Ex situ Normothermic Split Liver Machine Perfusion: Protocol for Robust Comparative Controls in Liver Function Assessment Suitable for Evaluation of Novel Therapeutic Interventions in the Pre-clinical Setting

Joseph A Attard, Daniel-Clement Osei-Bordom, Yuri Boteon, Lorraine Wallace, Vincenzo Ronca, Gary Reynolds, M T P R Perera, Ye Htun Oo, Hynek Mergental, Darius F Mirza, Simon C Afford, Joseph A Attard, Daniel-Clement Osei-Bordom, Yuri Boteon, Lorraine Wallace, Vincenzo Ronca, Gary Reynolds, M T P R Perera, Ye Htun Oo, Hynek Mergental, Darius F Mirza, Simon C Afford

Abstract

Background: Ex situ donor liver machine perfusion is a promising tool to assess organ viability prior to transplantation and platform to investigate novel therapeutic interventions. However, the wide variability in donor and graft characteristics between individual donor livers limits the comparability of results. We investigated the hypothesis that the development of a split liver ex situ machine perfusion protocol provides the ideal comparative controls in the investigation of machine perfusion techniques and therapeutic interventions, thus leading to more comparable results. Methods: Four discarded human donor livers were surgically split following identification and separation of right and left inflow and outflow vessels. Each lobe, on separate perfusion machines, was subjected to normothermic perfusion using an artificial hemoglobin-based oxygen carrier solution for 6 h. Metabolic parameters as well as hepatic artery and portal vein perfusion parameters monitored. Results: Trends in hepatic artery and portal vein flows showed a general increase in both lobes throughout each perfusion experiment, even when normalized for tissue weight. Progressive decreases in perfusate lactate and glucose levels exhibited comparable trends in between lobes. Conclusion: Our results demonstrate comparability between right and left lobes when simultaneously subjected to normothermic machine perfusion. In the pre-clinical setting, this model provides the ideal comparative controls in the investigation of therapeutic interventions.

Keywords: liver function; machine perfusion; normothermic; organ preservation; split liver technique.

Conflict of interest statement

JA is a clinical research fellow at the Queen Elizabeth Hospital in Birmingham and employed by University Hospitals Birmingham. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Copyright © 2021 Attard, Osei-Bordom, Boteon, Wallace, Ronca, Reynolds, Perera, Oo, Mergental, Mirza and Afford.

Figures

Figure 1
Figure 1
Liver Splitting Procedure: (A) Inspection of liver hilum (B) Opening inferior vena cava to identify hepatic venous drainage (C) Identification of portal vein branches (D) Identification of hepatic arterial branches and hepatic duct transection. BD, bile duct; CHA, common hepatic artery; LHV, left hepatic vein; LL, left lobe; MHV, middle hepatic vein; PV, portal vein; RL, right lobe; RHV, right hepatic vein; VC, vena cava.
Figure 2
Figure 2
Liver Splitting Procedure: (A) Parenchymal transection across gallbladder bed (B) Parenchymal transection complete (C) Reconstruction of hepatic artery using donor celiac artery trunk (D) Cannulation of hepatic artery and portal vein branches. CHA, common hepatic artery; LPV, left portal vein; PV, portal vein; RHA, right hepatic artery.
Figure 3
Figure 3
Split lobe perfusion: (A) Left lobe (B) Right lobe. CHA, common hepatic artery; LPV, left portal vein; MHV, middle hepatic vein; PV, portal vein; RHA, right hepatic artery; RPV, right portal vein.
Figure 4
Figure 4
Perfusate lactate (A) and glucose (B) levels for each individual split lobe over 6 h of end-ischaemic normothermic machine perfusion.
Figure 5
Figure 5
Hepatic artery (A) and portal vein (B) flows for each individual split lobe over 6 h of end-ischaemic normothermic machine perfusion.
Figure 6
Figure 6
PAS staining from two representative perfusion experiments. (A) (from liver case number 2) shows mild to moderate macrovesicular steatosis, portal inflammatory cell infiltration and patchy PAS staining which was the same at commencement and end of perfusion. (B) (from liver case number 4) shows a liver with evenly distributed PAS staining throughout. Again, a degree of portal inflammation was seen. T0: pre-perfusion, T6: end of perfusion.

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