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Histological bile duct injury. (A) H&E stained extrahepatic bile duct. The periluminal PBGs, as indicated by a single arrowhead, were largely intact in both groups. The deep PBGs are indicated by double markings on the arrow and appeared intact in both groups, suggesting a well-preserved niche of progenitor cells. (B) H&E stained intrahepatic bile duct showing >50% of the luminal epithelium intact. The periluminal PBGs, as indicated by a single arrowhead, were largely intact. Deep PBG can be observed but are not always present in IHBD, and these showed almost no signs of histological injury (double marked arrow). (C) VWF stained extrahepatic bile duct (×20). (D) VWF stained IHBD (×10). Asterisks indicates the bile duct lumen. IHBD, intrahepatic bile duct; PBG, peribiliary gland; VWF, von Willebrand factor.
Source publication
Background:
Hypothermic oxygenated machine perfusion (HOPE) reduces ischemia-reperfusion injury of donor livers and is increasingly used in clinical transplantation. However, it remains unclear whether perfusion via the portal vein alone (HOPE) or via both the portal vein and hepatic artery (dual HOPE or DHOPE) is superior.
Methods:
Twelve porci...
Contexts in source publication
Context 1
... epithelium lining the luminal side of the extrahepatic and intrahepatic bile ducts was absent in biopsies obtained after procurement, as well as at the end of warm reperfusion in both groups. Peribiliary glands (PBGs) were located either close to the lumen (periluminal PBGs) or at the junction of the stroma and fibromuscular layer of the bile duct wall (deep PBGs) ( Figure 4A and B). Damage of the periluminal and deep PBGs of the EHBDs before the start of machine perfusion and at the end of machine perfusion was not different between the 2 groups ( Table 1). ...
Citations
... Moreover, the type of HOPE perfusion-whether single portal perfusion or dual perfusion via both the portal vein and hepatic artery-may impact metabolic pathways, adding complexity to univariate data analysis. Although we performed dual HOPE, recent preclinical [54] and real-world clinical data [55] have shown excellent long-term outcomes for HOPE-treated organs, regardless of perfusion type or device. This supports the view of underlying metabolic pathway similarity. ...
Background: Hypothermic oxygenated machine perfusion has emerged as a strategy to alleviate ischemic-reperfusion injury in liver grafts. Nevertheless, there is limited data on the effectiveness of hypothermic liver perfusion in evaluating organ quality. This study aimed to introduce a readily accessible real-time predictive biomarker measured in machine perfusate for post-transplant liver graft function. Methods: The study evaluated perfusate analytes over a 90-day postoperative period in 26 patients randomly assigned to receive a liver graft following dual hypothermic machine perfusion in a prospective randomized controlled trial. Machine perfusion was consistently conducted end-ischemically for at least 120 min, with real-time perfusate assessment at 30-min intervals. Graft functionality was assessed using established metrics, including Early Allograft Dysfunction (EAD). Results: Perfusate lactate concentration after 120 min of machine perfusion demonstrated significant predictive value for EAD (AUC ROC: 0.841, p = 0.009). Additionally, it correlated with post-transplant peak transaminase levels and extended hospital stays. Subgroup analysis revealed significantly higher lactate accumulation in livers with post-transplant EAD. Conclusions: Liver graft quality can be effectively assessed during hypothermic machine perfusion using simple perfusate lactate measurements. The reliability and accessibility of this evaluation support its potential integration into diverse transplant centers.
... Yet, experimental and translational data on the direct comparison of HOPE-modalities is vastly lacking to date. In this context, one preclinical model reported by de Vries et al. [26] showed a significant reduction of hepatocellular and cholangio cellular injury as depicted by lower circulating ALT and bile LDH 4 h after OLT when using dHOPE versus sHOPE in pigs. In addition, a lower expression of the vasoconstrictor endothelin-1 in the hepatic artery of dHOPE-treated organs could be docu mented. ...
Background
Corroborating evidence for use of hypothermic oxygenated machine perfusion (HOPE) prior to orthotopic liver transplantation (OLT) suggests a beneficial effect in regards to biliary complications. Here, we aim to evaluate whether perfusion via portal vein alone (sHOPE) or via additional perfusion of the hepatic artery (dHOPE) have diverging impact on outcomes after OLT when compared to use of static cold storage (SCS).
Methods
Consecutive patients undergoing OLT at Medical University of Vienna (2018 to 2023) were retrospectively analyzed. Donor organs were procured using SCS, or subjected to end-ischemic sHOPE or dHOPE. Severity of biliary complications was classified according to degree of therapeutic intervention (endoscopic retrograde cholangiopancreatography or surgical revision).
Results
247 patients were included (69 SCS, 76 sHOPE, 102 dHOPE). Hospitalization was shorter for patients after HOPE (median in days: SCS=25 vs HOPE=20, P =0.019). Biliary complications were less frequent in patients after HOPE (SCS=37.7% vs HOPE=22.5%, P =0.015). A significantly lower incidence of surgical revisions for biliary complications was observed in the HOPE cohort (24.6% vs 11.8%, P =0.012). When evaluating outcome according to HOPE-modality, a significant reduction in biliary complications ( P =0.006) and surgical revisions ( P =0.002) was only observed in dHOPE patients in comparison to SCS. Further, only dHOPE was significantly associated with reduced need for surgical revision for biliary complications upon uni- and multivariable logistic regression (odds ratio=0.336, P =0.011).
Conclusion
HOPE leads to a reduction of biliary complications and associated surgical revisions. This effect seems to be primarily associated with use of dHOPE, while both methods appear as feasible options for preconditioning of donor grafts prior to OLT.
... Клинических исследований, демонстрирующих преимущество одного метода над другим, на сегодняшний день нет. Лишь в экспериментальной работе de Vries et al. (2021) в группе применения двойной перфузии были получены 2-кратное снижение пиковой концентрации аланинаминотрансферазы в перфузате (р = 0,045) и более низкая концентрация лактатдегидрогеназы в желчи (р = 0,04) по сравнению с классической HOPE [15]. При этом микроскопических признаков повреждения артерий не было ни в одной из групп. ...
Objective: to improve the outcomes of liver transplantation (LTx) from expanded criteria donors (ECDs) through hypothermic oxygenated machine perfusion (HOPE).
Material and methods. The study included 63 cases of LTx from suboptimal brain-dead donors. Group I (control) consisted of 34 persons in which liver transplant was preserved only by static cold storage (SCS), while group II (main) comprised 29 cases where ex situ HOPE was used after static preservation. We evaluated the efficacy and safety of the latter in a comparative clinical study and by studying ultrastructural changes in the liver using electron microscopy.
Results. No statistically significant differences between the groups in terms of baseline characteristics of donors, recipients and several perioperative parameters (p > 0.05) were obtained. Peak aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels in the first week after transplantation were 1,052 (IQR: 712–1,842) U/L and 1,213 (IQR: 613–2,032) U/L in the HOPE group, and 1,943 (IQR: 1,294–5,214) U/L and 2,318 (IQR: 1,032–6,219) U/L in the SCS group (control). The levels were statistically significantly lower (p = 0.002 and p < 0.001, respectively). Median comprehensive complication index (CCI) in the main and control groups was 0 (IQR: 0–22.6) and 27.6 (IQR: 0–100) respectively. The differences were statistically significant (p = 0.001). Similarly, statistically significant differences were noted in terms of recipient time in the intensive care unit (ICU) and overall length of hospital stay (p = 0.042 and p = 0.028) – they were less in the HOPE group. Electron microscopy evaluation of the morphology of liver grafts revealed that hepatocytes sustained less injury during HOPE.
Conclusion. Ex situ HOPE is a safe and effective way of preserving liver transplants. Its use in LTx from expanded criteria donors can lessen the severity of ischemia-reperfusion injury (IRI) in the organ and enable additional assessment of the suitability of an organ for transplantation.
... Adding a sequence of normothermic blood reperfusion at the end of the preservation period could unveil ischemia-reperfusion injuries and increase the significance of this work, and should be explored in subsequent studies. To date, only a few publications have focused on endothelial cells during MP [57,58]. Finally, comparing extracorporeal perfusion protocols with conventional microsurgery could be interesting (outcomes, safety, cost-effectiveness. . ...
Machine perfusion has developed rapidly since its first use in solid organ transplantation. Likewise, reconstructive surgery has kept pace, and ex vivo perfusion appears as a new trend in vascularized composite allotransplants preservation. In autologous reconstruction, fasciocutaneous flaps are now the gold standard due to their low morbidity (muscle sparing) and favorable functional and cosmetic results. However, failures still occasionally arise due to difficulties encountered with the vessels during free flap transfer. The development of machine perfusion procedures would make it possible to temporarily substitute or even avoid microsurgical anastomoses in certain complex cases. We performed oxygenated acellular sub-normothermic perfusions of fasciocutaneous flaps for 24 and 48 h in a porcine model and compared continuous and intermittent perfusion regimens. The monitored metrics included vascular resistance, edema, arteriovenous oxygen gas differentials, and metabolic parameters. A final histological assessment was performed. Porcine flaps which underwent successful oxygenated perfusion showed minimal or no signs of cell necrosis at the end of the perfusion. Intermittent perfusion allowed overall better results to be obtained at 24 h and extended perfusion duration. This work provides a strong foundation for further research and could lead to new and reliable reconstructive techniques.
... With the aim of technical standardization of HOPE-Split procedure, Authors agree with Rossignol et Al. that single portal perfusion would be preferable over DHOPE. Portal perfusion alone is easier to perform and allows to remove one of the partial grafts from the device without interrupting the perfusion of the contralateral partial graft, no data support the additional benefit of a dual perfusion compared with a single perfusion 25 , and cannulation of the branches of the hepatic artery might expose to arterial injury (increased risk of intimal dissection). ...
Hepatobiliary surgical oncology and liver transplantation (LT) surgery have mutually benefited from their technological progresses and technical achievements of the last decade. The application of machine perfusion (MP) to ex-situ hepatectomies allows more patients with primary unresectable tumours to have access to radical treatment. Furthermore, the growing need for liver grafts for transplant purpose engaged surgeons in finding new solutions such as liver splitting during dynamic storage through MP to preserve the possibility of two LTs when in-situ splitting is not feasible.
... Guarrera used a portal vein and hepatic artery, while Dutkowski used a portal vein only, with an oxygenated perfusion solution. It has now been shown that both technics lead to comparable outcomes 98,99 . ...
43% of early dysfunctions in liver transplantation are linked to the ischemia-reperfusion syndrome, describing the accumulation of lesions between liver removal from a donor and its transplantation into a recipient. Marginal livers (with curable diseases) are very susceptible to ischemia-reperfusion. Still, they are used to address organ shortages. The challenge today is to reduce postoperative complications by improving the quality of their preservation. Therefore, our research aims to develop new ex vivo liver preservation strategies. The most commonly used methods are the conservation of the graft in a cold preservation liquid called "static preservation" and its preservation on an oxygenated perfusion machine called "dynamic preservation." Using a rat liver transplantation model, we investigated the role of a new preservation solution and a new perfusion machine protocol.
... La perfusion hypothermique oxygénée (HOPE) consiste à hyperoxygéner un liquide de perfusion acellulaire et à perfuser le greffon hépatique par la veine porte (HOPE) ou par l'artère hépatique et la veine porte en simultanée (DHOPE). À noter qu'il n'existe pas de différence en terme de LIR entre ces deux techniques dans des modèles expérimentaux animaux et qu'une comparaison directe en clinique n'existe pas à ce jour [17]. La perfusion normothermique (NMP) utilise une solution de perfusion enrichie en globules rouges afin de garantir une oxygénation adéquate des tissus à 37 • C. La Fig. 2 résume les stratégies de conservation dynamique les plus fréquemment utilisées en routine clinique aujourd'hui. ...
Given the increasing graft shortage, the transplant community is forced to use so called marginal liver grafts with a higher susceptibility to ischemia-reperfusion injury. This exposes the recipient to a higher risk of graft failure and post-transplant complications. While static cold storage remains the gold standard in low-risk transplant scenarios, dynamic preservation strategies may allow to improve outcomes after transplantation of marginal liver grafts. Two dynamic preservation strategies, end-ischemic hypothermic oxygenated perfusion (HOPE) and continuous normothermic machine perfusion (cNMP), have been evaluated in randomized clinical trials. The results show improved preservation of liver grafts after cNMP and reduction of post-transplant biliary complications after HOPE. In comparison to cNMP, HOPE has the advantage of requiring less logistics and expertise with the possibility to return to default static cold storage. Both strategies allow to assess graft viability prior to transplantation and may thus contribute to optimizing graft selection and reducing discard rates. The use of dynamic preservation is rapidly increasing in France and results from a national randomized trial on the use of HOPE in marginal grafts will soon be available. Future applications should focus on controlled donation after circulatory death liver grafts, split grafts and graft treatment during perfusion. The final aim of dynamic liver graft preservation is to improve post-transplant outcomes, increase the number of transplanted grafts and allow expansion of transplant indications.
... La perfusion hypothermique oxygénée (HOPE) consiste à hyperoxygéner un liquide de perfusion acellulaire et à perfuser le greffon hépatique par la veine porte (HOPE) ou par l'artère hépatique et la veine porte en simultanée (DHOPE). À noter qu'il n'existe pas de différence en terme de LIR entre ces deux techniques dans des modèles expérimentaux animaux et qu'une comparaison directe en clinique n'existe pas à ce jour [17]. La perfusion normothermique (NMP) utilise une solution de perfusion enrichie en globules rouges afin de garantir une oxygénation adéquate des tissus à 37 • C. La Fig. 2 résume les stratégies de conservation dynamique les plus fréquemment utilisées en routine clinique aujourd'hui. ...
Résumé
La pénurie de greffons hépatiques, disponibles pour la greffe, justifie une utilisation croissante de greffons dits marginaux. Ces derniers sont plus sensibles aux lésions d’ischémie-reperfusion, ce qui expose le receveur à un risque majoré de dysfonction du greffon et, donc, à une morbidité post-transplantation plus importante. Alors que la conservation froide statique reste aujourd’hui la référence pour les greffons hépatiques standards, les greffons marginaux pourraient bénéficier de nouvelles stratégies de conservation dynamique. Deux de ces stratégies, utilisant des machines de perfusion, ont été récemment évaluées dans des essais randomisés : la perfusion post-ischémique hypothermique oxygénée (HOPE) et la conservation en normothermie continue (cNMP). Les résultats montrent une amélioration et une prolongation de la conservation des greffons hépatiques avec cNMP et HOPE ainsi qu’une réduction des complications biliaires après HOPE. À noter qu’en cas de problème technique lors de la perfusion, HOPE permet à l’inverse de la cNMP, un retour aux conditions standards de conservation froide statique et reste donc une stratégie plus simple et sécure. Les deux stratégies offrent la possibilité d’évaluer la qualité et la viabilité des greffons hépatiques avant transplantation, permettant ainsi de mieux sélectionner les greffons hépatiques et d’augmenter le taux d’utilisation. À noter que les résultats du premier essai randomisé national français, comparant HOPE à la conservation froide statique, sont attendus en 2023. Par ailleurs, ces stratégies de conservation dynamique peuvent aussi être appliquées aux greffons partiels ou aux greffons issus de donneurs décédés après arrêt circulatoire, et présentent des perspectives de traitements ciblés du greffon avant transplantation . La conservation dynamique a, ainsi, pour but, d’augmenter le nombre de greffons disponibles, tout en améliorant leur qualité, afin de permettre un élargissement des indications et d’améliorer les résultats après transplantation hépatique.
... However, recent studies suggest that portal vein perfusion alone with highly oxygenated perfusate is sufficient for the metabolic effect. [26,27] In contrast, successful perfusion under normothermic conditions requires both the portal vein and hepatic artery. ...
While liver transplantation is a true success story, many patients still die awaiting an organ. The increasing need for liver grafts remains therefore an unsolved challenge to the transplant community. To address this, transplant donor criteria have been expanded and, for example, more liver grafts with significant steatosis or from donors with circulatory death are being used. These marginal grafts, however, carry an increased risk of graft‐associated complications, such as primary non‐function, delayed graft function or late biliary injuries. Therefore, reliable assessment of graft viability before use is essential for further success. To achieve this, machine liver perfusion, a procedure developed more than 50 years ago but almost forgotten at the end of the last century, is again of great interest. We describe in this review the clinical most applied machine perfusion techniques, their mechanistic background, and a novel concept of combining immediate organ assessment during hypothermic oxygenated perfusion (HOPE), followed by an extended phase of normothermic machine perfusion, with simultaneous ex situ treatment of the perfused liver. Such a new approach may allow to dramatically increase the pool of usable livers and improve outcomes for recipients.
Introduction. A significant shortage of high-quality donor organs remains one of the most pressing challenges, especially when it comes to extended criteria donors or asystolic donors. The solution to this problem arises at the intersection of surgical skill, advanced biomedical technologies and a deep understanding of the mechanisms of ischemia-reperfusion injury (IRI). Objective. This study was carried out to substantiate and refine the technique of extracorporeal ex-vivo perfusion of a liver graft on an animal model using the Ex-Stream perfusion apparatus for extracorporeal oxygenation according to TU 32.50.21-002-75538036-2020 (RU holder Transbiotek LLC, St. Petersburg, Russia, manufacturer Biosoft-M LLC, Moscow, Russia). Materials and methods. The study was conducted on male pigs weighing 15–30 kg (n = 5). The study is based on the analysis of the results of hypothermic oxygenated perfusion of the liver transplant in a vivarium using a cardiopulmonary bypass apparatus. The study was conducted according to the following protocol: the donor liver was removed from the animal with the formation of a temporary venovenous bypass, pharmaco-cold preservation of the organ using the Ex-Stream apparatus and its subsequent replantation. Results. The following results were obtained in a series of 5 observations. Tissue damage markers (AST, ALT, LDH, GGTP) showed a gradual increase in their level in the perfusate over the course of ischemia. The average values of AST and ALT increased by 2-3 times, LDH - by 1.5-2 times, and GGTP - by 1.2-1.5 times compared to the initial values. The level of malondialdehyde, reflecting oxidative stress, increased by an average of 30–40% by the end of the experiment, while the level of glutathione decreased by 20–25%. Concentrations of proinflammatory cytokines (TNF-α, IL-6, IL-1β) in the perfusate increased 2–4 times compared to baseline values, indicating the development of an inflammatory response. Microscopic examination with hematoxylin and eosin staining revealed signs of ischemic damage to hepatocytes, such as cytoplasmic vacuolization, nuclear pyknosis, and disruption of the beam structure. The degree of damage increased with increasing ischemia time. Mason staining showed a moderate increase in connective tissue in the portal tracts and pericentral zones, indicating initial fibrotic changes. Ultramicroscopic examination (transmission electron microscopy) revealed swelling of mitochondria, disruption of the integrity of their cristae, expansion of the endoplasmic reticulum and formation of autophagosomes in hepatocytes. Oxygen consumption by liver tissue gradually decreased during the experiment, reaching 60-70% of the initial level by the end of the observation. Carbon dioxide production also decreased, but to a lesser extent, amounting to 75-85% of the baseline values. Analysis of the perfusate using a potentiostat-galvanostat IPS showed a gradual decrease in the oxidation-reduction potential, indicating an increase in hypoxia and depletion of antioxidant reserves. The activity of superoxide dismutase and catalase, key antioxidant enzymes, decreased by 30-40% and 20- 30%, respectively, compared with the initial values, indicating a weakening of the antioxidant defense. Conclusion. The obtained results indicate that the developed model using the Ex-Stream device is reproducible and allows for effective study of the state of ischemia-reperfusion injury. This opens up opportunities for conducting a larger and more comprehensive series of experiments, the results of which will be the subject of our further research.
