1. UC Davis Medical Center
Ex Vivo Normothermic Preservation in Deceased Donor Renal Transplantation
Richard Perez, MD
Transplant Surgery
UC Davis Medical Center

2. Deceased Donor Kidney Transplantation: A Model of Ischemia-Reperfusion Injury
Potential Deceased Donor
Hypotension, shock, acute inflammation, kidney injury
Brain death or DCD
Ex vivo
Organ preservation – Hypothermia and hypoxia
Recipient
Vascular anastomosis with
re-perfusion injury

3. Disadvantages of hypothermic preservation
Ongoing low level metabolism/tissue breakdown
Loss of energy stores
Predictions of ultimate viability and function limited in highest risk marginal donors
Not metabolically active so intervention for reconditioning/repair is limited
Many high risk kidneys discarded

4. Ex vivo normothermic perfusion for organ preservation/pre-conditioning
Maintain body temperature
Oxygenation
Support aerobic metabolism
Normal physiologic function
Advantages
Restore ATP
Able to assess organ function
Minimize cold ischemia injury
Regeneration and repair initiated?

5. Can ex vivo normothermic perfusion preservation be used to “rescue” discarded kidneys deemed “not transplantable” (2500/year)?

6. Hosgood / Nicholson, Transplantation 2011

7. Normothermic Perfusion System
Pressure Display
Pressure probe
Medtronic Console
Urine Collection
Flow probe
Heat Exchanger, 370C
Venous Reservoir
Kidneys were put on our system of EVNP for 3 hours. The perfusate was an Packed Red Blood Cells (PRBC) oxygenated and supplemented with parenteral nutrition and insulin. Exogenous creatinine was added to measure blood creat levels and clearance. One kidney was given Furosemide (10 mg) at the beginning to induce diuresis and assess acute kidney injury. Hemodynamic pump parameters and urine output were monitored. Blood and urine samples were collected at the start and every 30 minutes and analyzed for pH, oxygen, electrolytes, creatinine, and lactate. Wedge biopsies were collected pre & post perfusion & stained with alizarin red to measure calcium oxylate tubular deposition.
Oxygenator
Centrifugal Pump

8. UC Davis Pre-Clinical Ex Vivo Normothermic Renal Perfusion
April First sheep kidney perfused
Jan First human kidney perfused
Jan Nov human kidneys perfused
Donor ages: 1 day – 78 years old
Perfusion times: hours

9. I Palma, Y Smolins, J Woloszyn, et al. UC Davis Medical Center
Ex Vivo Normothermic Perfusion to Assess and Repair Kidney Ischemia-Reperfusion Injury
I Palma, Y Smolins, J Woloszyn, et al.
UC Davis Medical Center
Academic Surgical Congress 2015

10. Study Design Deceased donors (n=4)
presumed suitable for transplantation
Met criteria for discard
Paired kidneys (n=8) entered into study
Whole blood EVNP to simulate clinical allograft reperfusion (n=4)
Packed RBC EVNP to test optimized normothermic preservation (n=4)

11. Donor Characteristics
Pair 1
Pair 2
Pair 3
Pair 4
Donation Type
ECD
DCD
Reason for being discarded
Biopsy Results
Age (yrs.) 67 58 54 64
Cause of Death
Anoxia
CVA
KDPI 99 79 75 94
Cold Ischemia Time (hrs)
40.33
40.67
52.82
53.15
56.08
56.28
60.37
60.88

12. Human Kidney Pre-Perfusion 1 hour 2 hours 3 hours 10A- WB 10B- PRBCs
They appear to have normal appearance in color.
10B- PRBCs

13. Improved Hemodynamics with Optimized Normothermic Perfusion
These are the flows for the human kidneys 9 and 10 using 2 Way ANOVA analysis. There was no statistical significance but as you can see the flows were higher in the PRBCs throughout the 3 hour perfusion.
Academic Surgical Congress 2015

14. Ex vivo normothermic perfusion increases urine production
Academic Surgical Congress 2015

15. Decreased injury biomarkers with optimized normothermic perfusion
These are the Urine NGAL for the human kidneys 9 and 10 using 2 Way ANOVA analysis. There was statistical significance (p= ). The PRBCs had a lower level of urine NGAL which is an acute kidney injury biomarker. It is also secreted by white cells so we ran KIM1 to verify the NGAL results. This was measured by a Triage machine.

16. UC Davis Medical Center
Ex vivo Normothermic Perfusion for Assessment of High Risk Deceased Donor Kidneys for Transplantation
S Kabagambe, I Palma, Y Smolin, T Boyer, IP Palma, J Sageshima, Csanthanakrishnan, C Troppmann, J McVicar, R Perez
UC Davis Medical Center
Cutting Edge of Transplantation 2016

17. What criteria can we use to determine if an organ is transplantable?
Retrospective review of locally discarded kidneys
Study period: June 2014 – Oct 2015
Kidneys provisionally accepted for transplant but turned down due to biopsy and/or hypothermic perfusion parameters
Placed on EVNP research protocol
Assessment of gross appearance, blood flow, and urine output

18. n=6
Globally pink and well perfused
High blood flow
Good urine output
Probably transplantable with Low Risk
n=2
Pink, well perfused but patchy
High blood flow
Low urine output
Possibly transplantable with Moderate Risk
n=1
Pink and patchy
Low blood flow
No urine output
Deemed not transplantable

19. Donor & pump Characteristics
Moderate Risk
( n=2)
Low Risk
(n=6)
P value
Age (years)
51.00 ± 13.00
56.17 ± 3.48
0.76
KDPI (%)
73.50 ± 20.50
80.33 ± 5.35
0.80
Terminal Creatinine
2.44 ± 1.89
1.42 ± 0.27
0.68
Cold time (hrs)
50.93 ± 12.96
44.00 ± 4.90
0.69
Term hypo flow (ml/min)
73.50 ± 7.50
73.33 ± 4.13
0.99
Terminal hypo RRI
0.43 ± 0.05
0.39 ± 0.04
0.64
Terminal EVNP flow
250.0 ± 30.00
353.3 ± 33.83
0.09
Terminal EVNP RRI
0.29 ± 0.03
0.21 ± 0.03
0.15
Urine output (ml/hr)
2.25 ± 1.75
125.8 ± 43.14
0.04

20. Prospective clinical study of ex vivo normothermic perfusion in high risk deceased donor renal transplantation
Purpose
Demonstrate safety and feasibility of EVNP
Comparison of standard of care hypothermic machine perfusion versus hypothermic perfusion + short additional period (2-4 hrs) of ex vivo normothermic perfusion prior to transplantation
Establish a normothermic platform for further studies

21. Clinical trial of ex vivo normothermic perfusion in renal transplantation
Inclusion criteria: Paired kidneys from donors with increased risk for DGF
Donors with acute renal injury (Creat > 2.0)
Donation after circulatory death
Prolonged cold ischemia time (>36hrs)
Donors with KDPI >70%

22. Clinical trial of ex vivo normothermic perfusion in renal transplantation
Clinical protocol
Standard hypothermic machine perfusion preservation to paired kidneys from high risk donors
Control kidney transplanted after cold machine perfusion
Study kidney to have additional 2-4 hours of normothermic perfusion just prior to implantation of organ

23. Ex Vivo Normothermic Perfusion: Future Directions
Routine assessment of high risk/marginal organs
Normothermic perfusion as a means to intervene and optimize organ function pre-transplant
Pharmacologic
Gene therapy
Stem cells
Development of “Organ Repair Centers”

24. Participating OPOs One Legacy Sierra Donor Services
Donor Network of Arizona
LifeShare
Gift of Life Philadelphia
Gift of Hope Illinois
Life Link of Florida
Life Share Oklahoma
Life Center Northwest
LifeNet Health
Midwest Transplant Network
Southwest Transplant