lungs transplanted with and without EVLP. RESULTS In total, 98 EVLP cases were performed. Changes in metabolic indicators during EVLP were correlated with graft quality and transplantability, but not changes in physiological parameters. Among 58 transplanted lungs after EVLP, PGD3 at 72 h occurred in 36.9% and was associated with preservation time, mechanical support prior to transplant, and intraoperative transfusion volume. Compared with patients without EVLP, patients who received lungs screened with EVLP had a higher incidence of PGD3 and longer ICU and hospital stays. Lung grafts placed on EVLP exhibited a significantly higher chance of developing airway anastomotic ischemic injury by 30 days posttransplant. Acute and chronic graft rejection, pulmonary function, and posttransplant survival were not different between patients with lungs screened on EVLP versus lungs with no EVLP. CONCLUSION EVLP use is associated with an increase of early posttransplant adverse events, but graft functional outcomes and patient survival are preserved.
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Affiliation(s)
- Kentaro Noda
- Division of Lung Transplant and Lung Failure, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ernest G Chan
- Division of Lung Transplant and Lung Failure, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Masashi Furukawa
- Division of Lung Transplant and Lung Failure, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - John P Ryan
- Division of Lung Transplant and Lung Failure, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Sarah Clifford
- Division of Lung Transplant and Lung Failure, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - James D Luketich
- Division of Lung Transplant and Lung Failure, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Pablo G Sanchez
- Division of Lung Transplant and Lung Failure, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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15
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Johnson B, Bucio J, Salerno C, Jeevanandam V, Song T, Wool G. Decreasing blood wastage during ex vivo lung perfusion recovery through utilization of thermal control technology. J Card Surg 2022; 37:5011-5018. [PMID: 36349705 PMCID: PMC10099649 DOI: 10.1111/jocs.17147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 10/29/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND The Organ Care System (OCS) is a revolutionary ex vivo organ perfusion technology that can potentially expand the organ retrieval range. The OCS Lung device uses packed red blood cells (pRBC) with a proprietary solution. We report the ability to reduce blood waste during this procedure by using a thermal packaging solution in conjunction with the OCS platform. METHODS We retrospectively reviewed all OCS Lung recoveries performed by our recovery team, using pRBCfrom May 2019 to January 2021. Initially, units were stored using passive refrigeration with the Performance cooler at a temperature range of 1-6°C for 4 h. Subsequently, thermal control technology with the ProMed cooler was utilized to maintain the same temperature range for 72 h. RESULTS Twenty-three recoveries were initiated with 63 pRBC. The Performance cooler was used for 8, while the ProMed cooler for 13. 37.5% of pRBC transported with the Performance cooler was used within the validated time range, while 25.0% were used beyond the validated time range based on clinical judgment. In addition, 37.5% of pRBC transported with the Performance cooler were returned to the institution after canceled recoveries with an estimated loss of $1800; the ProMed cooler had no wastage. CONCLUSIONS This study showed that using an advanced thermal packaging solution facilitates proper storage of pRBC and represents an advancement for extended donor lung preservation. The elimination of blood wastage in this initial study portends ongoing benefits for the limited blood supply and reduced cost.
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Affiliation(s)
- Blaine Johnson
- Perfusion Services, UChicago Medicine, Chicago, Illinois, USA
| | - Jamie Bucio
- Department of Surgery, Section of Cardiac Surgery, University of Chicago, Chicago, Illinois, USA
| | - Christopher Salerno
- Department of Surgery, Section of Cardiac Surgery, University of Chicago, Chicago, Illinois, USA
| | - Valluvan Jeevanandam
- Department of Surgery, Section of Cardiac Surgery, University of Chicago, Chicago, Illinois, USA
| | - Tae Song
- Department of Surgery, Section of Cardiac Surgery, University of Chicago, Chicago, Illinois, USA
| | - Geoffrey Wool
- Department of Pathology, University of Chicago, Chicago, Illinois, USA
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16
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Boffini M, Cassoni P, Gambella A, Simonato E, Delsedime L, Marro M, Fanelli V, Costamagna A, Lausi PO, Solidoro P, Scalini F, Barbero C, Brazzi L, Rinaldi M, Bertero L. Is there life on the airway tree? A pilot study of bronchial cell vitality and tissue morphology in the ex vivo lung perfusion (EVLP) era of lung transplantation. Artif Organs 2022; 46:2234-2243. [PMID: 35717633 PMCID: PMC9796079 DOI: 10.1111/aor.14342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 05/24/2022] [Accepted: 06/13/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Ex vivo lung perfusion (EVLP) is a relevant procedure to increase the lung donor pool but could potentially increase the airway tree ischemic injury risk. METHODS This study aimed to evaluate the direct effect of EVLP on the airway tree by evaluating bronchial cell vitality and tissue signs of injury on a series of 117 bronchial rings collected from 40 conventional and 19 EVLP-treated lung grafts. Bronchial rings and related scraped bronchial epithelial cells were collected before the EVLP procedure and surgical anastomosis. RESULTS The preimplantation interval was significantly increased in the EVLP graft group (p < 0.01). Conventional grafts presented cell viability percentages of 47.07 ± 23.41 and 49.65 ± 21.25 in the first and second grafts which did not differ significantly from the EVLP group (first graft 50.54 ± 25.83 and second graft 50.22 ± 20.90 cell viability percentage). No significant differences in terms of histopathological features (edema, inflammatory infiltrate, and mucosa ulceration) were observed comparing conventional and EVLP samples. A comparison of bronchial cell viability and histopathology of EVLP samples retrieved at different time intervals revealed no significant differences. Accordingly, major bronchial complications after lung transplant were not observed in both groups. CONCLUSIONS Based on these data, we observed that EVLP did not significantly impact bronchial cell vitality and airway tissue preservation nor interfere with bronchial anastomosis healing, further supporting it as a safe and useful procedure.
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Affiliation(s)
- Massimo Boffini
- Cardiac Surgery Division, Department of Surgical SciencesUniversity of TurinTurinItaly
| | - Paola Cassoni
- Pathology Unit, Department of Medical SciencesUniversity of TurinTurinItaly
| | | | - Erika Simonato
- Cardiac Surgery Division, Department of Surgical SciencesUniversity of TurinTurinItaly
| | - Luisa Delsedime
- Pathology Unit, AOU Città della Salute e della ScienzaUniversity HospitalTurinItaly
| | - Matteo Marro
- Cardiac Surgery Division, Department of Surgical SciencesUniversity of TurinTurinItaly
| | - Vito Fanelli
- Department of Anesthesia and Intensive Care Medicine, Department of Surgical SciencesUniversity of TurinTurinItaly
| | - Andrea Costamagna
- Department of Anesthesia and Intensive Care Medicine, Department of Surgical SciencesUniversity of TurinTurinItaly
| | - Paolo Olivo Lausi
- Thoracic Surgery Division, Department of Surgical SciencesUniversity of TurinTurinItaly
| | - Paolo Solidoro
- Pneumology Division, Department of Medical SciencesUniversity of TurinTurinItaly
| | - Fabrizio Scalini
- Cardiac Surgery Division, Department of Surgical SciencesUniversity of TurinTurinItaly
| | - Cristina Barbero
- Cardiac Surgery Division, Department of Surgical SciencesUniversity of TurinTurinItaly
| | - Luca Brazzi
- Department of Anesthesia and Intensive Care Medicine, Department of Surgical SciencesUniversity of TurinTurinItaly
| | - Mauro Rinaldi
- Cardiac Surgery Division, Department of Surgical SciencesUniversity of TurinTurinItaly
| | - Luca Bertero
- Pathology Unit, Department of Medical SciencesUniversity of TurinTurinItaly
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17
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Fumagalli J, Colombo SM, Scaravilli V, Gori F, Pesenti A, Zanella A, Grasselli G. Limitations of arterial partial pressure of oxygen to fraction of inspired oxygen ratio for the evaluation of donor lung function. Artif Organs 2022; 46:2313-2318. [PMID: 35747906 PMCID: PMC9796039 DOI: 10.1111/aor.14350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 06/04/2022] [Accepted: 06/17/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Evaluation of donor lung function relies on the arterial oxygen partial pressure to inspired oxygen fraction ratio (PaO2 /FiO2 ) measurement. Hemodynamic, metabolic derangements, and therapeutic intervention occurring during brain dead observation may influence the evaluation of gas exchange. METHODS We performed a mathematical analysis to explore the influence of the extrapulmonary determinants on the interpretation of PaO2 /FiO2 in the brain-dead donor and during Ex-Vivo Lung Perfusion (EVLP). RESULTS High FiO2 and increased mixed venous oxygen saturation, caused by increased delivery and reduced consumption of oxygen, raise the PaO2 /FiO2 despite substantial intrapulmonary shunt. Anemia does not modify the PaO2 /FiO2 -intrapulmonary shunt relationship. During EVLP, the reduced artero-venous difference in oxygen content increases the PaO2 /FiO2 without this corresponding to an optimal graft function, while the reduced perfusate oxygen-carrying capacity linearizes the PaO2 /FiO2 -intrapulmonary shunt relationship. CONCLUSIONS Adopting PaO2 /FiO2 to evaluate graft suitability for transplantation should account for extrapulmonary factors affecting its interpretation.
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Affiliation(s)
- Jacopo Fumagalli
- Department of Anesthesia, Critical Care and EmergencyFondazione IRCCS Ca' Granda ‐ Ospedale Maggiore PoliclinicoMilanItaly
| | - Sebastiano Maria Colombo
- Department of Anesthesia, Critical Care and EmergencyFondazione IRCCS Ca' Granda ‐ Ospedale Maggiore PoliclinicoMilanItaly
| | - Vittorio Scaravilli
- Department of Anesthesia, Critical Care and EmergencyFondazione IRCCS Ca' Granda ‐ Ospedale Maggiore PoliclinicoMilanItaly,Department of Biomedical, Surgical, and Dental SciencesUniversity of MilanMilanItaly
| | - Francesca Gori
- Department of Anesthesia, Critical Care and EmergencyFondazione IRCCS Ca' Granda ‐ Ospedale Maggiore PoliclinicoMilanItaly
| | - Antonio Pesenti
- Department of Anesthesia, Critical Care and EmergencyFondazione IRCCS Ca' Granda ‐ Ospedale Maggiore PoliclinicoMilanItaly,Department of Pathophysiology and TransplantationUniversity of MilanMilanItaly
| | - Alberto Zanella
- Department of Anesthesia, Critical Care and EmergencyFondazione IRCCS Ca' Granda ‐ Ospedale Maggiore PoliclinicoMilanItaly,Department of Pathophysiology and TransplantationUniversity of MilanMilanItaly
| | - Giacomo Grasselli
- Department of Anesthesia, Critical Care and EmergencyFondazione IRCCS Ca' Granda ‐ Ospedale Maggiore PoliclinicoMilanItaly,Department of Pathophysiology and TransplantationUniversity of MilanMilanItaly
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18
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Zhang ZL, Moeslund N, Hu MA, Hoffmann R, Venema LH, Van De Wauwer C, Timens W, Okamoto T, Verschuuren EAM, Leuvenink HGD, Eiskjaer H, Erasmus ME. Establishing an economical and widely accessible donation after circulatory death animal abattoir model for lung research using ex vivo lung perfusion. Artif Organs 2022; 46:2179-2190. [PMID: 35730930 PMCID: PMC9796928 DOI: 10.1111/aor.14345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 05/21/2022] [Accepted: 06/06/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND Ex vivo lung perfusion (EVLP), is a platform that allows simultaneous testing and treatment of the lungs. However, use of EVLP is costly and requires access to lab animals and accompanying facilities. To increase the use of EVLP for research, we developed a method to perform EVLP using abattoir procured lungs. Furthermore, we were also able to significantly decrease costs. METHODS Six pair of lungs were procured from abattoir sheep. The lungs were then flushed and stored in ice for 3 h. A low-flow (20% of cardiac output) approach, a tidal volume of 6 ml/kg bodyweight and total perfusion time of 3 h were chosen. Perfusion fluids and circuits were self-made. Lung biopsies, perfusate collection, respiratory values, circulatory pressures were recorded and hourly blood gas analyses were performed. RESULTS Mean pO2 remained stable from 60 min (49.3 ± 7.1 kPa) to 180 min (51.5 kPa ± 8.0), p = 0.66. Pulmonary artery pressure remained ≤15 mm Hg and the left atrial pressure remained between 3 and 5 mm Hg and peak respiratory pressures ≤20 cmH2 O. Lactate dehydrogenase increased from start (96.3 ± 56.4 U/L) to the end of perfusion (315.8 ± 85.0 U/L), p < 0.05. No difference was observed in ATP between procurement and post-EVLP, 129.7 ± 37.4 μmol/g protein to 132.0 ± 23.4 μmol/g, p = 0.92. CONCLUSIONS Sheep lungs, acquired from an abattoir, can be ex vivo perfused under similar conditions as lab animal lungs with similar results regarding e.g., oxygenation and ATP restoration. Furthermore, costs can be significantly reduced by making use of this abattoir model. By increasing accessibility and lowering costs for experiments using lung perfusion, more results may be achieved in the field of lung diseases.
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Affiliation(s)
- Zhang Long Zhang
- Department of Cardio‐Thoracic SurgeryUniversity Medical Center Groningen, University of GroningenGroningenThe Netherlands
| | - Niels Moeslund
- Department of CardiologyAarhus University HospitalAarhusDenmark
| | - Michiel Andy Hu
- Department of Cardio‐Thoracic SurgeryUniversity Medical Center Groningen, University of GroningenGroningenThe Netherlands
| | - Roland Hoffmann
- Department of Cardio‐Thoracic SurgeryUniversity Medical Center Groningen, University of GroningenGroningenThe Netherlands
| | - Leonie Harmina Venema
- Department of Surgical ResearchUniversity Medical Center Groningen, University of GroningenGroningenThe Netherlands
| | - Caroline Van De Wauwer
- Department of Cardio‐Thoracic SurgeryUniversity Medical Center Groningen, University of GroningenGroningenThe Netherlands
| | - Wim Timens
- Department of PathologyUniversity Medical Center Groningen, University of GroningenGroningenThe Netherlands
| | - Toshihiro Okamoto
- Department of Thoracic Surgery and Lung TransplantationCleveland ClinicClevelandOhioUSA
| | - Erik Alfons Maria Verschuuren
- Department of Cardio‐Thoracic SurgeryUniversity Medical Center Groningen, University of GroningenGroningenThe Netherlands
| | - Henri Gerrit Derk Leuvenink
- Department of Surgical ResearchUniversity Medical Center Groningen, University of GroningenGroningenThe Netherlands
| | - Hans Eiskjaer
- Department of CardiologyAarhus University HospitalAarhusDenmark
| | - Michiel Elardus Erasmus
- Department of Cardio‐Thoracic SurgeryUniversity Medical Center Groningen, University of GroningenGroningenThe Netherlands
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19
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Russell C, Keshavamurthy S. Acute Massive and Submassive Pulmonary Embolism: Historical Considerations/Surgical Techniques of Pulmonary Embolectomy/Novel Applications in Donor Lungs with Pulmonary Emboli. Int J Angiol 2022; 31:188-193. [PMID: 36157100 PMCID: PMC9507568 DOI: 10.1055/s-0042-1756178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Abstract
Pulmonary embolectomy has a chequered history but the quest to surgically treat a patient diagnosed with pulmonary embolism effectively spurred the development of cardiopulmonary bypass and a new dawn for cardiac surgery. The advent of cardiopulmonary bypass, extracorporeal membrane oxygenation, and computed tomography pulmonary angiogram has allowed rapid diagnosis and made surgical pulmonary embolectomy a relatively safe procedure that should be considered when indicated. Pulmonary emboli in donor lungs, often get rejected for transplantation. Ex vivo lung perfusion is among newly available technology with the ability to not only recondition marginal lungs but also treat donor lung pulmonary embolisms, effectively increasing the donor pool.
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Affiliation(s)
- Cody Russell
- The American University of the Caribbean School of Medicine, Pembroke Pines, Florida
| | - Suresh Keshavamurthy
- University of Kentucky College of Medicine, Department of Surgery, Division of Cardiothoracic Surgery, Lexington, Kentucky
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20
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Lee ACH, Edobor A, Wigakumar T, Lysandrou M, Johnston LK, McMullen P, Mirle V, Diaz A, Piech R, Rose R, Jendrisak M, di Sabato D, Shanmugarajah K, Fung J, Donington J, Madariaga ML. Donor leukocyte trafficking during human ex vivo lung perfusion. Clin Transplant 2022; 36:e14670. [PMID: 35396887 PMCID: PMC9540615 DOI: 10.1111/ctr.14670] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 03/09/2022] [Accepted: 04/04/2022] [Indexed: 11/30/2022]
Abstract
Background Ex vivo lung perfusion (EVLP) is used to assess and preserve lungs prior to transplantation. However, its inherent immunomodulatory effects are not completely understood. We examine perfusate and tissue compartments to determine the change in immune cell composition in human lungs maintained on EVLP. Methods Six human lungs unsuitable for transplantation underwent EVLP. Tissue and perfusate samples were obtained during cold storage and at 1‐, 3‐ and 6‐h during perfusion. Flow cytometry, immunohistochemistry, and bead‐based immunoassays were used to measure leukocyte composition and cytokines. Mean values between baseline and time points were compared by Student's t test. Results During the 1st hour of perfusion, perfusate neutrophils increased (+22.2 ± 13.5%, p < 0.05), monocytes decreased (−77.5 ± 8.6%, p < 0.01) and NK cells decreased (−61.5 ± 22.6%, p < 0.01) compared to cold storage. In contrast, tissue neutrophils decreased (−22.1 ± 12.2%, p < 0.05) with no change in monocytes and NK cells. By 6 h, perfusate neutrophils, NK cells, and tissue neutrophils were similar to baseline. Perfusate monocytes remained decreased, while tissue monocytes remained unchanged. There was no significant change in B cells or T cell subsets. Pro‐inflammatory cytokines (IL‐1b, G‐CSF, IFN‐gamma, CXCL2, CXCL1 granzyme A, and granzyme B) and lymphocyte activating cytokines (IL‐2, IL‐4, IL‐6, IL‐8) increased during perfusion. Conclusions Early mobilization of innate immune cells occurs in both perfusate and tissue compartments during EVLP, with neutrophils and NK cells returning to baseline and monocytes remaining depleted after 6 h. The immunomodulatory effect of EVLP may provide a therapeutic window to decrease the immunogenicity of lungs prior to transplantation.
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Affiliation(s)
| | - Arianna Edobor
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | | | - Maria Lysandrou
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - Laura K Johnston
- Office of Shared Research Facilities, University of Chicago, Chicago, Illinois, USA
| | - Phillip McMullen
- Department of Pathology, University of Chicago, Chicago, Illinois, USA
| | - Vikranth Mirle
- Pritzker School of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Ashley Diaz
- Pritzker School of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Ryan Piech
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - Rebecca Rose
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | | | - Diego di Sabato
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | | | - John Fung
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - Jessica Donington
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
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21
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Ribeiro RVP, Ku T, Wang A, Pires L, Ferreira VH, Michaelsen V, Ali A, Galasso M, Moshkelgosha S, Gazzalle A, Jeppesen MG, Rosenkilde MM, Liu M, Singer LG, Kumar D, Keshavjee S, Sinclair J, Kledal TN, Humar A, Cypel M. Ex vivo treatment of cytomegalovirus in human donor lungs using a novel chemokine-based immunotoxin. J Heart Lung Transplant 2022; 41:287-297. [PMID: 34802874 DOI: 10.1016/j.healun.2021.10.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 10/12/2021] [Accepted: 10/15/2021] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Transmission of latent human cytomegalovirus (HCMV) via organ transplantation with post-transplant viral reactivation is extremely prevalent and results in substantial adverse impact on outcomes. Therapies targeting the latent reservoir within the allograft to mitigate viral transmission would represent a major advance. Here, we delivered an immunotoxin (F49A-FTP) that targets and kills latent HCMV aiming at reducing the HCMV reservoir from donor lungs using ex-vivo lung perfusion (EVLP). METHODS HCMV seropositive human lungs were placed on EVLP alone or EVLP + 1mg/L of F49A-FTP for 6 hours (n = 6, each). CD14+ monocytes isolated from biopsies pre and post EVLP underwent HCMV reactivation assay designed to evaluate viral reactivation capacity. Off-target effects of F49A-FTP were studied evaluating cell death markers of CD34+ and CD14+ cells using flow cytometry. Lung function on EVLP and inflammatory cytokine production were evaluated as safety endpoints. RESULTS We demonstrate that lungs treated ex-vivo with F49A-FTP had a significant reduction in HCMV reactivation compared to controls, suggesting successful targeting of latent virus (76% median reduction in F49A-FTP vs 15% increase in controls, p = 0.0087). Furthermore, there was comparable cell death rates of the targeted cells between both groups, suggesting no off-target effects. Ex-vivo lung function was stable over 6 hours and no differences in key inflammatory cytokines were observed demonstrating safety of this novel treatment. CONCLUSIONS Ex-vivo F49A-FTP treatment of human lungs targets and kills latent HCMV, markedly attenuating HCMV reactivation. This approach demonstrates the first experiments targeting latent HCMV in a donor organ with promising results towards clinical translation.
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Affiliation(s)
- Rafaela V P Ribeiro
- Latner Thoracic Surgery Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Terrance Ku
- Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Aizhou Wang
- Latner Thoracic Surgery Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Layla Pires
- Latner Thoracic Surgery Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Victor H Ferreira
- Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Vinicius Michaelsen
- Latner Thoracic Surgery Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Aadil Ali
- Latner Thoracic Surgery Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Marcos Galasso
- Latner Thoracic Surgery Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Sajad Moshkelgosha
- Latner Thoracic Surgery Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Anajara Gazzalle
- Latner Thoracic Surgery Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | | | - Mette M Rosenkilde
- Synklino ApS, Ole Måløes vej X, Copenhagen, Denmark; Laboratory of Molecular Pharmacology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Mingyao Liu
- Latner Thoracic Surgery Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Lianne G Singer
- Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Deepali Kumar
- Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Shaf Keshavjee
- Latner Thoracic Surgery Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada; Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - John Sinclair
- Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | | | - Atul Humar
- Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Marcelo Cypel
- Latner Thoracic Surgery Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada; Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada.
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22
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Miceli V, Bertani A. Mesenchymal Stromal/Stem Cells and Their Products as a Therapeutic Tool to Advance Lung Transplantation. Cells 2022; 11:cells11050826. [PMID: 35269448 PMCID: PMC8909054 DOI: 10.3390/cells11050826] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 02/18/2022] [Accepted: 02/25/2022] [Indexed: 02/07/2023] Open
Abstract
Lung transplantation (LTx) has become the gold standard treatment for end-stage respiratory failure. Recently, extended lung donor criteria have been applied to decrease the mortality rate of patients on the waiting list. Moreover, ex vivo lung perfusion (EVLP) has been used to improve the number/quality of previously unacceptable lungs. Despite the above-mentioned progress, the morbidity/mortality of LTx remains high compared to other solid organ transplants. Lungs are particularly susceptible to ischemia-reperfusion injury, which can lead to graft dysfunction. Therefore, the success of LTx is related to the quality/function of the graft, and EVLP represents an opportunity to protect/regenerate the lungs before transplantation. Increasing evidence supports the use of mesenchymal stromal/stem cells (MSCs) as a therapeutic strategy to improve EVLP. The therapeutic properties of MSC are partially mediated by secreted factors. Hence, the strategy of lung perfusion with MSCs and/or their products pave the way for a new innovative approach that further increases the potential for the use of EVLP. This article provides an overview of experimental, preclinical and clinical studies supporting the application of MSCs to improve EVLP, the ultimate goal being efficient organ reconditioning in order to expand the donor lung pool and to improve transplant outcomes.
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Affiliation(s)
- Vitale Miceli
- Research Department, IRCCS ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), 90127 Palermo, Italy
- Correspondence: (V.M.); (A.B.); Tel.: +39-091-21-92-430 (V.M.); +39-091-21-92-111 (A.B.)
| | - Alessandro Bertani
- Thoracic Surgery and Lung Transplantation Unit, IRCCS ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), 90127 Palermo, Italy
- Correspondence: (V.M.); (A.B.); Tel.: +39-091-21-92-430 (V.M.); +39-091-21-92-111 (A.B.)
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23
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Kalka K, Keldenich Z, Carstens H, Walter B, Rauen U, Ruhparwar A, Weymann A, Kamler M, Reiner G, Koch A. Custodiol-MP for ex vivo lung perfusion - A comparison in a porcine model of donation after circulatory determination of death. Int J Artif Organs 2022; 45:162-173. [PMID: 33530837 PMCID: PMC8777315 DOI: 10.1177/0391398821990663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 01/07/2021] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Ex vivo lung perfusion (EVLP) is an established technique to evaluate and eventually recondition lungs prior to transplantation. Custodiol-MP (C-MP) solution is a new solution, designed for clinical machine perfusion, that has been used for kidneys. The aim of this study was to compare the effects of EVLP with Custodiol-MP on lung functional outcomes to the gold standard of EVLP with Steen Solution™. MATERIAL AND METHODS In a porcine EVLP model of DCDD (Donation after Circulatory Determination of Death), lungs were perfused with Steen Solution™ (SS, n = 7) or Custodiol-MP solution supplemented with 55 g/l albumin (C-MP, n = 8). Lungs were stored cold for 4 h in low potassium dextran solution and subsequently perfused ex vivo for 4 h. During EVLP pulmonary gas exchange, activities of lactate dehydrogenase (LDH) and alkaline phosphatase (AP) as well as levels of lactate in the perfusate were recorded hourly. RESULTS Oxygenation capacity differed significantly between groups (averaged over 4 h: SS 274 ± 178 mmHg; C-MP 284 ± 151 mmHg p = 0.025). Lactate dehydrogenase activities and lactate concentrations were significantly lower in Custodiol-MP perfused lungs.In a porcine model of DCDD with 4 h of EVLP the use of modified Custodiol-MP as perfusion solution was feasible. The use of C-MP showed at least comparable lung functional outcomes to the use of Steen SolutionTM. Furthermore C-MP perfusion resulted in significantly lower lactate dehydrogenase activity and lactate levels in the perfusate and higher oxygenation capacity.
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Affiliation(s)
- Katharina Kalka
- Department of Thoracic and
Cardiovascular Surgery, Division of Thoracic Transplantation, West German Heart
Center, University Hospital Essen, Essen, Germany
| | - Zoe Keldenich
- Department of Thoracic and
Cardiovascular Surgery, Division of Thoracic Transplantation, West German Heart
Center, University Hospital Essen, Essen, Germany
| | - Henning Carstens
- Department of Cardiothoracic Surgery,
Center of Cardiology, University Hospital Cologne, Cologne, Nordrhein-Westfalen,
Germany
| | - Björn Walter
- Institut für Physiologische Chemie,
Universitätsklinikum Essen, Essen, Nordrhein-Westfalen, Germany
| | - Ursula Rauen
- Institut für Physiologische Chemie,
Universitätsklinikum Essen, Essen, Nordrhein-Westfalen, Germany
| | - Arjang Ruhparwar
- Department of Thoracic and
Cardiovascular Surgery, Division of Thoracic Transplantation, West German Heart
Center, University Hospital Essen, Essen, Germany
| | - Alexander Weymann
- Department of Thoracic and
Cardiovascular Surgery, Division of Thoracic Transplantation, West German Heart
Center, University Hospital Essen, Essen, Germany
| | - Markus Kamler
- Department of Thoracic and
Cardiovascular Surgery, Division of Thoracic Transplantation, West German Heart
Center, University Hospital Essen, Essen, Germany
| | - Gerald Reiner
- Department of Veterinary Clinical
Sciences, Swine Clinic, Justus-Liebig-University, Giessen, Hessen, Germany
| | - Achim Koch
- Department of Thoracic and
Cardiovascular Surgery, Division of Thoracic Transplantation, West German Heart
Center, University Hospital Essen, Essen, Germany
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24
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Nykänen AI, Mariscal A, Duong A, Estrada C, Ali A, Hough O, Sage A, Chao BT, Chen M, Gokhale H, Shan H, Bai X, Zehong G, Yeung J, Waddell T, Martinu T, Juvet S, Cypel M, Liu M, Davies JE, Keshavjee S. Engineered mesenchymal stromal cell therapy during human lung ex vivo lung perfusion is compromised by acidic lung microenvironment. Mol Ther Methods Clin Dev 2021; 23:184-197. [PMID: 34703841 PMCID: PMC8516994 DOI: 10.1016/j.omtm.2021.05.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 05/07/2021] [Indexed: 11/29/2022]
Abstract
Ex vivo lung perfusion (EVLP) is an excellent platform to apply novel therapeutics, such as gene and cell therapies, before lung transplantation. We investigated the concept of human donor lung engineering during EVLP by combining gene and cell therapies. Premodified cryopreserved mesenchymal stromal cells with augmented anti-inflammatory interleukin-10 production (MSCIL-10) were administered during EVLP to human lungs that had various degrees of underlying lung injury. Cryopreserved MSCIL-10 had excellent viability, and they immediately and efficiently elevated perfusate and lung tissue IL-10 levels during EVLP. However, MSCIL-10 function was compromised by the poor metabolic conditions present in the most damaged lungs. Similarly, exposing cultured MSCIL-10 to poor metabolic, and especially acidic, conditions decreased their IL-10 production. In conclusion, we found that "off-the-shelf" MSCIL-10 therapy of human lungs during EVLP is safe and feasible, and results in rapid IL-10 elevation, and that the acidic target-tissue microenvironment may compromise the efficacy of cell-based therapies.
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Affiliation(s)
- Antti I Nykänen
- Latner Thoracic Surgery Research Laboratories, Toronto General Hospital Research Institute, University Health Network and University of Toronto, 101 College Street, Toronto, ON M5G 1L7, Canada
| | - Andrea Mariscal
- Latner Thoracic Surgery Research Laboratories, Toronto General Hospital Research Institute, University Health Network and University of Toronto, 101 College Street, Toronto, ON M5G 1L7, Canada
| | - Allen Duong
- Latner Thoracic Surgery Research Laboratories, Toronto General Hospital Research Institute, University Health Network and University of Toronto, 101 College Street, Toronto, ON M5G 1L7, Canada
| | - Catalina Estrada
- Tissue Regeneration Therapeutics, 790 Bay Street, Toronto, ON M5G 1N8, Canada
| | - Aadil Ali
- Latner Thoracic Surgery Research Laboratories, Toronto General Hospital Research Institute, University Health Network and University of Toronto, 101 College Street, Toronto, ON M5G 1L7, Canada
| | - Olivia Hough
- Latner Thoracic Surgery Research Laboratories, Toronto General Hospital Research Institute, University Health Network and University of Toronto, 101 College Street, Toronto, ON M5G 1L7, Canada
| | - Andrew Sage
- Latner Thoracic Surgery Research Laboratories, Toronto General Hospital Research Institute, University Health Network and University of Toronto, 101 College Street, Toronto, ON M5G 1L7, Canada
| | - Bonnie T Chao
- Latner Thoracic Surgery Research Laboratories, Toronto General Hospital Research Institute, University Health Network and University of Toronto, 101 College Street, Toronto, ON M5G 1L7, Canada
| | - Manyin Chen
- Latner Thoracic Surgery Research Laboratories, Toronto General Hospital Research Institute, University Health Network and University of Toronto, 101 College Street, Toronto, ON M5G 1L7, Canada
| | - Hemant Gokhale
- Latner Thoracic Surgery Research Laboratories, Toronto General Hospital Research Institute, University Health Network and University of Toronto, 101 College Street, Toronto, ON M5G 1L7, Canada
| | - Hongchao Shan
- Latner Thoracic Surgery Research Laboratories, Toronto General Hospital Research Institute, University Health Network and University of Toronto, 101 College Street, Toronto, ON M5G 1L7, Canada
| | - Xiaohui Bai
- Latner Thoracic Surgery Research Laboratories, Toronto General Hospital Research Institute, University Health Network and University of Toronto, 101 College Street, Toronto, ON M5G 1L7, Canada
| | - Guan Zehong
- Latner Thoracic Surgery Research Laboratories, Toronto General Hospital Research Institute, University Health Network and University of Toronto, 101 College Street, Toronto, ON M5G 1L7, Canada
| | - Jonathan Yeung
- Latner Thoracic Surgery Research Laboratories, Toronto General Hospital Research Institute, University Health Network and University of Toronto, 101 College Street, Toronto, ON M5G 1L7, Canada
| | - Tom Waddell
- Latner Thoracic Surgery Research Laboratories, Toronto General Hospital Research Institute, University Health Network and University of Toronto, 101 College Street, Toronto, ON M5G 1L7, Canada
| | - Tereza Martinu
- Latner Thoracic Surgery Research Laboratories, Toronto General Hospital Research Institute, University Health Network and University of Toronto, 101 College Street, Toronto, ON M5G 1L7, Canada
| | - Stephen Juvet
- Latner Thoracic Surgery Research Laboratories, Toronto General Hospital Research Institute, University Health Network and University of Toronto, 101 College Street, Toronto, ON M5G 1L7, Canada
| | - Marcelo Cypel
- Latner Thoracic Surgery Research Laboratories, Toronto General Hospital Research Institute, University Health Network and University of Toronto, 101 College Street, Toronto, ON M5G 1L7, Canada
| | - Mingyao Liu
- Latner Thoracic Surgery Research Laboratories, Toronto General Hospital Research Institute, University Health Network and University of Toronto, 101 College Street, Toronto, ON M5G 1L7, Canada
| | - John E Davies
- Institute of Biomedical Engineering, University of Toronto, 164 College St, Toronto, ON M5S 3G9, Canada
| | - Shaf Keshavjee
- Latner Thoracic Surgery Research Laboratories, Toronto General Hospital Research Institute, University Health Network and University of Toronto, 101 College Street, Toronto, ON M5G 1L7, Canada
- Institute of Biomedical Engineering, University of Toronto, 164 College St, Toronto, ON M5S 3G9, Canada
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25
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Iske J, Hinze CA, Salman J, Haverich A, Tullius SG, Ius F. The potential of ex vivo lung perfusion on improving organ quality and ameliorating ischemia reperfusion injury. Am J Transplant 2021; 21:3831-3839. [PMID: 34355495 PMCID: PMC8925042 DOI: 10.1111/ajt.16784] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 08/02/2021] [Accepted: 08/03/2021] [Indexed: 01/25/2023]
Abstract
Allogeneic lung transplantation (LuTx) is considered the treatment of choice for a broad range of advanced, progressive lung diseases resistant to conventional treatment regimens. Ischemia reperfusion injury (IRI) occurring upon reperfusion of the explanted, ischemic lung during implantation remains a crucial mediator of primary graft dysfunction (PGD) and early allo-immune responses. Ex vivo lung perfusion (EVLP) displays an advanced technique aiming at improving lung procurement and preservation. Indeed, previous clinical trials have demonstrated a reduced incidence of PGD following LuTx utilizing EVLP, while long-term outcomes are yet to be evaluated. Mechanistically, EVLP may alleviate donor lung inflammation through reconditioning the injured lung and diminishing IRI through storing the explanted lung in a non-ischemic, perfused, and ventilated status. In this work, we review potential mechanisms of EVLP that may attenuate IRI and improve organ quality. Moreover, we dissect experimental treatment approaches during EVLP that may further attenuate inflammatory events deriving from tissue ischemia, shear forces or allograft rejection associated with LuTx.
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Affiliation(s)
- Jasper Iske
- Department of Cardiothoracic-, Transplant, and Vascular Surgery, Hannover Medical School, Hannover, Lower Saxony, Germany.,Division of Transplant Surgery, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher A. Hinze
- Department of Cardiothoracic-, Transplant, and Vascular Surgery, Hannover Medical School, Hannover, Lower Saxony, Germany
| | - Jawad Salman
- Department of Cardiothoracic-, Transplant, and Vascular Surgery, Hannover Medical School, Hannover, Lower Saxony, Germany
| | - Axel Haverich
- Department of Cardiothoracic-, Transplant, and Vascular Surgery, Hannover Medical School, Hannover, Lower Saxony, Germany.,Biomedical research in Endstage and Obstructive Lung Disease Hannover (BREATH), Member of the German Center for Lung Research (DZL), Hannover, Germany
| | - Stefan G. Tullius
- Division of Transplant Surgery, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Fabio Ius
- Department of Cardiothoracic-, Transplant, and Vascular Surgery, Hannover Medical School, Hannover, Lower Saxony, Germany.,Biomedical research in Endstage and Obstructive Lung Disease Hannover (BREATH), Member of the German Center for Lung Research (DZL), Hannover, Germany.,Correspondence: Fabio Ius, MD, Department of Heart-, Thoracic-, Vascular-, and Transplant Surgery, Hannover Medical School, 1 Carl-Neuberg-Street, 30625 Hannover, Germany, Tel: +49 511 532 2125, Fax: +49 511 532 8436,
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Shukrallah B, Ganapathi AM, Whitson BA. Donor Aorta as Conduit for Ex Vivo Lung Perfusion. ASAIO J 2021; 67:e182-e183. [PMID: 33769345 PMCID: PMC8560012 DOI: 10.1097/mat.0000000000001361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
For ex vivo lung perfusion (EVLP), there is often inadequate pulmonary artery for effective EVLP. Creation of a neopulmonary artery conduit with donor aorta alleviates this shortcoming. This technique will become of more importance and need as there are more donation after circulatory death donor (DCD) heart procurements as this is a common source of EVLP. With the time constraints associated with the DCD recovery approach, there is a high likelihood of having a short native pulmonary artery with the lung block necessitating this approach.
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Affiliation(s)
- Bassam Shukrallah
- From the Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Asvin M Ganapathi
- Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Bryan A Whitson
- Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
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Arni S, Maeyashiki T, Latshang T, Opitz I, Inci I. Ex Vivo Lung Perfusion with K(ATP) Channel Modulators Antagonize Ischemia Reperfusion Injury. Cells 2021; 10:cells10092296. [PMID: 34571948 PMCID: PMC8472464 DOI: 10.3390/cells10092296] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 08/25/2021] [Accepted: 09/02/2021] [Indexed: 11/18/2022] Open
Abstract
Ex vivo lung perfusion (EVLP) has been implemented to increase the number of donor lungs available for transplantation. The use of K(ATP) channel modulators during EVLP experiments may protect against lung ischemia-reperfusion injury and may inhibit the formation of reactive oxygen species. In a rat model of donation after circulatory death with 2 h warm ischemic time, we evaluated rat lungs for a 4-hour time in EVLP containing either mitochondrial-specific or plasma membrane and/or sarcolemmal-specific forms of K(ATP) channel modulators. Lung physiological data were recorded, and metabolic parameters were assessed. When compared to the control group, in the EVLP performed with diazoxide or 5-hydroxydecanoic acid (5-HD) we recorded significantly lower pulmonary vascular resistance and only in the diazoxide group recorded significant lung weight loss. In the perfusate of the 5-HD group, interleukin-1β and interleukin-1α were significantly lower when compared to the control group. Perfusate levels of calcium ions were significantly higher in both 5-HD and cromakalim groups, whereas the levels of calcium, potassium, chlorine and lactate were reduced in the diazoxide group, although not significantly when compared to the control. The use of a diazoxide mitochondrial-specific K(ATP) channel opener during EVLP improved lung physiological and metabolic parameters and reduced edema.
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Affiliation(s)
- Stephan Arni
- Department of Thoracic Surgery, University Hospital Zürich, 8091 Zürich, Switzerland; (S.A.); (T.M.); (I.O.)
| | - Tatsuo Maeyashiki
- Department of Thoracic Surgery, University Hospital Zürich, 8091 Zürich, Switzerland; (S.A.); (T.M.); (I.O.)
| | - Tsogyal Latshang
- Department of Pneumology, Kantonsspital Graubünden, 7000 Chur, Switzerland;
| | - Isabelle Opitz
- Department of Thoracic Surgery, University Hospital Zürich, 8091 Zürich, Switzerland; (S.A.); (T.M.); (I.O.)
| | - Ilhan Inci
- Department of Thoracic Surgery, University Hospital Zürich, 8091 Zürich, Switzerland; (S.A.); (T.M.); (I.O.)
- Correspondence: ; Tel.: +41-(0)-44-255-85-43
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Arni S, Necati C, Maeyashiki T, Opitz I, Inci I. Perfluorocarbon-Based Oxygen Carriers and Subnormothermic Lung Machine Perfusion Decrease Production of Pro-Inflammatory Mediators. Cells 2021; 10:cells10092249. [PMID: 34571898 PMCID: PMC8466246 DOI: 10.3390/cells10092249] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 08/19/2021] [Accepted: 08/27/2021] [Indexed: 12/20/2022] Open
Abstract
The quality of marginal donor lungs is clinically assessed with normothermic machine perfusion. Although subnormothermic temperature and perfluorocarbon-based oxygen carriers (PFCOC) have proven favourable for other organ transplants, their beneficial use for ex vivo lung perfusion (EVLP) still requires further investigation. In a rat model, we evaluated on a 4 h EVLP time the effects of PFCOC with either 28 °C or 37 °C perfusion temperatures. During EVLP at 28 °C with PFCOC, we recorded significantly lower lung pulmonary vascular resistance (PVR), higher dynamic compliance (Cdyn), significantly lower potassium and lactate levels, higher lung tissue ATP content, and significantly lower myeloperoxidase tissue activity when compared to the 37 °C EVLP with PFCOC. In the subnormothermic EVLP with or without PFCOC, the pro-inflammatory mediator TNFα, the cytokines IL-6 and IL-7, the chemokines MIP-3α, MIP-1α, MCP-1, GRO/KC as well as GM-CSF, G-CSF and the anti-inflammatory cytokines IL-4 and IL-10 were significantly lower. The 28 °C EVLP improved both Cdyn and PVR and decreased pro-inflammatory cytokines and pCO2 levels compared to the 37 °C EVLP. In addition, the 28 °C EVLP with PFCOC produced a significantly lower level of myeloperoxidase activity in lung tissue. Subnormothermic EVLP with PFCOC significantly improves lung donor physiology and ameliorates lung tissue biochemical and inflammatory parameters.
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Affiliation(s)
| | | | | | | | - Ilhan Inci
- Correspondence: ; Tel.: +41-(0)-44-255-85-43
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Snyder ME, Sembrat J, Noda K, Myerburg MM, Craig A, Mitash N, Harano T, Furukawa M, Pilewski J, McDyer J, Rojas M, Sanchez P. Human Lung-Resident Macrophages Colocalize with and Provide Costimulation to PD1 hi Tissue-Resident Memory T Cells. Am J Respir Crit Care Med 2021; 203:1230-1244. [PMID: 33306940 DOI: 10.1164/rccm.202006-2403oc] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Rationale: Tissue-resident memory T cells (TRM) play a critical role in the defense against inhaled pathogens. The isolation and study of human lung tissue-resident memory T cells and lung-resident macrophages (MLR) are limited by experimental constraints. Objectives: To characterize the spatial and functional relationship between MLR and human lung tissue-resident memory T cells using ex vivo lung perfusion (EVLP). Methods: TRM and MLR were isolated using EVLP and intraperfusate-labeled CD45 antibody. Cells isolated after 6 hours of EVLP were analyzed using spectral flow cytometry. Spatial relationships between CD3+ and CD68+ cells were explored with multiplexed immunohistochemistry. Functional relationships were determined by using coculture and T-cell-receptor complex signal transduction. Measurements and Main Results: Lungs from 8 research-consenting organ donors underwent EVLP for 6 hours. We show that human lung TRM and MLR colocalize within the human lung, preferentially around the airways. Furthermore, we found that human lung CD8+ TRM are composed of two functionally distinct populations on the basis of PD1 (programed cell death receptor 1) and ZNF683 (HOBIT) protein expression. We show that MLR provide costimulatory signaling to PD1hi CD4+ and CD8+ lung TRM,, augmenting the effector cytokine production and degranulation of TRM. Conclusions: EVLP provides an innovative technique to study resident immune populations in humans. Human MLR colocalize with and provide costimulation signaling to TRM, augmenting their effector function.
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Affiliation(s)
- Mark E Snyder
- Division of Pulmonary, Allergy, and Critical Care Medicine.,Department of Immunology.,Starzl Transplantation Institute, and
| | - John Sembrat
- Division of Pulmonary, Allergy, and Critical Care Medicine
| | - Kentaro Noda
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Andrew Craig
- Division of Pulmonary, Allergy, and Critical Care Medicine
| | - Nilay Mitash
- Division of Pulmonary, Allergy, and Critical Care Medicine
| | - Takashi Harano
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Masashi Furukawa
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - John McDyer
- Division of Pulmonary, Allergy, and Critical Care Medicine.,Starzl Transplantation Institute, and
| | - Mauricio Rojas
- Division of Pulmonary, Allergy, and Critical Care Medicine
| | - Pablo Sanchez
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
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Abstract
Lung transplantation has been established worldwide as the last treatment for end-stage respiratory failure. However, ischemia–reperfusion injury (IRI) inevitably occurs after lung transplantation. The most severe form of IRI leads to primary graft failure, which is an important cause of morbidity and mortality after lung transplantation. IRI may also induce rejection, which is the main cause of mortality in recipients. Despite advances in donor management and graft preservation, most donor grafts are still unsuitable for transplantation. Although the pulmonary endothelium is the primary target site of IRI, the pathophysiology of lung IRI remains incompletely understood. It is essential to understand the mechanism of pulmonary IRI to improve the outcomes of lung transplantation. Therefore, we reviewed the state-of-the-art in the management of pulmonary IRI after lung transplantation. Recently, the ex vivo lung perfusion (EVLP) system has been clinically introduced worldwide. Various promising therapeutic strategies for the protection of the endothelium against IRI, including EVLP, inhalation therapy with therapeutic gases and substances, fibrinolytic treatment, and mesenchymal stromal cell therapy, are awaiting clinical application. We herein review the latest advances in the field of pulmonary IRI in lung transplantation.
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Arni S, Maeyashiki T, Citak N, Opitz I, Inci I. Subnormothermic Ex Vivo Lung Perfusion Temperature Improves Graft Preservation in Lung Transplantation. Cells 2021; 10:748. [PMID: 33805274 PMCID: PMC8067331 DOI: 10.3390/cells10040748] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 03/23/2021] [Accepted: 03/26/2021] [Indexed: 02/06/2023] Open
Abstract
Normothermic machine perfusion is clinically used to assess the quality of marginal donor lungs. Although subnormothermic temperatures have proven beneficial for other solid organ transplants, subnormothermia-related benefits of ex vivo lung perfusion (EVLP) still need to be investigated. Material and Methods: In a rat model, we evaluated the effects of 28 °C temperature on 4-h EVLPs with subsequent left lung transplantation. The recipients were observed for 2 h postoperatively. Lung physiology data were recorded and metabolic parameters were assessed. Results: During the 4-h subnormothermic EVLP, the lung oxygenation was significantly higher (p < 0.001), pulmonary vascular resistance (PVR) lower and dynamic compliance (Cdyn) higher when compared to the 37 °C EVLP. During an end-of-EVLP stress test, we recorded significantly higher flow (p < 0.05), lower PVR (p < 0.05) and higher Cdyn (p < 0.01) in the 28 °C group when compared to the 37 °C group. After the left lung transplantation, Cdyn and oxygenation improved in the 28 °C group, which were comparable to the 37 °C group. Chemokines RANTES, MIP-3α, MIP-1α MCP-1 GRO/KC and pro-inflammatory mediators GM-CSF, G-CSF and TNFα were significantly lower after the 28 °C EVLP and remained low in the plasma of the recipient rats after transplantation. The lungs of the 28 °C group showed significantly lowered myeloperoxidase activity and lowered levels of TNFα and IL-1β. Conclusions: Compared to the normothermic perfusion, the 28 °C EVLP improved Cdyn and PVR and reduced both the release of pro-inflammatory cytokines and myeloperoxidase activity in lung tissue. These observations were also observed after the left lung transplantation in the subnormothermic group. The 28 °C EVLP significantly improved biochemical, physiological and inflammatory parameters in lung donors.
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Affiliation(s)
| | | | | | | | - Ilhan Inci
- Department of Thoracic Surgery, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland; (S.A.); (T.M.); (N.C.); (I.O.)
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Sage AT, Richard-Greenblatt M, Zhong K, Bai XH, Snow MB, Babits M, Ali A, Baciu C, Yeung JC, Liu M, Cypel M, Kain KC, Keshavjee S. Prediction of donor related lung injury in clinical lung transplantation using a validated ex vivo lung perfusion inflammation score. J Heart Lung Transplant 2021; 40:687-95. [PMID: 33781664 DOI: 10.1016/j.healun.2021.03.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 02/24/2021] [Accepted: 03/01/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Ex vivo lung perfusion (EVLP) is an isolated organ assessment technique that has revolutionized the field of lung transplantation and enabled a safe increase in the number of organs transplanted. The objective of this study was to develop a protein-based assay that would provide a precision medicine approach to lung injury assessment during EVLP. METHODS Perfusate samples collected from clinical EVLP cases performed from 2009 to 2019 were separated into development (n = 281) and validation (n = 57) sets to derive and validate an inflammation score based on IL-6 and IL-8 protein levels in perfusate. The ability of an inflammation score to predict lungs suitable for transplantation and likely to produce excellent recipient outcomes (time on ventilator ≤ 3 days) was assessed. Inflammation scores were compared to conventional clinical EVLP assessment parameters and associated with outcomes, including primary graft dysfunction and patient care in the ICU. RESULTS An inflammation score accurately predicted the decision to transplant (AUROC 68% [95% CI 62-74]) at the end of EVLP and those transplants associated with short ventilator times (AUROC 73% [95% CI 66-80]). The score identified lungs more likely to develop primary graft dysfunction at 72-hours post-transplant (OR 4.0, p = 0.03). A model comprised of the inflammation score and ∆PO2 was able to determine EVLP transplants that were likely to have excellent recipient outcomes, with an accuracy of 87% [95% CI 83-92]. CONCLUSIONS The adoption of an inflammation score will improve accuracy of EVLP decision-making and increase confidence of surgical teams to determine lungs that are suitable for transplantation, thereby improving organ utilization rates and patient outcomes.
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Shin J, Hsin MK, Baciu C, Chen Y, Zamel R, Machuca T, Yeung J, Cypel M, Keshavjee S, Liu M. Use of metabolomics to identify strategies to improve and prolong ex vivo lung perfusion for lung transplants. J Heart Lung Transplant 2021; 40:525-35. [PMID: 33849769 DOI: 10.1016/j.healun.2021.02.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 02/03/2021] [Accepted: 02/09/2021] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Normothermic ex vivo lung perfusion (EVLP) allows for functional assessment of donor lungs; thus has increased the use of marginal lungs for transplantation. To extend EVLP for advanced organ reconditioning and regenerative interventions, cellular metabolic changes need to be understood. We sought to comprehensively characterize the dynamic metabolic changes of the lungs during EVLP, and to identify strategies to improve EVLP. METHODS Human donor lungs (n = 50) were assessed under a 4-hour Toronto EVLP protocol. EVLP perfusate was sampled at first (EVLP-1h) and fourth hour (EVLP-4h) of perfusion and were submitted for mass spectrometry-based untargeted metabolic profiling. Differentially expressed metabolites between the 2 timepoints were identified and analyzed from the samples of lungs transplanted post-EVLP (n = 42) to determine the underlying molecular mechanisms. RESULTS Of the total 312 detected metabolites, 84 were up-regulated and 103 were down-regulated at EVLP-4h relative to 1h (FDR adjusted p < .05, fold change ≥ |1.1|). At EVLP-4h, markedly decreased energy substrates were observed, accompanied by the increase in fatty acid β-oxidation. Concurrently, accumulation of amino acids and nucleic acids was evident, indicative of increased protein and nucleotide catabolism. The uniform decrease in free lysophospholipids and polyunsaturated fatty acids at EVLP-4h suggests cell membrane remodeling. CONCLUSIONS Untargeted metabolomics revealed signs of energy substrate consumption and metabolic by-product accumulation under current EVLP protocols. Strategies to supplement nutrients and to maintain homeostasis will be vital in improving the current clinical practice and prolonging organ perfusion for therapeutic application to further enhance donor lung utilization.
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Miceli V, Bertani A, Chinnici CM, Bulati M, Pampalone M, Amico G, Carcione C, Schmelzer E, Gerlach JC, Conaldi PG. Conditioned Medium from Human Amnion-Derived Mesenchymal Stromal/Stem Cells Attenuating the Effects of Cold Ischemia-Reperfusion Injury in an In Vitro Model Using Human Alveolar Epithelial Cells. Int J Mol Sci 2021; 22:ijms22020510. [PMID: 33419219 PMCID: PMC7825633 DOI: 10.3390/ijms22020510] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 12/30/2020] [Accepted: 01/03/2021] [Indexed: 02/07/2023] Open
Abstract
The clinical results of lung transplantation (LTx) are still less favorable than other solid organ transplants in both the early and long term. The fragility of the lungs limits the procurement rate and can favor the occurrence of ischemia-reperfusion injury (IRI). Ex vivo lung perfusion (EVLP) with Steen SolutionTM (SS) aims to address problems, and the implementation of EVLP to alleviate the activation of IRI-mediated processes has been achieved using mesenchymal stromal/stem cell (MSC)-based treatments. In this study, we investigated the paracrine effects of human amnion-derived MSCs (hAMSCs) in an in vitro model of lung IRI that includes cold ischemia and normothermic EVLP. We found that SS enriched by a hAMSC-conditioned medium (hAMSC-CM) preserved the viability and delayed the apoptosis of alveolar epithelial cells (A549) through the downregulation of inflammatory factors and the upregulation of antiapoptotic factors. These effects were more evident using the CM of 3D hAMSC cultures, which contained an increased amount of immunosuppressive and growth factors compared to both 2D cultures and encapsulated-hAMSCs. To conclude, we demonstrated an in vitro model of lung IRI and provided evidence that a hAMSC-CM attenuated IRI effects by improving the efficacy of EVLP, leading to strategies for a potential implementation of this technique.
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Affiliation(s)
- Vitale Miceli
- Research Department, IRCCS ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), 90127 Palermo, Italy; (M.B.); (P.G.C.)
- Correspondence: ; Tel.: +39-091-21-92-649
| | - Alessandro Bertani
- Thoracic Surgery and Lung Transplantation Unit, Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione, 90127 Palermo, Italy;
| | - Cinzia Maria Chinnici
- Regenerative Medicine Unit, Fondazione Ri.MED, 90127 Palermo, Italy; (C.M.C.); (M.P.); (G.A.); (C.C.)
- Department of Laboratory Medicine and Advanced Biotechnologies, IRCCS–ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), 90127 Palermo, Italy
| | - Matteo Bulati
- Research Department, IRCCS ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), 90127 Palermo, Italy; (M.B.); (P.G.C.)
| | - Mariangela Pampalone
- Regenerative Medicine Unit, Fondazione Ri.MED, 90127 Palermo, Italy; (C.M.C.); (M.P.); (G.A.); (C.C.)
- Department of Laboratory Medicine and Advanced Biotechnologies, IRCCS–ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), 90127 Palermo, Italy
| | - Giandomenico Amico
- Regenerative Medicine Unit, Fondazione Ri.MED, 90127 Palermo, Italy; (C.M.C.); (M.P.); (G.A.); (C.C.)
- Department of Laboratory Medicine and Advanced Biotechnologies, IRCCS–ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), 90127 Palermo, Italy
| | - Claudia Carcione
- Regenerative Medicine Unit, Fondazione Ri.MED, 90127 Palermo, Italy; (C.M.C.); (M.P.); (G.A.); (C.C.)
| | - Eva Schmelzer
- Department of Surgery, School of Medicine, McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA 15219-3130, USA; (E.S.); (J.C.G.)
| | - Jörg C. Gerlach
- Department of Surgery, School of Medicine, McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA 15219-3130, USA; (E.S.); (J.C.G.)
- Department of Bioengineering, School of Medicine, McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA 15219-3130, USA
| | - Pier Giulio Conaldi
- Research Department, IRCCS ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), 90127 Palermo, Italy; (M.B.); (P.G.C.)
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Bobba CM, Nelson K, Dumond C, Eren E, Black SM, Englert JA, Ghadiali SN, Whitson BA. A Novel Negative Pressure-Flow Waveform to Ventilate Lungs for Normothermic Ex Vivo Lung Perfusion. ASAIO J 2021; 67:96-103. [PMID: 32404613 PMCID: PMC9218878 DOI: 10.1097/mat.0000000000001168] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Ex vivo lung perfusion (EVLP) is increasingly used to treat and assess lungs before transplant. Minimizing ventilator induced lung injury (VILI) during EVLP is an important clinical need, and negative pressure ventilation (NPV) may reduce VILI compared with conventional positive pressure ventilation (PPV). However, it is not clear if NPV is intrinsically lung protective or if differences in respiratory pressure-flow waveforms are responsible for reduced VILI during NPV. In this study, we quantified lung injury using novel pressure-flow waveforms during normothermic EVLP. Rat lungs were ventilated-perfused ex vivo for 2 hours using tidal volume, positive end-expiratory pressure (PEEP), and respiratory rate matched PPV or NPV protocols. Airway pressures and flow rates were measured in real time and lungs were assessed for changes in compliance, pulmonary vascular resistance, oxygenation, edema, and cytokine secretion. Negative pressure ventilation lungs demonstrated reduced proinflammatory cytokine secretion, reduced weight gain, and reduced pulmonary vascular resistance (p < 0.05). Compliance was higher in NPV lungs (p < 0.05), and there was no difference in oxygenation between the two groups. Respiratory pressure-flow waveforms during NPV and PPV were significantly different (p < 0.05), especially during the inspiratory phase, where the NPV group exhibited rapid time-dependent changes in pressure and airflow whereas the PPV group exhibited slower changes in airflow/pressures. Lungs ventilated with PPV also had a greater transpulmonary pressure (p < 0.05). Greater improvement in lung function during NPV EVLP may be caused by favorable airflow patterns and/or pressure dynamics, which may better mimic human respiratory patterns.
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Affiliation(s)
- Christopher M Bobba
- From the Division of Pulmonary, Critical Care, and Sleep Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
- Dorothy M. Davis Heart and Lung Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Kevin Nelson
- From the Division of Pulmonary, Critical Care, and Sleep Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
- Dorothy M. Davis Heart and Lung Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Curtis Dumond
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio; and
- Department of Surgery, Collaboration for Organ Perfusion, Protection, Engineering and Regeneration (COPPER) Laboratory, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Emre Eren
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio; and
- Department of Surgery, Collaboration for Organ Perfusion, Protection, Engineering and Regeneration (COPPER) Laboratory, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Sylvester M Black
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio; and
- Department of Surgery, Collaboration for Organ Perfusion, Protection, Engineering and Regeneration (COPPER) Laboratory, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Joshua A Englert
- From the Division of Pulmonary, Critical Care, and Sleep Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
- Dorothy M. Davis Heart and Lung Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Samir N Ghadiali
- From the Division of Pulmonary, Critical Care, and Sleep Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
- Dorothy M. Davis Heart and Lung Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Bryan A Whitson
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio; and
- Department of Surgery, Collaboration for Organ Perfusion, Protection, Engineering and Regeneration (COPPER) Laboratory, The Ohio State University Wexner Medical Center, Columbus, Ohio
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Inci I, Arni S, Iskender I, Citak N, Rodriguez JM, Weisskopf M, Opitz I, Weder W, Frauenfelder T, Krafft MP, Spahn DR. Functional, Metabolic and Morphologic Results of Ex Vivo Donor Lung Perfusion with a Perfluorocarbon-Based Oxygen Carrier Nanoemulsion in a Large Animal Transplantation Model. Cells 2020; 9:E2501. [PMID: 33218154 DOI: 10.3390/cells9112501] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 11/06/2020] [Accepted: 11/09/2020] [Indexed: 01/01/2023] Open
Abstract
Background: Ex vivo lung perfusion (EVLP) is a technology that allows the re-evaluation of questionable donor lung before implantation and it has the potential to repair injured donor lungs that are otherwise unsuitable for transplantation. We hypothesized that perfluorocarbon-based oxygen carrier, a novel reconditioning strategy instilled during EVLP would improve graft function. Methods: We utilized perfluorocarbon-based oxygen carrier (PFCOC) during EVLP to recondition and improve lung graft function in a pig model of EVLP and lung transplantation. Lungs were retrieved and stored for 24 h at 4 °C. EVLP was done for 6 h with or without PFCOC. In the transplantation groups, left lung transplantation was done after EVLP with or without PFCOC. Allograft function was assessed by means of pulmonary gas exchange, lung mechanics and vascular pressures, histology and transmission electron microscopy (TEM). Results: In the EVLP only groups, physiological and biochemical markers during the 6-h perfusion period were comparable. However, perfusate lactate potassium levels were lower and ATP levels were higher in the PFCOC group. Radiologic assessment revealed significantly more lung infiltrates in the controls than in the PFCOC group (p = 0.04). In transplantation groups, perfusate glucose consumption was higher in the control group. Lactate levels were significantly lower in the PFCOC group (p = 0.02). Perfusate flavin mononucleotide (FMN) was significantly higher in the controls (p = 0.008). Post-transplant gas exchange was significantly better during the 4-h reperfusion period in the PFCOC group (p = 0.01). Plasma IL-8 and IL-12 levels were significantly lower in the PFCOC group (p = 0.01, p = 0.03, respectively). ATP lung tissue levels at the end of the transplantation were higher and myeloperoxidase (MPO) levels in lung tissue were lower in the PFCOC group compared to the control group. In the PFCOC group, TEM showed better tissue preservation and cellular viability. Conclusion: PFCOC application is safe during EVLP in lungs preserved 24 h at 4 °C. Although this strategy did not significantly affect the EVLP physiology, metabolic markers of the donor quality such as lactate production, glucose consumption, neutrophil infiltration and preservation of mitochondrial function were better in the PFCOC group. Following transplantation, PFCOC resulted in better graft function and TEM showed better tissue preservation, cellular viability and improved gas transport.
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Lautner L, Himmat S, Acker JP, Nagendran J. The efficacy of ice recrystallization inhibitors in rat lung cryopreservation using a low cost technique for ex vivo subnormothermic lung perfusion. Cryobiology 2020; 97:93-100. [PMID: 33031822 DOI: 10.1016/j.cryobiol.2020.10.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 10/02/2020] [Indexed: 02/06/2023]
Abstract
Although lung transplant remains the only option for patients with end-stage lung failure, short preservation times result in an inability to meet patient demand. Successful cryopreservation may ameliorate this problem; however, very little research has been performed on lung cryopreservation due to the inability to prevent ice nucleation or growth. Therefore, this research sought to characterize the efficacy of a small-molecule ice recrystallization inhibitor (IRI) for lung cryopreservation given its well-documented ability to control ice growth. Sprague-Dawley heart-lung blocks were perfused at room temperature using a syringe-pump. Cytotoxicity of the IRI was assessed through the subsequent perfusion with 0.4% (w/v) trypan blue followed by formalin-fixation. Ice control was assessed by freezing at a chamber rate of -5 °C/min to -20 °C and cryofixation using a low-temperature fixative. Post-thaw cell survival was determined by freezing at a chamber rate of -5 °C/min to -20 °C and thawing in a 37 °C water bath before formalin-fixation. In all cases, samples were paraffin-embedded, sliced, and stained with eosin. The IRI studied was found to be non-toxic, as cell membrane integrity following perfusion was not significantly different than controls (p = 0.9292). Alveolar ice grain size was significantly reduced by the addition of this IRI (p = 0.0096), and the addition of the IRI to DMSO significantly improved post-thaw cell membrane integrity when compared to controls treated with DMSO alone (p = 0.0034). The techniques described here provide a low-cost solution for rat ex vivo lung perfusion which demonstrated that the ice control and improved post-thaw cell survival afforded by IRI-use warrants further study.
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Affiliation(s)
- Larissa Lautner
- Department of Surgery, University of Alberta, Edmonton, AB, T6G 2B7, Canada
| | - Sayed Himmat
- Department of Surgery, University of Alberta, Edmonton, AB, T6G 2B7, Canada
| | - Jason P Acker
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, AB, T6G 2R3, Canada; Centre for Innovation, Canadian Blood Services, 8249 114th Street, Edmonton, AB, T6G 2R8, Canada.
| | - Jayan Nagendran
- Department of Surgery, University of Alberta, Edmonton, AB, T6G 2B7, Canada; Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, AB, T6G 2B7, Canada
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Wang A, Ali A, Keshavjee S, Liu M, Cypel M. Ex vivo lung perfusion for donor lung assessment and repair: a review of translational interspecies models. Am J Physiol Lung Cell Mol Physiol 2020; 319:L932-L940. [PMID: 32996780 DOI: 10.1152/ajplung.00295.2020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
For patients with end-stage lung disease, lung transplantation is a lifesaving therapy. Currently however, the number of patients who require a transplant exceeds the number of donor lungs available. One of the contributing factors to this is the conservative mindset of physicians who are concerned about transplanting marginal lungs due to the potential risk of primary graft dysfunction. Ex vivo lung perfusion (EVLP) technology has allowed for the expansion of donor pool of organs by enabling assessment and reconditioning of these marginal grafts before transplant. Ongoing efforts to optimize the therapeutic potential of EVLP are underway. Researchers have adopted the use of different large and small animal models to generate translational preclinical data. This includes the use of rejected human lungs, pig lungs, and rat lungs. In this review, we summarize some of the key current literature studies relevant to each of the major EVLP model platforms and identify the advantages and disadvantages of each platform. The review aims to guide investigators in choosing an appropriate species model to suit their specific goals of study, and ultimately aid in translation of therapy to meet the growing needs of the patient population.
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Affiliation(s)
- Aizhou Wang
- Latner Thoracic Surgery Research Laboratories, Toronto General Research Institute, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Aadil Ali
- Latner Thoracic Surgery Research Laboratories, Toronto General Research Institute, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Shaf Keshavjee
- Latner Thoracic Surgery Research Laboratories, Toronto General Research Institute, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Mingyao Liu
- Latner Thoracic Surgery Research Laboratories, Toronto General Research Institute, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Marcelo Cypel
- Latner Thoracic Surgery Research Laboratories, Toronto General Research Institute, University Health Network, University of Toronto, Toronto, Ontario, Canada
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Ribeiro RVP, Ali A, Cypel M. Ex vivo perfusion in lung transplantation and removal of HCV: the next level. Transpl Int 2020; 33:1589-1596. [PMID: 32888320 DOI: 10.1111/tri.13730] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 04/14/2020] [Accepted: 08/26/2020] [Indexed: 01/14/2023]
Abstract
The large gap between high demand and low availability of lungs is still a limiting factor for lung transplantation which leads to important mortality rates on the waiting list. In the last years, with the advent of potent direct-acting antivirals (DAAs), donors carrying active hepatitis C (HCV) infection became an important source in expanding the donor pool. Recent clinical trials exploring different treatment regimens post-transplantation when using HCV-positive abdominal and thoracic organs into HCV-negative recipients have shown encouraging results. Although early data shows no toxicity and similar survival rates when compared to non-HCV organ transplantation, long-term outcomes evaluating the effect of either the transmission of HCV into the recipients or the deliberate use of DAAs to treat the virus remains absent. An important and innovative strategy to overcome this limitation is the possibility of mitigating viral transmission with the use of ex vivo donor organ treatment prior to transplantation. Recent pre-clinical and clinical studies explore the use of ex vivo perfusion and the removal of HCV prior to transplantation with the addition of other innovative therapies, which will be reviewed in this article.
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Affiliation(s)
| | - Aadil Ali
- Latner Thoracic Surgery Research Laboratories, University Health Network, Toronto, ON, Canada
| | - Marcelo Cypel
- Latner Thoracic Surgery Research Laboratories, University Health Network, Toronto, ON, Canada.,Division of Thoracic Surgery, University Health Network, Toronto, ON, Canada
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Ayyat KS, Okamoto T, Niikawa H, Sakanoue I, Dugar S, Latifi SQ, Lebovitz DJ, Moghekar A, McCurry KR. A CLUE for better assessment of donor lungs: Novel technique in clinical ex vivo lung perfusion. J Heart Lung Transplant 2020; 39:1220-1227. [PMID: 32773324 DOI: 10.1016/j.healun.2020.07.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 07/13/2020] [Accepted: 07/16/2020] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND The direCt Lung Ultrasound Evaluation (CLUE) technique was proven to be an accurate method for monitoring extravascular lung water in donor lungs during ex vivo lung perfusion (EVLP) in an experimental model. The aim of this study was to examine the application of CLUE in the clinical setting. METHODS Lungs were evaluated using acellular EVLP protocol. Ultrasound images were obtained directly from the lung surface. Images were graded according to the percentage of B-lines seen on ultrasound. CLUE scores were calculated at the beginning and end of EVLP for the whole lung, each side, and lobe based on the number (No.) of images in each grade and the total No. of images taken and evaluated retrospectively. RESULTS A total of 23 EVLP cases were performed resulting in 13 lung transplants (LTxs) with no hospital mortality. Primary graft dysfunction (PGD) occurred in only 1 recipient (PGD3, no PGD2). Significant differences were found between suitable and non-suitable lungs in CLUE scores (1.03 vs 1.85, p < 0.001), unlike the partial pressure of oxygen/fraction of inspired oxygen ratio. CLUE had the highest area under the receiver operating characteristic curve (0.98) compared with other evaluation parameters. The initial CLUE score of standard donor lungs was significantly better than marginal lungs. The final CLUE score in proned lungs showed improvement when compared with initial CLUE score, especially in the upper lobes. CONCLUSIONS The CLUE technique shows the highest accuracy in evaluating donor lungs for LTx suitability compared with other parameters used in EVLP. CLUE can optimize the outcomes of LTx by guiding the decision making through the whole process of clinical EVLP.
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Affiliation(s)
- Kamal S Ayyat
- Department of Inflammation and Immunology, Lerner Research Institute and; Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio; Department of Cardiothoracic Surgery, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Toshihiro Okamoto
- Department of Inflammation and Immunology, Lerner Research Institute and; Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio; Transplant Center
| | - Hiromichi Niikawa
- Department of Inflammation and Immunology, Lerner Research Institute and; Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Ichiro Sakanoue
- Department of Inflammation and Immunology, Lerner Research Institute and; Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | | | - Samir Q Latifi
- Department of Pediatric Critical Care, Cleveland Clinic, Cleveland, Ohio; Lifebanc, Cleveland, Ohio
| | - Daniel J Lebovitz
- Lifebanc, Cleveland, Ohio; Department of Critical Care Medicine, Akron Children's Hospital, Akron, Ohio
| | | | - Kenneth R McCurry
- Department of Inflammation and Immunology, Lerner Research Institute and; Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio; Transplant Center.
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Qaqish R, Watanabe Y, Hoetzenecker K, Yeung J, Chen M, Pierre A, Yasufuku K, Donahoe L, de Perrot M, Waddell T, Keshavjee S, Cypel M. Impact of donor time to cardiac arrest in lung donation after circulatory death. J Thorac Cardiovasc Surg 2020; 161:1546-1555.e1. [PMID: 32747131 DOI: 10.1016/j.jtcvs.2020.04.181] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 04/27/2020] [Accepted: 04/30/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Acceptance of lungs from donation after circulatory determination of death has been generally restricted to donors who have cardiac arrest within 60 minutes after withdrawal of life-sustaining therapies. We aimed to determine the effect of the interval between withdrawal of life-sustaining therapies to arrest and recipient outcomes. Second, we aimed to compare outcomes between donation after circulatory determination of death transplants and donation after neurologic determination of death transplants. METHODS A single-center, retrospective review was performed analyzing the clinical outcomes of transplant recipients who received donation after circulatory determination of death lungs and those who received donation after neurologic determination of death lungs. Donation after circulatory determination of death cases were then grouped on the basis of the interval between withdrawal of life-sustaining therapies and asystole: 0 to 19 minutes (rapid), 20 to 59 minutes (intermediate), and more than 60 minutes (long). Recipient outcomes from each of these groups were compared. RESULTS A total of 180 cases of donation after circulatory determination of death and 1088 cases of donation after neurologic determination of death were reviewed between 2007 and 2017. There were no significant differences in the 2 groups in terms of age, gender, recipient diagnosis, and type of transplant (bilateral vs single). Ex vivo lung perfusion was used in 118 of 180 (65.6%) donation after circulatory determination of death cases and 149 of 1088 (13.7%) donation after neurologic determination of death cases before transplantation. The median survivals of recipients who received donation after circulatory determination of death lungs versus donation after neurologic determination of death lungs were 8.0 and 6.9 years, respectively. Time between withdrawal of life-sustaining therapies and asystole was available for 148 of 180 donors (82.2%) from the donation after circulatory determination of death group. Mean and median time from withdrawal of life-sustaining therapies to asystole were 28.6 minutes and 16 minutes, respectively. Twenty donors required more than 60 minutes to experience cardiac arrest, with the longest duration being 154 minutes before asystole was recorded. Recipients of donation after circulatory determination of death lungs who had cardiac arrest at 0 to 19 minutes (90 donors), 20 to 59 minutes (38 donors), and more than 60 minutes (20 donors) did not demonstrate any significant differences in terms of short- and long-term survivals, primary graft dysfunction 2 and 3, intensive care unit stay, mechanical ventilation days, or total hospital stay. CONCLUSIONS Short- and long-term outcomes in recipients who received donation after neurologic determination of death versus donation after circulatory determination of death lungs are similar. Different withdrawals of life-sustaining therapies to arrest intervals were not associated with recipient outcomes. The maximum acceptable duration of this interval has yet to be established.
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Affiliation(s)
- Robert Qaqish
- Toronto Lung Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Yui Watanabe
- Toronto Lung Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Konrad Hoetzenecker
- Toronto Lung Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Jon Yeung
- Toronto Lung Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Manyin Chen
- Toronto Lung Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Andrew Pierre
- Toronto Lung Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Kazuhiro Yasufuku
- Toronto Lung Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Laura Donahoe
- Toronto Lung Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Marc de Perrot
- Toronto Lung Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Tom Waddell
- Toronto Lung Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Shaf Keshavjee
- Toronto Lung Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Marcelo Cypel
- Toronto Lung Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada.
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42
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Ali A, Watanabe Y, Galasso M, Watanabe T, Chen M, Fan E, Brochard L, Ramadan K, Ribeiro RVP, Stansfield W, Gokhale H, Gazzalle A, Waddell T, Liu M, Keshavjee S, Cypel M. An extracellular oxygen carrier during prolonged pulmonary preservation improves post-transplant lung function. J Heart Lung Transplant 2020; 39:595-603. [PMID: 32334946 DOI: 10.1016/j.healun.2020.03.027] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 03/06/2020] [Accepted: 03/25/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND The use of a novel extracellular oxygen carrier (EOC) preservation additive known as HEMO2Life has recently been shown to lead to a superior preservation of different types of solid organs. Our study aimed to investigate the effect of this EOC on extending lung preservation time and its mechanism of action. METHODS Donor pigs were randomly allocated to either of the following 2 groups (n = 6 per group): (1) 36 hours cold preservation or (2) 36 hours cold preservation with 1 g/liter of EOC. The lungs were evaluated through 12 hours of normothermic ex vivo lung perfusion (EVLP) followed by a left-single lung transplant into a recipient pig. Grafts were reperfused for 4 hours, followed by right pulmonary artery clamping to assess graft oxygenation function. RESULTS During EVLP assessment, EOC-treated lungs showed improvements in physiologic parameters, whereas the control lungs deteriorated. After a total of 48 hours of preservation (36 hours cold + 12 hours normothermic EVLP), transplanted grafts in the treatment group displayed significantly better oxygenation than in the controls (PaO2/FiO2: 437 ± 36 mm Hg vs 343 ± 27 mm Hg, p = 0.041). In addition, the use of EOC led to significantly less edema formation (wet-to-dry ratio: 4.95 ± 0.29 vs 6.05 ± 0.33, p = 0.026), less apoptotic cell death (p = 0.041), improved tight junction preservation (p = 0.002), and lower levels of circulating IL-6 within recipient plasma (p = 0.004) compared with non-use of EOC in the control group after transplantation. CONCLUSION The use of an EOC during an extended pulmonary preservation period led to significantly superior early post-transplant lung function.
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Affiliation(s)
- Aadil Ali
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Yui Watanabe
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Marcos Galasso
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Tatsuaki Watanabe
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Manyin Chen
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Eddy Fan
- Divisions of Respirology and Critical Care Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Laurent Brochard
- Divisions of Respirology and Critical Care Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Khaled Ramadan
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Rafaela Vanin Pinto Ribeiro
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - William Stansfield
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Hemant Gokhale
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Anajara Gazzalle
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Thomas Waddell
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Mingyao Liu
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Shaf Keshavjee
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Marcelo Cypel
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, Toronto, Ontario, Canada.
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Choi AY, Jawitz OK, Raman V, Mulvihill MS, Halpern SE, Barac YD, Klapper JA, Hartwig MG. Predictors of nonuse of donation after circulatory death lung allografts. J Thorac Cardiovasc Surg 2020; 161:458-466.e3. [PMID: 32563573 DOI: 10.1016/j.jtcvs.2020.04.111] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Revised: 04/07/2020] [Accepted: 04/08/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Despite growing evidence of comparable outcomes in recipients of donation after circulatory death and donation after brain death donor lungs, donation after circulatory death allografts continue to be underused nationally. We examined predictors of nonuse. METHODS All donors who donated at least 1 organ for transplantation between 2005 and 2019 were identified in the United Network for Organ Sharing registry and stratified by donation type. The primary outcome of interest was use of pulmonary allografts. Organ disposition and refusal reasons were evaluated. Multivariable regression modeling was used to assess the relationship between donor factors and use. RESULTS A total of 15,458 donation after circulatory death donors met inclusion criteria. Of 30,916 lungs, 3.7% (1158) were used for transplantation and 72.8% were discarded primarily due to poor organ function. Consent was not requested in 8.4% of donation after circulatory death offers with donation after circulatory death being the leading reason (73.4%). Nonuse was associated with smoking history (P < .001), clinical infection with a blood source (12% vs 7.4%, P = .001), and lower PaO2/FiO2 ratio (median 230 vs 423, P < .001). In multivariable regression, those with PaO2/FiO2 ratio less than 250 were least likely to be transplanted (adjusted odds ratio, 0.03; P < .001), followed by cigarette use (0.28, P < .001), and donor age >50 (0.75, P = .031). Recent transplant era was associated with significantly increased use (adjusted odds ratio, 2.28; P < .001). CONCLUSIONS Nontransplantation of donation after circulatory death lungs was associated with potentially modifiable predonation factors, including organ procurement organizations' consenting behavior, and donor factors, including hypoxemia. Interventions to increase consent and standardize donation after circulatory death donor management, including selective use of ex vivo lung perfusion in the setting of hypoxemia, may increase use and the donor pool.
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Affiliation(s)
| | - Oliver K Jawitz
- Department of Surgery, Duke University Medical Center, Durham, NC
| | - Vignesh Raman
- Department of Surgery, Duke University Medical Center, Durham, NC
| | | | | | - Yaron D Barac
- The Division of Cardiovascular and Thoracic Surgery, Rabin Medical Center, Petach-Tikva, Israel
| | - Jacob A Klapper
- Department of Surgery, Duke University Medical Center, Durham, NC
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Ohsumi A, Kanou T, Ali A, Guan Z, Hwang DM, Waddell TK, Juvet S, Liu M, Keshavjee S, Cypel M. A method for translational rat ex vivo lung perfusion experimentation. Am J Physiol Lung Cell Mol Physiol 2020; 319:L61-L70. [PMID: 32233924 DOI: 10.1152/ajplung.00256.2019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
The application of ex vivo lung perfusion (EVLP) has significantly increased the successful clinical use of marginal donor lungs. While large animal EVLP models exist to test new strategies to improve organ repair, there is currently no rat EVLP model capable of maintaining long-term lung viability. Here, we describe a new rat EVLP model that addresses this need, while enabling the study of lung injury due to cold ischemic time (CIT). The technique involves perfusing and ventilating male Lewis rat donor lungs for 4 h before transplanting the left lung into a recipient rat and then evaluating lung function 2 h after reperfusion. To test injury within this model, lungs were divided into groups and exposed to different CITs (i.e., 20 min, 6 h, 12 h, 18 h and 24 h). Experiments involving the 24-h-CIT group were prematurely terminated due to the development of severe edema. For the other groups, no differences in the ratio of arterial oxygen partial pressure to fractional inspired oxygen ([Formula: see text]/[Formula: see text]) were observed during EVLP; however, lung compliance decreased over time in the 18-h group (P = 0.012) and the [Formula: see text]/[Formula: see text] of the blood from the left pulmonary vein 2 h after transplantation was lower compared with 20-min-CIT group (P = 0.0062). This new model maintained stable lung function during 4-h EVLP and after transplantation when exposed to up to 12 h of CIT.
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Affiliation(s)
- Akihiro Ohsumi
- Latner Thoracic Surgery Research Laboratories, Toronto General Hospital Research Institute, Toronto, Ontario, Canada.,Department of Thoracic Surgery, Kyoto University Hospital, Kyoto, Japan
| | - Takashi Kanou
- Latner Thoracic Surgery Research Laboratories, Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Aadil Ali
- Latner Thoracic Surgery Research Laboratories, Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Zehong Guan
- Latner Thoracic Surgery Research Laboratories, Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - David M Hwang
- Latner Thoracic Surgery Research Laboratories, Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Thomas K Waddell
- Latner Thoracic Surgery Research Laboratories, Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Stephen Juvet
- Latner Thoracic Surgery Research Laboratories, Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Mingyao Liu
- Latner Thoracic Surgery Research Laboratories, Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Shaf Keshavjee
- Latner Thoracic Surgery Research Laboratories, Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Marcelo Cypel
- Latner Thoracic Surgery Research Laboratories, Toronto General Hospital Research Institute, Toronto, Ontario, Canada
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Iskender I, Arni S, Maeyashiki T, Citak N, Sauer M, Rodriguez JM, Frauenfelder T, Opitz I, Weder W, Inci I. Perfusate adsorption during ex vivo lung perfusion improves early post-transplant lung function. J Thorac Cardiovasc Surg 2020; 161:e109-e121. [PMID: 32201002 DOI: 10.1016/j.jtcvs.2019.12.128] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 11/29/2019] [Accepted: 12/05/2019] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Improvement in ex vivo lung perfusion protocols could increase the number of donors available for transplantation and protect the lungs from primary graft dysfunction. We hypothesize that perfusate adsorption during ex vivo lung perfusion reconditions the allograft to ischemia-reperfusion injury after lung transplantation. METHODS Donor pig lungs were preserved for 24 hours at 4°C, followed by 6 hours of ex vivo lung perfusion according to the Toronto protocol. The perfusate was additionally adsorbed through a CytoSorb adsorber (CytoSorbents, Berlin, Germany) in the treatment group, whereas control lungs were perfused according to the standard protocol (n = 5, each). Ex vivo lung perfusion physiology and biochemistry were monitored. Upon completion of ex vivo lung perfusion, a left single lung transplantation was performed. Oxygenation function and lung mechanics were assessed during a 4-hour reperfusion period. The inflammatory response was determined during ex vivo lung perfusion and reperfusion. RESULTS The cytokine concentrations in the perfusate were markedly lower with the adsorber, resulting in improved ex vivo lung perfusion physiology and biochemistry during the 6-hour perfusion period. Post-transplant dynamic lung compliance was markedly better during the 4-hour reperfusion period in the treatment group. Isolated allograft oxygenation function and dynamic compliance continued to be superior in the adsorber group at the end of reperfusion, accompanied by a markedly decreased local inflammatory response. CONCLUSIONS Implementation of an additional cytokine adsorber has refined the standard ex vivo lung perfusion protocol. Furthermore, cytokine removal during ex vivo lung perfusion improved immediate post-transplant graft function together with a less intense inflammatory response to reperfusion in pigs. Further studies are warranted to understand the beneficial effects of perfusate adsorption during ex vivo lung perfusion in the clinical setting.
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Affiliation(s)
- Ilker Iskender
- Department of Thoracic Surgery, University Hospital Zurich-University of Zurich, Zurich, Switzerland
| | - Stephan Arni
- Department of Thoracic Surgery, University Hospital Zurich-University of Zurich, Zurich, Switzerland
| | - Tatsuo Maeyashiki
- Department of Thoracic Surgery, University Hospital Zurich-University of Zurich, Zurich, Switzerland
| | - Necati Citak
- Department of Thoracic Surgery, University Hospital Zurich-University of Zurich, Zurich, Switzerland
| | - Mareike Sauer
- Department of Surgical Research, University Hospital Zurich-University of Zurich, Zurich, Switzerland
| | | | - Thomas Frauenfelder
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich-University of Zurich, Zurich, Switzerland
| | - Isabelle Opitz
- Department of Thoracic Surgery, University Hospital Zurich-University of Zurich, Zurich, Switzerland
| | - Walter Weder
- Department of Thoracic Surgery, University Hospital Zurich-University of Zurich, Zurich, Switzerland
| | - Ilhan Inci
- Department of Thoracic Surgery, University Hospital Zurich-University of Zurich, Zurich, Switzerland.
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Tavasoli F, Liu M, Machuca T, Bonato R, Grant DR, Cypel M, Keshavjee S, Grasemann H. Increased Arginase Expression and Decreased Nitric Oxide in Pig Donor Lungs after Normothermic Ex Vivo Lung Perfusion. Biomolecules 2020; 10:E300. [PMID: 32075026 DOI: 10.3390/biom10020300] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 01/30/2020] [Accepted: 02/11/2020] [Indexed: 01/12/2023] Open
Abstract
An established pig lung transplantation model was used to study the effects of cold ischemia time, normothermic acellular ex vivo lung perfusion (EVLP) and reperfusion after lung transplantation on l-arginine/NO metabolism in lung tissue. Lung tissue homogenates were analyzed for NO metabolite (NOx) concentrations by chemiluminescent NO-analyzer technique, and l-arginine, l-ornithine, l-citrulline and asymmetric dimethylarginine (ADMA) quantified using liquid chromatography-mass spectrometry (LC-MS/MS). The expression of arginase and nitric oxide synthase (NOS) isoforms in lung was measured by real-time polymerase chain reaction. EVLP preservation resulted in a significant decrease in concentrations of NOx and l-citrulline, both products of NOS, at the end of EVLP and after reperfusion following transplantation, compared to control, respectively. The ratio of l-ornithine over l-citrulline, a marker of the balance between l-arginine metabolizing enzymes, was increased in the EVLP group prior to reperfusion. The expression of both arginase isoforms was increased from baseline 1 h post reperfusion in EVLP but not in the no-EVLP group. These data suggest that EVLP results in a shift of the l-arginine balance towards arginase, leading to NO deficiency in the lung. The arginase/NOS balance may, therefore, represent a therapeutic target to improve lung quality during EVLP and, subsequently, transplant outcomes.
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Burki S, Noda K, Philips BJ, Velayutham M, Shiva S, Sanchez PG, Kumar A, D'Cunha J. Impact of triptolide during ex vivo lung perfusion on grafts after transplantation in a rat model. J Thorac Cardiovasc Surg 2020; 161:S0022-5223(20)30191-4. [PMID: 32169373 DOI: 10.1016/j.jtcvs.2019.12.104] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 10/30/2019] [Accepted: 12/19/2019] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Ex vivo lung perfusion creates a proinflammatory environment leading to deterioration in graft quality that may contribute to post-transplant graft dysfunction. Triptolide has been shown to have a therapeutic potential in various disease states because of its anti-inflammatory properties. On this basis, we investigated the impact of triptolide on graft preservation during ex vivo lung perfusion and associated post-transplant outcomes in a rat transplant model. METHODS We performed rat normothermic ex vivo lung perfusion with acellular Steen solution containing 100 nM triptolide for 4 hours and compared the data with untreated lungs. Orthotopic single lung transplantation after ex vivo lung perfusion was performed. RESULTS Physiologic and functional parameters of lung grafts on ex vivo lung perfusion with triptolide were better than those without treatment. Graft glucose consumption was significantly attenuated on ex vivo lung perfusion with triptolide via inhibition of hypoxia signaling resulting in improved mitochondrial function and reduced oxidative stress. Also, intragraft inflammation was markedly lower in triptolide-treated lungs because of inhibition of nuclear factor-κB signaling. Furthermore, post-transplant graft function and inflammatory events were significantly improved in the triptolide group compared with the untreated group. CONCLUSIONS Treatment of lung grafts with triptolide during ex vivo lung perfusion may serve to enhance graft preservation and improve graft protection resulting in better post-transplant outcomes.
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Affiliation(s)
- Sarah Burki
- Division of Lung Transplant and Lung Failure, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Kentaro Noda
- Division of Lung Transplant and Lung Failure, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Brian J Philips
- Division of Lung Transplant and Lung Failure, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Murugesan Velayutham
- Department of Medicine, Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, Pa; Department of Surgery, Thomas E. Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, Pa
| | - Sruti Shiva
- Department of Medicine, Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, Pa
| | - Pablo G Sanchez
- Division of Lung Transplant and Lung Failure, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Ajay Kumar
- Division of Lung Transplant and Lung Failure, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Jonathan D'Cunha
- Department of Cardiothoracic Surgery, Mayo Clinic Arizona, Pheonix, Ariz.
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Hozain AE, Tipograf Y, Pinezich MR, Cunningham KM, Donocoff R, Queen D, Fung K, Marboe CC, Guenthart BA, O'Neill JD, Vunjak-Novakovic G, Bacchetta M. Multiday maintenance of extracorporeal lungs using cross-circulation with conscious swine. J Thorac Cardiovasc Surg 2019; 159:1640-1653.e18. [PMID: 31761338 PMCID: PMC7094131 DOI: 10.1016/j.jtcvs.2019.09.121] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 09/05/2019] [Accepted: 09/09/2019] [Indexed: 12/11/2022]
Abstract
Objectives Lung remains the least-utilized solid organ for transplantation. Efforts to recover donor lungs with reversible injuries using ex vivo perfusion systems are limited to <24 hours of support. Here, we demonstrate the feasibility of extending normothermic extracorporeal lung support to 4 days using cross-circulation with conscious swine. Methods A swine behavioral training program and custom enclosure were developed to enable multiday cross-circulation between extracorporeal lungs and recipient swine. Lungs were ventilated and perfused in a normothermic chamber for 4 days. Longitudinal analyses of extracorporeal lungs (ie, functional assessments, multiscale imaging, cytokine quantification, and cellular assays) and recipient swine (eg, vital signs and blood and tissue analyses) were performed. Results Throughout 4 days of normothermic support, extracorporeal lung function was maintained (arterial oxygen tension/inspired oxygen fraction >400 mm Hg; compliance >20 mL/cm H2O), and recipient swine were hemodynamically stable (lactate <3 mmol/L; pH, 7.42 ± 0.05). Radiography revealed well-aerated lower lobes and consolidation in upper lobes of extracorporeal lungs, and bronchoscopy showed healthy airways without edema or secretions. In bronchoalveolar lavage fluid, granulocyte-macrophage colony-stimulating factor, interleukin (IL) 4, IL-6, and IL-10 levels increased less than 6-fold, whereas interferon gamma, IL-1α, IL-1β, IL-1ra, IL-2, IL-8, IL-12, IL-18, and tumor necrosis factor alpha levels decreased from baseline to day 4. Histologic evaluations confirmed an intact blood–gas barrier and outstanding preservation of airway and alveolar architecture. Cellular viability and metabolism in extracorporeal lungs were confirmed after 4 days. Conclusions We demonstrate feasibility of normothermic maintenance of extracorporeal lungs for 4 days by cross-circulation with conscious swine. Cross-circulation approaches could support the recovery of damaged lungs and enable organ bioengineering to improve transplant outcomes.
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Affiliation(s)
- Ahmed E Hozain
- Department of Biomedical Engineering, Columbia University Medical Center, Columbia University, New York, NY; Department of Surgery, Columbia University Medical Center, Columbia University, New York, NY
| | - Yuliya Tipograf
- Department of Surgery, Columbia University Medical Center, Columbia University, New York, NY; Departments of Thoracic and Cardiac Surgery, Vanderbilt University, Nashville, Tenn
| | - Meghan R Pinezich
- Department of Biomedical Engineering, Columbia University Medical Center, Columbia University, New York, NY
| | - Katherine M Cunningham
- Department of Biomedical Engineering, Columbia University Medical Center, Columbia University, New York, NY
| | - Rachel Donocoff
- Institute of Comparative Medicine, Columbia University Medical Center, Columbia University, New York, NY
| | - Dawn Queen
- Vagelos College of Physicians and Surgeons, Columbia University Medical Center, Columbia University, New York, NY
| | - Kenmond Fung
- Department of Clinical Perfusion, Columbia University Medical Center, Columbia University, New York, NY
| | - Charles C Marboe
- Department of Pathology and Cell Biology, Columbia University Medical Center, Columbia University, New York, NY
| | - Brandon A Guenthart
- Department of Biomedical Engineering, Columbia University Medical Center, Columbia University, New York, NY
| | - John D O'Neill
- Department of Biomedical Engineering, Columbia University Medical Center, Columbia University, New York, NY
| | - Gordana Vunjak-Novakovic
- Department of Biomedical Engineering, Columbia University Medical Center, Columbia University, New York, NY; Department of Medicine, Columbia University Medical Center, Columbia University, New York, NY.
| | - Matthew Bacchetta
- Department of Biomedical Engineering, Columbia University Medical Center, Columbia University, New York, NY; Departments of Thoracic and Cardiac Surgery, Vanderbilt University, Nashville, Tenn.
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Beller JP, Byler MR, Money DT, Chancellor WZ, Zhang A, Zhao Y, Stoler MH, Narahari AK, Shannon A, Mehaffey JH, Tribble CG, Laubach VE, Kron IL, Roeser ME. Reduced-flow ex vivo lung perfusion to rehabilitate lungs donated after circulatory death. J Heart Lung Transplant 2019; 39:74-82. [PMID: 31761511 DOI: 10.1016/j.healun.2019.09.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 09/04/2019] [Accepted: 09/05/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Current ex vivo lung perfusion (EVLP) protocols aim to achieve perfusion flows of 40% of cardiac output or more. We hypothesized that a lower target flow rate during EVLP would improve graft function and decrease inflammation of donation after circulatory death (DCD) lungs. METHODS A porcine DCD and EVLP model was utilized. Two groups (n = 4 per group) of DCD lungs were randomized to target EVLP flows of 40% (high-flow) or 20% (low-flow) predicted cardiac output based on 100 ml/min/kg. At the completion of 4 hours of normothermic EVLP using Steen solution, left lung transplantation was performed, and lungs were monitored during 4 hours of reperfusion. RESULTS After transplant, left lung-specific pulmonary vein partial pressure of oxygen was significantly higher in the low-flow group at 3 and 4 hours of reperfusion (3-hour: 496.0 ± 87.7 mm Hg vs. 252.7 ± 166.0 mm Hg, p = 0.017; 4-hour: 429.7 ± 93.6 mm Hg vs. 231.5 ± 178 mm Hg, p = 0.048). Compliance was significantly improved at 1 hour of reperfusion (20.8 ± 9.4 ml/cm H2O vs. 10.2 ± 3.5 ml/cm H2O, p = 0.022) and throughout all subsequent time points in the low-flow group. After reperfusion, lung wet-to-dry weight ratio (7.1 ± 0.7 vs. 8.8 ± 1.1, p = 0.040) and interleukin-1β expression (927 ± 300 pg/ng protein vs. 2,070 ± 874 pg/ng protein, p = 0.048) were significantly reduced in the low-flow group. CONCLUSIONS EVLP of DCD lungs with low-flow targets of 20% predicted cardiac output improves lung function, reduces edema, and attenuates inflammation after transplant. Therefore, EVLP for lung rehabilitation should use reduced flow rates of 20% predicted cardiac output.
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Affiliation(s)
- Jared P Beller
- Departments of Surgery, University of Virginia, Charlottesville, Virginia
| | - Matthew R Byler
- Departments of Surgery, University of Virginia, Charlottesville, Virginia
| | - Dustin T Money
- Departments of Surgery, University of Virginia, Charlottesville, Virginia
| | | | - Aimee Zhang
- Departments of Surgery, University of Virginia, Charlottesville, Virginia
| | - Yunge Zhao
- Departments of Surgery, University of Virginia, Charlottesville, Virginia
| | - Mark H Stoler
- Departments of Pathology, University of Virginia, Charlottesville, Virginia
| | | | - Alexander Shannon
- Departments of Surgery, University of Virginia, Charlottesville, Virginia
| | - J Hunter Mehaffey
- Departments of Surgery, University of Virginia, Charlottesville, Virginia
| | - Curtis G Tribble
- Departments of Surgery, University of Virginia, Charlottesville, Virginia
| | - Victor E Laubach
- Departments of Surgery, University of Virginia, Charlottesville, Virginia
| | - Irving L Kron
- Departments of Surgery, University of Virginia, Charlottesville, Virginia; Department of Surgery, University of Arizona Department of Health Sciences, Tuscon, Arizona
| | - Mark E Roeser
- Departments of Surgery, University of Virginia, Charlottesville, Virginia.
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Lonati C, Bassani GA, Brambilla D, Leonardi P, Carlin A, Maggioni M, Zanella A, Dondossola D, Fonsato V, Grange C, Camussi G, Gatti S. Mesenchymal stem cell-derived extracellular vesicles improve the molecular phenotype of isolated rat lungs during ischemia/reperfusion injury. J Heart Lung Transplant 2019; 38:1306-16. [PMID: 31530458 DOI: 10.1016/j.healun.2019.08.016] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 07/14/2019] [Accepted: 08/20/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Lung ischemia/reperfusion (IR) injury contributes to the development of severe complications in patients undergoing transplantation. Mesenchymal stem cell (MSC)-derived extracellular vesicles (EVs) exert beneficial actions comparable to those of MSCs without the risks of the cell-based strategy. This research investigated EV effects during IR injury in isolated rat lungs. METHODS An established model of 180-minutes ex vivo lung perfusion (EVLP) was used. At 60 minutes EVs (n = 5) or saline (n = 5) were administered. Parallel experiments used labeled EVs to determine EV biodistribution (n = 4). Perfusate samples were collected to perform gas analysis and to assess the concentration of nitric oxide (NO), hyaluronan (HA), inflammatory mediators, and leukocytes. Lung biopsies were taken at 180 minutes to evaluate HA, adenosine triphosphate (ATP), gene expression, and histology. RESULTS Compared with untreated lungs, EV-treated organs showed decreased vascular resistance and a rise of perfusate NO metabolites. EVs prevented the reduction in pulmonary ATP caused by IR. Increased medium-high-molecular-weight HA was detected in the perfusate and in the lung tissue of the IR + EV group. Significant differences in cell count on perfusate and tissue samples, together with induction of transcription and synthesis of chemokines, suggested EV-dependent modulation of leukocyte recruitment. EVs upregulated genes involved in the resolution of inflammation and oxidative stress. Biodistribution analysis showed that EVs were retained in the lung tissue and internalized within pulmonary cells. CONCLUSIONS This study shows multiple novel EV influences on pulmonary energetics, tissue integrity, and gene expression during IR. The use of cell-free therapies during EVLP could constitute a valuable strategy for reconditioning and repair of injured lungs before transplantation.
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