Machine perfusion preservation of the non-heart-beating donor rat livers using polysol, a new preservation solution

AIMS: The increasing shortage of donor organs has led to a focus on extended criteria donors, including the non-heart-beating donor (NHBD). An optimal preservation method is required to facilitate successful transplantation of these ischemically damaged organs. The recent literature has shown clear advantages of hypothermic machine perfusion (MP) over cold storage (CS). For MP, modified University of Wisconsin perfusion solution (UW-G) is often used, which, however, is known to cause microcirculatory obstruction, is difficult to obtain, and is expensive. Therefore, Polysol was developed as a MP preservation solution that contains specific nutrients for the liver, such as amino acids, energy substrates, and vitamins. The aim of this study was to compare Polysol with UW-G in a NHBD rat liver model. METHODS: After 24 hours hypothermic MP of NHBD rat livers using UW-G or Polysol, liver damage and function parameters were assessed during 60 minutes of reperfusion with Krebs-Henseleit buffer. Control livers were reperfused after 24 hours CS in UW. RESULTS: Liver enzyme release was significantly higher among the CS-UW group compared to MP using UW-G or Polysol. Flow during reperfusion was significantly higher when using Polysol compared to UW-G. Bile production and ammonia clearance were highest when using Polysol compared to UW-G. There was less cellular edema after preservation with Polysol compared to UW-G. CONCLUSIONS: MP of NHBD rat livers for 24 hours using UW-G or Polysol resulted in less hepatocellular damage than CS in UW. MP of NHBD livers for 24 hours using Polysol is superior to MP using UW-G.     

Long-term outcome of controlled, non-heart-beating donor liver transplantation

BACKGROUND: Previous reports have established the feasibility of using livers from controlled, non-heart-beating donors (CNHBD) with good immediate graft function. This has been largely borne out of necessity because of the donor shortage. METHODS: Retrospective database review for the last 7 years (1995-2002), encompassing 19 patients receiving CNHBD, with follow-up period of 1,000 +/- 694 days, median 762 days. Detailed review of recipient characteristics, operative and clinical course, immunosuppression, complications, survival rates, and comparison with the results obtained in patients receiving transplants of allografts procured in standard fashion, from heart-beating donors RESULTS: Kaplan-Meier patient survival rates were 100%, 89.5%, and 83.5% at 30 days, 1, and 2 years, respectively, which is not different from recipients of livers procured from heart-beating cadaveric donors (P=0.74, log-rank test). Five patients died at a mean follow-up time of 492 (range 46-1,103) days. The causes of death were related to secondary sclerosing cholangitis (n=1), cardiac failure (n=1), and sepsis (n=3). Two (10.5%) recipients underwent retransplantation, one for primary graft nonfunction and one because of biliary cast syndrome with cholangitis. Significant preservation damage (ALT>2,000) developed in five patients, but this did not affect survival. The incidence of vascular (15.6% vs. 9.6%, P=0.34) and biliary complications (10.55 vs. 13.8%, P=0.68) was no different than for those recipients receiving standard cadaveric donors. CONCLUSIONS: CNHBD safely expands the donor pool with similar long-term results as those obtained in patients receiving organs from brain-dead donors under standard procurement techniques.     

Controlled non-heart-beating donor liver transplantation: a successful single center experience, with topic update

BACKGROUND: The critical shortage of transplantable organs necessitates utilization of unconventional donors. We describe a successful experience of controlled non-heart-beating donor (NHBD) liver transplantation. METHODS: Controlled NHBDs had catastrophic head injury, prognosis for no meaningful recovery, decision to withdraw life support, and subsequent consent for donation. After stopping mechanical ventilation in the operating room, death determination by a nontransplant caregiver, and rapid aortic cannulation, liver and kidneys were recovered. RESULTS: Controlled NHBDs contributed 5% of hepatic allografts (8/164) from August 1996 through June 1999 (9% in 1998). Sixteen NHBDs afforded 8 livers and 24 kidneys. Liver donors (n=8) were 11-66 years old; half were >50 years old. Premortem alanine aminotransferase was 25-157 U/L. Arrest occurred 3-27 min after stopping ventilation. Perfusion started 3-5 min after incision, and <22 min after hypotension (mean arterial pressure: <50 mmHg). Patient and graft survivals are 100% at 18+/-12 months follow-up. There was no intraoperative complication, reperfusion syndrome, poor graft function, primary nonfunction, arterial thrombosis, biliary complication, or serious infection. Postoperative day 2 prothrombin time was 13+/-1 sec. Peak alanine aminotransferase was 980+/-601 U/L. Intensive care unit and posttransplant lengths of stay were 2+/-2 and 10+/-7 days, respectively. Soon after transplantation there was frequent temporary hyperbilirubinemia (five of eight recipients; bilirubin peak: 7-29 mg/dl, 2-3 weeks after transplantation) and rejection (4/8 recipients, <3 weeks after transplantation). CONCLUSIONS: NHBDs significantly and safely expanded our donor pool. NHBD surgeons must be capable of rapid procurement. Cautious liberalization of criteria for accepting livers from NHBDs with confounding risk factors is justified. Refined ethics guidelines would broaden approval of NHBDs.     

The comparison of the perioperative changes in lactate and prothrombin time between deceased versus living donor liver transplantation

Introduction

The present study compared the functional capacity of the grafts by evaluating changes in lactate and PT after reperfusion among deceased donor liver transplantation (DDLT) versus living donor liver transplantation (LDLT).

Methods

We performed a retrospective analysis of primary adult liver transplantations (45 and 77 recipients in DDLT and LDLT, respectively) between January 2007 and December 2009. Lactate was recorded from 5 minutes after reperfusion of graft (R0) to intensive care unit admission (P0). PT expressed in international normalized ratio (INR) was recorded from R0 to postoperative day (POD) 5. These values were compared between two groups.

Results

The cold ischemia time (CIT), Child-Turcotte-Pugh score, Model for End-stage Liver Disease score, INR, and graft-to-recipient weight ratio were greater in the recipients of DDLT versus LDLT. Lactate and INR at R0 were similar between the two groups, but, the values showed a faster recovery from 1 hour after reperfusion until P0 for lactate and until POD 5 for INR among DDLT recipients. The fresh frozen plasma requirements during corresponding periods were similar between the two groups.

Conclusion

The functional capacity of the graft measured by changes in lactate and PT after reperfusion showed faster recovery among DDLT versus LDLT recipients despite poorer graft quality (longer CIT) and the recipients' preoperative medical conditions-higher MELD and CTP scores.     

Expanding the donor pool: the elderly non-heart-beating donor

The need for transplantable organs continues to far outweigh the number of organs available for transplantation through donation. To date, many avenues for expanding the donor pool have been explored, including non-heart-beating donor protocols and the expansion of acceptable criteria. This case study reviews the successful procurement of a liver and kidney from a 72-year-old non-heart-beating donor.     

Safety and efficacy of living donor liver preservation with HTK solution

BACKGROUND: In living donor liver transplantation (LDLTx) organ procurement is usually well controlled, and allows to assess liver preservation and graft function under standardized conditions. Because publications on histidine-tryptophan-ketoglutarate (HTK) solution are limited, we prospectively studied its safety and efficacy in a consecutive series of LDLTx. METHODS: Twenty-four patients received 22 right, 1 left, and 1 left lateral lobe graft. Liver preservation was done by gravity perfusion with HTK through portal vein, and hepatic artery, and flushing of bile ducts. Total ischemia time was 191 +/- 68 minutes. RESULTS: There was no primary nonfunction, and all partial liver grafts showed good recovery: peak aspartate aminotransferase 577 U/L, total bilirubin 15.15 mg/dL, and partial thromboplastin time 49.37 seconds. One graft was lost from parenchymal fracture secondary to portal hyperperfusion after 6 days, and the patient was salvaged with retransplantation. Thirty-day mortality, including sudden cardiac death, pancreatitis, and hepatic artery rupture, was not related to graft dysfunction. Eight of 24 recipients developed early biliary leakage. There was no late ischemic type biliary lesion. CONCLUSION: These results confirm that HTK solution is safe and effective when used in LDLTx. Potential advantages of HTK in comparison to other preservation solutions are low potassium concentration, low viscosity, no particles, in situ perfusion, no need to flush before reperfusion, improved biliary protection, better recovery of microcirculatory changes, ready to use, and lower costs. Because the risk-benefit ratio is of particular importance in LDLTx the use of HTK solution should be encouraged.     

Successful segmental auxiliary liver transplantation from a non-heart-beating donor: implications for split-liver transplantation

BACKGROUND: Liver transplantation (LT) using grafts from non-heart-beating donors (NHBDs) has been shown to be a successful practice. Recently reported primary nonfunction rates are similar to those of LT using grafts from brain-dead donors. METHOD: We report the use of an NHBD liver, which was cut into a right-lobe graft and implanted as an auxiliary partial orthotopic liver transplant for acute liver failure in a 11-year-old child. The warm ischemia time was 21 minutes, and the cold ischemia was 8 hours. RESULTS: Initial graft function was excellent, and the child is well, with normal liver function 2 months posttransplant. CONCLUSION: Reduction and splitting of livers from NHBDs for transplantation is a realistic option, provided there is careful selection of the graft.     

Lactate and liver function tests after living donor right hepatectomy: a comparison of solutions with and without lactate

Background: Hyperlactatemia can predict the prognosis of patients undergoing liver resection. The effects of lactated Ringer's solution on liver function have not been evaluated in patients undergoing major liver resection. We therefore compared the effects of two different crystalloid solutions, with and without lactate, on liver function test data and serum lactate level in living donors undergoing right hepatectomy. Methods: A total of 104 donors undergoing right hepatectomy for liver transplantation were randomly allocated to receive lactated Ringer's (LR) solution (n=52) or Plasmalyte (n=52). Anesthetic and fluid management were standardized. Acid–base status, lactate concentration, and liver function tests were analyzed at predetermined time points during the first 5 post‐operative days. Results: The lactate concentrations were significantly higher in the LR group than in the Plasmalyte group 1 h after hepatectomy [4.2 (3.2–5.7) vs. 3.3 (2.6–4.6) mmol/l; P=0.005, median (interquartile ranges)]. In addition, the nadir concentration of albumin was significantly lower and the peak total bilirubin concentration and prothrombin time were significantly higher in the LR group compared with the Plasmalyte group. However, these changes in the LR group subsided within the first or second post‐operative days, without apparent complications or prolongation of hospital stay. Post‐operative peak concentrations of lactate were not correlated with nadir albumin concentration, peak bilirubin, or peak prothrombin time, in either group. Conclusion: This prospective randomized study showed that non‐lactate‐containing crystalloid solution may have important advantages over LR solution, concerning lactate and liver profiles, in living donors undergoing right hepatectomy.     

增加供肝的肝糖原贮备减轻心脏停搏大鼠供肝的热缺血再灌注损伤

目的探讨肝移植术前增加供肝的肝糖原贮备能否减轻心脏停搏大鼠供肝的热缺血再灌注损伤。方法雄性SD大鼠作为肝移植的供、受者被随机分为A、B、C三组。A组供者正常饮水；B组供者术前连续4d饮糖水；C组供者在B组的基础上于供肝获取前3～4h注射500g／L的葡萄糖。A、B、C三组再按供者经历的心脏停搏时间（心脏停搏60min、90min、120min和150min）各分为4个小组，行原位肝移植术并检测移植肝组织中肝糖原和ATP的含量；同时观察受者术后1周存活率以及血清丙二醛（MDA）和超氧化物歧化酶（SOD）的水平。结果B、C两组供肝的肝糖原贮备和ATP含量均明显高于A组（P〈0．01）；B-60min、B-90min、B-120min和C-90min、C-120min、C-150min组受者的1周存活率分别为80％、50％、1（）％和70％、60％、20％，部分受者可长期存活；B、C两组受者MDA水平明显低于A组，SOD水平明显高于A组（P〈0.05）。结论术前增加大鼠供肝的肝糖原贮备能明显减轻供肝的热缺血再灌注损伤，减少了术后原发性移植肝无功能的发生，提高了心脏停搏供肝移植术后的存活率。     

L-arginine reduces liver and biliary tract damage after liver transplantation from non-heart-beating donor pigs

BACKGROUND: To evaluate whether L-arginine reduces liver and biliary tract damage after transplantation from non heart-beating donor pigs. METHODS: Twenty-five animals received an allograft from non-heart-beating donors. After 40 min of cardiac arrest, normothermic recirculation was run for 30 min. The animals were randomly treated with L-arginine (400 mg x kg(-1) during normothermic recirculation) or saline (control group). Then, the animals were cooled and their livers were transplanted after 6 hr of cold ischemia. The animals were killed on the 5th day, liver damage was assessed on wedged liver biopsies by a semiquantitative analysis and by morphometric analysis of the necrotic areas, and biliary tract damage by histological examination of the explanted liver. RESULTS: Seventeen animals survived the study period. The histological parameters assessed (sinusoidal congestion and dilatation, sinusoidal infiltration by polymorphonuclear cells and lymphocytes, endothelitis, dissociation of liver cell plates, and centrilobular necrosis) were significantly worse in the control group. The necrotic area affected 15.9 +/- 14.5% of the liver biopsies in the control group and 3.7 +/- 3.1% in the L-arginine group (P<0.05). Six of eight animal in the control group and only one of eight survivors in the L-arginine group developed ischemic cholangitis (P<0.01). L-Arginine administration was associated with higher portal blood flow (676.9 +/- 149.46 vs. 475.2 +/- 205.6 ml x min x m(-2); P<0.05), higher hepatic hialuronic acid extraction at normothermic recirculation (38.8 +/- 53.7% vs. -4.2 +/- 18.2%; P<0.05) and after reperfusion (28.6 +/- 55.5% vs. -10.9 +/- 15.5%; P<0.05) and lower levels of alpha-glutation-S-transferase at reperfusion (1325 +/- 1098% respect to baseline vs. 6488 +/- 5612%; P<0.02). CONCLUSIONS: L-Arginine administration during liver procurement from non heart beating donors prevents liver and biliary tract damage.     

Combined liver and pancreas procurement from a controlled non-heart-beating donor with aberrant hepatic arterial anatomy

BACKGROUND: The critical shortage of transplantable organs has resulted in the use of extended donors, including non-heart-beating donors (NHBDs). Combined procurement of both a whole pancreas and a liver from a single cadaver is always anatomically feasible. However, when aberrant vasculature is present, the potential for vascular injury increases. Because the rapid flush technique is used in NHBD procurement, the inability to palpate arterial pulsation may also increase the chance of vascular damage. METHODS: We report a case of a successful combined procurement of hepatic, pancreatic, and renal grafts from a controlled NHBD with right replaced and left accessory hepatic arteries. RESULT: The liver and the pancreas were successfully transplanted to two different recipients in two different institutions without any complications. All grafts are functioning well at 14 months of follow-up. CONCLUSION: Safe procurement of both the liver and pancreas is possible from certain controlled NHBDs, even with aberrant anatomy.     

无心跳供体中供肝微循环的动态变化

目的 探讨不同热缺血时间下大鼠无心跳供体肝组织微循环的变化规律，预测供肝耐受热缺血的安全时限。方法 实验动物按供肝热缺血时间分别为0、15、30、45、60min，随机分为5组。然后按各组条件分别作原位肝移植．对肝移植术后各组血清透明质酸(HA)的水平进行动态检测，以及观察肝组织微循环超微结构的动态变化。结果 在热缺血30min以内，移植肝组织复流后能逐渐恢复至正常的微循环结构和功能。热缺血45min，复流后大部分肝血窦腔可逐渐恢复通畅。但部分血窦仍充满较多的膜浆泡和血细胞积滞；热缺血45min以前各组术后3d血清HA可基本恢复。热缺血60min，复流后内皮细胞损伤不但不能恢复，且出现加重、扩大趋势。结论 供肝经受30min以内热缺血损伤，肝组织微循环的变化处在可复性阶段。45min的热缺血时间可能县供肝微循环功能耐受热缺血损伤的极限．热缺血60min以后．呈现不可逆性的微循环障碍．     

Machine perfusion preservation of the pig liver using a new preservation solution, polysol

INTRODUCTION: The current gold standard for donor liver preservation is cold storage in a preservation solution (4 degrees C), such as Celsior or the University of Wisconsin solution (UW). Recent studies have suggested the benefits of machine perfusion (MP) over cold storage. To improve the results of MP, an enriched preservation solution (named Polysol) was developed, which in a rat liver preservation model proved to be superior to the UW-gluconate solution. The aim of this study was to assess Polysol in a pig liver preservation model. MATERIALS AND METHODS: Female pigs (35 to 40 kg) were used as liver donors. After heparinization, the liver was washed out using Ringer's lactate, followed by the preservation solution (4 degrees C). The liver was preserved for 24 hours by either cold storage using Celsior (n=5) or MP using Polysol (n=5). For analysis of liver damage and function, livers were reperfused for 60 minutes using oxygenated Krebs-Henseleit buffer. RESULTS: CS-Celsior caused significantly more damage compared with MP-Polysol (t=60, AST: 622+/-215 versus 222+/-55; ALT: 17+/-6 versus 5+/-1). Intravascular resistance during reperfusion was significantly higher after CS-Celsior compared with MP-Polysol (t=0, 0.20+/-0.01 and 0.11+/-0.02 mm Hg/mL/min, respectively). No differences were seen regarding ammonia clearance and urea production. In both groups, no bile was produced during reperfusion. CONCLUSIONS: In an ex vivo pig liver preservation model significantly less damage was observed after machine perfusion preservation using Polysol, in comparison to cold storage using Celsior.     

高温诱导热休克蛋白70在无心跳供体大鼠肝移植中的保护作用

为探讨高温诱导热休克蛋白 70在大鼠无心跳供体肝中含量的增加是否对移植肝肝功能具有保护作用。笔者将SD大鼠 64只随机分为供体和受体各 3 2只。供体又随机分为室温组 (An组 ,n =16)和高温预处理组 (Bn组 ,n =16)。An组麻醉后 2 4h ,制作成热缺血 2 0min无心跳供体模型 ,进行原位肝移植。Bn组麻醉后行高温预处理 ,预处理后 2 4h制作成热缺血 2 0min无心跳供体模型 ,行原位肝移植。分别于移植后 2 4h及 72h处死大鼠取肝组织及取血 ,检测大鼠移植肝中HSP70表达 ;对比移植肝病理变化及肝转氨酶变化、观察术后存活时间。结果示 ,Bn组移植后 1,3d的HSP70表达明显高于An组 (P <0 .0 5 ) ;转氨酶升高明显低于An组 (P <0 .0 5 ) ;移植肝的病理学改变较An组为轻 ( P <0 .0 5 ) ;移植后 1周生存率明显高于An组 ( P <0 .0 5 )。提示高温诱导HSP70在无心跳供体肝中的高表达可减轻移植肝的病理损伤 ,保护移植肝的功能 ,延长受体的术后存活时间。     

The non-heart-beating donor: Bridging the gap to the future

Renal grafts from NHBDs result in long-term function that does not compromise current clinical standards and therefore make the NHBD a viable way to expand the donor pool. Several programs around the world are beginning to use NHBD livers in clinical transplantation; thus, there is certain to be a surge of reports appearing in the literature in the near future. It appears from available data to date that NHBD livers retrieved in a controlled fashion from category 3 donors may offer a safe source for more organs. Further research and clinical experience with NHBD transplantation for both kidney and liver should help define reproducible and acceptable methods. However, until an alternative source of organs becomes available, the NHBD represents an increasingly important means to alleviate the growing demand for transplant organs.     

Prehospital management by EMS of a potential non-heart-beating donor

After their prehospital management by EMS system and on-scene declaration of death, some patients are potential non-heart-beating donors. We report the case of refractory cardiac arrest, transferred to the hospital assisted by chest compression device. Time factor might be an important brake on prehospital recruitment. Future networks should attempt to shorten the time intervals.     

The significance of preserving the energy status and microcirculation in liver grafts from non-heart-beating donor

To complete a successful liver transplantation (LTx) from non-heart-beating donors (NHBD), it is necessary to both improve the energy status in liver grafts and to reduce the exposure to free radicals. This study investigated the effects of short perfusion with oxygenated buffer on the grafts prior to cold preservation. In addition, the effects of the antioxidant, biliverdin, for reduction of free radicals was investigated. Male Wistar rats were used. Livers were retrieved, preserved in UW solution, and perfused for 60 min with oxygenated Krebs-Henseleit solution. Rats were allocated to six groups as follows (n=5): (i) control group-no warm ischemia (WI) and cold preservation, (ii) HBD group--no WI with cold preservation for 6 h; (iii) NHBD group--with 30 min of WI and cold preservation, (iv) NM group--with WI including nafamostat mesilate infusion before cardiac arrest and cold preservation; (v) PRE group--with WI, 30-min pre-cold preservation perfusion with oxygenated buffer after cardiac arrest, and cold preservation, (vi) BV group-with the same treatment as the PRE group plus the addition of biliverdin to the pre-cold preservation perfusion. The portal flow volume, bile production, AST, and TNF-alpha in perfusate, energy charge (EC), and ATP level in the tissue, and histological findings were investigated. The portal flow volume in the NM, PRE, and BV groups were higher than in the NHBD group. The bile production in the PRE and BV groups were also higher than in the NHBD group. The EC and ATP level of the BV group after reperfusion were higher than those of the NHBD group. Pre-cold preservation perfusion and addition of biliverdin to perfusate improved viability of grafts from NHBD. The results indicate that the preservation of the energy status and microcirculation of the graft is important for successful LTx from NHBD.