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      Avoiding initial hypothermia does not improve liver graft quality in a porcine donation after circulatory death (DCD) model of normothermic perfusion

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          Abstract

          Background

          Normothermic machine perfusion (NMP) of liver grafts donated after circulatory death (DCD) has shown promise in large animal and clinical trials. Following procurement, initial flush with a cold preservation solution is the standard of care. There is concern that initial cooling followed by warming may exacerbate liver injury, and the optimal initial flush temperature has yet to be identified. We hypothesize that avoidance of the initial cold flush will yield better quality liver grafts.

          Methods

          Twenty-four anaesthetized pigs were withdrawn from mechanical ventilation and allowed to arrest. After 60-minutes of warm ischemia to simulate a DCD procurement, livers were flushed with histidine-tryptophan-ketoglutarate (HTK) at 4°C, 25°C or 35°C (n = 4 per group). For comparison, an adenosine-lidocaine crystalloid solution (AD), shown to have benefit at warm temperatures in heart perfusions, was also used (n = 4 per group). During 12-hours of NMP, adenosine triphosphate (ATP), lactate, transaminase levels, and histological injury were determined. Bile production and hemodynamics were monitored continuously.

          Results

          ATP levels recovered substantially following 1-hour of NMP reaching pre-ischemic levels by the end of NMP with no difference between groups. There was no difference in peak aspartate aminotransferase (AST) or in lactate dehydrogenase (LDH). Portal vein resistance was lowest in the 4°C group reaching significance after 2 hours (0.13 CI -0.01,0.277, p = 0.025). Lactate levels recovered promptly with no difference between groups. Comparison to AD groups showed no statistical difference in the abovementioned parameters. On electron microscopy the HTK4°C group had the least edema with mean cell thickness of 2.92μm (p = 0.41) while also having the least sinusoidal dilatation with a mean diameter of 5.36μm (p = 0.04). For AD, the 25°C group had the lowest mean cell thickness at 3.14μm (p = 0.09).

          Conclusions

          Avoidance of the initial cold flush failed to demonstrate added benefit over standard 4°C HTK in this DCD model of liver perfusion.

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          Most cited references33

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          A randomized trial of normothermic preservation in liver transplantation

          Liver transplantation is a highly successful treatment, but is severely limited by the shortage in donor organs. However, many potential donor organs cannot be used; this is because sub-optimal livers do not tolerate conventional cold storage and there is no reliable way to assess organ viability preoperatively. Normothermic machine perfusion maintains the liver in a physiological state, avoids cooling and allows recovery and functional testing. Here we show that, in a randomized trial with 220 liver transplantations, compared to conventional static cold storage, normothermic preservation is associated with a 50% lower level of graft injury, measured by hepatocellular enzyme release, despite a 50% lower rate of organ discard and a 54% longer mean preservation time. There was no significant difference in bile duct complications, graft survival or survival of the patient. If translated to clinical practice, these results would have a major impact on liver transplant outcomes and waiting list mortality.
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            Hepatic ischemia and reperfusion injury: effects on the liver sinusoidal milieu.

            Ischemia-reperfusion injury is an important cause of liver damage occurring during surgical procedures including hepatic resection and liver transplantation, and represents the main underlying cause of graft dysfunction post-transplantation. Cellular and biochemical processes occurring during hepatic ischemia-reperfusion are diverse and complex, and include the deregulation of the healthy phenotype of all liver cellular components. Nevertheless, a significant part of these processes are still unknown or unclear. The present review aims at summarizing the current knowledge in liver ischemia-reperfusion, but specifically focusing on liver cell phenotype and paracrine interaction deregulations. Moreover, the most updated therapeutic strategies including pharmacological, genetic and surgical interventions, as well as some of the scientific controversies in the field will be described. Finally, the importance of considering the subclinical situation of liver grafts when translating basic knowledge to the bedside is discussed. Copyright © 2013 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.
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              Liver Transplantation After Ex Vivo Normothermic Machine Preservation: A Phase 1 (First-in-Man) Clinical Trial.

              The number of donor organs suitable for liver transplantation is restricted by cold preservation and ischemia-reperfusion injury. We present the first patients transplanted using a normothermic machine perfusion (NMP) device that transports and stores an organ in a fully functioning state at 37°C. In this Phase 1 trial, organs were retrieved using standard techniques, attached to the perfusion device at the donor hospital, and transported to the implanting center in a functioning state. NMP livers were matched 1:2 to cold-stored livers. Twenty patients underwent liver transplantation after NMP. Median NMP time was 9.3 (3.5-18.5) h versus median cold ischaemia time of 8.9 (4.2-11.4) h. Thirty-day graft survival was similar (100% NMP vs. 97.5% control, p = 1.00). Median peak aspartate aminotransferase in the first 7 days was significantly lower in the NMP group (417 IU [84-4681]) versus (902 IU [218-8786], p = 0.03). This first report of liver transplantation using NMP-preserved livers demonstrates the safety and feasibility of using this technology from retrieval to transplantation, including transportation. NMP may be valuable in increasing the number of donor livers and improving the function of transplantable organs.
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                Author and article information

                Contributors
                Role: InvestigationRole: Writing – original draft
                Role: InvestigationRole: Writing – review & editing
                Role: Formal analysis
                Role: Investigation
                Role: Investigation
                Role: Investigation
                Role: Investigation
                Role: ConceptualizationRole: MethodologyRole: SupervisionRole: Writing – review & editing
                Role: SupervisionRole: Writing – review & editing
                Role: Funding acquisitionRole: MethodologyRole: SupervisionRole: Writing – review & editing
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                6 August 2019
                2019
                : 14
                : 8
                : e0220786
                Affiliations
                [1 ] Department of Surgery, Division of General Surgery, University of Alberta, Edmonton AB, Canada
                [2 ] Department of Surgery, Division of Surgical Research, University of Alberta, Edmonton AB, Canada
                [3 ] Department of Mathematics and Statistical Sciences, University of Alberta, Edmonton AB, Canada
                [4 ] Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton AB, Canada
                [5 ] Department of Physiology, University of Alberta, Edmonton AB, Canada
                [6 ] Department of Biomedical Engineering, University of Alberta, Edmonton AB, Canada
                [7 ] Department of Surgery, Division of Cardiac Surgery, University of Alberta, Edmonton AB, Canada
                University of Colorado, Anschutz Medical Campus, UNITED STATES
                Author notes

                Competing Interests: DF is a non-salaried employee of Tevosol, Inc as CSO. Tevosol did not play a role in study design, data collection and analysis, decision to publish or preparation of the manuscript. Tevosol did not provide support in any way, whether direct or indirect. DF’s contributions to the project were under the auspices of his appointment as Associate Professor in the Department of Surgery, University of Alberta. DF’s commercial affiliation with Tevosol, Inc does not alter our adherence to PLOS ONE policies on sharing data and materials.

                Author information
                http://orcid.org/0000-0002-3984-5700
                http://orcid.org/0000-0002-6239-1444
                Article
                PONE-D-19-13763
                10.1371/journal.pone.0220786
                6684160
                31386697
                992e4b03-6d88-47e1-84a6-ed5751acf860
                © 2019 Nostedt et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 15 May 2019
                : 23 July 2019
                Page count
                Figures: 6, Tables: 4, Pages: 17
                Funding
                JN was funded by the University of Alberta Clinician Investigator Program. The funder provided support in the form of salaries for JN, but did not have any additional role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. The specific roles of this author are articulated in the ‘author contributions’ section.
                Categories
                Research Article
                Medicine and Health Sciences
                Surgical and Invasive Medical Procedures
                Digestive System Procedures
                Liver Transplantation
                Medicine and Health Sciences
                Surgical and Invasive Medical Procedures
                Transplantation
                Organ Transplantation
                Liver Transplantation
                Biology and Life Sciences
                Anatomy
                Cardiovascular Anatomy
                Blood Vessels
                Veins
                Portal Veins
                Medicine and Health Sciences
                Anatomy
                Cardiovascular Anatomy
                Blood Vessels
                Veins
                Portal Veins
                Biology and Life Sciences
                Cell Biology
                Cellular Types
                Animal Cells
                Epithelial Cells
                Endothelial Cells
                Biology and Life Sciences
                Anatomy
                Biological Tissue
                Epithelium
                Epithelial Cells
                Endothelial Cells
                Medicine and Health Sciences
                Anatomy
                Biological Tissue
                Epithelium
                Epithelial Cells
                Endothelial Cells
                Medicine and Health Sciences
                Vascular Medicine
                Ischemia
                Physical Sciences
                Chemistry
                Chemical Compounds
                Organic Compounds
                Amino Acids
                Basic Amino Acids
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                Organic Compounds
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                Histidine
                Biology and Life Sciences
                Biochemistry
                Proteins
                Amino Acids
                Basic Amino Acids
                Histidine
                Biology and Life Sciences
                Anatomy
                Liver
                Medicine and Health Sciences
                Anatomy
                Liver
                Biology and Life Sciences
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                Medicine and Health Sciences
                Anatomy
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                Bile
                Medicine and Health Sciences
                Anatomy
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                Biology and Life Sciences
                Physiology
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                Medicine and Health Sciences
                Physiology
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