title: Multifactorial biological modulation of warm ischemia reperfusion injury in liver transplantation from non-heart-beating donors eliminates primary nonfunction and reduces bile salt toxicity.
abstract: OBJECTIVE
  To design a multifactorial biological modulation approach targeting ischemia reperfusion injury to augment viability of porcine liver grafts from non-heart-beating donors (NHBD).
  
  
  BACKGROUND
  Liver Transplantation (LTx) from NHBD is associated with an increased risk of primary nonfunction (PNF) and biliary complications. In porcine NHBD-LTx, we previously reported a 50% risk of PNF and toxic bile formation in grafts exposed to > or =30' warm ischemia (WI).
  
  
  METHODS
  Porcine livers exposed to 45' WI were cold stored, transplanted and either modulated (n = 6) or not (controls, n = 9). In the modulation group, donor livers were flushed with warm Ringers (avoiding cold-induced vasoconstriction), streptokinase (eliminating stagnating thrombi), and epoprostenol (vasodilator, platelet aggregation inhibitor) prior to cold storage. In recipients, glycine (Kupffer cell stabilizer), alpha1-acid-glycoprotein (anti-inflammatory protein), MAPKinase-inhibitor (pro-inflammatory cytokine generation inhibitor), alpha-tocopherol and glutathione (anti-oxidants), and apotransferrin (iron chelator) were administrated intravenously. PNF, survival, lactate, transaminase, TNF-alpha, redox-active iron, and biliary bile salt-to-phospholipid ratio were monitored.
  
  
  RESULTS
  No PNF was observed in modulated versus 55% in control pigs (P = 0.025). Survival was 83% in modulated versus 22% in control pigs (P = 0.02). At 180' postreperfusion, lactate was lower in modulated (5.4 +/- 1.9 mmol/L) versus control pigs (9.4 +/- 2.2 mmol/L; P = 0.011). At 60' postreperfusion, there was a trend for lower AST in modulated versus control pigs at 60' (939 +/- 578 vs. 1683 +/- 873 IU/L; P = 0.089). Postreperfusion, TNF-alpha remained stable in modulated pigs (49 +/- 27 pg/mL at 15' and 85 +/- 26 pg/mL at 180'; P = 0.399) but increased in control pigs (107 +/- 36 pg/mL at 15' and 499 +/- 216 pg/mL at 180'; P = 0.023). At 180' postreperfusion, redox-active iron was higher in control pigs versus modulated pigs (0.21+/-0.18 vs. 0.042+/-0.062 mum; P = 0.038). Biliary bile salt-to-phospholipid ratio post-LTx was lower in modulated versus control pigs (1128 +/- 447 vs. 4836 +/- 4619; P = 0.05).
  
  
  CONCLUSIONS
  A multifactorial biological modulation eliminates PNF, improves liver function and increases survival. Biochemically, TNF-alpha and redox-active iron are suppressed and biliary bile salt toxicity is reduced. Translating this strategy clinically may lead to wider and safer use of NHBD.
authors.affiliation: Liver research facility/Department of Abdominal Transplant Surgery, University Hospitals Leuven, Herestraat 49, B-3000 Leuven, Belgium. Diethard.Monbaliu@uzleuven.be
authors.forename: Diethard
authors.initials: D
authors.lastname: Monbaliu
authors.forename: Katrien
authors.initials: K
authors.lastname: Vekemans
authors.forename: Harm
authors.initials: H
authors.lastname: Hoekstra
authors.forename: Lauri
authors.initials: L
authors.lastname: Vaahtera
authors.forename: Louis
authors.initials: L
authors.lastname: Libbrecht
authors.forename: Katelijne
authors.initials: K
authors.lastname: Derveaux
authors.forename: Jaakko
authors.initials: J
authors.lastname: Parkkinen
authors.forename: Qiang
authors.initials: Q
authors.lastname: Liu
authors.forename: Veerle
authors.initials: V
authors.lastname: Heedfeld
authors.forename: Tine
authors.initials: T
authors.lastname: Wylin
authors.forename: Hugo
authors.initials: H
authors.lastname: Deckx
authors.forename: Marcel
authors.initials: M
authors.lastname: Zeegers
authors.forename: Erika
authors.initials: E
authors.lastname: Balligand
authors.forename: Wim
authors.initials: W
authors.lastname: Buurman
authors.forename: Jos
authors.initials: J
authors.lastname: van Pelt
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Porte
authors.forename: Jacques
authors.initials: J
authors.lastname: Pirenne
mesh_terms: D000818:Animals; D001647:Bile Acids and Salts / Q000032:analysis*; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage / Q000494:pharmacology; D005978:Glutathione / Q000008:administration & dosage / Q000494:pharmacology; D005998:Glycine / Q000008:administration & dosage / Q000494:pharmacology; D006085:Graft Survival; D016031:Liver Transplantation / Q000379:methods*; D009961:Orosomucoid / Q000008:administration & dosage / Q000494:pharmacology; D055031:Primary Graft Dysfunction / Q000517:prevention & control*; D011720:Pyrazoles / Q000008:administration & dosage / Q000494:pharmacology; D011725:Pyridines / Q000008:administration & dosage / Q000494:pharmacology; D015427:Reperfusion Injury / Q000503:physiopathology / Q000517:prevention & control*; D013300:Streptokinase / Q000008:administration & dosage / Q000494:pharmacology; D013552:Swine; D052096:Warm Ischemia; D024502:alpha-Tocopherol / Q000008:administration & dosage / Q000494:pharmacology
chemical_list: D001647:Bile Acids and Salts; C104334:FR 167653; D005343:Fibrinolytic Agents; D009961:Orosomucoid; D011720:Pyrazoles; D011725:Pyridines; D013300:Streptokinase; D005978:Glutathione; D024502:alpha-Tocopherol; D005998:Glycine