Development of ex vivo normothermic perfusion as an innovative method to assess pancreases after preservation

Ann Ogbemudia, Julien Branchereau (Joint first authors), Gabriella Hakim, Fungai Dengu, FaysalEl-Gilani, John Mulvey, Kaithlyn Rozenberg, Thomas Prudhomme, Letizia Lo Faro, James Hunter,Paul Johnson, Rutger Ploeg and Peter Friend Objective Static cold storage (SCS) is the standard method for pancreas preservation but does not facilitate objective organ assessment prior to transplantation. Normothermic machine perfusion (NMP) has been used to test other abdominal and thoracic organs’ function and viability in transplantation settings. Our aim was to develop a NMP protocol specific for pancreases and then investigate its potential as an organ assessment strategy. Method 8 porcine pancreases were procured in conditions replicating donation after circulatory death with warm ischaemia time of 25 minutes. After 3 hours of static cold storage (SCS) the pancreases were divided into 3 experimental groups 1) the feasibility group (n=2) that underwent 2.5 hours of NMP 2) the SCS group (n = 2) that underwent an additional 6 hours of SCS prior to assessment on NMP for an hour and 3) the Oxygenated Hypothermic Machine Perfusion (oxyHMP) group (n = 4) that underwent 6 hours of oxyHMP followed by 1-hour assessment on NMP. The NMP protocol used autologous, leucodepleted blood delivered at a mean arterial pressure of 40mmHg with a temperature of 37oC. At timed intervals during NMP, perfusate samples were collected for gas analysis and perfusion parameters were recorded. Results The feasibility group was used to develop the NMP protocol and demonstrated stable perfusion parameters throughout NMP. Compared to the SCS group the oxyHMP group demonstrated better average perfusion characteristics with lower resistances, higher flow rates, lower mean lactate levels and physiological pH. The oxyHMP group maintained normal macroscopic appearances during NMP. At the end of NMP the SCS group had an average 32% weight increase compared to the oxyHMP group that were found to have a 17% weight reduction. Conclusion Normothermic machine perfusion of whole pancreases is feasible after cold preservation and potentially useful as an assessment strategy. Furthermore, it demonstrated that oxygenated HMP may be beneficial for pancreas preservation compared to SCS.

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PRESERVAÇÃO DE FÍGADOS HUMANOS COM PERFUSÃO EX-VIVO: UMA VISÃO DO ESTADO DA ARTE

Brazilian Journal of Transplantation ◽

10.53855/bjt.v20i1.77 ◽

2017 ◽

Vol 20 (1) ◽

pp. 20-24

Author(s):

Samuel Roque Alves ◽

Lucas Medeiros Lopes ◽

Ivelise Regina Canito Brasil

Keyword(s):

Cold Storage ◽

Ex Vivo ◽

Ex Situ ◽

Machine Perfusion ◽

University Of Wisconsin ◽

Hypothermic Machine Perfusion ◽

Normothermic Machine Perfusion

SCS (Static Cold Storage) é a técnica mais utilizada para preservação de órgãos. A HMP (Hypothermic Machine Perfusion) foi inicialmente proposta por Belzer, nos anos 1960. A NMP (Normothermic machine perfusion) evita isquemia fria, mantém a função hepática, monitora a função do enxerto em tempo real pelo fluxo de produção de bile. O presente trabalho visa sumarizar estudos de preservação hepática ex-situ e os resultados com diferentes combinações de parâmetros, dando enfoque aos trabalhos com fígados humanos. Realizamos revisão da literatura, selecionamos 73 artigos, sendo 15 revisões de literatura e 58 estudos experimentais. Destes, oito foram realizados em humanos, 12 em porcos e 39 em ratos. Dos oito estudos com fígados humanos, cinco utilizaram HMP, dois utilizaram SNMP e um utilizou NMP. Todos mostraram melhora da função do enxerto e marcadores bioquímicos de lesão. Quanto às soluções utilizadas, a maioria usou a solução UW (University of Wisconsin), enquanto um trabalho utilizou solução de concentrado de hemácias. O tempo de perfusão variou de 30 minutos a 24 horas. A utilização de órgãos critério-expandidos surge como alternativa para pacientes esperando transplante. As máquinas de perfusão estão cada vez mais presentes no contexto do transplante de órgãos sólidos e serão essenciais para redução das filas de espera, fornecendo maior número de enxertos viáveis para transplante. O desenvolvimento de máquinas viáveis e práticas para perfusão de fígados humanos já está se tornando realidade e representa o futuro do transplante de fígado; espera-se que mais modelos e protocolos sejam testados nos próximos anos e passem a ter utilização clínica rotineira.

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Normothermic Ex Vivo Kidney Perfusion Improves Early DCD Graft Function Compared With Hypothermic Machine Perfusion and Static Cold Storage

Transplantation Journal ◽

10.1097/tp.0000000000003066 ◽

2020 ◽

Vol 104 (5) ◽

pp. 947-955 ◽

Cited By ~ 5

Author(s):

Peter Urbanellis ◽

Matyas Hamar ◽

J. Moritz Kaths ◽

Dagmar Kollmann ◽

Ivan Linares ◽

...

Keyword(s):

Cold Storage ◽

Ex Vivo ◽

Graft Function ◽

Machine Perfusion ◽

Hypothermic Machine Perfusion ◽

Kidney Perfusion

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A simple ex vivo model of human renal allograft preservation using the gonadal vein

Annals of The Royal College of Surgeons of England ◽

10.1308/rcsann.2019.0107 ◽

2019 ◽

Vol 101 (8) ◽

pp. 609-616

Author(s):

WP Ries ◽

Y Marie ◽

K Patel ◽

C Turnbull ◽

TB Smith ◽

...

Keyword(s):

Cold Storage ◽

Organ Preservation ◽

Caspase 3 ◽

Ex Vivo ◽

Human Model ◽

Machine Perfusion ◽

Flow Conditions ◽

Ex Vivo Perfusion ◽

Gonadal Vein ◽

Hypothermic Machine Perfusion

Introduction Hypothermic machine perfusion, an organ preservation modality, involves flow of chilled preservation fluid through an allograft’s vasculature. This study describes a simple, reproducible, human model that allows for interrogation of flow effects during ex vivo organ perfusion. Materials and methods Gonadal veins from deceased human renal allografts were subjected to either static cold storage or hypothermic machine perfusion for up to 24 hours. Caspase-3, Krüppel-like factor 2 expression and electron microscopic analysis were compared between ‘flow’ and ‘no-flow’ conditions, with living donor gonadal vein sections serving as negative controls. Results The increase in caspase-3 expression was less pronounced for hypothermic machine-perfused veins compared with static cold storage (median-fold increase 1.2 vs 2.3; P < 0.05). Transmission electron microscopy provided ultrastructural corroboration of endothelial cell apoptosis in static cold storage conditions. For static cold storage preserved veins, Krüppel-like factor 2 expression diminished in a time-dependent manner between baseline and 12 hours (P < 0.05) but was abrogated and reversed by hypothermic machine perfusion (P < 0.05). Conclusions Our methodology is a simple, reproducible and successful model of ex vivo perfusion in the context of human organ preservation. To demonstrate the model’s utility, we establish that two widely used markers of endothelial health (caspase-3 and Krüppel-like factor 2) differ between the flow and no-flow conditions of the two predominant kidney preservation modalities. These findings suggest that ex vivo perfusion may mediate the induction of a biochemically favourable endothelial niche which may contribute tohypothermic machine perfusion’s association with improved renal transplantation outcomes.

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Machine Perfusion of the Liver: A Review of Clinical Trials

Frontiers in Surgery ◽

10.3389/fsurg.2021.625394 ◽

2021 ◽

Vol 8 ◽

Author(s):

Nikolaos Serifis ◽

Rudy Matheson ◽

Daniel Cloonan ◽

Charles G. Rickert ◽

James F. Markmann ◽

...

Keyword(s):

Clinical Trials ◽

Animal Studies ◽

Ex Vivo ◽

Machine Perfusion ◽

Advantages And Disadvantages ◽

Hypothermic Machine Perfusion ◽

Normothermic Machine Perfusion ◽

Novel Strategy ◽

Liver Machine Perfusion

Although efforts have been made by transplant centers to increase the pool of available livers by extending the criteria of liver acceptance, this practice creates risks for recipients that include primary non-function of the graft, early allograft dysfunction and post-operative complications. Donor liver machine perfusion (MP) is a promising novel strategy that not only decreases cold ischemia time, but also serves as a method of assessing the viability of the graft. In this review, we summarize the data from liver machine perfusion clinical trials and discuss the various techniques available to date as well as future applications of machine perfusion. A variety of approaches have been reported including hypothermic machine perfusion (HMP) and normothermic machine perfusion (NMP); the advantages and disadvantages of each are just now beginning to be resolved. Important in this effort is developing markers of viability with lactate being the most predictive of graft functionality. The advent of machine perfusion has also permitted completely ischemia free transplantation by utilization of in situ NMP showed promising results. Animal studies that focus on defatting steatotic livers via NMP as well as groups that work on regenerating liver tissue ex vivo via MP. The broad incorporation of machine perfusion into routine clinical practice seems incredible.

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A multicentre randomised controlled trial to compare the efficacy of ex-vivo normothermic machine perfusion with static cold storage in human liver transplantation

Protocol Exchange ◽

10.1038/protex.2018.027 ◽

2018 ◽

Cited By ~ 1

Author(s):

David Nasralla ◽

Mohammed Zeeshan Akhtar ◽

Ally Bradley ◽

Andrew Butler ◽

...

Keyword(s):

Liver Transplantation ◽

Randomised Controlled Trial ◽

Cold Storage ◽

Human Liver ◽

Ex Vivo ◽

Controlled Trial ◽

Machine Perfusion ◽

Normothermic Machine Perfusion ◽

Randomised Controlled

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Normothermic Ex Vivo Machine Perfusion for Liver Grafts Recovered from Donors after Circulatory Death: A Systematic Review and Meta-Analysis

HPB Surgery ◽

10.1155/2018/6867986 ◽

2018 ◽

Vol 2018 ◽

pp. 1-8 ◽

Cited By ~ 7

Author(s):

Jordan J. Nostedt ◽

Daniel T. Skubleny ◽

A. M. James Shapiro ◽

Sandra Campbell ◽

Darren H. Freed ◽

...

Keyword(s):

Cold Storage ◽

Meta Analysis ◽

Mean Difference ◽

Large Animal ◽

Machine Perfusion ◽

Donation After Circulatory Death ◽

Economic Implications ◽

Normothermic Perfusion ◽

Normothermic Machine Perfusion ◽

Circulatory Death

As a result of donation after circulatory death liver grafts’ poor tolerance to cold storage, there has been increasing research interest in normothermic machine perfusion. This study aims to systematically review the current literature comparing normothermic perfusion to cold storage in donation after circulatory death liver grafts and complete a meta-analysis of published large animal and human studies. A total of nine porcine studies comparing cold storage to normothermic machine perfusion for donation after circulatory death grafts were included for analysis. There was a significant reduction in AST (mean difference −2291 U/L, CI (−3019, −1563); P ≤ 0.00001) and ALT (mean difference −175 U/L, CI (−266, −85); P=0.0001), for normothermic perfusion relative to static cold storage, with moderate (I2 = 61%) and high (I2 = 96%) heterogeneity, respectively. Total bile production was also significantly higher (mean difference = 174 ml, CI (155, 193); P≤0.00001). Further research focusing on standardization, performance of this technology following periods of cold storage, economic implications, and clinical trial data focused on donation after circulatory death grafts will be helpful to advance this technology toward routine clinical utilization for these grafts.

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