Hypothermic pulsatile perfusion of human pancreas: Preliminary technical feasibility study based on histology

doi:10.1016/j.cryobiol.2018.10.002

Cryobiology

Volume 85, December 2018, Pages 56-62

https://doi.org/10.1016/j.cryobiol.2018.10.002 Get rights and content

Abstract

Background

There are currently two approaches to hypothermic preservation for most solid organs: static or dynamic. Cold storage is the main method used for static storage (SS), while hypothermic pulsatile perfusion (HPP) and other machine perfusion-based methods, such as normothermic machine perfusion and oxygen persufflation, are the methods used for dynamic preservation. HPP is currently approved for kidney transplantation.

Methods

We evaluated, for the first time, the feasibility of HPP on 11 human pancreases contraindicated for clinical transplantation because of advanced age and/or history of severe alcoholism and/or abnormal laboratory tests. Two pancreases were used as SS controls, pancreas splitting was performed on 2 other pancreases for SS and HPP and 7 pancreases were tested for HPP. HPP preservation lasted 24 h at 25 mmHg. Resistance index was continuously monitored and pancreas and duodenum histology was evaluated every 6 h.

Results

The main finding was the complete absence of edema of the pancreas and duodenum at all time-points during HPP. Insulin, glucagon and somatostatin staining was normal. Resistance index decreased during the first 12 h and remained stable thereafter.

Conclusion

24 h hypothermic pulsatile perfusion of marginal human pancreas-duodenum organs was feasible with no deleterious parenchymal effect. These observations encourage us to further develop this technique and evaluate the safety of HPP after clinical transplantation.

Introduction

Pancreas transplantation alone (PTA) is currently one of the best treatments proposed in highly selected patients with unstable and brittle type 1 diabetes, while simultaneous pancreas and kidney transplantation (SPK) and pancreas after kidney transplantation (PTA) are more commonly performed in selected patients with diabetic nephropathy and chronic renal dysfunction, and kidney transplant patients with pre-existing diabetes [12]. Technical progress in surgery and immunology, combined with meticulous donor screening, have reduced the morbidity and mortality of pancreas transplantation [7,24]. However, the number of pancreas transplants failing within the first days after surgery and postoperative morbidity remain highly significant compared to other solid organ transplants. Graft pancreatitis and thrombosis remain the major cause of graft loss despite numerous approaches designed to prevent and resolve these severe complications, such as anticoagulation, strict donor selection and/or short cold ischemia time [13,19]. Cold ischemia time is generally limited to less than 15 h in the case of whole pancreas transplantation [9]. A long cold ischemia time can be harmful to pancreatic tissue and represents one of the main variables of immediate post-transplant failure [5]. Reducing cold ischemia time and/or improving the organ preservation process could help to achieve better graft outcomes.

As for other solid organ transplants, there is growing trend to include marginal donors for pancreas transplantation [6,16]. Acceptable results have been reported with the use of marginal donors, but with a high rate of technical failures. As for the kidney, the use of continuous hypothermic perfusion may theoretically be more efficient than the standard static storage method, especially when marginal donors are used. Hypothermic pulsatile perfusion (HPP) was initially developed by Alexis Carrel in experimental transplant models more than a century ago [14]. Belzer et al. introduced this procedure in the clinical setting of kidney transplantation [4]. The benefit of this procedure has been clearly, mainly when kidneys are obtained from extended criteria donors and/or after cardiac arrest [21].

The first experimental perfusions of pancreas transplants were published more than forty years ago in a canine model. Major edema resulting from perfusion was observed [10]. Hypothermic preservation of pancreas transplants by static storage has therefore remained the reference method [3,15]. The pancreas is a fragile organ and is highly sensitive to barotrauma. Interstitial edema of the gland may lead to complete venous thrombosis. Very few studies have focused on hypothermic pulsatile perfusion for preservation of the pancreas. The main objective of these experiments was not to transplant the organ but to isolate the islets of Langerhans [17,26].

This preliminary technical study was designed to evaluate the feasibility of HPP of human pancreases, for potential organ transplantation (HPP of the pancreas has not yet been approved for clinical transplantation in our country). We evaluated, for the first time, the feasibility of HPP on human pancreases contraindicated for clinical transplantation. The secondary objective was to evaluate the quality (i.e. histology) of the human pancreas after 24 h of HPP.

Section snippets

Materials and methods

We evaluated human pancreases rejected for vascularized organ or islet transplantation. Agreement from the donor's family to remove the organ for the purposes of scientific research was routinely obtained by the organ donor coordination team. This study was approved by the National Biomedicine Agency (ABM; authorization ref. PFS08-017, specific amendment dated 6/8/2014). All pancreases were removed by the same surgeon and in the same center according to a conventional organ removal procedure.

Macroscopic examination

Macroscopic examination of the two control pancreases under SS conditions showed no edema (ES = 0) at 12 h. A single evaluation was done at 24 h showing ES = 1.

Perfusion of the head of the pancreas of split organs was complex, as arterial vessels had to be ligated as extensively as possible. Arterial leakage causes a massive drop in resistance, resulting in ineffective perfusion. The macroscopic appearance of the head of the pancreas was very slightly modified after 24 h of HPP with ES = 1. The

Discussion

We describe, for the first time, the feasibility and practical issues of hypothermic human pancreas perfusion for 24 h. Our preliminary results indicate that 24-h perfusion of human pancreases rejected for clinical transplantation did not induce any edema or necrosis of the whole pancreas parenchyma and the duodenal villi. In addition, immunostaining for insulin, glucagon and somatostatin remained unchanged during the 24 h of perfusion. This preliminarily study did not analyze reperfusion

Authorship

J Branchereau: Research design, writing of the paper.

K Renaudin: Histological analysis.

D Kervella: Research design.

S Bernardet: Research design.

G Karam: Research design.

G Blancho: Research design.

D Cantarovich: Research design, writing of the paper.

Disclosure

The authors declare no conflict of interest.

Funding

None.

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Hypothermic pulsatile perfusion of human pancreas: Preliminary technical feasibility study based on histology

Abstract

Background

Methods

Results

Conclusion

Introduction

Section snippets

Materials and methods

Macroscopic examination

Discussion

Authorship

Disclosure

Funding

Blood

Transplant. Proc.

Transplant. Proc.

Am. J. Med.

J. Surg. Res.

J. Thorac. Cardiovasc. Surg.

Transplant. Rev.

Transplant. Proc.

Gastroenterol. Clin. N. Am.

Transplant. Rev.

Is extracorporeal hypothermic machine perfusion of the liver better than the 'good old icebox'?

Curr. Opin. Organ Transplant.

Organ preservation in pancreas and islet transplantation

Curr. Opin. Organ Transplant.

24-hour and 72-hour preservation of canine kidneys

Lancet

Pancreas transplantation in the United States: an analysis of the UNOS registry

Clin. Transpl.

Pancreas after kidney transplants in posturemic patients with type I diabetes mellitus

J. Am. Soc. Nephrol.